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Ontoersitp  of  JBortb  Carolina 


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pfjilantfjropic  Societies 

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v.  103 

1 94 1 


M«i.  lib. 


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he  taken  from  the 
Lihrary  huilding. 


Digitized  by  the  Internet  Archive 

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Tei-State   Meeting — Feb.   24-25 — Greensboro 


<tmm. 


VOLUME  103 
Number  1 


JANUARY,  1941 


PER  ANNUM  2.50 
Single   Copies  50c 


w 

ORIGINAL   ARTICLES 

A  Concept  of  Anxiety,  /.  G.  N.  disking  1 

Surgery  in  Diabetes,  G.   T.  Tyler,  Jr 6 

Some  Complications  of  Pregnancy, 

Creighlon  Wrenn  9 

Uterine    Dystocia — Calcium    tn    the    Treatment, 

B.  C.  Nolle  14 

NOTES 
A  Review  of  Progress  During  1940, 

Davis  Hospital  Stag  17 

DEPARTMENTS 
Is  There  Balm  in  Gilead?  \ 

Prudence  Instead  of  Persecution   '  j   j^    rr  ..  ,„  ,n 
Inclusive?   Exclusive?  [ 

Unrecognized  Hypothyroidism         / 

Plasma  Transfusion  in  War,  G.  H.  Bunch  20 

Rabbit  Fever,  N.   T.  Ennett  21 

Prevention   of   Deafness,  C.   W.  Evatt   22 

Hoarseness  in  Tuberculosis,  John  Donnelly  22 

Keratitis  Cured  by  Removal  of  Teeth, 
/.  H.   Guion 23 


Treatment  of  Acute  Deltria  ^  ,  p    iwa./,  74  25 

Bismuth  in   Syphilis  I 

Apnea  Neonatorum,  /.  M.  Procter  25 

Trichomonas  Infection  ln  Males    i  .-,    ~   Cnnh     11 
Benign  Gynecologic  Hemorrhages  1 
Treatment  of  Intractable  Pain,  W.  J  Lackey  ....  27 
Doing  More  of  Our  Own  Work  With  Better 

Drugs  Lowers  Cost  of  Treatment, 

W.  J.  Lackey   36 

Foreign  Bodies  of  the  Cornea,  H.  C.  Neblett  ....  28 

Why  Tax  The  Sick  Man?,  R.  B.  Davis  29 

Diets  in  Eczema,  G.  W.  Kutscher,  Jr 35 

EDITORIALS 

The  Tri-State  Meeting  Next  Month  31 

Cancer  of  the  Stomach  32 

Smallpox  in  the  United  States  33 

Artificial  Insemination  in  the  United  States  ....  34 

NEWS    3S 

Our  Medical   Schools  39 

BOOKS    43 

CHUCKLES   47 


ABSTRACTS:  The  Patient  Who  Is  Always  Tired,  The  Fibroid  Uterus,  Diabetes— 5;  Viking 
Announcement  for  1941 — 8;  Treatment  of  Chronic  Leg  Ulcers,  Carcinoma  of  the  Rectum — 13; 
Acute  Appendicitis  in  the  Johns  Hopkins  Hospital,  Treatment  of  Infectious  Diarrhea  With 
Sulfapyridine — 16;  Pneumonectomy  For  Carcinoma — 19;  Refrigeration  Therapy — 21;  75  Years 
for  Parke,  Davis  &  Company — 30;  Sublingual  Therapy  in  Addison's  Disease,  Prevention  of 
Diabetes,  Relief  in  Ureteral  Colic — 36;  Not  Too  Old  For  Surgery,  John  Browne  and  His 
Treatise,  Diagnosis  of   Breast  Tumors — 46. 


entered  charlotte,  n.  c,  postoffice  as  second  class  mail 
Published  Monthly  by  CHARLOTTE  MEDICAL  PRESS,  Charlotte,  N.  C. 


For  your  high  protein  diets  may  we  suggest 

VALENTINE'S  HIGH  PROTEIN  MIXTURE 

Consisting  of 

Animal  Protein  74.1% 

Fat    10.6% 

Moisture   8.0% 

Ash    5.2% 

Undetermined  2.1% 

116  Calories  per  ounce 

Suitable  for  tube  feeding  by  suspending  in  liquids. 
Literature  and  samples  sent  on  request. 

VALENTINE  COMPANY,  INC. 

RICHMOND,  VIRGINIA 


PANOPEPTON 

A  RESTORATIVE,  STIMULATING,  NOURISHING  FOOD  FOR  THE  SICK 

AND  THE  CONVALESCENT 
PANOPEPTON  presents  in  an  agreeable  menstruum  a  concentrate  of  the  proteins 
of  beef,  largely  in  the  form  of  amino  acids,  plus  the  carbohydrates  and  proteins  of 
the  whole  wheat  berry. 

PANOPEPTON,  designed  especially  for  the  nutrition  of  the  sick,  is  useful  during 
acute  illness,  fevers,  epidemics,  such  as  influenza;  in  surgical  cases  before  and  after 
operation;  for  rectal  feeding;  in  convalescence,  weakened  digestion,  defective  assimi- 
lation, seasickness,  insomnia,  and  for  the  elderly  neurasthenic  type. 

PANOPEPTON  is  ready  for  instant  use,  always  available,  and  is  compatible  with 
every  form  of  medical  treatment.   Many  physicians  find  it  useful  as  a  vehicle. 

Originated  and  Made  by 
Descriptive    literature    gladly    sent    on  Faiixhild   Bl"OS.   &   Foster 

rcg"esL  New  York,  N.  Y. 


THE  JOURNAL  OF 
SOUTHERN  MEDICINE  AND  SURGERY 

306  North  Tryon  Street,  Charlotte,  N.  C. 

The  Journal  assumes  no  responsibility  for  the  authenticity  o  f  opinion  or  statements  made  by  authors  or  in  communica- 
tions submitted  to  this  Journal  for  publication. 


JAMES   M.   NORTHINGTON,   M.  D.,   Editor 


CHARLOTTE.  N.  C.  JANUARY,   1941 


A  Concept  of  Anxiety 

J.  G.  N.  Cushing,  M.  D.,  Pinebluff,  North  Carolina 


FOR  the  most  part,  investigators  who  have 
dealt  with  the  problem  of  anxiety  have  at- 
tempted to  differentiate  between  anxiety  and 
fear.  At  first  it  was  considered  purely  on  a  phy- 
siological basis,  as  in  Brissaud's  theory  that  anxiety 
is  a  "neurosis  of  the  vagus."  It  was  in  1890  that 
he  studied  the  work  of  Francois-Frank1  who  pro- 
duced anxiety  in  animals  by  compression  of  the 
vagus.  Many  philosophers,  too,  were  concerned 
with  defining  and  differentiating  anxiety  and  fear. 
One  of  these  who  was  most  prominently  concerned 
with  this  was  Pascal,  who  felt  that  anxiety  was  a 
forerunner  of  fear — finally  building  up  to  a  climax 
of  fear.  Spinoza  and  Heidegger  considered  fear 
as  something  tangible  to  the  mind  and  anxiety  as 
dealing  with  "nothingness."  However,  in  consider- 
ing this  question  of  differentiation  it  would  be  too 
burdensome  to  quote  every  worker,  so  we  will  skip 
both  years  and  theories. 

Freud  was  the  most  prominent  of  the  latter-day 
psychiatrists  to  be  concerned  with  the  question. 
In  some  of  his  early  papers  he  demarcated  anxiety 
neuroses,  or  angstneurose,  from  neurasthenia  as  a 
secondary  variety  of  "actual  neurosis.'"  At  the 
same  time  he  emphasized  that  anxiety,  in  contra- 
distinction to  fear,  is  characterized  by  a  feeling  of 
hopelessness  toward  danger.  Amongst  our  con- 
temporaries, Goldstein,  in  presenting  his  holistic 
concepts,  has  stated  that  fear  is  led  to  by  the 
"experience  of  the  possibility  of  the  concept  of 
anxiety."'  It  is,  of  course,  quite  obvious  to  the 
unbiased  observer  of  human  life  that  anxiety  and 
fear  cannot  be  the  same  thing,  although  at  times 
they  may  produce  the  same  subjective  phenomena. 
Nor  can  we  agree  that  anxiety  is  the  forerunner  of 


fear,  although  viewed  from  the  purely  superficial 
aspect  this  would  seem  to  be  a  logical  concept. 
That  anxiety  deals  with  nothingness,  of  course,  is 
to  the  modern  mind  not  only  unproven  but  un- 
provable, and  highly  unscientific.  Even  looking 
at  it  in  a  detached  manner  it  is  difficult  for  me  to 
picture  fear  as  being  a  situation  in  which  one  fears 
anxiety. 

A  human  being  is  a  stratification  of  entities — a 
phylogenetic  representation  within  one  frame.  At 
last  we  appear  to  have  come,  despite  ages  of 
philosophical  thinking,  to  the  point  of  believing 
that  there  is  no  dichotomy  of  mind  and  body.  For 
this  reason  we  believe  that  one  cannot  observe  an 
isolated  reaction  of  a  patient  and  analyze  it  into 
its  elements  without  also  considering  it  as  the 
reaction  of  the  total  personality.  This  leads  to 
much  difficulty  in  psychiatric  thinking  because  of 
the  implications  accompanying  each  symptom. 

It  is  quite  obvious,  even  to  the  untrained  ob- 
server, that  there  is  not  only  a  mental  equation 
concerned  in  the  states  of  fear  and  anxiety,  but  also 
a  physical  concomitant.  One  of  the  most  promi- 
nent of  these  is  the  release  of  adrenalin  during 
these  states  which  we  are  discussing.  It  is  well 
known  that  adrenalin  acts  on  the  neuro-muscular 
endplates  of  the  sympathetic  nervous  system  and 
produces  the  same  effect  as  electrical  stimulation 
would,  except  upon  the  pilomotor  muscles  and 
sweat  glands.  Adrenalin  will  not  cause  sweating. 
Adrenalin  mobilizes  glucose  by  releasing  it  from  its 
storehouse  in  the  liver  where  it  exists  as  glycogen, 
thereby  increasing  the  sugar  content  of  the  blood. 
It  diminishes  muscular  fatigue  and  checks  secre- 
tion of  the  digestive  glands.   It  causes  tachycardia, 


ANXIETY— Cushing 


January   1940 


increase  in  the  cardiac  action,  anemia  of  the  gastro- 
intestinal and  respiratory  tracts  and  rise  in  blood 
pressure.  Thyroxin  stimulates  the  adrenal  and 
adrenalin  stimulates  the  sympathetic  system,  and 
the  thyroid  in  turn  is  stimulated  by  the  sympa- 
thetic. By  yirtue  of  this  complicated  procedure  we 
see  some  of  these  prominent  distortions  of  the  or- 
ganism in  states  of  fear  and  anxiety  as  tachycardia, 
palpitation  and  shortness  of  breath.  As  the  degree 
of  emotion  becomes  stronger,  other  symptoms  will 
develop  such  as  dizziness,  unsteadiness,  the  vaso- 
motor skin  reactions  with  hot  and  cold  sensations, 
difficulty  in  focussing  as  blurred  vision,  frequency 
and  urgency  of  urination,  etc.  When  these  states 
become  more  jelled  they  are  spoken  of  by  the  psy- 
chiatrist as  a  neurosis.  They  frequently  manifest 
other  symptoms  such  as  sexual  stimulation,  even 
to  orgasm,  with  or  without  erection,  an  increase  in 
the  metabolic  rate,  impulsive  yawning,  and  ap- 
parently causeless  sleepiness.  It  is  to  be  noted 
that  the  symptoms  which  may  be  caused  by  fear 
are  usually  understood  by  the  victim  and  will  dis- 
appear when  the  palpable  cause  of  the  fear  no 
longer  concerns  the  individual.  However,  if  an 
impalpable  cause  threatens  an  individual,  these 
symptoms  or  variations  of  them  will  appear  and 
will  remain  until  the  organism  arrives  at  an  under- 
standing of  the  basic  cause.  In  other  words  it  is 
believed  by  some  of  us  that  the  difference  between 
fear  and  anxiety  lies,  not  in  the  physiological  re- 
actions, but  in  the  differentiation  between  the  pal- 
pable (consciously  acceptable)  and  impalpable 
(consciously  unacceptable)  object. 

Anatomically  it  is  believed  by  some  that  fear  is 
an  emotion  of  subcortical  source  and  that  anxiety 
is  a  neocortical  function.  This  assumption  is  based 
on  some  studies  made  by  Bard  at  the  Johns  Hop- 
kins University  School  of  Medicine'  in  which  he 
removed  the  neocortex,  much  of  the  rhinencephalon 
and  most  of  the  striatum  in  cats.  The  animals  so 
treated  showed  fear  reactions,  even  to  the  point  of 
acute  terror,  to  certain  auditory  stimuli.  We  may 
then  say  that  fear  is  an  emotion  concerning  a 
danger  which  is  consciously  acceptable  and  can 
be  prehended  by  the  cortex.  However,  one  need 
not  have  an  intact  cortex  to  experience  fear:  it 
can  be  recognized  by  some  subcortical  region.  In 
the  decorticate  animal  danger  is  recognized  and 
translated  immediately  into  a  fear  reaction;  in  the 
cortically  intact  animal  the  danger  is  also  recog- 
nized and  may  be  feared,  but  the  reactions  to  that 
fear  are  controlled  by  the  higher  centres. 

Now,  it  would  appear  that  fear  connotes  a  cer- 
tain amount  of  experience  regarding  the  object — 
we  do  not  fear  the  sudden  blast  of  a  steam  whistle 
because  we  know  from  experience  that  it  can  do 
us  no  harm.  However,  a  baby  or  person  who  has 
never  previously  heard  a  siren,  or  an  animal  which 


is  decorticate,  will  exhibit  symptoms  of  fear.  If  an 
infant  or  a  lad  who  has  never  previously  heard  a 
siren  becomes  accustomed  to  hearing  one  sounded 
daily,  he  discovers  that  it  will  do  him  no  harm  and 
he  will  then  cease  to  exhibit  symptoms  of  fear. 
This  can  be  rather  readily  pictured  in  a  modern-day 
experience  if  we  are  to  believe  the  press  reports 
we  get  from  London  and  other  bombed  areas  that 
people  in  the  attacked  areas  become  nightly  ac- 
customed to  hearing  the  sirens  and,  although  there 
is  potential  danger  present,  they  become  so  famil- 
iar with  this  danger  that  they  no  longer  exhibit 
fear  of  the  bombing  nor  fear  when  the  siren  is 
sounded.  This  is  even  carried  to  the  extent  that 
many  will  avoid  the  A.R.P.  workers  and  run  into 
doorways  or  on  the  roofs  of  houses  to  watch  the 
attacking  planes. 

These  persons  who  are  frequently  disturbed  by  a 
siren  gradually  become  accustomed  to  it,  realizing 
that  there  is  no  danger  in  the  sound  itself.  But 
they  may  never  get  too  near  the  source  of  the 
sound  because  of  another  fear  that  there  may  be 
one  chance  in  a  million  that  the  steam  whistle  may 
blow  up  and  hurt  them.  This  latter  is  described 
as  a  reaction  of  "controlled  fear"  which  will  have 
none  of  the  concomitant  physiological  reactions 
which  were  present  the  first  time  the  siren  was 
heard.  A  decorcitate  animal  will  never  have  the 
power  of  learning  this  secondary  controlled  fear 
because  it  does  not  have  the  storehouse  of  experi- 
ence with  other  objects,  nor  can  it  learn  to  be  ac- 
customed to  the  sound,  for  the  same  reason;  and 
it  will  display  all  the  physiological  reactions  every 
time  the  siren  is  sounded  in  its  vicinity. 

Anxiety  will  have  the  same  physiological  re- 
actions, but  its  object  will  be  different  in  that  it 
cannot  be  prehended  by  the  individual;  further- 
more the  object  will  be  unacceptable  to  the  con- 
sciousness. Hence  this  is  a  reaction  to  an  unap- 
prehended threat  to  the  individual's  security  and 
as  such  will  produce  the  symptoms  outlined  above 
in  varying  degree.  The  degree  of  the  anxiety  will 
depend  upon  the  security  which  the  individual  has 
attained  in  life  and  the  degree  of  the  threat  im- 
plied. 

Since  we  have  brought  up  the  concept  of  se- 
curity, it  must  have  some  sort  of  definition.  It  can 
be  pictured  as  that  assurance  or  certainty  that 
human  beings  have  concerning  a  personal  universe 
of  which  each  individual  is  the  center.  This  per- 
sonalized universe  comprises  within  it  all  the  ac- 
tivities of  the  human  being — the  physiological  ac- 
tions such  as  eating,  breathing,  sleeping,  moving, 
etc.;  the  environmental  stresses  and  supports  as 
finances,  working,  playing,  etc.;  and  the  emotional 
factors  as  love,  sorrow,  fear,  hate,  etc.  This  uni- 
verse differs  from  our  solar  system  in  this  wise:  It 
has  a  beginning  and  an  ending— birth  and  death. 


lanuarv   1940 


ANXIETY— dishing 


While  according  to  Jean's  theory  our  universe  is 
practically  limitless  and  theoretically  merges  only 
with  outer  universes,  this  personalized  universe  is 
bounded  on  two  ends  by  birth  and  death,  and  the 
circumference  is  limited  by  the  environmental  con- 
tacts which  that  individual  makes.  To  the  cen- 
tral individual  of  this  little  solar  system  every- 
thing will  be  certain  or  sure  as  long  as  the  gravi- 
tational equations  between  the  central  point  and 
ench  of  its  actions  or  reactions  remains  at  an  opti- 
mum. Once  the  delicate  balance  of  this  mecha- 
nism is  disturbed,  there  is  a  distinct  threat  that 
the  whole  system  may  be  disrupted.  This  threat 
of  disruption  may  be  actual  or  potential  and  im- 
palpable, in  which  case  it  will  be  recognized  by 
the  consciousness  of  the  central  individual.  The 
reaction  of  this  person  to  the  threat  will  depend 
on  the  amount  of  experience  and/or  knowledge 
concerned  with  that  particular  kind  of  danger,  or 
it  may  be  impalpable  and  potential,  in  which  case 
it  will  not  be  recognized  by  the  consciousness  but 
will  be  unconsciously  accepted. 

Let  us  now  bring  this  personalized  universe 
down  to  the  size  of  a  ping-pong  ball.  This  ball  is 
kept  in  its  spherical  shape  by  certain  stresses  and 
strains,  both  internal  and  external.  The  internal 
strains  may  be  likened  to  the  emotional  factors 
and  gravitational  forces  mentioned  above  in  our 
personalized  universe,  and  the  external  stresses  to 
the  environmental  pressures.  As  long  as  the  gravi- 
tational forces  of  the  universe  are  maintained  in 
ba'ance  the  security  of  that  universe  is  kept  whole. 
As  long  as  the  external  stresses  and  strains  of  the 
ping-pong  ball  are  kept  in  balance  with  those  in- 
side the  ball,  its  spherical  shape  or  security  is  kept 
whole  and  hence  its  performance  is  at  an  optimum. 
Xow,  suppose  that  this  ball  suffers  a  dent  against 
the  corner  of  the  table — its  shape  is  then  ruined 
and  it  can  no  longer  bounce  in  the  direction  which 
we  originally  intended,  but  instead  will  proceed  at 
a  tangent. 

In  our  personalized  universe  we  are  slammed 
and  bounced  around  much  as  the  ping-pong  ball, 
but  as  long  as  our  gravitational  balances  between 
the  various  elements  of  that  universe  are  maintain- 
ed, our  security  suffers  no  more  harm  than  does 
the  ping-pong  ball  during  the  course  of  an  ordi- 
nary »arae.  Although  during  that  game  there  are 
many  threats  to  the  security.  We  may  then  hit  a 
sharp  corner,  which  produces  a  threat  to  our  se- 
curity and  sets  out  of  line  those  gravitational  bal- 
ances which  maintained  it.  This  is  then  what  we 
term  an  anxiety  neurosis  or  anxiety  tension  state, 
and  is  simply  a  jelling  of  those  symptoms  or  dis- 
tortions of  the  organism  which  we  have  mentioned. 

Every  individual  suffers  consciously  non-accept- 
able threats  to  his  security  which  produce  mo- 
mentary anxiety  states.  But  when  such  a  threat  be- 


comes great  and  appears  to  be  an  actuality,  but 
still  consciously  non-acceptable,  we  have  the  anx- 
iety tension  state.  Every  individual  maintains 
the  balance  of  his  personalized  universe  in  his  own 
peculiar  manner,  which  he  has  learned  by  count- 
less moments  of  anxiety  when  being  slapped  around 
by  life,  much  as  the  ping-pong  ball  is  slapped 
around  between  two  players.  For  a  person  of  the 
narcissistic  type,  whose  safety  rests  on  being  ap- 
preciated and  admired,  the  vital  danger  is  that  of 
losing  admiration.  In  him  anxiety  may  appear  if 
he  finds  himself  in  an  environment  which  does  not 
recognize  him.  If  the  individual's  safety  rests  on 
merging  with  others,  anxiety  may  arise  if  he  is 
alone.  If  a  person's  safety  rests  on  being  unob- 
trusive, anxiety  may  emerge  if  he  is  in  the  lime- 
light, and  so  on.  These  symptoms  of  anxiety  are 
solutions  to  problems  posed  to  the  organism  in  its 
attempt  to  maintain  the  balance  of  its  security. 

To  see  if  this  theory  fits  the  fact,  let  us  consider 
the  case  of  a  twenty-five-year-old  married  woman 
who  came  to  us  complaining  of  dizzy  spells  and 
headaches.  The  dizzy  spells  had  begun  three  years 
previously  in  a  setting  of  disappointment  over  a 
love  affair  and  her  first  trip  to  New  York.  They 
were  aggravated  by  her  engagement  and  wedding 
plans.  After  marriage  they  gave  way  to  nightmares 
and  finally  returned,  accompanied  by  headaches, 
eight  months  previous  to  this  consultation.  They 
always  occurred  in  times  of  emotional  stress.  She 
had  been  to  many  physicians  and  had  had  several 
procedures  carried  out  in  hopes  of  hitting  on  some- 
thing that  would  stop  the  pain. 

It  is  to  be  noted  that  this  young  lady  started 
out  in  life  with  a  good  deal  of  security — she  was 
born  the  daughter  of  the  most  prominent  man  in 
a  small  town.  Her  early  life  was  hedged  by  vari- 
ous securing  factors — money,  position  and  good 
health.  At  the  age  of  six  her  mother  died  and 
as  a  result  she  was  pampered,  for  everyone  felt 
they  should  do  all  they  could  to  make  up  for  the 
loss  of  her  mother.  This  was  her  first  experience 
with  real  insecurity,  and  it  is  seen  that  she  was 
helped  over  this  hurdle  by  her  five  older  siblings 
and  father  through  the  medium  of  pampering.  Two 
years  later  her  father  married  a  friend  of  his  first 
wife,  of  whom  the  patient  was  quite  fond,  and 
whom  she  regarded  as  a  mother,  which  also  helped 
to  readjust  the  'imbalance  caused  by  her  first  in- 
security. 

When  the  patient  was  thirteen  the  family  moved 
to  a  large  town  where  she  had  great  difficulty  in 
making  new  friends  and  in  relinquishing  the  posi- 
tion of  a  member  of  the  town's  first  family.  She 
responded  to  this  second  buffet  of  insecurity  by 
feeling  uncomfortable,  especially  in  crowds.  She 
readjusted  to  this  and  was  just  well  established 
in  the  social  group  she  coveted  when  she  went  to 


ANXIETY— Cashing 


January  1940 


college.  Here  she  was  again  insecure,  first  because 
of  some  of  the  comments  that  she  had  her  grades 
because  of  her  father's  position  as  legal  advisor 
to  the  University,  and,  secondly  because  she  did 
not  get  bid  to  the  sorority  that  she  had  set  her 
heart  on.  Natheless,  she  was  reasonably  happy 
and  popular  in  college  and  went  to  many  of  the 
dances.  She  went  out  with  various  boys  but  was 
only  seriously  interested  in  one  before  her  engage- 
ment to  her  present  husband.  This  interest  cen- 
tered about  a  young  interne  to  whom  she  consider- 
ed herself  practically  engaged  when  he  shifted  his 
affections  and  married  another  girl  in  the  spring 
of  1935.  This  was  quite  a  shock  to  her  and  a 
staggering  blow  to  her  pride. 

The  patient  exhibited  her  first  definite  anxiety 
symptoms  in  August  1935,  when  she  had  a  "groggy 
sensation"  while  shopping  in  New  York  City.  Please 
note  that  this  was  the  forerunner  of  many  similar 
sensations  of  dizziness,  groggy  feelings  and  head 
pain,  and  that  this  first  attack  occurred  in  a  setting 
of  crowds.  When  she  had  first  moved  to  a  large 
city  her  first  reaction  had  been  to  feel  uncomfor- 
table in  crowds. 

In  the  fall  of  1935  her  father  had  a  dizzy  spell 
while  arguing  a  case  in  court.  For  three  years  he 
would  not  rise  in  court  or  lecture  hall  for  fear  of 
a  recurrence  of  a  dizzy  spell,  although  he  was 
otherwise  quite  healthy.  The  father  is  extremely 
fond  of  the  patient  because  she  is  the  only  one  of 
his  children  who  resembles  her  mother.  He  is  quite 
close  to  her  and  the  bonds  of  affection  between 
them  are  very  strong.  The  following  spring  the 
patient  began  going  steadily  with  her  present  hus- 
band and  their  engagement  was  announced  in  Jan- 
uary, 1937.  During  this  time  the  patient  worried 
a  great  deal  about  her  father's  health  and  was 
much  concerned  that  he  was  unable  to  rise  to  plead 
his  cases  in  court,  but  did  so  sitting  down.  Here 
again  we  can  tie  some  of  the  pieces  together.  The 
patient  added  to  the  insecurity  caused  by  a  suitor's 
rejection  the  possibility  of  her  father's  demise  in 
the  near  future.  She  responded  in  two  ways — by  an 
increase  in  the  symptoms  of  dizziness  and  grog- 
giness,  and  by  trying  to  compensate  and  secure  her 
future  through  the  announcement  of  her  engage- 
ment. 

The  day  following  the  announcement  the  patient 
was  very  anxious,  for  although  she  felt  certain  that 
she  wished  to  marry  the  boy,  she  was  conscious  of 
the  unfortunate  marriages  of  both  her  sisters  and 
anxious  for  her  father's  approval — a  quite  under- 
standable anxiety  in  that  setting.  The  couple  began 
having  sex  relations  previous  to  marriage,  and  while 
she  was  shopping  for  her  trousseau  she  had  fre- 
quent groggy  spells.  The  wedding  took  place  in 
June,  1937.    The  patient  was  very  tense  and  anx- 


ious before  the  ceremony  and  has  little  recollection 
of  it.  Again  a  quite  understandable  anxiety  in  one 
facing  a  life  with  an  individual  who  is  practically 
unknown  to  her. 

Her  dizziness  stopped  after  marriage  but  she  be- 
gan having  nightmares.  The  cessation  of  the  dizzi- 
ness was  probably  due  to  her  feeling  of  tangible 
security,  but  its  sublimation  to  the  form  of  dreams 
shows  that  the  security  was  unconsciously  not  ac- 
ceptable. In  September  the  patient  missed  a  pe- 
riod, was  thought  to  be  pregnant,  took  ergot  and 
her  periods  returned.  Neither  she  nor  her  husband 
wanted  children  their  first  year  of  marriage. 

The  following  December  she  developed  a  stab- 
bing pain  behind  her  right  eye.  Then  began  a 
series  of  visits  to  ENT  men  and  internists  with  the 
resulting  administration  of  analgesics,  extraction  of 
a  wisdom  tooth,  and  injections  of  the  sphenopala- 
tine ganglion.  During  this  time  her  husband  made 
business  trips  on  which  she  accompanied  him.  It 
was  noted  on  these  trips  that  the  pain  was  aggra- 
vated by  talking  to  strangers,  particularly  while 
they  were  in  the  larger  cities.  Finally  she  saw  a 
neurologist,  had  a  thorough  study,  and  was  refer- 
red for  psychiatric  consultation. 

In  working  with  the  patient  it  was  found  that 
she  had  a  fear  of  being  alone  as  a  result  of  thwarted 
social  ambitions  and  feelings  of  inadequacy  because 
of  difficulties  in  making  friends  in  the  city  to  which 
she  had  moved  from  a  small  town:  her  second 
contact  with  insecurity  and  one  to  which  she  had 
responded  by  being  uncomfortable  in  crowds.  She 
then  had  difficulty  in  attaining  prominence  socially 
in  college  as  measured  by  sorority  standing.  Then 
the  strength  of  her  attachment  to  her  father  and 
the  determination  to  marry  a  man  he  approved 
of  at  any  cost.  The  indecisions  and  difficulties  en- 
countered in  this  coupled  with  the  rejection  by 
her  suitor  started  her  off  on  her  first  marked  anx- 
iety symptoms  which  closely  patterned  those  of 
her  father's  illness.  Later  a  connection  was  found 
between  the  disappearances  of  her  symptoms  while 
her  husband  was  with  her  and  their  reappearance 
when  alone,  for  she  wanted  all  his  attention  and 
found  it  hard  to  share  him  with  his  work. 

Here  we  see  that  the  patient  tried  to  readjust 
the  balances  of  her  personal  universe.  She  reacted 
with  anxiety  to  the  rejection  by  the  first  boy,  her 
symptoms  then  patterned  after  her  father's  with 
imminence  of  the  possibility  of  his  death.  Later 
came  her  resolution  to  find  new  security  in  a  hus- 
band who  was  approved  of  by  her  father,  the  basis 
of  her  former  security.  The  various  possibilities 
she  had  staring  her  in  the  face  considering  her 
sisters'  unfortunate  marriages  made  this  new  se- 
curity appear  a  bit  dubious.  The  dubiosity  of  the 
security  furnished  by  her  marriage  was  heightened 


January  1940 


ANXIETY— Cashing 


when  she  found  that  her  husband  could  not  give 
his  entire  attention  to  her.  This  was  when  she  re- 
ceived the  final  blow  which  upset  the  balance  of 
her  universe  and  set  her  symptoms  in  the  pattern 
of  an  anxiety  tension  state,  much  as  the  ping-pong 
ball  is  dented  by  the  corner  of  the  table. 

The  patient  had  a  thorough  study  of  her  phy- 
sical status,  a  refractive  error  was  corrected  and 
the  causal  relationships  of  emotional  stress  and 
symptoms  were  worked  out  with  her.  She  develop- 
ed excellent  insight  and  was  discharged  improved. 

The  imbalances  of  internal  and  external  stresses 
and  strains  were  set  aright  so  that  the  patient  was 
again   a   functioning  and  balanced  whole. 

The  diagnosis  here  was  that  of  an  anxiety  ten- 
sion state  with  hypochondriasis.  It  is  my  belief 
that  every  case  of  so-called  hypochondriasis  can 
eventually  be  traced  back  to  anxiety,  albeit  at 
times  with  a  great  deal  of  effort  and  time.  If  the 
cause  of  the  anxiety  can  then  be  determined  and 
the  patient  be  brought  to  an  understanding  of 
them,  these  hypochondriacal  symptoms  of  anxiety 
can  be  obviated  or  at  least  so  alleviated  that  the 
patient  will  be  more  comfortable  in  their  presence, 
the  balance  of  security  being  restored. 

Bibliography 

1.  Brissaud;  De  l'anxiete  paroxystique,  Semaine  Med., 
pp.  410,   1890.  Also  Rev  Neurol.   10:762,  1902. 

2.  Freud;  Selected  papers  on  hysteria  and  other  psy- 
choneuroses,  Nerv.  &  Ment.  Dis.  Monogr.  No.  4,  N.  Y., 
1920    (ed.   3). 

3.  Goldstein,  K.;  Zum  Problem  der  Angst,  Allg.  aerytl. 
Ztsche.  f.  Psychotherap  etc.  II  Heft  7.  pp.  409-437, 
1927.  The  Organism,  Amer.  Psychol.  Series — Amer.  Book 
Co.,  1939. 

4.  Bard,  P.;  Central  Nervous  Mechanisms  for  Emotional 
Behaviour  Patterns  in  Animals.  The  Inter-relationship 
of  Mind  &  Body,  Williams  and  Wilkins  Co.,  1939. 


WHAT'S   WRONG   WITH   THE   PATIENT   WHO   IS 
ALWAYS  TIRED? 

(\V     C.   Alvarez,    Rochester,   Minn.,    in   Minn.   Med.,   Nov.) 

Every  week  I  see  a  number  of  patients  whose  main 
complaint  is  that  the  least  exertion  makes  them  feel  worn 
out. 

When  the  failure  in  strength  and  energy  and  the  loss 
of  a  sense  of  well-being  come  to  a  man  or  woman  past 
middle  age  who  has  previously  enjoyed  good  health,  the 
physician  must  hunt  for  carcinoma,  pernicious  anemia, 
hypothyroidism,  hypertension,  diabetes,  or  a  failing  heart 
or  kidney. 

If  the  fatigue  and  loss  of  interest  in  life  come  suddenly 
in  a  person  past  middle  age,  the  cause  is  almost  certainly 
a  small  stroke.  It  is  rare  for  a  physician  to  think  of 
this  possibility  when  the  thrombosis  docs  happen  to  in- 
volve the  centers  for  speech  or  for  arm  or  leg.  Commonly 
the  episode  is  thought  to  be  due  to  an  "acute  indigestion" 
because  it  is  so  often  associated  with  dizziness,  vomiting 
and  abdominal  discomfort.  Sometimes  close  questioning 
will  bring  out  several  of  these  small  episodes,  which  are 
especially  apt  to  occur  in  the  morning  when  the  patient 
wakes.  There  is  likely  to  be  some  loss  of  memory,  a 
lose  of  interest  and  zest  in  life.  The  story  must  be  dug 
out.     It  is  useless  to  try  to  help  the  patient  or  to  cheer 


him  up.     His  brain  is  injured. 

Often  the  fatigue  state  has  followed  an  influenza,  sug- 
gesting a  mild  encephalitis.  Mild  generalized  arthritis  or 
fibrosiiis  is  more  common  the  patient  aching  all  over, 
and  with  this  having  a  feeling  of  fatigue  and  toxicity. 

In  the  case  of  college  students,  vague  ill  health  with 
indigestion  and  feelings  of  fatigut  shouli  suggest  subacute 
appendicitis. 

In  many  cases  nothing  is  found  on  through  examination. 
Then  the  physician  must  be  careful  not  to  grasp  at  diag- 
nostic straws.  Then  he  must  see  if  the  patient  has  had 
strain,  unhappiness,  sorrow  or  insomnia  to  account  for 
the  situation.  In  many  cases,  with  or  without  strain,  a 
person  with  a  psychopathic  inheritance  breaks  down.  It 
is  unfortunate  that  mild  melancholia  is  today  rarely  recog- 
nized by  clinicians. 


THE  FIBROID  UTERUS 
(E    D.   Plass,  Iowa  City,  in  //  Mo.  Med.  Also.,  Jan.) 

One  out  of  5  women  in  late  sexual  life  has  larger 
or  smaller  fibroids,  composed  of  varying  proportions  of 
fibrous  tissue  and  smooth  muscle.  A  small  tumor  with 
a  high  proportion  of  muscle  tissue  will  grow  rapidly  during 
gestation  and  will  atrophy  with  even  greater  rapidity 
after  delivery;  predominantly  fibrous  tumors  are  subject 
to   less  marked  changes  in  size. 

Because  of  the  commonly  inadequate  blood  supply,  the 
fibroid  nodules  are  frequently  edematous  and  may  show 
some  type   of   degeneration. 

The  most  common  manifestations  are  uterine  bleeding, 
pressure  complaints,  obstetric  difficulties,  leukorrhea  and 
general   symptoms. 

In  the  presence  of  adhesions  to  neighboring  organs, 
intermittent  "stretching"  pain  may  ensue.  Acute  discom- 
fort suggests  the  torsion  of  the  pedicle  of  a  subserous 
nodule  or  of  "red"  degeneration  with  some  elevation  of 
t.   and  leukocytosis. 

When  a  tumor  is  symmetrical,  and  especially  when  it 
is  soft,  pregnancy  must  be  considered;  the  biologic  preg- 
nancy tests  should  be   utilized. 

In  general  symptomless  tumors  need  no  treatment;  they 
nrobably  will  regress  or  disappear  after  the  menopause. 
Medical  treatment  usually  is  ineffective  although  the  ex- 
hibition of  oxytocic  drugs  (pituitrin  or  ergot)  may  be 
effective  temporarily  in  controlling  excessive  bleeding  and 
calcium  may  have  some  value.  Anemia  from  bleeding 
requires  adequate  diet  with  plenty  of  protein,  with  some 
form   of  iron   and   vitamin  B. 

Radiation  by  roentgen  ray  is  useful  in  women  near  the 
menopause  who  have  relatively  small  tumors  not  pedun- 
culated, not  larger  than  a  3-months  pregnancy.  In  any 
event,  curettage  should  precede  the  irradiation  in  order 
to   eliminate   the  possibility   of   malignant   disease. 

Myomectomy  is  indicated  in  young  women  who  wish 
to  retain  their  childbearing  functions.  There  is  always  a 
considerable  chance  that  additional  fibroids  will  appear 
later  and   demand  a  second  operation. 

Vagina]  hysterectomy  in  general  is  not  so  satisfactory 
as  the  abdominal  operation.  The  operation  is  more  suit- 
able for  the  removal  of  small  tumors,  which  ordinarily 
do  not  produce  symptoms  indicating  treatment  of  any 
sort. 


DIABETES 

(C.   M.   MacBrydc,   St.   Louis,  in  Jl  Mo.   Med.   Asso.,  Jan.) 
The    physician    should:    1)    fit   the   diet   to   the  patient 
using  low-  moderate-  or  high-carbohydrate — whichever  leads 
to   maximum   carbohydrate  tolerance;    2)    strive   to   utilize 
ii  ntij    the    new   slow-acting   insulin. 


SOUTHERN  MEDICINE  &  SURGERY 


January  1940 


Surgery  in  Diabetes* 

George  T.  Tyler,  Jr.,  A.  M.,  M.  D.,  Greenville,  South  Carolina 


DIABETES  is  an  error  in  metabolism,  due 
chiefly  to  lack  of  insulin.  It  has  been 
known  since  ancient  times.  Digestion 
converts  the  disaccharides — cane  sugar  and  milk 
sugar;  and  the  polysaccharides  —  the  starches  — 
into  monosacccharides — dextrose,  levulose  and  gal- 
actose, which  by  dehydration  become  glycogen 
— C  Hu  0«-H.  O  =  C  Hio  Os.  One  third  of  the 
glycogen  is  stored  in  the  liver,  two  thirds  in  the 
muscles.  That  in  the  liver  is  ready  for  immediate 
metabolic  demands.  Glycogen  is  formed  also  from 
proteins  and  fats;  58  per  cent  of  proteins,  and 
10  per  cent  of  fats  become  glucose.  Normally 
the  glucose  in  the  blood  is  from  .08  to  .12  per 
cent.  In  diabetes  the  physiology  is  altered  in  the 
liver,  the  circulation  (heart  and  blood  vessels), 
also  in  the  kidneys,  and  in  the  lungs. 

Hepatic  insufficiency  is  evidenced  by  decrease 
in  the  deposit  of  glycogen,  with  an  increase  in 
fat.  The  liver  is  enlarged.  There  is  a  desatura- 
tion  of  the  fatty  acids  with  increased  circulating 
acetone,  and  diacetic  and  beta-oxybutyric  acids. 
This  means  acidosis.  Cholesterol  is  not  broken 
down.  It  accumulates  in  the  circulation,  favoring 
the  development  of  cholecystitis  and  gallstones. 
Gallbladder  disease  inhibits  the  function  of  the 
pancreas,  with  aggravation  of  the  diabetes.  With 
deaminization  of  amino-acids,  less  urea  is  formed. 
The  abnormal  liver  cells  fail  to  destroy  bacteria 
and  toxins. 

Heart  and  blood-vessel  changes,  including  coron- 
ary sclerosis,  are  common.  From  33  to  52  per 
cent  of  diabetics  have  coronary  sclerosis  of  some 
degree.  The  myocardium  is  weakened.  It  is 
common  knowledge  that  diabetics  have  a  marked 
tendency  to  arteriosclerosis.  Few  altogether  escape 
arterial  thickening;  71  per  cent  of  Joslin's  patients 
showed  this  degeneration.  The  diabetic  develops 
it  10  years  before  the  non-diabetic.  The  physio- 
logical age  of  a  diabetic  is  his  age  in  years  plus 
the  duration  of  his  diabetes.  With  diminished 
blood  supply,  there  is  impairment  of  nutrition; 
68  per  cent  of  these  patients  have  impaired  circu- 
lation in  the  feet. 

In  the  lungs,  bronchitis,  pneumonia  and  tuber- 
culosis are  common.  The  respiratory  quotient  is 
lowered.  The  tension  of  CO*  in  the  alveolar  air 
is  reduced  (normally  38  to  45).  The  kidneys  are 
irritated  by  sugar,  ketone  bodies  and  uncombined 
organic  acids.     Uremia  is  not  uncommon.     There 


is  a  decreased  urea  output,  with  albuminuria  and 
a  depletion  of  the  stores  of  sodium,  potassium, 
magnesium  and  calcium.  With  the  lowering  of 
body  resistance,  infection  is  more  likely.  Pus  part- 
ly neutralizes  the  effect  of  insulin. 

Up  to  1922,  diabetics  were  nursed.  Since  the 
discovery  of  insulin,  they  are  treated.  Diabetes 
has  been  named  the  price  of  obesity,  since  from 
76  to  85  per  cent  of  these  patients  are  overweight. 
Except  for  the  young,  the  average  length  of  life 
of  diabetics  has  not  been  increased  since  the  use 
of  insulin  began.  Formerly  acidosis  with  resulting 
coma  was  the  principal  means  of  death.  Now 
the  surgical  complications  take  off  most  diabetics. 
Joslin  says  that  the  surgical  diabetic  is  the  one 
that  dies.  In  three-and-a-half  years,  he  had  a 
mortality  of  11.5  per  cent  in  his  surgical,  but 
only  1.7  per  cent  in  his  non-surgical,  cases.  Hence 
the  surgical  is  six  times  as  liable  to  die  as  the 
non-surgical  diabetic.  Therefore  he  requires  six 
times  the  care  of  the  patient  without  surgical  com- 
plications. From  S3  to  50  per  cent  of  diabetics 
acquire  surgical  ailments  during  the  disease.  Dis- 
ease of  the  extremities  constitutes  a  third  of  the 
conditions  requiring  operation.  When  infection 
supervenes  in  the  limb  with  impaired  circulation 
the  condition  is  grave.  If  there  is  a  blood-stream 
infection  chance  of  recovery  is  small  no  matter 
how  well  the  patient  is  treated. 

I  have  come  to  regard  the  surgical  diabetic  as 
still  a  medical  patient;  and  am  unwilling  to  assume 
the  sole  responsibility  of  his  care.  Both  before 
and  after  operation  I  want  the  internist  to  have 
fharge  of  the  patient.  Only  by  close  team-work, 
the  surgeon  playing  the  lesser  role  except  in  the 
operating  room,  will  surgery  on  diabetics  have  a 
lower  mortality.  The  statistics  of  the  Mayo  Clinic 
demonstrate  this  fact.  John,  of  Cleveland,  induced 
several  surgeons  to  cooperate  with  him  in  treating 
these  patients.  Their  mortality  dropped  to  8  and 
9  per  cent.  One  surgeon  refused  to  join  them. 
His  mortality  was  17  per  cent.  At  the  Greenville 
General  Hospital,  all  diabetics  on  the  charity  ser- 
vice are  admitted  as  medical  patients.  If  surgical 
conditions  develope,  they  are  referred  to  the  surgeon 
when  they  are  in  proper  condition  for  operation. 
After  operation,  they  are  returned  to  the  medical 
service,  the  surgeon  treating  the  wound.  This  man- 
agement has  lessened  our  mortality. 

Joslin  has  placed  surgical  complications  in  dia- 


*Rcad  before   the   Fourth    (S.    C.)    District   Medical    Society   Meeting   at    Spartanburg,    Oct.    21st.    1940. 


January  1941 


SURGERY  IN  DIABETES— Tyler 


betes  in  two  groups:  preventable — infection,  gan- 
grene and  cataract;  and  non-preventable — thyroid 
disease,  appendicitis  and  pelvic  operations.  Rab- 
inovitz  and  Weismann  suggest  a  better  classifica- 
tion: emergency — as  appendicitis,  ruptured  gas- 
tric ulcer,  strangulated  hernia;  elective — as  pelvic 
repair,  hernia  and  thyroid  operations;  preventive 
—as  cholecystectomy.  Before  the  elective  opera- 
tion, tolerance  should  be  studied  by  urinary 
response  to  diet.  In  infections  operate  as  soon  as 
possible.  If  the  patient  is  anemic  transfuse  be- 
forehand. In  an  emergency  examine  urine  and 
blood  for  sugar;  transfuse,  or  give  glucose  intra- 
venously— covering  with  insulin,  usually  a  double 
dose  to  combat  the  effect  of  the  anesthetic.  The 
patient  must  not  go  to  the  operation  starved.  He 
must  be  fortified  by  insulin,  glucose,  and,  if  pos- 
sible, carbohydrate  by  mouth.  If  a  transfusion 
is  given,  blood  taken  a  few  hours  after  a  heavy 
meal  has  the  effect  of  insulin  also.  The  patient 
then  requires  less  insulin. 

Spinal  or  infiltration  anesthesia  I  prefer  when- 
ever possible.  Ether  depletes  glycogen,  inhibits 
the  secretion  of  bile,  depresses  the  formation  of 
urea,  and  increases  the  fat  in  the  blood,  tending 
to  acidosis.  Respiratory  function  and  carbohy- 
drate metabolism  are  disturbed  in  general  anes- 
thesia. The  loss  of  fluid  by  sweating  must  be 
replaced  by  glucose  and  salt  solution.  After  opera- 
tion these  solutions  are  given  generously,  with 
carbohydrate  by  mouth,  as  soon  as  possible.  Urine 
must  be  examined  frequently  and  insulin  given  to 
meet  the  needs.  If  the  insulin  requirment  is  not 
less  in  a  short  time,  look  for  a  pocket  of  pus. 
Have  the  patient  out  of  bed  as  soon  as  possible. 

Only  a  few  of  the  many  surgical  conditions  of 
diabetes  will  be  discussed. 

Hyperthyroidism  disturbs  the  carbohydrate 
metabolism  by  interfering  with  the  storage  of 
glycogen,  and  by  requiring  an  increased  amount 
of  insulin.  This  is  in  addition  to  the  loss  of  car- 
bohydrate already  present.  Insulin,  glucose,  car- 
bohydrate and  iodine  are  given  for  stabilization. 
The  possibility  of  hyperthyrodidism  should  be 
considered  in  every  case  of  acidosis,  according  to 
Wilder.  After  operation,  the  glucose  tolerance 
will  be  increased.  Hyperinsulinism  then  must  be 
guarded  against.  The  diabetic  with  hypothyroidism 
is  fortunate,  for  there  is  an  increased  glucose 
tolerance  with  need  for  less  insulin.  Rudy  et  al. 
report  a  case  of  diabetes  not  well  controlled  by 
insulin,  in  a  young  woman,  and  complicated  by 
pulmonary  tuberculosis.  The  normal  thyroid  was 
totally  removed,  and  the  basal  metabolism  main- 
tained at  —  25.  The  lung  disease  was  arrested;  the 
diabetes  was  controlled  by  insulin;  and  the  patient 
was  restored  to  activity. 


The  diagnosis  of  appendicitis  is  difficult,  for  it 
must  be  distinguished  from  acidosis.  Both  have 
nausea,  vomiting,  pain  and  leucocytosis.  Fever 
may  be  present.  John  thinks  that  in  acidosis  the 
vomiting  precedes  pain;  that  in  appendicitis  the 
reverse  is  the  case.  Glucose  will  relieve  acidosis 
in  an  hour  or  two.  Symptoms  persisting  after 
this  time  probably  mean  appendicitis.  If  acidosis 
is  present,  lavage  should  be  done. 

Diabetics  are  prone  to  gallbladder  disease.  There 
is  an  excess  of  cholesterol  in  the  system.  In  a 
series  of  autopsies  reported  by  Warren,  there  were 
among  245  diabetics,  62  cases  of  gallstones.  In 
400  non-diabetic  autopsies,  there  were  54  cases 
of  gallstones.  This  is  in  contrast  with  the  occur- 
rence of  5.4  per  cent  of  patients  with  gallstones 
among  2584  diabetics  seen  at  the  Mayo  Clinic. 
Wilder  quotes  Joslin  that  operation  for  gallstones 
in  diabetics  is  no  more  to  be  desired  than  in 
non-diabetics.  Joslin  also  calls  this  the  most 
favored  surgical  condition  a  diabetic  can  have. 
He  thinks  that  early  operation  in  cholecystitis 
prevents  diabetes.  This  view  was  advanced  in 
1910  by  Mayo  Robson.  The  advice  given  at  the 
Mayo  Clinic  to  non-diabetics  with  cholecystitis  is 
operation,  because  1)  it  prevents  repeated  attacks; 

2)  it  prevents  cancer  of  the  head  of  the  pancreas; 

3)  it  prevents  diabetes.  A  fourth  reason  might 
well  have  been  added:  operation  prevents  serious 
liver  damage.  To  diabetics  with  cholecystitis,  the 
advice  is  operation  when  the  time,  place,  physican 
and  surgeon  are  in  accord.  It  is  common  to  see 
marked  improvement,  with  increased  glucose  toler- 
ance and  lessened  insulin  requirement,  after  cho- 
lecystectomy. 

Carbuncles  occur  oftenest  about  the  neck.  The 
familiar  saying  that  "the  washed  neck  never  boils" 
is  not  entirely  true;  for  boils  occur  on  necks  that 
are  kept  clean.  Irritation  from  the  collar,  and 
the  tendency  to  scratch  (the  monkey  in  us)  are 
frequently  responsible  for  spread  of  infection  in 
this  region.  By  way  of  prevention,  a  diabetic 
should  not  have  his  neck  shaved  when  his  hair 
is  cut.  In  treatment,  conservative  measures  are 
preferred.  Wilder  advises  bed  rest,  control  of  the 
glycosuria,  warm  dressings  wet  with  a  solution  of 
equal  parts  of  50  per  cent  alchol  and  saturated 
solution  of  boric  acid.  Methenamine  intravenously 
is  administered  daily  for  a  week.  When  the  car- 
buncle has  softened,  the  edges  are  spread,  and  the 
contents  allowed  to  escape.  Sulfanilamide  may  be 
placed  in  the  crater.  X-ray  therapy,  begun  early, 
is  said  to  benefit.  If  operation  is  done,  wide  in- 
cision, undermining  the  edges,  and  adequate  pack- 
ing are  necessary. 

The  incidence  of  cancer  of  the  larger  bowel  is 
greater,  and  the  death  rate  from  operations  for 


SURGERY  IN  DIABETES— Tyler 


January  1941 


cancer  of  the  stomach  is  much  higher  in  this  group 
of  patients. 

Besides  ridding  the  diabetic  of  infections — bad 
teeth,  diseased  tonsils,  infected  paranasal  sinuses, 
paronychia,  prostatitis — since  68  per  cent  of  them 
have  impaired  circulation  in  the  feet,  much  can 
be  done  to  prevent  extension  of  the  trouble;  for 
the  outlook  at  best  is  gloomy.  "Keep  the  feet 
as  clean  as  the  face"  is  a  happy  slogan.  But  it 
does  not  go  far  enough.  They  must  be  kept  warm, 
and  free  from  even  minor  abrasions.  Joslin  says 
that  he  would  like  for  his  epitaph  nothing  more 
than,  "He  taught  Jews  and  Gentiles  to  wash  their 
feet".  He  insists  on  examining  the  feet  of  all  his 
diabetics.  The  slightest  injury,  a  cracking  of  the 
skin  between  the  toes,  callosities,  pared  nails,  epi- 
dermophytosis— one  or  several — may  be  responsi- 
ble for  beginning  gangrene.  Hot-water  bottles 
should  not  be  used.  The  skin  must  be  kept  soft 
and  moist.  Woolen  socks  must  be  worn,  and 
changed  daily.  The  incidence  of  gangrene  in  dia- 
betics is  from  2.4  to  18  per  cent.  The  average 
from  13  reported  series  of  cases  was  5.2  per  cent. 
It  occurs  when  arteriosclerosis  is  advanced.  The 
best  thing  a  diabetic  can  have  for  his  feet  is  a 
good  collateral  circulation.  He  should  not  tend 
his  feet.  The  patient's  attention  is  first  called  to 
his  feet  by  coldness,  or  pain  on  exertion,  and  pain- 
ful calves  of  the  legs,  especially  on  lying  down. 
Where  pain  is  a  prominent  symptom,  Sandstead 
and  Beam  found  that  20  gms.  of  sodium  chloride 
taken  daily  for  two  weeks,  with  an  equal  time 
of  rest,  and  continued  in  this  manner  for  a  year 
or  more,  will  relieve  the  pain.  Ischemia,  from 
arteriosclerosis,  is  the  cause.  Sodium  chloride  is 
a  vasodilator.  Buerger's  exercises  as  modified  by 
Allen,  the  vacuum  pump,  contrast  baths,  are  all 
familiar  methods. 

By  palpation,  one  can  determine  the  level  of  the 
pulse.  Pachon's  oscillometer  is  accurate;  but  it 
gives  no  information  regarding  the  collateral  cir- 
culation. Histamine  intradermally  determines  this 
level  by  the  extent  of  the  "flare".  If  gangrene 
appears  in  spite  of  preventive  measures,  infection 
is  almost  certain  to  result.  The  question  then 
arises  regarding  the  extent  of  operation.  If  the 
collateral  circulation  is  good,  more  tissue  can  be 
saved.  Samuels  reports  cases  where,  even  in  the 
presence  of  infection,  amputation  of  one  or  more 
toes,  opening  pus  pockets,  and  packing  with  azo- 
chloramide  has  produced  good  results.  Here  the 
collateral  circulation  was  good.  If  the  infection 
extends,  amputation  at  a  higher  level  must  be 
done.  In  a  decision  as  to  the  level  of  amputation, 
several  factors  must  be  considered — the  general 
condition  of  the  patient,  his  age,  his  vision,  his 
ability   to   use   an   artificial   limb   if   he   recovers. 


These  patients  are  well  beyond  middle  life, 
i  f  not  in  years,  certainly  in  the  condition 
of  their  blood  vessels.  Few  of  them  will  be  able 
to  lead  an  active  life.  Hence  they  must  not  be 
treated  as  is  the  younger  non-diabetic.  They  still 
have  their  diabetes.  A  good  general  rule  is  to 
amputate  below  the  knee  if  pulsation  of  the  pop- 
liteal is  obtained.  Otherwise,  amputate  above  the 
knee.  Gentle  handling  of  tissues,  placing  sutures 
without  tension,  and  complete  hemostasis  are  essen- 
tials. Skin  closure,  with  space  between  stitches 
until  weeping  has  ceased,  then  additional  stitches 
or  clips,  has  resulted  in  prompt  healing.  Tourni- 
quets should  not  be  used. 

The  mortality  from  major  amputations  is  high. 
Standard  et  al.  from  Bellevue,  report  a  16  per  cent 
mortality  in  the  clinic  group.  In  the  non-clinic 
group  it  was  49  per  cent.  McKittrick's  total  mor- 
tality in  495  patients  was  13.9  per  cent:  in  300 
supracondylar  amputations  it  was  11.7  per  cent. 
Obesity,  advanced  age,  arteriosclerosis  and  infec- 
tion increase  the  surgical  risk  in  all  diabetics.  The 
mortality  from  operation  for  diabetic  gangrene  in 
this  country  is  13  to  65  per  cent. 

Any  blood-stream  infection,  John  thinks,  should 
be  cleared  up  before  operation.  With  sulfanila- 
mide, this  is  now  possible.  But  if  improvement 
is  not  prompt,  amputation  in  a  clean  area  above 
the  obstruction  should  be  done,  with  continued 
effort  to  control  the  infection. 

In  any  patient  not  doing  well  in  spite  of  insulin 
control,  look  for  pus,  tuberculosis,  or  cancer  of 
the  head  of  the  pancreas. 

Bibliography 
Abrahamson:    Annals   of  Surgery,   1932:    96:   49. 
Adams   &   Wilder:   Surgical  Clinics  of  N.  A.,  April  1924. 
John,   H.   J.:    Surgical   Clinics   of  N.   A.,   Aug.    1924. 
Idem:   Annals  of  Surgery,  Dec.  1938. 
Joslin,    E.:    Boston    Med.    &    Surg.    J.,    Jan.    27,    1927. 
McKittrick:    Am.  J.   Surgery,  April   1939. 
McKittrick   &   Root:    Diabetic   Surgery,   Lea  &   Febiger. 
Mueller,  G.  P.:   Surgical  Clinics  of  N.  A.,  Feb.   1924. 
Paullln,  J.   E.:   5.   G.   &  0.  Vol.  68,  p.   503. 
Rabdjovitz  &  Weisman:    N.  E.  Jour,  of  Med.  Sept.  22, 1938. 
Rudy,   Blumgart,   Berlin:    Am.   J.  Med.  Sci.,   July    193S. 
Samuel,   S:    /.   A.  M.   A.,  June  4,   1927. 
Idem:   S.  G.  &  O.,  Sept.   1939. 

Sandstead   &   Beams:   Arch.  Int.  Med.,  March  1938. 
Standard  et  al.:   J.  A.  M.  A.,  Feb.  26,  1938. 
Williams   &  O'kane:   5.  G.  &  O.,  May  1937. 
Wilder,  R:   5.  Med.  Jour.   1926:   9:   241. 
Idem:   Diabetes  &  Hyperinsulinism,  Saunders. 


A  MAJOR  VIKING  ANNOUNCEMENT  FOR  1941 
The  Viking  Press  is  now  privileged  to  announce  this 
biography  of  William  Henry  Welch,  one  of  the  greatest 
figures  in  American  medicine,  by  Simon  Flexner  and  James 
Thomas  Flexner.  Simon  Flexner,  now  director  emeritus 
of  the  Rockefeller  Institute,  was  an  early  pupil  of  Dr. 
Welch's  and  throughout  the  rest  of  his  life  associated 
with   him   in   many   important   undertakings. 


January  1941 


SOUTHERN  MEDICINE  &  SURGERY 


Some  Complications  of  Pregnancy* 

Creighton  Wrenn,  M.  D.,  Mooresville,  N.  C. 


THIS  presentation  will  be  confined  to  the 
common  complications  which  the  general 
practitioner  frequently  encounters;  how- 
ever, any  physician  who  undertakes  the  care  of 
maternity  cases  should  remember  that  every  case 
is  subject  to  any  of  the  complications  of  pregnancy. 
As  in  other  diseases,  prevention  is  the  ideal;  and 
proper  care  throughout  pregnancy  is  the  first  ob- 
jective in  obstetrics.  Unfortunately,  many  of  the 
complications  of  pregnancy  are  unpreven table ; 
but  much  can  be  done  if  one  will  keep  in  mind  the 
probable  complications  of  the  various  stages  of 
pregnancy,  and  treat  those  which  appear  from  their 
onset. 

Nausea  and  Vomiting 
The  commonest  and  usually  the  first  complica- 
tion of  pregnancy  is  vomiting.  The  cause  is  still 
unknown.  It  has  been  classified  into  reflex,  neu- 
rotic and  toxemic  types.  The  reflex  theory  will  be 
dismissed  by  stating  that  local  irritative  conditions 
have  proved  to  be  only  coincidental  findings  rather 
than  causative.  Williams  and  his  group  at  Hopkins 
have  long  held  that  a  large  percentage  of  these 
cases  are  neurotic  or  psychic  in  origin.  The  vast 
majority  of  writers  on  the  subject  agree  that  some 
form  of  toxemia  causes  the  vomiting.  Until  more 
is  learned  about  this  toxemia,  we  are  limited 
largely  to  treating  the  effects  of  the  vomiting — 
acidosis,  dehydration  etc. — rather  than  the  vomit- 
ing itself.  Fortunately,  most  of  these  cases  are  mild 
and  can  be  controlled  by  a  high-carbohydrate  diet 
and  the  use  of  sedatives  an  hour  or  so  before  eat- 
ing. Chloral  hydrate  is  still  a  good  drug  and  since 
it  exerts  a  local  anesthetic  action  on  the  gastric 
mucosa  it  is  probably  more  efficacious  in  this  con- 
dition than  the  bromides  or  barbiturates.  Rest  is 
of  value,  especially  at  the  time  the  patient  is  nau- 
seated. Proper  bowel  function  should  not  be  for- 
gotten and  here  diet  plays  an  important  part.  When 
fruits  especially  prunes  fail  us,  a  combination  of 
mineral  oil  and  cascara  or  some  other  mild  laxa- 
tive should  be  resorted  to.  In  the  more  severe 
cases  bed-rest  is  essential,  and  sedatives  should  be 
increased  and  given  per  rectum,  nothing  being  al- 
lowed by  mouth;  and  large  amounts  of  glucose 
should  be  given  intravenously,  with  one-half  unit 
of  insulin  for  each  gram  of  glucose.  The  hypo- 
dermic or  intravenous  administration  of  an  ampoule 
of  corpus  luteum  once  or  twice  daily  seems  to  help 
in  most  of  these  cases,  although  some  prominent 
obstetricians  still  question  the  value  of  its  use. 


In  those  cases  which  appear  to  be  psychic  or 
neurotic  in  origin  the  feeding  of  liquids  through  a 
duodenal  tube  will  prove  beneficial. 

If,  after  three  to  six  days  of  intensive  treatment 
of  the  more  severe  cases  the  patient  does  not  im- 
prove, therapeutic  abortion  is  indicated,  especially 
if  there  is  fever,  a  rapid  pulse  or  jaundice. 

Vaginal  bleeding  is  a  frequent  complication  of 
pregnancy  during  the  first  trimester.  It  may  be 
physiological,  but  it  is  more  often  the  first  symp- 
tom of  an  ectopic  pregnancy  or  of  an  abortion. 
Occasionally  rupture  of  an  ectopic  pregnancy  is 
dramatic,  with  pain,  shock  and  fainting.  It  rarely 
has  a  rapidly  fatal  termination.  More  often  the 
pain  is  less  severe,  with  slight  atypical  vaginal 
bleeding,  and  dizziness  followed  by  a  pelvic  dis- 
comfort which  continues  for  a  few  days  to  be  fol- 
lowed by  another  attack  of  pain  and  dizziness,  or 
perhaps  fainting  due  to  internal  bleeding.  This 
bleeding  from  the  ruptured  tube  is  usually  con- 
tinuous but  it  is  rarely  so  severe  that  life  is  put 
in  immediate  danger.  At  this  time,  or  soon  after- 
wards, pain  may  be  referred  to  the  shoulder  girdle 
or  rectum.  Usually  when  there  is  a  pint  or  more 
of  blood  in  the  abdomen  shifting  dullness  can  be 
demonstrated  by  percussion  over  the  lower  abdo- 
men. When  there  is  slow  bleeding  from  the  rup- 
tured tube  the  blood  coagulates  in  the  cul-de-sac, 
and  in  such  cases  a  pelvic  mass  can  usually  be 
felt  on  careful  bimanual  examination.  An  extremely 
tender  cervix  is  a  valuable  point  in  the  diagnosis 
of  a  ruptured  tube  when  acute  salpingitis  can  be 
excluded.  Sedimentation  rates  and  blood  counts 
may  be  the  same  in  the  two  conditions,  but  the 
examination  of  smears  taken  from  the  cervix  and 
Skene's  ducts  will  usually  clarify  the  situation. 

An  early  abortion  must  also  be  considered  in 
the  differential  diagnosis  of  ruptured  tubal  preg- 
nancy with  vaginal  bleeding.  When  vaginal  ex- 
amination fails  to  do  this  a  curettage  will  occa- 
sionally have  to  be  resorted  to.  But  one  must  re- 
member that  a  tubal  pregnancy  and  a  uterine  preg- 
nancy may  occur  at  the  same  time,  294  such  cases 
having  been  reported  in  the  literature  to  date1. 
Two  such  cases  have  occurred  in  the  Lowrance 
Hospital  during  the  past  five  years.  These  have 
not  been  reported. 

Tubal  pregnancy  with  rupture  or  abortion  de- 
mands surgery  under  the  most  favorable  circum- 
stances obtainable. 


•Presented  to  the  Ninth   District   (N.   C.)    Medical  Society  meeting  at   Mooresville. 


PREGNANCY  COMPLICATIONS— Wrenn 


January  1941 


Abortion 
The  most  common  major  complication  of  preg- 
nancy is  abortion.  It  has  been  estimated  that  one 
out  of  every  three  or  four  pregnancies  terminate 
in  abortion,  of  which  quite  a  few  are  criminally 
induced.  The  other  causative  factors  are  legion 
and  in  many  cases  it  is  impossible  to  find  the  cause. 
Fibroids  or  endometritis  may  be  blamed.  A  dis- 
eased cervix,  a  retrodisplaced  uterus  or  an  ovarian 
cyst  will  occasionally  be  a  factor.  Trauma  is 
frequently  held  responsible  but  seldom  does  it 
seem  to  be  the  sole  or  chief  cause.  In  many 
instances  the  embryo  has  not  developed  properly. 
Debilitating  diseases,  especially  the  chronic  ones, 
account  for  their  share.  Endocrine  deficiencies 
play  a  definite  role,  particularly  as  regards  hypo- 
thyroidism. Lack  of  vitamin  E  has  a  part  in  the 
causation  of  many  spontaneous  abortions. 

The  symptoms  of  abortion  are  vaginal  bleeding, 
which  may  be  alarming  if  the  pregnancy  has  ad- 
vanced to  three  months  or  more;  pains  in  the 
lower  abdomen  and  back,  with  history  of  amen- 
orrhea. With  this  history  our  first  inquiries  should 
be  whether  it  is  spontaneous  or  induced,  threatened 
or  inevitable,  complete  or  incomplete,  aseptic  or 
septic.  Treatment  must  be  instituted  accordingly. 
For  threatened  abortion  the  invariable  rule  should 
be  absolute  rest  in  bed,  continuing  three  or 
four  days  after  all  pain  and  bleeding  have 
ceased.  Progesterone  and  morphine  should  be 
given  to  allay  all  uterine  contractions  and  to  keep 
the  patient  quiet.  Wheat  germ  oil,  which  has 
proved  so  valuable  in  habitual  abortion,  should 
be  tried  in  large  doses.  No  vaginal  examination 
should  be  made  unless  abortion  appears  to  be  in- 
evitable as  indicated  by  hemorrhage.  In  the  inevi- 
table aseptic  cases  with  hemorrhage  and  in  the 
clean  incomplete  cases  curettage  should  be  done 
under  the  most  rigid  aseptic  precautions,  remem- 
bering always  that  the  pregnant  uterus  is  easily 
punctured  with  sound  or  curette.  An  ampoule  of 
pituitrin  injected  deeply  into  the  cervix  at  the 
beginning  of  any  intrauterine  manipulation  will 
lessen  the  danger  of  perforation  and  of  hemor- 
rhage. 

In  the  treatment  of  septic  or  infected  abortion 
much  judgment  is  frequently  required.  If  the 
infection  seems  to  be  severe  and  is  comparatively 
recent  conservatism  is  indicated.  All  textbooks 
warn  against  interference  until  the  temperature 
has  been  normal  three  to  five  days.  However,  if 
the  cervix  is  open  and  the  contents  are  readily 
accessible,  it  is  safe  to  gently  evacuate  the  intra- 
uterine contents;  and  here  the  fingers  are  safer 
than  any  instrument. 

Sulfanilamide  and  repeated  small  blood  trans- 
fusions are  indicated  in  practically  all  cases  of 
septic  abortion. 


Tuberculosis 
A  few  words  should  be  said  about  tuberculosis 
and  pregnancy  since  in  recent  years  there  has  been 
such  a  change  in  the  method  of  handling  these 
cases.  Pregnancy  and  tuberculosis  is  not  an  in- 
frequent combination.  It  was  formerly  taught 
that  all  pregnant  women  with  active  tuberculosis 
should  have  an  abortion.  This  measure  was  not 
based  on  the  information  that  is  now  available. 
Recent  investigators,  in  reviewing  more  than  30,000 
cases3,  could  find  no  case  of  pulmonary  tubercu- 
losis which  proved  to  be  aggravated  by  pregnancy. 
Of  course  proper  obstetrical  care  with  the  con- 
tinued treatment  of  the  tuberculosis  is  indicated. 
The  reasons  why  tuberculous  patients  do  well 
during  gestation  are: 

1.  All  physiological  processes  function  at  their 
best  during  pregnancy. 

2.  As  the  size  of  the  gravid  uterus  gradually 
increases,  the  intraabdominal  pressure  is  increased. 
This  in  turn  results  in  the  splinting,  with  eleva- 
tion, of  the  diaphragm.  As  a  result,  changes  in 
the  size  and  contour  of  the  chest  take  place  which 
tend  favorably  to  influence  recovery  from  tubercu- 
losis. After  labor,  however,  when  the  diaphragm 
suddenly  descends  and  expands  the  lungs  again, 
there  is  danger  of  reactivating  this  relatively  quies- 
cent tuberculous  process.  This  effect  can  be  ade- 
quately modified  or  prevented  by  artificial  pneu- 
mothorax, pneumoperitoneum  or  a  phrenic  opera- 
tion immediately  following  labor. 

Pyelitis 
Even  though  it  occurs  in  only  about  4  per 
cent  of  all  pregnant  women,  pyelitis  often  causes 
permanent  damage  to  the  kidneys,  the  degree 
proportional  to  the  severity  and  duration  of  the 
infection.  True  uncomplicated  pyelitis  seldom 
exists;  it  is  practically  always  a  pyelonephritis. 
The  diagnosis  is  usually  easy,  but  occasionally 
catheterization  of  the  ureter  is  essential  to  arrive 
at  the  cause  of  the  fever,  which  may  or  may  not 
be  associated  with  chills.  Urinary  symptoms  and 
pain  over  the  lumbar  region  are  usually  but  not 
always  present.  The  treatment  consists  of  rest 
in  bed,  plenty  of  fluids,  free  elimination,  a  light 
diet  and  the  knee-chest  position  (if  possible)  two 
or  three  times  daily.  Urinary  antiseptics  are  very 
helpful  but  only  when  there  is  function  and  fairly 
adequate  drainage  from  the  involved  kidney.  The 
causative  organism  should  be  identified  by  culture 
to  give  the  patient  maximum  benefit  from  the 
newer  and  more  potent  urinary  antiseptics.  Uro- 
tropin  with  acid  may  be  given  from  the  beginning. 
It  is  inexpensive  and  causes  little  or  no  harm  in 
any  case.  When  practicable  and  convenient,  cys- 
toscopy with  ureteral  catheterization  should  be 
done.  Carefully  performed,  this  procedure  should 
not  be  feared  as  a  possible  cause  of  abortion. 


January  1941 


PREGNANCY  COMPLICATIONS— Wrenn 


In  the  milder  cases  the  pelves  are  usually  irri- 
gated and  the  catheters  withdrawn.  In  the  more 
severe  cases  it  is  better  to  leave  the  catheters  in 
24  hours  and  irrigate  every  three  or  four  hours. 
In  chronic  or  recurrent  cases  of  pyelitis  the  pre- 
paration and  administration  of  an  autogenous 
vaccine  will  occasionally  result  in  a  cure  when 
all  other  therapeutic  measures  have  failed.  In 
rare  instances,  when  careful  and  intensive  treat- 
ment fails,  therapeutic  abortion  must  be  performed. 

Appendicitis 

Appendicitis  can  and  often  does  prove  to  be 
a  rather  serious  complication  of  pregnancy.  For- 
tunately more  than  80  per  cent  of  the  reported 
cases  occurred  in  the  first  six  month  of  pregnancy 
when  diagnosis  and  treatment  presents  less  diffi- 
culty. In  the  first  trimester  the  symptoms  are 
comparable  to  those  occurring  in  the  non-pregnant 
woman,  and  may  be  as  classical,  or  as  atypical, 
as  this  common  disease  may  be.  As  the  uterus 
enlarges  there  is  a  gradual  upward  displacement 
of  the  cecum  and  appendix,  so  that  they  may 
eventually  lie  under  the  liver.  Leukocytosis  is 
variable  in  uncomplicated  pregnancy,  and  is  there- 
fore an  unreliable  index  to  the  degree  of  inflam- 
mation of  the  appendix  during  pregnancy  The 
thinning  of  the  abdominal  musculature  during  the 
latter  part  of  pregnancy  makes  rigidity  a  less 
reliable  sign;  however,  it  makes  tenderness  more 
significant  and  the  diagnosis  is  best  made  by  this 
one  sign. 

The  only  rational  treatment  of  acute  appendi- 
citis with  pregnancy  is  appendectomy.  Ectopic 
gestation  and  twisted  adnexal  tumors  likewise 
demand  prompt  surgical  interference  and  their 
presence  never  should  be  allowed  to  so  cloud  the 
picture  as  to  permit  an  inflamed  appendix  to  rup- 
ture. Postoperatively,  adequate  doses  of  morphine 
should  always  be  given  to  forestall  labor  when 
any  inflammation  has  spread  beyond  the  appendix, 
and  in  all  premature  cases.  Postoperative  labor 
has  little  or  no  effect  on  the  healing  of  the  well- 
sutured  McBurney  wound. 

Heart  Disease 
Pregnancy  increases  the  work  of  the  heart,  dur- 
ing the  last  trimester  around  SO  per  cent.  Only 
by  calling  on  the  heart  to  do  more  work,  however, 
does  pregnancy  affect  the  diseased  heart.  No  one 
has  ever  been  able  to  demonstrate  that  pregnancy 
itself  is  able  to  cause  any  exacerbation  of  rheu- 
matic heart  disease.  Therefore,  if  a  patient  is 
compensating  and  feels  no  cardiac  embarrassment 
while  doing  light  work,  however  loud  or  rough 
the  murmur  may  be,  pregnancy  will  not  impose 
serious  trouble  if  she  follows  adequate  rules  for 
care  during  pregnancy.  Her  activities  should  be 
adjusted  to  her  capacity,  and  infection,  especially 


colds,  should  be  treated  with  the  greatest  of  care. 
Should,  however,  compensation  fail  in  late  preg- 
nancy a  real  risk  may  be  encountered  during  labor. 
If  such  cases  do  not  respond  to  treatment  inter- 
ruption should  be  seriously  considered.  If  the 
patient  seems  to  have  strength  to  stand  delivery 
from  below  this  is  preferable,  but  the  use  of  forceps 
to  aid  her  is  clearly  indicated;  or  if  decompensa- 
tion does  not  improve  under  treatment,  or  becomes 
worse,  cesarean  section  under  local  anesthesia  prob- 
ably offers  her  the  best  chance. 

Hemorrhage 

During  the  last  trimester  of  pregnancy  the  hem- 
orrhagic complications  offer  the  most  formidable 
of  all  the  complications  of  the  gestational  period, 
and  to  combat  these  complications  successfully  it 
is  necessary  to  treat  them  with  precision  and  at 
times  with  celerity.  One  should  not  only  check 
bleeding  but  should  prevent  shock  and  infection. 
Placenta  praevia  and  premature  separation  of  the 
normally  implanted  placenta  may  occur  at  any 
time  during  the  last  trimester. 

Placenta  praevia  is  diagnosed  by  the  sudden 
onset  of  painless  vaginal  bleeding,  seemingly  with- 
out cause.  The  initial  bleeding  is  rarely  fatal. 
The  shock  is  in  proportion  to  the  amount  of  visible 
blood  lost.  It  is  difficult  at  times  to  determine 
the  type,  whether  it  is  lateral,  marginal,  or  central. 
Especially  is  this  true  with  an  undilated  or  parti- 
ally dilated  cervix.  Vaginal  examination  in  such 
cases  is  hazardous  unless  done  under  the  most  rigid 
aseptic  precautions.  Be  prepared  before  any  ex- 
amination to  combat  hemorrhage  by  packing  or  by 
immediate  cesarean  section.  Have  the  blood  typed 
and  have  donors  immediately  available.  Cesarean 
section  as  a  rule  should  be  done  as  soon  as  the 
diagnosis  of  placenta  praevia  is  made.  Occasion- 
ally one  will  see  a  multipara  with  slight  bleeding 
and  dilated  or  dilatable  cervix  in  whom  rupture 
of  the  membranes  with  or  without  insertion  of  a 
hydrostatic  bag  will  suffice.  Also  in  an  occasional 
case  when  the  baby  is  small  and  the  cervix  is  soft 
and  somewhat  dilated,  an  immediate  version  will 
be  preferable.  Braxton-Hicks  version  is  not  indi- 
cated if  the  baby  is  alive,  but  may  be  done  if 
the  fetus  is  dead  and  the  cervix  one-half  dilated. 
It  is  well  to  keep  in  mind  that  any  intrauterine 
manipulation  increases  the  blood  loss,  shock  and 
infection.  Also  there  is  possible  danger  of  rupture 
of  the  lower  uterine  segment  if  version  is  attempt- 
ed. 

Premature  separation  of  the  normally  implanted 
placenta  is  an  extremely  dangerous  occurrence. 
At  times  it  is  seen  during  labor  and  here  it  is 
frequently  not  suspected  until  the  patient  is  in 
shock.  If  the  onset  is  during  labor  the  only  symp- 
tom may  be  expulsion  of  small  clots  during  pains. 


PREGNA  NCY   COM  PLICA  TIONS—Wrenn 


January  1940 


The  onset  of  most  cases  is  rather  sudden  with 
constant  labor-like  pains,  fading  fetal  heart  sounds, 
board-like  rigidity  of  the  uterus,  with  or  without 
visible  hemorrhage.  Shock  is  usually  out  of  pro- 
portion to  the  visible  blood-loss.  There  is  usually 
a  history  of  recent  trauma,  and  often  a  history 
of  toxemia.  One  should  especially  be  concerned 
if  there  is  a  history  of  nephritis,  because  in  such 
cases  anuria  and  uremia  are  prone  to  occur,  and 
early  treatment  should  be  instituted  to  combat 
these. 

The  treatment  of  premature  separation  is  im- 
mediate delivery  by  cesarean  section,  in  practically 
all  cases  except  those  in  whifh  the  separation 
occurs  late  in  the  first  stage  of  labor.  In  these 
cases  simple  rupture  of  the  membranes  with  ac- 
celeration of  delivery  of  the  fetus  and  placenta  is 
sufficient.  If  the  fetus  in  the  second  stage  of  labor 
is  in  distress,  as  evidenced  by  the  fetal  heart  rate, 
version  may  allow  safe  delivery  of  a  live  baby 
and  save  the  mother.  Premature  separation  before 
the  onset  of  labor,  or  early  in  the  first  stage,  if 
neglected  means  the  loss  of  the  baby  and  probably 
the  loss  of  the  mother,  or  necessitates  the  removal 
of  the  uterus  because  of  the  infiltration  of  blood 
into  the  uterine  wall  with  the  loss  of  contracti- 
bility  and  subsequent  post  partum  hemorrhage.  If 
premature  separation  of  the  placenta  is  recognized 
early  the  maternal  mortality  should  be  slight;  how- 
ever, if  treatment  is  not  begun  until  late,  many 
patients  will  die  despite  the  best  treatment  that 
is  at  present  available. 

Late   Toxemias 

These  are  the  most  thoroughly  investigated,  but 
probably  the  least  understood,  of  all  the  complica- 
tions of  pregnancy.  There  is  still  no  unanimity 
of  opinion  as  to  the  classification  of  these  toxemias. 
They  may  be  divided  into  the  acute  non-convulsive 
(preeclamptic)  and  the  convulsive  (eclamptic) 
toxemias.  The  entire  syndrome  develops  in  the 
course  of  a  given  pregnancy  and  is  distinct  from 
the  chronic  cardiovascular-renal  conditions  with 
which  the  woman  was  affected  prior  to  the  instant 
pregnancy. 

We  know  that  in  eclampsia  and  preeclampsia 
angiospasm  is  a  common  pathogenic  factor  under- 
lying all  the  varying  expressions.  This  vascular 
manifestation  is  at  first  functional,  but  if  allowed 
to  last  too  long  the  walls  of  the  small  vessels  become 
thick  and  sclerotic.  This  occurs  not  only  in  the 
kidneys,  but  in  the  liver,  brain  and  other  organs 
as  well. 

From  various  statistics  it  appears  that  clinical 
evidence  of  preeclampsia  occurs  in  10  per  cent  of 
the  child-bearing  population.  With  treatment,  not 
more  than  two  or  three  per  cent  of  these  will  have 
eclampsia. 


General   Vascular   Sclerosis 

It  is  sometimes  difficult  to  distinguish  between 
preexisting  chronic  general  vascular  sclerosis,  or 
chronic  nephritis,  which  may  complicate  pregnancy, 
and  the  acute  toxemias  which  make  their  appear- 
ance in  the  latter  months  of  pregnancy.  A  non- 
pregnant woman  may  have  mild  chronic  nephritis 
and  yet  all  the  blood  examinations  and  kidney 
function  tests  will  be  normal.  Should  such  a 
woman  become  pregnant,  she  will  show  hyperten- 
sion and  albuminuria  before  the  third  trimester; 
whereas  acute  toxemia  rarely  manifests  itself  before 
the  seventh  month.  In  this  early  appearance  of 
symptoms  in  chronic  nephritis  and  the  late  ap- 
pearance of  symptoms  in  the  toxemias  lies  a  reli- 
able and  practicable  means  of  differentiating  be- 
tween the  two  conditions.  It  is  unfortunate  that 
mild  chronic  nephritis  cannot  always  be  diagnosed 
before  the  onset  of  pregnancy — not  even  by  the 
technical  urea  clearance  test  and  the  Addis  count. 

Those  patients  who  exhibit  no  symptoms  of 
nephritis  or  hypertensive  disease  before  pregnancy 
but  who  in  early  pregnancy  have  mild  hyperten- 
sion (around  140/90),  who  have  at  most  a  trace 
of  albumin,  whose  renal  function  is  within  normal 
limits  may  be  treated  expectantly;  but  both  phy- 
sician and  patient  must  accept  more  than  the 
average  risk  of  aggravation  of  the  existing  con- 
dition by  superimposed  toxemia. 

A  woman  who  shows  more  hypertension  and 
more  albumin  during  the  early  months  of  preg- 
nancy may  be  carried  on  to  term,  but  irreparable 
damage  to  her  kidneys  with  shortening  of  her  life 
is  to  be  expected.  Kuder  and  Stander'  found  that 
more  than  40  per  cent  of  women  died  within  ten 
years  after  chronic  nephritis  was  first  recognized 
in  the  course  of  pregnancy.  It  appears,  therefore, 
that  if  the  disease  is  manifest  at  conception,  abor- 
tion should  be  done  promptly.  If  the  disorder 
has  been  latent  and  appears  early  in  pregnancy 
and  is  associated  with  considerable  albuminuria 
which  tends  to  increase  despite  treatment,  it  is 
unlikely  that  pregnancy  can  go  on  to  proper  ter- 
mination. If  to  albuminuria  is  added  edema  or 
hypertension  pregnancy  should  be  arrested  without 
delay. 

The  treatment  of  preeclampsia  is  at  present  more 
encouraging  than  formerly.  It  consists  of  adequate 
elimination,  mild  sedation,  bed  rest  and  dietary 
restrictions.  Sodium  chloride  should  be  cut  down 
to  a  minimum  and  only  vegetable  and  milk  pro- 
teins should  be  allowed.  For  the  milder  cases  the 
diet  may  consist  of  skimmed  milk,  fruits,  vegeta- 
bles and  salads;  for  the  more  severe  cases  only 
sweet  fruit  juries  should  be  allowed.  Mcllroy' 
and  other  British  obstetricians  gave  as  their  opin- 
ion  that  a  diet  sufficient  in  vitamins,  especially 


January  1940 


PREGNANCY  COMPLICATIONS— Wrenn 


vitamin  D;  and  inorganic  constituents,  such  as 
calcium,  iron  and  iodine,  is  vital  in  preventing  and 
treating  preeclampsia.  All  agree  that  high-carbo- 
hydrate diet,  including  in  many  cases  frequent 
intravenous  injections  of  hypertonic  glucose,  and 
of  magnesium  sulphate  to  the  severely  sick  pati- 
ents, give  excellent  results.  However,  if  treatment 
fails  to  cause  improvement,  termination,  of  the 
pregnancy  is  indicated.  To  induce  labor  in  these 
cases  conservative  methods  are  preferable  to  cesa- 
rean section. 

Despite  most  adequate  prenatal  care  and  every 
known  method  of  treatment  of  preeclampsia,  true 
eclampsia  may  occur  and  may  be  fatal.  Eclamptic 
convulsions  present  an  immediate  emergency  which 
calls  for  active  but  not  radical  treatment.  Therapy 
should  be  instituted  to  control  the  convulsions  and 
remove  the  edema  by  diuresis.  Here,  hypertonic 
glucose,  frequently  administered,  has  its  greatest 
calling.  It  dehydrates,  protects  the  liver  and  pre- 
vents the  development  of  acidosis.  For  sedation, 
morphine,  chloral  hydrate  and  the  barbiturates 
have  all  proved  effective.  The  intravenous  use  of 
magnesium  sulphate  is  an  important  part  of  the 
conservative  treatment  of  eclampsia.  In  addition 
to  its  sedative  effect,  it  helps  to  rid  the  patient 
of  edema  by  promoting  diuresis.  McNeille6  has 
given  20  c.  c.  of  a  10  per  cent  solution  intraven- 
ously every  hour  for  as  many  as  six  doses  with  ex- 
cellent results.  It  is  the  consensus  of  opinion,  how- 
ever that  this  drug  should  be  given  with  caution 
when  oliguria  or  anuria  is  present. 

Current  writers  seem  to  have  little  favor  for 
venesection  as  a  treatment  of  eclampsia.  Should, 
however,  pulmonary  edema  develop,  venesection, 
atropine  and  oxygen  should  be  employed — as  well 
as  50  per  cent  glucose  intravenously. 

As  to  termination  of  pregnancy  in  the  eclamp- 
tic patient  experience  has  shown  that  all  the 
methods  of  delivery  are  inadvisable  until  the  con- 
vulsions have  been  controlled.  Even  then  force- 
ful, mechanical  emptying  of  the  uterus  is  to  be 
condemned.  Plass"  found  the  mortality  following 
radical  treatment  of  eclampsia  to  be  21.7  per  cent 
of  4,607  cases,  and  only  11.1  per  cent  of  5,978 
cases  in  which  treatment  was  conservative. 

Summary 
Only  the  more  frequent  and  more  significant 
complications  of  pregnancy  have  been  discussed. 
The  trend  is  more  and  more  toward  keeping  the 
pregnant  woman  in  a  state  of  physiological  equi- 
librium by  encouraging  the  use  of  a  high-vitamin 
diet  and  one  which  contains  the  essential  inorganic 
constituents.  This  appears  to  lessen  the  incidence 
of  many  of  these  complications,  or  at  least  to  give 
the  patient  more  tolerance  to  such  complications 
when    they   appear   and   make    them   less   severe. 


The  active  treatment  of  such  complications  is 
directed  toward  the  complication  itself,  and  toward 
restoring  and  keeping  the  physiological  processes 
as  near  to  the  normal  state  as  possible.  Only 
by  anticipating  the  sequence  of  events  in  regard 
to  the  patient  as  a  whole  can  the  maximum  ther- 
apeutic results  be  obtained  as  to  any  morbid 
state.  Much  progress  has  been  made  in  both  the 
prevention  and  treatment  of  the  complications  of 
pregnancy;  but  vast  strides  are  yet  to  be  made 
before  any  newly-pregnant  woman  can  be  assured 
that  on  the  expected  day  of  confinement  every- 
thing will  go  well. 

References 

1.  Bernstein,  A.:   Am.  J.  Surg.,  March,   1940. 

2.  Buford,  C.  E.  et  al.:   J.  Missouri  M.  A.,  March, 
1939. 

3.  Kuder,   K.   and  Stander,  H.   J.:   New   York  State 
J.  M.,  May,   1936. 

4.  Mcllroy,   h.:Lancet,   1934,   2:291. 

5.  McNeille,  L.  G.J.  Am.  M.  Assoc,  1934,  103:548. 

6.  Plass    (quoted    by    Dieckman).:    Arch.   Int.   Med, 
1935,    55:420. 

7.  Practitioner,  Feb.,   1939,   142:143-152. 

8.  Lovibond,    J.    L.:     Mid.    Hosp.    J.,    Dec.     1938, 
38:153-158. 

9.  James,  J.  D.:/.  Missouri  M.  A.,  March   1939. 

10.  Loury,   W.   P.:    Texas  State  J.  Med.,  May    1939. 

11.  Massey   and   Ferber:    Lancet,   Jan.   1938. 

12.  King,  E.  L.:  Miss.  Doctor,  March  1938. 

13.  Johnston,  R.  W.:    Brit.  Med.  J.,   1:765-770. 

14.  Ross,  R.  A.   et  al.:  Am.  J.  Gynec.  &  Obs.,  35:426- 
440. 

15.  Tew,  W.   P.:      Can.  Med.  Assoc.  J.,  38:20-24. 

16.  Royston,    C.   D.    et   al.:    Am.  J.   Gynec.   &  Obs. 
Aug.   1937. 


THE  TREATMENT  OF  CHRONIC  LEG  ULCERS 
(I.    Zweigel,    Newark,    ia    CUn.    Med.,    Nov.) 

The  patient  is  examined  physically  and  has  a  routine 
urine  examination  and  Wassermann  test.  Diabetes  mellitus, 
cardiorenal  disease,  tuberculosis,  or  overweight  require 
medical  treatment.  If  varicosities  of  the  small  or  long 
saphenous  vein  are  large  and  a  Trendelenberg  test  posi- 
tive in  one  or  both  legs,  unilateral  or  bilateral  saphenous 
ligation  at  one  or  two  points  is  advised,  in  addition  to 
local  treatment.  Any  related  constitutional  condition  is 
treated. 

For  the  first  48  to  72  hours,  wet  dressings  of  a  satu- 
rated solution  of  boric  acid  are  applied.  After  this  a 
1:500  solution  of  azochloramid  in  triacetin,  for  3  days; 
wet  dressings  of  azochloramid-saline  solution,  1:3300,  for 
the  next  4  days.  These  dressings  in  this  routine  repeated 
for  at  least  4  weeks.  In  2  cases  a  mild,  local  skin  irri- 
tation developed  around  the  ulcer. 

At  the  end  of  4  weeks  of  treatment  (on  the  average), 
the  secondary  infection  had  disappeared,  granulation  tissue 
was   abundant,   and   the   skin   edges   were   growing   in. 


CARCINOMA   OF   THE   RECTUM 

(C.    W     McLaughlin,    Jr.,    &    W.    M.    Dilworth,    Omaha,    in 
Neb.    State   Med.   11.,   Jan.) 

In  cancer  of  the  rectum  the  definite  symptoms  appear 
late.  Alterations  in  bowel  habit  during  midlife  in  a  previ- 
ously regular  individual  should  always  be  viewed  with 
suspicion.  Every  patient  with  a  rectal  complaint  merits 
a  careful   rectal   and  proctoscopic  examination. 


SOUTHERN  MEDICINE  &  SURGERY 


January  1940 


Prolonged  Labor  due  to  Uterine  Dystocia — Calcium 
in  the  Treatment* 


M 


Brodie  C.  Nai.le,  M.  D..  Charlotte,  North  Carolina 

Y  PURPOSE  is  to  discuss  the  frequency,  The    diagnosis    of    pathological    retraction    ring 

the  cause  and  the  treatment  of  prolonged      and  constriction  ring  is  not  always  easy,  but  the 
labors  due  to  functional  dystocias  of  the     conditions  may   be  suspected  in  prolonged  labors 


uterus  and  cervix  -  not  those  due  to  disproportions, 
malpositions  and  deformities. 

A  great  many  cesarean  sections  have  been  pre- 
formed for  functional  dystocias  of  the  uterus  and 
cervix  which  might  have  been  managed  more  con- 
servatively. Hamilton  found  in  1000  consecutive 
labors  one-third  classified  as  true  labor,  the  other 
two-thirds  as  false  labor  and  preliminary  labor. 
He  reviewed  17,000  cases  in  which  section  was 
done  for  cervical  dystocia,  and  concluded  that 
section  was  indicated  in  only  three  of  the  17,000 
cases.  This  seems  a  rather  sad  commentary  on 
our  obstetrical  judgement,  and  possibly  helps  to 
explain  our  low  rating  in  the  surgical  world. 


in  winch  there  is  little  or  no  progress,  in  cases  in 
which  there  is  a  great  variation  in  time  and  force 
of  the  pains,  and  particularly  when  the  uterus 
remains  more  or  less  constantly  contracted.  A 
constriction  ring  can  frequently  be  felt  by  vaginal 
examination  at  the  internal-  or  external  os,  or  even 
above  the  cervix. 

It  is  generally  agreed  that  in  normal  labor  there 
are  two  distinct  processes — contraction  and  re- 
traction of  the  muscles  of  the  uterus — and  a 
rhythmical  coordinated  action  of  these  two  pro- 
cesses is  necessary  for  the  normal  progress  of  labor. 
Normal  contraction  and  retraction  result  in  re- 
arrangement of  the  muscles  of  the  uterus;  i.  e.,  in 


The   musculature   consisting  of   three   layers  of  a  thickening  of  the  muscles  of  the  upper  segment, 

the  uterus  is  arranged  in  a  rather  complicated  way:  a   thinning  of   the  muscles  of  the  lower  segment 

( 1 )    the   external   layer   in   which   the   fibres   run  and  dilatation  of  the  cervix.     When  for  any  rea- 

transversely   around    the   front   and    back   of    the  SOn,  mechanical  or  functional,  we  do  not  have  this 

uterus;    (2)    the  middle  layer  composed  of  circu-  rhythmical,  coordinated  action  of  the  muscles  of 

lar,  oblique  and  longitudinal  fibres;    (3)    the   in-  the  uterus  the  result  is  false  pains,  tetanoid  pains, 

ternal  layer  composed  of  circular  fibres  arranged  false  labor,  preliminary  labor.    This  condition  may 

in  two  cone  shapes.     The  apex  of  each  cone  is  last  for  hours  or  days  without  progress;    i.  e.,  a 

situated  at  the  junction  of  the  uterus  and  fallopian  condition  in  which  there  is  not  the  normal  sequence 

tube,  the  fibres  of  one  cone  converging  with  the  and  normal  strength  ratio  between  the  contractions 

fibres  of  the  other  cone  about  the  middle  of  the  0f  the  different  muscles  of  the  uterus,  but  an  im- 

uterus.     With  such  a  complicated  arrangement  of  balanced  action  of  the  muscles  in  which  the  circu- 

muscle   fibres   incoming   from   all   directions   there  iar    fibres    exert    the    greater    force.     Pathological 

must   necessarily   be   a   perfect   coordinjation   and  retraction   ring   and   constriction   ring   are   always 

timing  in   the  action   in   order   for   the   uterus   to  preceded  by  false  or  tetanic  pains.     Therefore,  if 

perform    its    function    normally.     The    uterus    is  false,  tetanic  pains  can  be  prevented,  we  can  pre- 


divided  into  an  upper  and  lower  segment.  At  the 
junction  of  these  two  segments  is  the  physiological 
retraction  ring  _  which  is  Nature's  provision  for 
keeping  the  product  of  conception  in  the  upper 
portion  of  the  uterus.  Under  certain  conditions 
this  physiological  retraction  ring  becomes  a  patho- 


vent  pathological  retraction  and  constriction  ring 
and  thereby  avoid  many  dangerous  complications 
of  labor. 

My  purpose  is  to  find  the  causes  in  (1)  a  dis- 
turbed autonomic  system,  (2)  calcium  deficiency, 
or  (3)  in  a  combination  of  the  two.     It  must  be 


logical   retraction   ring   and   produces   troublesome  remembered    the    uterus    gets    most    of    its    nerve 

and  dangerous  hindrances  to  delivery.     Pathologi-  SUpplv  from  the  sympathetic  system.     We  would 

cal  retraction  ring  occurs  when  labor  is  obstructed  therefore    expect    a    normally    acting    sympathetic 

mechanically   or   by   improper   functioning   of   the  SyStem  to  produce  the  normal  physiological  actions 

muscles  of  the  uterus,  and  in  this  condition   the  0f   the   muscles   of   the   uterus;    i.   e.,   rhythmical 

muscle,  drawn   up  pathologically  high,  is  usually  contraction  and  retraction,  and  normal  labor:  but 

called   Bandl's  ring.     Also  constriction  rings,  due  we  wouid  not  expect  the  same  from  a  disturbed 

to  the  same  causes,  may  occur  at  any  level  of  the  sympathetic  system.     The  autonomic  nervous  sys- 

uterus — at  the  external  os,  the  internal  os,  or  even  tem,  consisting  of  the  sympathetic  and  para-sym- 

in  the  fundus  of  the  uterus — and  interfere  seriously  pathetic,  is  an  involuntary  system,  much  influenced 

with  delivery.  by  the  emotions    of  anger,  fear,  pain  and  anxiety, 

♦Presented  to  the  Twenty-first  New  Year  Meeting  of  the  Mareboro  County,  S.  C.   Medical  Society  Bennett  sville,   January   9th. 


January  1940 


CALCIUM  IN  DYSTOCIA— Nolle 


and  especially  by  suppressed  emotions.  By  these 
emotions  the  sympathetic  is  quickly  stimulated,  and 
the  cranial  division  of  the  parasympathetic  (i.  e., 
the  vagus)  is  inhibited.  We  must  remember  the 
very  close  association  and  interaction  of  the  endo- 
crine glands,  the  sympathetic  nervous  system  and 
the  organs  of  reproduction;  also  that  the  adrenals, 
the  thyroid  and  pituitary  are  stimulated  by  the 
sympathetic  and  that  each  acts  and  reacts  with 
the  reproductive  organs. 

Langdon  Brown  says,  "With  increasing  civiliza- 
tion the  threshold  to  pain  and  painful  emotions 
becomes  lowered  and  the  resulting  disabilities  are 
exaggerated."  He  further  says,  "The  evil  effect  of 
depressing  emotions  of  anxiety,  fear,  pain  and 
anger  receive  an  explanation  when  we  see  that 
through  the  sympathetic  nervous  system  they  can 
lead  to  functional  disturbances,  even  to  structural 
changes."  We  see  then  disturbing  emotions  exciting 
the  sympathetic  system,  the  sympathetic  stimu- 
lating the  secretions  of  the  endocrine  glands,  and 
these  in  turn  stimulating  both  the  organs  of  re- 
production and  the  sympathetic  system.  So  we 
have  a  vicious  cycle  established  which  would  pro- 
duce anything  but  a  normal  functioning  of  the 
musculature  of  the  uterus.  We  know  of  the 
emotional  disturbances  in  pregnant  women.  If  we 
grant  disturbing  influences  of  pregnancy  and  labor 
sufficient  to  upset  the  normal  action  of  the  sym- 
pathetic, then  we  have  a  probable  cause  for  the 
abnormal,  arrhythmical,  uncoordinated,  ineffective 
contractions  of  the  uterus,  called  by  many  names, 
which  precede  and  result  in  pathological  contrac- 
tion ring,  constriction  ring,  prolonged  and  often 
impossible  labors. 

The  normal  calcium  content  of  the  blood  is 
about  10  mgs.  to  100  c.  c.  There  is  much  doubt 
about  the  exact  forms  in  which  calcium  exists  in 
the  blood.  The  physiologically  active  and  diffu- 
sible portion  is  supposed  to  be  controlled  by  the 
active  principle  of  the  parathyroids.  We  may  have 
a  condition  of  normal  blood  calcium,  but  with  a 
deficiency  of  diffusible  calcium,  and  from  this 
complex  all  the  symptoms  of  calcium  deficiency. 
The  idea  of  calcium  deficiency  being  a  cause  of 
false  pains  etc.  was  suggested  by  the  frequency 
with  which  false  uterine  pains  occurring  during 
the  later  part  of  pregnancy  and  during  labor,  are 
attended  by  cramps  in  the  calves  of  the  legs  and 
various  other  paresthesias  suggestive  of  calcium 
deficiency.  Since  the  estimation  of  diffusible  blood 
calcium  is  so  difficult,  we  may  rely  upon  the  cal- 
cium deficiency  syndrome  as  evidence  of  a  defici- 
ency of  tiiffusible  , blood  calcium.  There  is  an 
extra  demand  for  calcium  during  pregnancy,  especi- 
ally during  the  last  ten  weeks,  the  time  during 
which  false  pains  etc.  are  most  apt  to  occur. 


With  a  nervous,  fearful  patient  whose  sympathet- 
ic system  is  disturbed,  there  can  be  found  good 
reasons  to  explain  a  calcium  deficiency.  Excite- 
ment of  the  sympathetic  (1)  stimulates  the  thy- 
roid, which  in  turn  increases  the  oxidation  of 
calcium;  and  (2)  inhibits  the  vagus  and  thereby 
diminishes  the  digestion  and  assimilation  of  cal- 
cium. Also,  through  its  effects  on  the  parathyroids, 
it  diminishes  not  only  the  total  quantity,  but 
the  diffusible  portion,  of  calcium.  Alkalemia  and 
nephritis  decrease  diffusible  calcium. 

Available  blood  calcium  in  normal  amoui>t  pro- 
duces normal  muscle  contractions,  and  has  a  quiet- 
ing effect  on  the  sympathetic  system.  A  lack  of 
blood  calcium  produces  tetanic  muscle  contractions 
and  excites  the  sympathetic  system. 

How  to  recognize  false  pains  etc.: 

( 1 )  Anticipate  them  in  intensely  nervous,  anxi- 
ous and  fearful  patients,  especially  in  those 
attempting  to  suppress  their  emotions  and 
in  patients  who  have  had  previous  difficult 
labor. 

(2)  In  those  cases  which  show  no  progress 
after  hours  of  hard  pains  and  whose  pains 
are  now  irregular  in   time  and   force. 

(3)  When  contractions  are  induced  by  even 
laying  the  hand  on  the  uterus  or  by  vaginal 
examinations. 

(4)  When  the  patient  complains  unduly  of 
pains  low  in  the  pelvis,  frequently  worse 
in  the  back. 

(5)  When  the  uterus  remains  hard  or  tetanic 
between  pains;  i.  e.,  appears  almost  con- 
stantly contracted. 

Colicky  action  of  the  uterus  can  be  recognized 
by  the  fact  that  pain  of  the  uterine  contraction 
persists  after  the  palpable  hardening  of  the  uterus 
has  disappeared.  In  normal  contraction  of  the 
uterus  the  pain  stops  before  the  contraction  has 
stopped.  This  in  my  experience  is  a  valuable 
diagnostic  point. 

Treatment 

( 1 )  Prenatal  attention  to  the  physical  and  ner- 
vous system  in  preparation  for  the  ordeal 
of  labor,  removal  as  far  as  possible  of  the 
fear  and  dread  of  childbirth.  Administra- 
tion of  calcium  with  vitamin  D  from  the 
third  month  of  pregnancy. 

(2)  During  labor  sparing  the  patient  as  far  as 
possible  all  disconcerting  surroundings  and 
influences,  such  as  the  presence  of  nervous, 
anxious  members  of  the  family  and  friends. 
Avoid  anything  which  would  excite  the 
sympathetic  system.  An  encouraging,  train- 
ed and  consoling  attendant  is  of  the  greatest 
help.  Early  sedation  is  indicated,  for  the 
more  nervous,  anxious  type  of  patient.  Frer 


CALCIUM  IN  DYSTOCIA— Nallc 


January  1940 


quent  vaginal  examinations,  and  frequent 
laying  of  hands  and  pressure  on  the  ab- 
domen by  either  physician  or  other  atten- 
dant tends  to  increase  the  frequency  of 
futile  pains.  Give  no  oxytocic.  In  case  of 
the  appearance  of  false,  colicky  pains,  pro- 
duce further  sedation,  if  necessary  with 
morphine.  In  those  cases  in  which  sedation 
is  not  effective  I  have  found  the  intravenous 
use  of  calcium  most  helpful.  Especially  is 
calcium  useful  in  those  cases  which  would 
require  such  deep  sedation  as  to  stop  the 
progress  of  labor.  Frequently  these  cases, 
with  mild  sedation  and  calcium,  will  go  into 
a  normal  productive  labor.  Sedation  by 
itself  is  not  sufficient  if  the  cajcium  defici- 
ency is  great. 

Summary 

(1)  Too  many  cesarean  sections  are  done  and  too 
much  operative  interference,  in  cases  of  dys- 
tocia consequent  on  abnormal  physiology  of 
the  uterus  and  cervix. 

(2)  The  uterus  gets  most  of  its  nerve  supply  from 
the  sympathetic  system.  Normal  action  of 
the  sympathetic  system  produces  normal, 
rhythmical,  coordinated  muscular  action  of 
the  uterus — that  essential  normal  contraction 
and  retraction  which  constitutes  normal  labor. 

(3)  The  emotions  —  pain,  fear  etc.  —  excite  the 
sympathetic  system. 

(4)  Emotionally  excited,  the  sympathetic  nervous 
system  produces  abnormal,  arrhythmical,  un- 
coordinated, muscular  action -of  the  uterus — 
the  false,  colicky  or  tetanoid  pains,  which 
often  precede  and  terminate  in  contraction 
and  constriction  rings  and  difficult,  dangerous 
deliveries. 

(5)  Calcium  deficiency  may  produce  false,  tetanic 
pains  in  the  uterus  and  also  excite  the  sympa- 
thetic system. 

(6)  By  maintaining  a  normal  sympathetic  system 
and  a  normal  available  bhood  calcium,  we 
should  be  able,  in  the  greater  number  of  cases, 
to   prevent   prolonged   labor   due   to   uterine 

dystocia. 


THE    MORTALITY    FROM    ACUTE    APPENDICITIS 
IN  THE  JOHNS  HOPKINS  HOSPITAL 

(E     S.    Stafford    &    D.    H.    Sprong,    Jr..    Baltimore,    in 
H.   A.   M.  A.,   Oct.    12th.) 

In  the  surgical  service  of  the  Johns  Hopkins  Hospital 
patients  considered  to  have  acute  appendicitis  in  any 
stage  of  the  disease  are  subjected  to  immediate  operation. 
From  Sept.  1st,  1931,  to  Sept.  1st,  1939,  1317  of  these 
patients  had  acute  appendicitis.  All  cases  in  which  there 
was  no  gross  perforation  of  the  appendix  are  classified 
under  simple  acute  appendicitis.  All  those  in  which  per- 
foration of  the  appendix  was  found  at  operation  (except 
those  in  which  rupture  was  caused  by  handling  during 
operation)    are   divided  into   two   groups: 


1.  Appendicitis  with  perforation  and  abscess-forma- 
tion. 

2.  Appendicitis  with   perforation  and  peritonitis. 
No    attempt    has    been    made    to    distinguish    between 

"local,"  "spreading"  and  "generalized  pertonitis.  We  agree 
with  Ladd  that  "no  surgeon  really  knows  how  diffuse 
the  process  is  unless  he  has  done  a  very  improper  opera- 
tion." 


No.   of 

Patients  Deaths  <%, 
838  0  0 


7.00 


Condition 
Simple  acute  appendicitis 
Appendicitis    with    perforation 

and    abscess  238         20 

Appendicitis   with    perforation 

and    peritonitis  196         28         14.23 

A  study  of  the  48  fatal  cases  leads  to  certain  conclusions. 

The  use  of  drains  is  open  to  question.  We  have  em- 
ployed drainage  as  a  matter  of  routine  when  pus  was 
present  but  have  come  to  feel  that  the  presence  of  drains 
may  in  some  instances  produce  adhesions  which  cause 
mechanical  ileus.  We  are  not  prepared  to  say  whether 
this  danger  is  greater  than  that  of  the  complications 
which   might   arise   if   drainage   were   not   employed. 

The  most  controversial  subject  which  has  arisen  with 
regard  to  appendicitis  is  the  so-called  delayed  or  expec- 
tant treatment  of  perforative  appendicitis.  We  are  certain 
that  this  is  poor  treatment  and  that  advocacy  of  this 
method  has  had  an  unfortunate  effect  on  the  general 
practitioner.  The  most  experienced  doctors  are  at  times 
unable  to  determine  whether  or  not  an  appendix  has 
perforated.  Granted  that  a  patient  has  signs  of  peri- 
tonitis, it  is  not  always  possible  to  know  the  cause  be- 
fore operation.  Through  a  McBurney  incision  it  has  been 
found  that  peritonitis  may  be  due  to  perforation  of  a 
peptic  ulcer,  to  Meckel's  diverticulum  or  to  an  infected 
diverticulum  of  the  sigmoid  flexure  of  the  colon.  In  the 
past  two  years  one  of  us  has  operated  in  three  cases  of 
primary  pneumococcic  peritonitis  .having  made  a  preopera- 
tive diagnosis  of  perforative  appendicitis.  The  correct 
diagnosis  made  at  operaton  permitted  treatment  with  spe- 
cific  serum   and   sulfapyridine,   with   prompt   recovery. 

In  a  series  of  85  consecutive  cases  of  perforative  appen- 
dicitis treated  in  this  hospital  during  the  years  1928  to 
1931  there  were  16  deaths,  a  mortality  rate  of  18.8%. 
This  is  nearly  twice  that  of  our  present  series.  The  only 
real  differences  in  treatment  in  the  two  series  were  the 
institution  of  suction  and  the  administration  of  intravenous 
fluids  in  the  cases  making  up  the  present  series. 

It  has  been  argued  that  operation  on  an  appendical 
abscess  often  spreads  infection.  In  our  series  283  patients 
with  appendical  abscess  were  subjected  to  immediate  op- 
eration. In  only  two  of  them  did  spreading  peritonitis 
cause  death,  and  in  one  of  these  two  the  outcome  was 
due  to  our  failure  to  recognize  and  deal  with  the  primary 
appendical  abscess.  In  the  other  case  it  is  not  certain 
whether  the  spread  of  infection  occurred  before,  during 
or  after  operation. 


TREATMENT    OF    INFECTOUS    DIARRHEA 

WITH  SULFAPYRIDINE 
(A.  J  Villani,  Welch,  in  W.  Va.  Med.  11,  Sept) 
Sixteen  cases  of  infectious  diarrhea  are  presented  in 
which  sulfapyridine  seemed  a  specific.  Within  24  to  48 
hours  after  the  first  dose  of  the  drug,  the  t.  dropped  to 
normal  and  shortly  afterward  the  stools  returned  to  nor- 
mal. In  9  cases,  stool  cultures  were  negative  for  members 
of  the  typhoid  or  dysentery  group.  In  the  remaining  cases, 
no  stool  cultures  were  obtained.  There  was  one  death. 
In  this  case  the  sulfapyridine  was  discontinued  because 
the  infant  was  unable  to  retain  the  drug.  There  were 
no  serious  complications  from  the  use  of  sulfapyridine.  The 
minimum  dose  was  administered  and  its  action  was  ap- 
parently prompt. 


January  1940 


SOUTHERN  MEDICINE  &  SURGERY 


SURGICAL  OBSERVATIONS 

OF 

DAMS   HOSPITAL   STAFF 
States ville 

A  REVIEW  OF  SOME  OF  THE  PROGRESS  IN 
GENERAL  MEDICINE,  GENERAL  SURGERY 

AND   THE   SPECIALTIES   DURING   1940 

In  the  fields  of  medicine,  surgery  and  their  vari- 
ous specialties,  there  has  been  great  progress  made 
in  the  past  year. 

As  we  enter  the  New  Year,  war  clouds  are  rapid- 
ly gathering  over  America.  Those  who  recall  events 
prior  to  the  first  World  War  recognize  the  signs 
of  a  country  getting  ready  to  go  to  war,  together 
with  the  war-like  evolution  of  public  sentiment 
which  usually  precedes  all  wars. 

During  World  War  I,  surgery  made  the  greatest 
advances.  Medicine  advanced  too.  As  the  various 
armies  fought  to  destroy  each  other,  the  medical 
profession  worked  even  harder  to  save  the  wounded 
and  rehabilitate  and  restore  to  usefulness. 

The  more  seriously  injured  and  those  who  re- 
ceived injuries  which  were  classed  as  permanent 
were  given  careful  treatment  with  the  aim  of  best 
enabling  them  to  make  their  own  living  and  take 
their  places  again  among  their  fellowmen,  even 
though  many  had  to  change  their  occupations  be- 
cause of  war  injuries.  Many  of  these,  of  course, 
were  never  able  to  work  again,  but  the  majority 
were  able  to  take  up  some  profession,  trade  or 
vocation  which  would  enable  them  to  earn  a  living, 
at  least  in  part. 

This  rehabilitation  program  continued  for  many 
years  after  the  close  of  the  war.  Members  of  the 
medical  profession  have  to  work  many  years  after 
a  war  is  over  to  obtain  maximum  improvement 
and  best  results  for  the  wounded. 

With  the  coming  of  another  war  even  greater 
and  more  rapid  progress  will  probably  be  made 
when  the  test  comes.  This  is  about  the  only  favor- 
able and  encouraging  thing  about  the  entire  situ- 
ation. 

Better  means  of  immunization  against  various 
infections  are  now  available  and  this  alone  will  be 
a  tremendous  factor  in  saving  lives.  The  avail- 
ability of  sulfanilamide  and  its  derivatives  will 
enable  us  to  control  many  infections  that  killed 
thousands  during  the  last  war.  The  various  strep- 
tococcic infections,  pneumonias,  and  certain  ven- 
eral  diseases  can  be  handled  much  more  satisfac- 
torily and  with  the  minimum  of  morbidity  and 
mortality.  Pneumonia  especially  has  come  under 
control  by  use  of  sulfapyridine  and  sulfathiazole 
and   the  specific  serums   for  certain   types. 

Plastic  surgery,  bone  surgery,  especially  bone 
grafting,  and  reconstruction  surgery  generally  can 
offer  even  greater  hope  to  the  maimed  and  wounded 


than  ever  before.  Vocational  rehabilitation  as  a 
sort  of  follow-up  procedure  will  be  an  important 
feature  in   the  seriously  wounded   . 

Aviation  medicine  has  now  progressed  to  the 
point  where  would-be  pilots  can  be  examined  and 
the  unfit  weeded  out  with  great  accuracy.  During 
the  past  World  War  of  every  100  pilots  who  were 
killed  two  were  killed  by  enemy  action;  eight  by 
defective  airplanes;  and  ninety  died  due  to  defects 
in  themselves.  Thanks  to  aviation  medicine,  which 
has  reached  a  high  point  of  development,  the  unfit 
pilots  can  be  eliminated  before  a  great  deal  of 
money  is  spent  in  training  them,  and  the  ninety 
per  cent  who  died  due  to  defects  will  be  saved 
for  the  work  for  which  they  are  suited.  The  great 
improvement  in  airplanes  will  eliminate  many  of 
the  eight.    This  means  an  enormous  saving  in  life. 

Improved  methods  of  sanitation,  water  supply, 
care  and  preparation  of  fo|od,  should  eliminate 
much  sickness  and  many  diseases.  These  are  only 
a  few  of  the  things  that  may  be  mentioned  as  being 
important  factors  in  the  care  of  the  armed  forces 
of  our  country  in  the  war  which  appears  imminent. 

In  other  fields  of  medicine  and  surgery,  we  have 
improved  methods  for  the  treatment  of  carcinoma 
and  a  greater  percentage  of  cures  are  effected  than 
ever  before.  In  the  incurable  cases  better  means 
are  available  for  prolonging  life  in  comfort.  Bio- 
chemisty  also  offers  many  hopes  for  the  possibility 
of  specific  treatment  of  cancer.  New  developments 
in  the  splitting  up  of  atoms  by  the  various  cyclo- 
trons offer  great  hope  of  obtaining  radiation  that 
may  be  a  great  aid  in  treating  cancer. 

In  the  field  of  urology  the  treatment  of  the 
prostate  gland  has  improved  to  the  point  where 
the  percentage  of  good  results  in  prostate  surgery, 
especially  from  transurethral  resection,  is  greater 
than  would  have  been  dreamed  of  twenty  years 
ago.  If  patients  come  in  before  there  has  been 
permanent  impairment  of  the  kidneys,  good  results 
are  fairly  uniform.  Urinary  infections,  too,  many 
of  which  were  formerly  difficult  to  treat,  now  yield 
readily  to  sulfanilamide  and  its  various  derivatives. 
In  urinary  conditions,  also,  we  are  able  to  treat 
certain  conditions  in  men  by  use  of  the  male  sex 
hormone  and  restore  them  to  a  fairly  normal  con- 
dition and  relieve  many  of  the  mild  mental  symp- 
toms and  the  debility  that  are  usually  distressing. 

The  treatment  of  gonorrhea  and  syphilis  is  on 
a  firmer  basis  and  gives  a  higher  percentage  of 
good  results. 

In  the  fields  of  ophthalmology  and  otolarygology 
great  improvements  have  been  made  in  the  treat- 
ment, especially  in  sinus  conditions  and  verious 
chronic  infections  which  formerly  were  most  diffi- 
cult to  treat. 

In  orthopedic  surgery,  especially  in  the  treat- 


SOUTHERN  MEDICINE  &  SURGERY 


January  1940 


ment  of  fractures,  great  improvements  have  been 
made.  In  the  treatment  of  compound  fractures 
we  can  often  eliminate  infections  which  formerly 
retarded  healing  and  sometimes  caused  non-union. 
In  the  treatment  of  intracapsular  fractures  of 
the  hip  and  intertrochanteric  fractures,  we  have 
a  method  now  which  gives  good  results  in  most 
cases.  The  use  of  the  Smith-Petersen  nail  in  sim- 
ple intracapsular  fractures,  and  in  intertrochanteric 
fractures  the  combined  use  of  the  Smith-Petersen 
nail  with  an  angle  bar,  will  take  care  of  many 
fractures  which  otherwise  would  have  been  most 
difficult.  The  former  methods  of  treating  fractures 
of  the  neck  of  the  femur  with  plaster  splints,  which 
required  the  patient  to  be  encased  in  a  splint  for 
a  period  of  time,  was  naturally  the  cause  of  many 
complications  such  as  pneumonia,  bed  sores  and 
Other  serious  conditions.  Now,  however,  the  use 
of  the  Smith-Petersen  nail  has  enabled  us  to  get 
good  results,  even  in  very  aged  patients  where 
otherwise  non-union  would  have  been  the  rule  no 
matter  what  treatment  was  given.  Also,  this  method 
of  treating  fractures  of  the  neck  of  the  femur  makes 
it  easv  for  the  patient,  who  can  usually  be  up  in 
a  chair  a  day  or  so  after  the  operation.  Another 
good  thing  is  that  the  operation  is  not  associated 
with  much  shock. 

All  in  all,  one  of  the  greatest  improvements  in 
the  treatment  of  fractures  of  the  hip  was  made 
with  the  advent  of  the  Smith-Petersen  nail.  We 
must  not  forget,  however,  that  the  Albee  bone  pin 
is  still  useful  in  many  cases  and  that  to  Albee  much 
credit  for  the  improvement  in  treating  fractures  of 
the  hip  is  due.  The  Austin  Moore  pins,  also,  are 
very  useful  in  certain  types  of  fractures  of  the 
neck  femur. 

In  the  treatment  of  fractures  generally,  the  use 
of  Vitallium  bone  plates  and  Vitallium  screws  has 
enabled  us  to  put  plates  on  manv  fractures  and 
leave  the  plates  in  position  for  long  periods  of 
time  and  obtain  healing  bv  the  maintenance  of 
good  apposition  and  mobility.  As  everyone  remem- 
bers, steel  bone  plates  and  ordinary  screws  were 
useful  in  some  cases,  but  often  they  would  come 
loose.  This  was  found  to  be  due  to  electric  action. 
Where  union  was  rapid  the  plates  would  hold  suffi- 
ciently long,  but  where  union  was  slow  they  would 
come  loose  too  soon.  Now,  however,  with  the  use 
of  Vitallium  plates  and  screws,  which  we  use  ex- 
clusively for  plating  fractures,  we  obtain  better 
results  than  ever  before.  Also  these  plates  and 
screws  may  be  left  in  indefinitely  and.  in  some 
cases,  do  not  have  to  be  removed  at  any  fixed  date. 

A  condition  which  has  been  extremely  difficult 
for  both  doctor  and  patient  is  the  menopausal 
svndrome.  Now  wf  can  treat  this  with  a  great 
deal   more   assurance   than   ever   before   with   the 


use  of  estrogenic  hormones  and  stilbestrol  and  some 
of  its  derivatives.  In  many  instances  the  relief 
from  the  nervousness,  hot  flashes,  chills  and  the 
various  other  manifestations,  as  well  as  the  mental 
symptoms,  can  make  the  patient  comfortable,  con- 
tented and  relieve  the  family  of  the  strain  of  caring 
for  the  patient,  who  is  often  a  great  burden  to 
those  about  her. 

The  use  of  vitamines,  which  are  now  available 
in  forms  which  may  be  used  hypodermically  or 
intramuscularly,  will  enable  us  rapidly  to  obtain 
results  in  otherwise  prolonged  and  difficult  cases. 

A  microscope  has  been  devised  which  uses  elec- 
trons instead  of  light  and  by  means  of  this  instru- 
ment, the  study  of  organisms  will  be  greatly  faci- 
litated and  certain  diseases,  formerly  classed  as 
virus  diseases  are  now  known  to  be  caused  by 
definite  microorganisms. 

Bacteriology.  A  microscope  that  will  magnify 
25,000  to  30.000  times  will  open  up  to  the  bac- 
teriologist and  to  the  research  worker  fields  never 
before  dreamed  of. 

In  the  study  of  organisms  heretofore  invisible 
even  with  the  most  powerful  microscope  many 
minute  pathologenic  bacteria  that  have  not  been 
seen  before  will  now  be  clearly  visible  and  in  their 
most  minute  detail.  Before  long,  it  is  to  be  hoped, 
diseases  the  causes  of  which  are  unknown,  will  have 
their  causes  disclosed  by  means  of  these  powerful 
microscopes,  and  we  thereby  enabled  to  prevent 
manv  more  diseases,  save  many  more  lives. 

Anesthesia.  One  of  the  most  helpful  anesthetics 
for  short  operations  is  pentothal  sodium.  This  can 
be  used  with  a  maximum  of  safety  and  assurance 
of  great  simplification  of  certain  surgical  operations 
which  require  general  anesthesia  of  some  kind. 
Many  patients  who  are  unable  to  take  inhalation 
anesthetics  are  able  to  stand  pentothal  sodium 
without  disturbance.  Some  surgeons  are  using 
this  for  many  major  operation.  In  military  sur- 
gery we  believe  that  this  anesthetic  will  be  one 
of  the  greatest  helps  because  it  can  be  administered 
easily  and  is  especially  suited  for  the  manipulation 
and  reduction  of  fractures  and  the  various  surgical 
procedures  of  military  surgery.  Debridement  of 
wounds,  secondary  closures  and  the  various  mili- 
tary surgical  procedures  requiring  a  short  anesthe- 
tic to  prevent  the  infliction  of  extreme  pain  and 
shock  can  be  done  nicely  with  this  anesthetic. 

The  many  advancements  in  the  technique  of  the 
administration  of  spinal  anesthesia  make  this  one 
of  the  most  useful  and  satisfactory  anesthetics  for 
general  surgery,  especially  surgery  below  the  dia- 
phragm. 

We  may  view  medicine  and  surgery  and  the 
various  subdivisions  as  now  on   the  threshold  of 


January  1940 


SOUTHERN  MEDICINE  &  SURGERY 


even  greater  progress  than  ever  before,  and  as  we 
view  another  war  there  never  was  a  time  when 
these  are  more  badly  needed. 

The  medical  profession,  is  constantly  striving  to 
eliminate  sickness  and  disease,  to  save  and  prolong 
life  and  make  the  world  happier. 

Today  the  world  is  dismayed,  agonized  and 
generally  upset.  The  destruction  of  life  and  pro- 
perty is  appalling.  In  many  ways  it  seems  that 
the  world  is  going  backwards.  However,  so  long 
as  the  medical  profession  maintains  its  indepen- 
dence and  continues  to  augment  its  powers  to  save 
mankind  we  can  look  toward  the  future  with  con- 
fidence^— that  everything  will  eventually  come  out 
all  right. 


DEPARTMENTS 


PNEUMONECTOMY  FOR  BRONCHOGENIC 

CARCINOMA 
(J.   D.    Bisgard,   Omaha,   in  Neb.  State  Med.  Jl.,  Jan.) 

The  first  successful  total  removal  of  a  lung  for  primary 
carcinoma  was  performed  by  Graham  7  years  ago.  This 
patient  is  well  and  enjoys  a  normal  active  life.  From 
various  clinics  throughout  the  world  there  have  been  re- 
ported cases  of  persons  living  and  well  5  and  3  years 
after  total  pneumonectomy. 

Primary  carcinoma-  of  the  lung  is  not  an  uncommon 
disease.  It  was  found  to  have  an  incidence  second  only 
to  carcinoma  of  the  stomach  in  a  series  of  7,685  routine 
consecutive  autopsies  performed  at  the  Cleveland  Hospital; 
in  Jaffe's  series  of  6,800  the  lungs  held  third  place  in 
point  of  primary  source  of  carcinoma ;  the  stomach  and 
bowel  holding  first  and  second  places,  respectively. 

The  early  symptoms  are  cough,  pain  hemoptysis  and 
wheezing.  The  sputum  may  become  purulent  and  even 
fetid.  Blood-streaked  sputum  or  gross  hemoptysis  are 
very  alarming  symptoms,  but  they  do  not  occur  in  the 
majority  of  cases.  Fever  is  a  common  and  misleading 
symptom. 

Dyspnea  and  wheezing  (often  interpreted  as  asthma) 
may  occur  early  from  partial  occlusion  of  a  bronchus. 
Early,  many  patients  complain  of  sensations  of  pressure 
or   vague   distress;   only   a  few  of   actual  pain. 

The  diagnosis  may  be  suspected  upon  the  basis  of 
symptoms  and  physical  findings.  An  absolute  diagnosis 
can  be  made  only  from  a  biopsy  obtained  by  broncho- 
scope examination  possible  in  the  majority  of  cases  but 
impossible  in  those  cases  in  which  the  tumor  it  seated 
well  "around  the  corner"  in  an  upper-lobe  bronchus  or 
in  a  peripheral  portion  of  the  lung.  Biopsy  material  has 
been  procured  by  aspiration  into  a  needle  passed  through 
the  chest  wall  and  lung  into  the  tumor,  but  this  procedure 
is  too  dangerous.  Carcinoma  cells  have  been  found  oc- 
casionally in  the  sputum  so  that  a  search  of  several 
specimens  of  sputum  may  be  worth  while. 

In  those  cases  in  which  biopsy  material  cannot  be 
obtained,  but  in  which  the  evidence  otherwise  is  fairly 
conclusive,   exploratory   thoracotomy   should   be  done. 

In  a  case  of  my  own  this  operation  was  done  on  July 
19th,  1939.  Except  for  an  unexplained  period  of  high 
f>ver  lasting  a  few  hours  his  convalescence  was  unevent- 
••'    and    he    was    discharged    from    the    hospital    S    weeks 

'"-.  When  last  heard  from  8  months  after  operation, 
lie  felt  well  and  was  able  to  carry  on  his  usual  activities. 

Every  casualty  in  the  British  Army  now  receives  pro- 
phylactic sulfanilamide  for  48  hours  after  wounding.  The 
measure  is  an  important  step  in  reducing  mortalities.— R. 
Hare,  Toronto,  in   Canadian   Pub.   Health  Jl.,  Sept. 


HUMAN  BEHAVIOUR 

James    K.    Haix,    M.D.,    Editor,    Richmond,    Va. 


IS  THERE  BALM  IN  GILEAD? 

Not  since  Napoleon  was  at  the  height  of  his 
rampaging  in  Europe  has  a  new  year  made  its 
advent  into  a  world  so  filled  with  tragedy,  human 
slaughter,  destruction  of  property,  gloom,  fear  and 
hopelessness.  One  cannot  avoid  the  thought  that 
the  events  of  the  current  year  may  determine  for 
centuries  the  destinies  of  many  peoples.  Many 
governments  have  been  destroyed;  many  political 
geographic  lines  have  been  obliterated  by  the  mili- 
tary machine.  New  national  affiliations  have  been 
created  by  the  application  of  force.  Human  lives 
have  been  destroyed  by  the  millions.  Those  not 
yet  born  will  look  upon  the  blind,  the  seared,  the 
warped  and  the  distorted  by  the  millions — victims 
of  modern  military  efficiency. 

But  the  most  dreadful  injuries  will  not  be  ob- 
vious to  the  eye.  The  most  dreadful  assaults  are 
falling  upon  the  emotions  and  the  spirits  of  those 
within  the  countries  engaged  in  war.  Many  of 
the  victims  are  far  from  the  front  lines  of  war. 
But  the  battle-lines  can  no  longer  be  so  spoken 
of,  for  the  enemy,  unseen,  may  do  his  hurt  to  civil- 
ians from  the  air,  from  beneath  the  surface  of  the 
water,  from  an  armored  mobile  fort,  proof  against 
shot  and  shell.  And  many  traumatized  permanent- 
ly in  their  attributes  will  remain  helpless  cripples 
until  the  Boatman  takes  them  across  the  River. 
There  must  be  already  in  Europe  and  in  Asia 
millions  untouched  by  military  missiles  who  are 
helpless,  nervous  and  mental  wrecks,  consequent 
upon  the  terrors  through  which  they  have  lived. 
And  the  number  is  constantly  being  multiplied. 
Can  a  robust,  wholesome  progeny  spring  from 
parents  who  have  lived  through  the  devastations 
of  a  modern  war? 


PRUDENCE  INSTEAD  OF  PERSECUTION 
Neither  the  daily  press  nor  the  medical  jour- 
nals have  lately  referred  to  the  purpose  of  the 
President  of  the  United  States  and  his  responsive 
Prosecutors  to  bring  into  the  court-rooms  all  those 
many  physicians  who  were  only  recently  charged 
with  the  commission  of  grave  crimes.  Has  the 
President  decided  that  it  would  be  more  prudent 
t?  vai'  until  afler  the  physicians  had  ministered 
to  the  sick  and  the  wounded  of  the  services  in  the 
war  oul  of  which  the  President  has  kept  our  coun- 
try. 1  rfnre  he  Ins  the  doctors  convicted  and  branded 
as  malefactors?     The  Presidential  hostility  to  the 


SOUTHERN  MEDICINE  &  SURGERY 


January  1941 


physicians  has  lessened,  apparently,  just  as  his 
hostility  to  the  industrialists  has  likewise  cooled — 
and  for  the  same  reason — because  he  realizes  that 
he  would  be  handicapped,  indeed,  as  Commander- 
in-Chief  if  denied  the  enthusiastic  support  of  physi- 
cians and  manufacturers.  Had  the  war  alarm  come 
two  or  three  years  sooner  the  United  States  Sup- 
reme Court  would  have  been  saved  from  successful 
Presidential  assault.  Had  the  war-scare  not  dis- 
turbed the  Presidential  peace  of  mind  the  harass- 
ment of  the  physicians  and  the  industrialists  would 
have  been  kept  up. 

Once  upon  a  time  the  President  intimated  that 
he  had  dipped  an  eye  into  Macaulay;  or  did  one 
of  his  shadow-readers  do  the  dipping?  Sometime 
when  on  a  naval  or  a  piscatorial  cruise  he  might  turn 
the  Presidential  eye  to  an  essay  of  Bacon,  and 
learn  that,  in  the  opinion  of  that  mighty  Briton, 
adversity  is  the  most  effective  schoolmaster  the 
world  has  ever  known. 


INCLUSIVE?  EXCLUSIVE? 

The  instrument  of  the  press-photographer  seem- 
ed to  be  unable  to  find  in  the  group  of  medical 
notables  that  graced  the  recent  dedication  of  the 
new  psychiatric  addendum  to  Duke  Hospital  any 
psychiatrist  from  North  Carolina  save  Dr.  Robert 
Sproul  Carroll,  of  Asheville. 


UNRECOGNIZED  HYPOTHYROIDISM 
Not  infrequently  I  find  the  patient's  thyroid 
gland  is  apparently  not  functioning  up  to  the  nor- 
mal level.  I  should  say  rather  tha,t  the  presenting 
symptoms  of  the  patient  bring  me  to  that  diag- 
nostic thought.  What  complaints,  especially,  should 
cause  the  doctor  to  turn  his  thought  to  the  thyroid? 
In  a  youngster,  to  be  sure,  lessened  energy,  lessened 
interest,  inertia,  and  often  complaint  of  being  un- 
able to  do  at  all  except  by  vigorous  effort  those 
things  that  had  formerly  been  done  cheerfully  and 
easily  and  efficiently.  Gloominess  and  desponden- 
cy, with  self-reproaches  and  not  infrequently  with 
a  thought  of  suicide,  are  not  unusual  concomitants 
of  the  too-sluggish  thyroid  situation.  The  pulse 
is  likely  to  be  too  slow,  the  blood  pressure  below 
the  normal  level,  and  the  temperature  is  inclined 
to  be  subnormal.  The  hair  and  the  skin  are  gene- 
rally dry.  From  the  subthyroid  individual  the 
doctor  can  find  out  by  tactful  questioning  that 
even  the  most  torrid  summer  is  preferable  to  even 
a  mild  winter.  The  appetite  is  usually  lessened. 
Constipation  may  be  a  complaint.  The  appear- 
ance of  the  individual  may  have  undergone  change. 
There  may  be  a  tendency  to  pudginess.  The  lips 
may  be,  for  example,  slightly  thickened,  the  eyelids 
may  look  heavier,  and  the  tissues  about  the  eyes 
may  appear  a  little  puffy. 

Though  physical  and  mental  sluggishness  are 


usually  associated  with  hypothyroidism,  the  sub- 
thyroid  individual  may  be  rather  restless,  irritable, 
and  complaining,  acting,  indeed,  as  if  the  situation 
constituted  a  conscious  sort  of  vexation.  A  basal 
metabolism  test  will  usually  give  added  helpful 
diagnostic  information. 

I  am  certain  that  we  should  keep  constantly  in 
our  medical  minds  the  probability  of  existing  thy- 
roid dysfunction — more  especially  lowered  activity. 
In  the  first  third  of  life  the  condition  is  not  un- 
usual. I  think  I  mav  say  that  in  young  people 
the  condition  is  not  unusual.  Mayhap  the  demands 
made  upon  the  nervous  system  and  the  ductless 
glands  bv  the  hurry  and  the  hazards  and  the  ten- 
sion of  modern  life  cause  fatigue  of  the  thyroid; 
and  sometimes,  on  the  other  hand,  excitement  of 
the  gland,  with  too  much  outpouring  of  the  secre- 
tion. 


SURGERY 

Geo.   H.   Bunch,  M.  D.,   Editor,  Columbia,   S.   C. 


PLASMA  AS  AN  AGENT  FOR  TRANSFUSION 
IN  WAR 

The  increased  demand  for  blood  transfusions 
has  caused  the  establishment  of  blood  banks  in 
most  of  the  larger  hospitals  so  that  blood  of  any 
type  is  made  immediately  available  for  emergency 
use.  The  blood  bank  has  proved  its  worth;  many 
lives  are  being  saved  by  it. 

As  an  essential  part  in  the  national  defense  pro- 
gram which  is  being  put  into  operation  in  the 
United  States  every  soldier  with  a  negative  blood 
Wassermann  test  should  have  his  blood  typed  and 
the  type  recorded  with  the  name  of  the  soldier 
and  his  regiment  on  the  metal  identification  tag 
which  he  is  required  to  wear  suspended  from  his 
neck.  This  would  greatly  facilitate  finding  suit- 
able donors  to  supply  the  urgent  demand  for  blood 
which  would  arise  during  and  after  a  battle. 

However,  recently  acquired  evidence  that  plasma 
as  an  agent  for  transfusion  may  be,  apparently, 
in  many  cases  in  every  way  as  effective  and  as 
restorative  as  whole  blood  has  materially  changed 
our  conception  of  the  importance  of  the  causative 
role  played  by  the  loss  of  red  blood  corpuscles 
and  of  hemoglobin  in  the  symptoms  of  hemorrhage 
and  of  shock.  Transfusion  after  severe  burns 
should  always  be  of  plasma. 

For  military  use  plasma  has  many  advantages. 
Following  the  introduction  of  cellophane  tubing 
as  a  substitute  for  rubber  tubing  Hartman  (/.  A. 
M.  A.  Dec.  7th.  1940)  noted  the  rapid  concen- 
tration of  whole  blood  hung  up  in  Va-inch  tubes 
with  complete  desiccation  (drying)  of  ISO  c.  c.  in 
twelve  hours  at   70°   F.     Upon  this  principle  he 


January   1940 


SOUTHERN  MEDICINE  &  SURGERY 


has  perfected  a  method  by  which  plasma  may  be 
readilv  and  cheaply  desiccated  in  sterile  cellophane 
containers.  It  is  believed  that  in  these  containers 
desiccated  plasma  may  be  transported  and  kept 
indefinitely  before  use.  Upon  the  addition  of  ster- 
ile water  the  plasma  dissolves  and  is  ready  for 
transfusion.  However,  "In  case  of  an  emergency 
in  which  distilled  water  is  not  available  the  desic- 
cated plasma  may  be  regenerated  by  simply  im- 
mersing the  cylinders  in  water,  as  the  cellophane 
is  impermeable  to  bacteria  and  pyrogens.  By  rota- 
tion, sufficient  water  is  taken  up  so  that  a  satis- 
factory though  concentrated  plasma  is  obtained  in 
a  few  hours."  It  is  of  practical  interest  to  know 
that  the  cellophane  tubing  described  is  the  synthe- 
tic covering  or  skin  used  in  the  making  of  'hot 
dogs.' 

The  ability  to  concentrate,  to  dry  and  to  pre- 
serve plasma  cheaply  and  effectively  in  containers 
that  may  be  readily  stored  and  transported  will 
enable  America  to  send  quantities  of  it  overseas. 
To  be  effective  in  any  given  case  is  should  be 
administered  in  sufficient  quantity.  A  severely 
wounded  person  may  have  to  be  given  several  pints 
of  plasma. 

Unused  blood  in  the  bank  after  ten  days  storage 
may  be  salvaged  by  being  made  into  plasma. 

The  British  have  found  that  serum  is  equally 
useful  as  an  agent  for  transfusion  and  may  be 
preserved  in  a  similar  way  to  that  of  plasma. 
"There  are  certain  advantages  in  collecting  serum 
rather  than  plasma,  since  serum  will  dry  somewhat 
more  easily  than  plasma  owing  to  the  absence  of 
fibrin,  of  sodium  citrate,  sodium  chloride  and  pos- 
sibly dextrose."  (J.  A.  M.  A.  Dec.  28th.  1940, 
2285). 

Although  the  substitution  of  plasma  for  blood 
in  transfusion  is  still  somewhat  in  the  experimental 
stage  we  may  rest  assured  that  sufficient  progress 
has  been  made  to  greatly  simplify  the  problem 
of  transfusion  in  war. 


ture  as  an  adjunct  to  other  forms  of  treatment  of  cancer 
is  urged. 


A  CRITICAL  STUDY  OF  REFRIGERATION  THERAPY 

(M.    E.    Sano    &    L.    W.    Smith,    Philadelpha    in 

Jl   Lab.    &    Clin.    Med.,   Dec) 

This  is  a  study  of  SO  patients  with  malignant  disease 
subjected  to  local,  generalized,  or  combined  refrigeration, 
compared  to  37  closely  analogous  terminal  cases  of  cancer 
given   only   the   usual   treatment. 

Critical  analysis  of  the  heart,  lung,  liver,  spleen,  and 
the  kidney  findings  reveals  no  very  significant  differences 
in   the   two   groups. 

Acute  pancreatic  changes  were  found  in  about  10% 
<  I   the   persons   given    refrigeration. 

The  effect  of  refrigeration  upon  metastatic  disease,  as 
demonstrated  by  serial  x-ray  as  well  as  autopsy  studies, 
is  discussed.  It  is  suggested  that  at  least  240  hours  of 
such  generalized  refrigeration  is  apparently  needed  to  in- 
duce any  significant  regression  of  such  metastases,  and 
that  such   regressions  are  of  irregular  occurrence  only. 

The  further  exploration  of  the  use  of  reduced  tempera- 


PUBLIC  HEALTH 

N.   Thomas   Ennf.tt,  M.  D.,   Health   Officer  Pitt   County, 
Greenville,  N.  C,  Editor 


TULAREMIA— OR  RABBIT  FEVER 

We  are  now  in  what  is  known  as  the  rabbit 
season  in  North  Carolina,  the  time  of  year  when 
the  rabbit  is  a  part  of  the  diet  of  a  large  number 
of  our  citizens,  especially  those  in  the  rural  areas. 

Within  the  past  two  weeks,  two  cases  of  tulare- 
mia have  been  reported  in   Pitt  County. 

It  is  probable  that  other  areas  in  the  State  are 
similarly  affected,  and  we  have  to  assume  that 
where  two  cases  of  this  disease  are  reported  there 
are  many  others  unreported — undiganosed,  either 
because  no  physician  was  called  or  that  the  physi- 
can  did  not  study  the  case  with  tularemia  in  mind. 

We,  of  course,  are  interested  in  tularemia  chiefly 
from  the  public  health  standpoint.  What  we  shall 
say  about  the  disease  is  based  largely  upon  Rose- 
nau's  description  in  his  Preventive  Medicine  & 
Hygiene.  He  states  in  general,  that  the  only  ani- 
mals found  affected  in  nature  are  the  ground  squir- 
rels of  California  and  Utah  and  the  jack  rabbits 
and  cotton-tail  rabbits  of  the  several  states.  Rab- 
bits raised  in  rabbitries  are  not  affected. 

The  disease  is  transmitted  from  one  rabbit  to 
another  by  the  wood  tick.  Man  contracts  it  in 
this  way  and  by  handling  infected  animals  br 
carcasses,  which  accounts  for  the  incidence  among 
hunters,  cooks,  market  men  and  laboratory  workers. 

The  disease  was  first  described  by  McCoy  in 
1911  as  a  "plague-like  disease  of  rodents"  in 
California,  Tulare  County;  hence  the  name  tulare- 
mia. McCoy  and  Chapin  in  1912  discovered  the 
causative  organism,  Bacterium  tularense. 

The  incubation  period  is  from  two  to  five  days; 
the  onset  is  sudden  with  headache,  chills,  body 
pains,  vomiting  and  fever.  An  inflamed  papule 
develops  at  the  site  of  the  infection,  which  soon 
breaks  down,  liberating  a  necrotic  core  and  leaving 
a  small  punched-out  ulcer  with  raised  edges.  The 
regional  lumpnodes  become  painful,  swollen  and 
often  suppurate.  The  picture  is  that  of  an  acute 
lymphadenitis.  The  fever  lasts  two  or  three  weeks 
and  may  reach  104°  with  a  transient  remission 
on  the  third  or  fourth  day,  or  daily  remissions 
suggesting  a  septic  condition.  Convalescence  is 
slow  and  drags  along  with  weakness  for  several 
in  nibs,  nic'iinfs  ,i  year.  There  are  no  sequelae 
and  fatal  cases  in  man  are  rare.  So  far  as  is 
known,  the  disease  is  confined  to  the  U.  S.  and 
Japan. 


SOUTHERN  MEDICINE  (r  SURGERY 


January  1940 


The  history  of  the  case  and  the  symptoms  may 
suggest  tularemia,  but  the  diagnosis  depends  upon 
agglutinins  and  cultures  of  Bacterium  tularense. 

It  is  said  that  one  attack  in  man  confers  im- 
munity. Prevention  of  the  disease  is  chiefly  a 
matter  of  wearing  rubber  gloves  when  dressing 
rabbits. 

The  health  officer  can  inform  the  public  through 
the  newspapers  and  by  radio,  and  such  information 
to  the  public  can  be  greatly  extended  if  the  family 
physician  will  also  sound  a  word  of  caution  to  the 
families  under  his  care. 


RHINO-OTO-LARYNGOLOGY 

Clat  W.  Evatt,  M.D.,  Editor,  Charleston,  S.  C. 


PREVENTION  OF  DEAFNESS 

Many  cases  of  deafness  in  adults  can  be  pre- 
vented by  the  proper  treatment  in  childhood.  The 
Eustachian  tube  is  a  ventilator  and  its  obstruc- 
tion by  lymphoid  tissue  will  result  in  a  painless 
and  insidious  type  of  progressive  deafness.  Before 
the  age  of  puberty  adenoids  recur  in  more  than 
75  per  cent  of  the  children  whose  adenoids  and 
tonsils  have  been  removed...  In  many  cases  this 
tissue  cannot  be  removed  surgically.  This  lymph- 
oid obstruction  can  be  removed  safely  with  radium 
if  the  radium  is  used  in  the  proper  dosage,  at 
proper  time  intervals  by  a  competent  radiologist. 
Radium  must  not  be  used  indiscriminately  as  a 
treatment  of  deafness  but  only  in  those  cases  that 
show: 

1.  On  otoscopic  examination — Retraction 
of  the  tympanic  membrane — especially  Sharpnell's 
membrane. 

2.  On  nasopharyngoscopic  examination — 
Obstruction  of  the  Eustachian  tube  orifice  by 
lymphoid  tissue. 

3.  On  audiometric  testing — With  especial 
reference  to  8,000  d.  v.  and  the  higher  tones,  i.  e., 
their  reduction. 

If  these  conditions  are  found  in  a  child  before 
the  age  of  puberty  the  use  of  radium  is  indicated. 

In  using  radium  the  following  points  must  be 
kept  in  mind: 

1.  Radium  must  not  be  used  indiscrimin- 
ately as  a  treatment  for  deafness. 

2.  It  should  never  be  used  within  two 
weeks  of  an  upper-respiratory  infection. 

3.  The  best  results  are  obtained  in  child- 
ren with  beginning  impairment  of  hearing  as  a 
result  of  lymphoid  hypertrophy  obstructing  the 
Eustachian  tube  orifice. 

4.  Radium  in  the  form  of  Radon  seeds 


1.    Abstracted    from   an    article    in    The   Laryngoscope   for   July 
1940,    by    S.    J.    Crowe,    Baltimore. 


is  an  effective,  safe  and  painless  method  of  reduc- 
ing lymphoid  tissue  in  and  around  the  Eustachian 
tubes. 

5.  The  dosage  should  be  1.8  to  2  gram 
minutes  given  not  oftener  than  at  six  (6)  weeks 
intervals.  In  many  cases  it  has  been  found  neces- 
sary to  repeat  the  treatment  once  or  twice  a  year 
until  puberty. 

It  is  the  reviewer's  impression  that  this  work 
by  Dr.  Crowe  and  his  associates  is  a  noteworthy 
contribution  to  preventive  medicine,  translatable 
to  useful  application  in  the  hands  of  all  of  us  in 
our  daily  work. 

TUBERCULOSIS 

J.  Doiwdxt,  M.D.,  Editor,  Charlotte,  N.  C. 

HOARSENESS  IN  TUBERCULOSIS 

Hoarseness  in  the  course  of  tuberculous  disease 
is  a  frequently  occurring  symptom,  and  varies  from 
slight  voice  change  to  occasional  complete  aphonia. 
Many  patients  with  this  symptom  are  suspected 
of  having  laryngeal  tuberculous  ulceration,  and 
are  referred  to  the  laryngologist  for  examination 
for  that  condition.  Although  hoarseness  is  the 
most  frequent  symptom  in  tuberculosis  of  the  lar- 
ynx, the  percentage  of  patients  with  that  symptom 
who  have  tuberculous  laryngeal  ulceration  is  small. 
Indeed  there  may  be  at  times  extensive  tuberculous 
laryngeal  involvement  with  no  hoarseness  at  all. 

William  F.  Hulse  in  an  article  appearing  in  the 
December  issue  of  the  American  Review  of  Tuber- 
culosis discusses  this  symptom  when  found  asso- 
ciated with  tuberculosis,  the  possible  causes  and 
the  usual  significance  of  the  symptom.  He  says 
that  the  symptom  of  hoarseness  should  be  taken 
only  as  "a  valuable  adjunct  in  the  diagnosis  of 
laryngeal  tuberculosis  and  not  as  a  classical  sign 
or  symptom".  The  hoarseness  in  laryngeal  tuber- 
culosis is  often  described  as  typical  or  character- 
istic, but  he  has  not  found  this  to  be  true;  more- 
over, the  vocal  cords  are  not  solely  responsible 
for  the  quality  and  quantity  of  the  voice.  "The 
muscles  of  voice  production",  he  says  "should  not 
be  thought  of  as  including  only  those  which  alter 
the  position  and  tonus  of  the  vocal  cords".  To 
these  of  the  so-called  intrinsic  group  he  adds  an 
extrinsic  group.  Changes  in  the  voice  may  be  due 
to  either  intrinsic  or  extrinsic  factors  or  both. 

In  the  author's  opinion  pain  in  tuberculous  laryn- 
gitis is  not  frequent  unless  secondary  infection  has 
taken  place,  and  hoarseness  in  this  condition  is 
often  a  protective  measure  when  pain  is  present 
on  phonation.  Movement  of  the  cords  in  certain 
types  of  laryngeal  involvement  causes  such  severe 
pain  that  a  patient  will  speak  with  an  altered  voice 


January  1941 


SOUTHERN  MEDICINE  &  SURGERY 


in  order  to  attempt  to  keep  the  larynx  in  as  neu- 
tral a  position  as  possible.  In  tuberculous  disease 
of  the  larynx  the  following  causes  and  types  of 
hoarseness  are  given:  (1)  partial  or  total  fixation 
of  one  or  both  cords,  the  most  common  cause  of 
longstanding  hoarsenesss;  (2)  involvement  of  the 
arytenoid  joints,  the  resultant  hoarseness  being 
usually  persistent,  even  permanent;  (3)  involve- 
ment of  only  the  cords,  causing  hoarseness  through 
which  the  normal  voice  breaks  from  time  to  time; 
(4)  formation  of  a  mass  of  granulation  tissue  in 
the  posterior  commissure,  producing  more  pro- 
nounced hoarseness  than  the  causal  factor  seems 
to  warrant  (removal  of  tissue  by  cautery  causes 
return  to  normal  voice  in  a  few  days);  (5)  in 
exudative  types  of  laryngeal  tuberculosis  involving 
the  cords  the  hoarseness  is  uniform  in  contrast  to 
the  irregular  hoarseness  caused  by  the  ulcerative 
and  productive  type  of  lesions. 

Causes  of  hoarseness  in  tuberculosis  not  caused 
by  specific  involvement  of  the  larynx  are  given  as: 
(1)  hoarseness  caused  by  the  mechanical  irritation 
by  coughing,  in  which  the  larynx  shows  marked 
injection  with  many  dilated  blood  vessels,  but  no 
ulceration;  (2)  in  cases  with  an  associated  rather 
severe  bronchitis  due  to  irritation,  the  secretion 
spilling  over  into  the  larynx  and  causing  hoarseness 
from  the  resulting  adema;  (3)  hoarseness  caused 
by  the  thicker  sputum  in  the  chronic  stage  of 
disease  becoming  difficult  to  dislodge  from  between 
the  cords;  (4)  hoarseness  caused  by  various  types 
of  anomalies,  either  congenital  or  acquired.  (5) 
hoarseness  caused  by  the  common  cold,  when  it 
also  affects  the  larynx,  it  being  necessary  to  remem- 
ber that  tuberculous  patients  are  no  more  immune 
to  acute  infections  than  are  any  other  individuals. 
Hoarseness  due  to  a  cold  will  usually  clear  up  in 
a  week  or  two,  and,  in  the  author's  experience, 
patients  who  are  susceptible  to  repeated  attacks 
of  non-specific  laryngitis,  do  not  seem  to  be  sus- 
ceptible to  the  specific  type.  Bed-rest  and  collapse 
therapy  in  any  form  will  usually  relieve  at  least 
some  of  these  types  of  non-specific  laryngitis  by 
reducing  the  quantity  of  the  sputum.  A  patient 
who  is  hoarse  and  who  does  not  cough  and  who 
has  little  or  no  sputum  should  be  frequently  ex- 
amined to  determine  if  possible  the  cause  of  the 
hoarseness. 

The  author  enumerates  several  so-called  extrinsic 
causes  of  hoarseness  which  are  difficult  to  diagnose. 
These  include:  (1)  nerves  supplying  both  intrinsic 
and  extrinsic  muscles  of  the  larynx  may  be  affected 
by  actual  tuberculosis  or  by  toxic  absorption;  (2) 
some  early  obscure  central  nervous  system  lesions 
occasionally  manifest  themselves  by  hoarseness; 
(3)  tuberculosis  in  the  mediastinal  nodes  may 
cause  pressure  on  the  recurrent  laryngeal  nerves; 


(4)  cervical  lymphnode  involverment  may  cause 
vagus  nerve  pressure,  although  hoarseness  is  rare 
in  children  whose  tuberculosis  is  confined  to  the 
lymphatic  systems  of  the  lungs  and  cervical  region; 

(5)  hoarseness  caused  by  too  high  pressures  in 
the  induction  of  pneumothorax,  the  mediastinum 
being  displaced  to  the  other  side  causing  tension 
on  the  recurrent  nerves;  (6)  hoarseness  sometimes 
associated  with  tuberculosis  in  the  extreme  apex, 
when  fibrosis  has  exerted  tension  on  the  upper 
mediastinum  and  the  recurrent  nerves;  and  (7) 
hoarseness  is  often  present  in  patients  whose  gen- 
eral physical  condition  is  poor. 

It  is  emphasized  particularly  that  only  a  small 
percentage  of  patients  with  an  active  tuberculosis 
ease  of  the  larynx,  and  that  the  cause  of  horseness 
may  be  extrinsic  as  well  as  intrinsic.  Nevertheless, 
the  symptom,  when  it  has  a  tendency  to  persist 
or  recur,  should  be  thoroughly  investigated  for  the 
causative  factor.  In  the  examination  of  patients 
afflicted  with  active  tuberculous  disease  it  is  safer 
to  be  even  somewhat  over-zealous  in  the  search 
for  the  cause  of  certain  symptoms  than  to  be  lax 
in  any  particular.  Many  cases  of  tuberculous 
laryngeal  ulceration  are  rather  readily  curable 
under  the  proper  procedure,  and  the  earlier  the 
diagnosis  of  the  condition,  as  in  any  form  of  tuber- 
culosis, the  easier  and  quicker  the  eventual  cure. 


DENTISTRY 

J.   H.   Guioh,  D.D.S.,  Editor,  Charlotte,   N.   C. 

KERATITIS  CAUSED  BY  ABSCESSED  TEETH 
CURED   BY  THEIR   REMOVAL 

Many  reports  have  been  made  of  cure  of  infec- 
tive conditions  of  the  eye,  and  probable  saving  of 
vision,  by  removal  of  dental  foci  of  infection.  Such 
a  report1,  made  recently,  appears  to  bear  out  the 
importance  of  keeping  this  possibility  in  mind, 
although  it  is  unlikely  that  many  such  cases  will 
come  under  the  care  of  any  one  ophthalmologist 
or  any  one  dentist. 

The  typical  branching  corneal  vesiculation  of 
dendritic  keratitis  is  usually  associated  in  America 
with  malarial  infection.  In  the  case  reported,  no 
malaria  organisms  were  found. 

Four  first  permanent  molars  were  decayed  be- 
yond repair;  the  pulps  exposed  in  the  lower  right 
and  left.  The  roots  of  the  upper  right  and  lower 
left  were  partially  covered  with  gum  tissue.  These 
diseased  teeth  had  not  been  extracted  because  their 
presence  was  considered  necessary  to  prevent  the 
development  of  malocclusion. 

1.   E.   Shapiro,  D    D.   S..  and  H.   D.   Coles,  M.   D.,   Chicago,  in 
Jl.   Am.   Dental  Assn.,   August 


SOUTHERN  MEDICINE  &  SURGERY 


January  1940 


The  4  involved  molars  were  removed  under 
nitrous  oxide  anesthesia.  A  greenish  yellow  exu- 
date oozed  from  the  socket  of  the  upper  right  first 
molar  and  as  the  remaining  upper  roots  were  ex- 
traced;  and  around  the  apices  of  the  roots  were 
small  abscesses. 

Bacteriologic  studies,  made  from  the  extracted 
teeth,  the  cornea  and  the  conjunctiva  showed  white 
colonies  of  a  small  gram-positive  bacillus.  No 
streptococci  were  obtained. 

The  postoperative  complications  were  limited  to 
a  single,  hard  edematous  area  in  the  lower  left 
molar  region  which  prevented  the  patient  from 
opening  the  mouth  normally.  The  use  of  surgical 
packs  and  warm  moist  applications  to  this  area 
reduced  the  swelling  so  that  the  mouth  could  be 
opened  normally.  No  tenderness  to  pressure  nor 
fever  was  noted. 

One  day  later  the  branching  corneal  ulcer  had 
healed  although  there  had  been  no  change  in  the 
symptomatic  medication.  The  patient  was  dis- 
charged. 

The  report  indicates  that  infected  teeth  are  a 
probable  focus  in  keratitis  dendritica  as  medication 
of  the  cornea  proved  futile  before  the  dental  ex- 
tractions. Healing  of  the  eye  within  48  hours  after 
extraction  furnished  strong  evidence  that  the  focus 
of  infection  was  the  teeth.  It  would  seem  that 
prompt  cooperation  of  the  dentist  and  the  physi- 
cian saved  the  involved  eye. 

In  cases  of  infection  of  the  eye  that  do  not 
respond  to  treatment,  the  ophthalmologists  are 
having  all  foci  of  infection  in  the  mouth  cleaned 
up  and  are  getting  good  results  in  many  cases.  It 
is  just  as  important  that  pyorrhea  be  cured  as  it 
is  to  remove  teeth  with  apical  abscesses. 


THERAPEUTICS 

F.   Nash,   M.  D.,   Editor,   Saint   Pauls,   N 


THE  TREATMENT  OF  ACUTE  DELIRIA 
A  large  percentage  of  restraint  is  due  to  lack 
of  an  adequate  force  of  nurses,  budget  limitations 
in  hospitals  and  the  private  resources  of  patients; 
we  must  choose  restraint  as  the  lesser  of  two  evils. 
Patients  will  exhaust  themselves  more  rapidly  in 
restraint  than  if  allowed  to  get  up  and  wander 
about.  When  restraint  is  used  nurses  are  required 
to  loosen  every  two  hours. 

In  cases  of  cardiac  delirium  one  of  the  best 
remedies  is  %  to  y2  grain  of  morphine  intraven- 
ously. As  a  rule  morphine  is  not  the  best  drug 
for  excited  or  delirious  patients.  If  the  patient 
cannot  sleep  because  of  pain,  morphine  will  pro- 

1.   K    M.   Bowman,  New  York  City, 


duce  the  desired  effect. 

Hyoscine  is  uncertain.  Bromides  are  too  mild. 
Barbital  has  a  cumulative  action  if  used  over 
any  long  period.  It  may  be  desirable  to  omit  all 
medication  for  24  to  48  hours  to  see  if  the  patient 
does  not  quiet.  There  is  too  much  rather  than 
too  little  drugging.  The  urine  or  blood  should  be 
tested   for  bromides  and  barbiturates. 

Paraldehyde  seems  the  best  and  safest  hypnotic. 
If  a  patient  takes  it  eagerly  and  seems  to  enjoy 
it,  he  is  an  alcoholic.  Paraldehyde  is  the  most 
widely  used  hypnotic  in  psychiatric  hospitals,  less 
used  outside.  If  cannot  be  given  by  mouth,  thert 
either  rectally  with  a  small  amount  of  milk  to 
prevent  irritation,  or  it  may  be  given  intravenously. 
Another  excellent  hypnotic  fallen  into  disfavor 
is  chloral  hydrate.  As  much  as  30  grains  may 
be  given  as  a  single  dose,  repeated  in  one  hour  if 
necessary.  It  is  a  milder  drug  than  paraldehyde. 
The  reason  is  not  clear  but  experience  has  shown 
than  many  restless,  disturbed  patients  become 
quieter  when  given  plain  enemas. 

The  continuous  bath  at  96°  to  98°,  with  the 
patient  on  a  hammock  suspended  in  the  water  for 
long  periods,  even  days,  is  an  efficient  measure 
much  used  in  hospitals. 

The  cold  wet  pack  is  often  of  great  value.  Sheets 
dipped  in  cold  water  are  wrung  out  and  wrapped 
around  the  patient.  Blankets  are  then  added  out- 
side the  sheets.  A  hot-water  bottle  is  placed  at 
the  feet  and  an  ice-cap  or  cold  cloths  to  the  head. 
Do  not  continue  for  more  than  two  or  three  hours, 
watching  continuously  for  any  signs  of  collapse. 
An  overactive  febrile  patient  needs  more  liquids 
and  food  than  the  normal  person,  must  supply  at 
least  3,000  c.  c.  of  fluid  daily  to  prevent  fluid  loss, 
a  person  active  or  febrile  still  more.  A  minimum 
of  15  grams  of  salt  is  to  be  taken  every  24  hours. 
Probably  some  calcium  lactate.  Ordinary  studies 
of  blood  chemistry  tell  us  little  about  salt  loss. 
For  persons  finding  salt  unpleasant,  enteric-coated 
pills  are  used. 

Most  of  the  author's  exicited  and  delirious  pati- 
ents, a  large  unmber  in  alcoholic  deliria,  were 
given  two  capsules  of  sodium  chloride,  1  gram 
each,  q.  4  h.  during  the  first  day.  Orange  juice 
with  one  tablespoonful  of  sucrose  in  each  glass 
constituted  the  bulk  of  fluid  given.  Patients  who 
vomited  frequently  could  usually  retain  orange 
juice.  Patients  refusing  to  drink,  if  a  little  orange 
juice  was  spilled  on  their  lips  they  would  often 
take  the  rest.  Salt  and  fluid  often  quiet  without 
hypnotics.  Pulmonary  edema  is  likely  from  large 
amounts  of  intravenous  saline ,  especially  given 
rapidly.  Hypertonic  solution  of  sodium  chloride, 
300  c.  c.  of  a  5%  solution  intravenously,  had  a 

W.   Va.  Med.  Jl.    Dec    Q11'61'11?  effeCt  0n  the  Patients  and  then  tneY  WOuld 


January  1940 


SOUTHERN  MEDICINE  &  SURGERY 


ask  for  water. 

A  patient  with  much  alcohol  in  his  blood  is 
given  glucose  and  insulin  and  the  alcohol  will  be 
eliminated  at  twice  the  normal  rate.  If  will  take 
glucose  by  mouth,  give  from  SO  to  100  grams  of 
glucose,  and  10  to  25  units  of  insulin,  repeated 
two  or  three  times  daily. 

Vitamin  A  builds  up  the  capacities  of  the  organ- 
ism to  resist  infection.  Vitamin  B,  particularly 
Bi  and  nicotinic  acid,  absence  may  cause  mental 
disorders.  In  vitamin  C  deficiency  delirium  with 
scurvy  may  develop.  Vitamins  A,  Bj,  nicotinic 
acid  and  C — give  in  large  doses.  Vitamin  Bi  has 
a  fairly  specific  action  on  alcoholic  polyneuritis 
and  that  with  Korsakoff's  psychosis. 

Nicotinic  acid  seems  to  have  a  specific  effect  on 
certain  severe  deliria. 

A  patient  who  will  not  eat  and  whose  stomach 
is  not  so  inflamed  as  to  make  gastric  feeding  un- 
desirable, may  be  placed  in  a  camisole,  a  stomach 
tube  by  nose  and  kept  in  for  several  hours.  The 
Levine  tube  is  probably  preferable.  First  100  c.  c. 
of  saline  solution,  in  20  minutes  200  to  300  c.  c. 
of  water,  in  another  20  to  30  minutes  this  repeated. 
Giving  large  amounts  causes  risk  of  regurgitation, 
followed  by  asphyxiation  or  pneumonia.  After  giv- 
ing 1000  c.  c.  of  water  give  300  c.  c.  of  orange 
juice  with  50  grams  of  glucose  added:  25  units 
of  insulin  should  be  given  at  this  time.  The  Levine 
tube  is  then  withdrawn  and  restraint  removed.  As 
the  patient  improves  tub  therapy  is  discontinued 
and  the  patient  is  allowed  to  take  a  more  liberal 
diet.  Colloidal  aluminum  hydroxide  may  be  con- 
tinued as  long  as  gastritis  is  present,  in  which  case 
the  diet  must,  of  course,  be  bland.  Salt  is  con- 
tinued at  the  rate  of  90  grains  a  day  in  salt  tablets. 
Patients  will  ask  for  water  and  drink  large  amounts. 
Orange  juice  freely,  insulin  is  continued  in  small 
decreasing  doses  for  quieting  and  for  utilization 
of  carbohydrates.  Large  amounts  of  vitamins  are 
continued. 

PROTECTIVE  VALUE  OF  BISMUTH 
IN  SYPHILIS 

Bismuth  compounds  injected  intramusculary 
have  been  found1  to  protect  against  experimental 
syphilis  in  rabbits  and  against  clinical  syphilis 
in  prostitutes.  Sobisminol  is  effective  by  mouth  in 
all  stages  of  clinical  syphilis,  and  controlled  drink- 
ing of  sobisminol  solution  by  rabbits  acts  as  a 
preventive  of  syphilis  by  inoculation. 

Sobisminol  orally  should  be  comparatively  safe 
for  human  beings,  but  it  should  be  given  under 
the  supervision  of  a  physician,  clinic,  or  public 
health  department,  and  the  medication  should  be 

1.   P.  J.   Hanzlik  et  al,   in  Am.  J.   Syph.,   Gonor.   &   Ven.   Dit„ 
St.    Louis.,   July    1940 


controlled  by  frequent  examinations  and  a  chemi- 
cal test  for  bismuth  in  the  urine. 

Human  prophylaxis  has  not  yet  been  attempted 
with  sobisminol,  but  the  possibilities  of  making 
such  tests  appear  practically  feasible  on  special 
groups.     A  tentative  outline  for  this  is  suggested. 

A  complete  prophylactic  attack  on  syphilis  in 
a  country  as  a  whole  should  include,  in  addition 
to  premedication  and  postmedication,  the  following 
measures  favored  by  French  physicians:  (1)  Moral 
prophylaxis,  (2)  sartitary  education  of  youth,  and 
(3)  laws  to  provide  compulsory  physical  examina- 
tion before  marriage.  Drug  prophylaxis,  of  course, 
is  only  one  means  of  combat  in  the  general  war- 
fare on  syphilis. 

This  piece  of  investigative  work  looks  promising. 
It  seems  probable  that  this  may  be  an  effective 
element  in  the  nation-wide  crusade  against  syphilis. 
Developments  along  this  line  of  study  should  be 
watched  with  interest  and  applied  in  our  practice. 


OBSTETRICS 

Ivan   Marriott  Procter,  M.D.,   F.A.C.S.,   Editor 


APNEA  NEONATORUM 
All  of  us  want  to  improve  our  obstetric  results. 
A  recent  article  gives  us  some  valuable  points. 

The  author1  says  certain  obstetric  terms  are  so 
inept  that  they  lead  to  incorrect  thinking  and  even 
an  erroneous  concept  of  the  condition  designated. 
Referring  particularly  to  the  derivation  of  as- 
phyxia neonatorum,  he  states  that  the  term  comes 
from  the  Greek  and  means  not  to  throb,  literally 
an  absence  of  pulsation.  Galen  used  it  to  describe 
the  state  of  an  artery  distal  to  a  tourniquet  and 
as  late  as  1778  the  word  was  being  used  in  a 
broader  sense  to  convey  the  idea  of  apparent  death, 
as  from  drowning.  A  much  more  important  objec- 
tion to  the  term  is  that  obstetricians  have  com- 
monly come  to  use  it  to  describe  failure  of  a 
baby  to  breathe  at  birth,  whether  the  cause  be 
a  lack  of  oxygen,  cerebral  hemorrhage,  congenital 
defect  or  what  not?  A  few  physicians  entirely 
ignore  the  gravest  cause  of  apnea,  which  is  birth 
trauma,  as  well  as  the  commonest  cause  of  tem- 
porary apnea,  which  we  see  in  modern  obstetrical 
practice,  due  to  narcosis.  The  term  apnea  neon- 
atorum is  merely  descriptive  and  does  not  refer 
to  etiology.  It  is  preferable  to  the  term  asphyxia, 
which  should  be  limited  to  such  conditions  as  pro- 
lapse of  the  cord  and  premature  separation  of  the 
placenta,  which  prevent  proper  oxygenation  of  the 
blood. 


1.   J.    Eastman,    M     D.,    Baltimore,   in  Am.   Jour.    Obi.   &   Cyn., 
Oct.    1940. 


SOUTHERN  MEDICINE  &  SURGERY 


January  1941 


Etiology  and  Prevention 
Cerebral  Hemorrhage — The  most  common  cause 
of  fatal  apnea  at  birth  is  cerebral  hemorrhage,  the 
greater  number  from  the  trauma  of  operative  de- 
livery. Newborns  show  a  special  tendency  to  bleed, 
and  it  seems  probable  that  this  diathesis  plays  an 
auxiliary  role.  During  the  last  two  years  Hellman 
and  Shettles  of  Johns  Hopkins  Hospital  have  ex- 
plored the  possibility  of  raising  low  plasma  pro- 
thrombin of  newborn  infants  by  the  administration 
of  vitamin  K  to  mothers  in  the  prenatal  period. 
The  prothrombin  level  has  been  raised  when  vita- 
min K  was  given  four  hours  before  delivery.  Mas- 
sive cerebral  hemorrhage  of  birth  tramua  could 
not  be  so  prevented,  but  the  commonest  minor 
hemorrhage  from  the  subtentorial  space  may  be 
reduced  in  this  manner.  Hellman  and  Shettle 
after  administering  vitamin  K  to  500  expectant 
mothers  concluded  that  the  procedure  reduces  the 
incidence  of  all  types  of  hemorrhage  in  the  new- 
born. 

Narcosis — The  commonest  cause  of  temporary 
apnea  neonatorum  is  anesthesia  and  analgesia.    In 
the  experience  of  Eastman  nitrous  oxide-oxygen 
pushed  without  ether  to  the  point  of  surgical  anes- 
thesia is  a  more  frequent  offender  than  realized, 
because  of  the  resultant  fetal  anoxia.     The  time 
element  is  important  and  pure  nitrous  oxide  admin- 
istered for  four  or  five  breaths  to  produce  analgesia 
probably  causes  less  anoxia  than  a  mixture  of  85:15 
continued  for  five  minutes.     It  seems  plain  that 
when  nitrous  oxide-oxygen  is  given  a  woman  in 
labor  in  concentration  of  90:10  or  stronger  over 
a  period  longer  than  five  minutes,  marked  degrees 
of  anoxia  are  produced  in  about  one  baby  out  of 
three.     The  anoxia  may  not  prove  harmful,  but 
occasionally  it  leads  to  profound  and  even  fatal 
apena.    For   adequate   saturation    of    fetal   blood 
with  oxygen  the  mother  must  receive  15  parts  of 
oxygen   to   every    100   parts   of   nitrous   oxide;    if 
such  a  mixture  does  not  suffice  for  anesthesia,  one 
should  then  give  ether  in  addition.     Babies  with- 
stand long  labors  poorly  and  if  an  operation  is 
necessary   in   such   cases   give   ether   on   an   open 
mask  to  insure  liberal  oxygenation  of  the  child's 
blood.     The  same  is  true   in  breech  extraction, 
where  there  is  a  tendency  to  fetal  anoxia  due  to 
the  pressure  of  the  child's  head  and  shoulders  upon 
the  umbilical  cord.     Ether  passes  directly  through 
the  placenta  and  naturally  exerts  an  anesthetic 
effect  upon  the  child  and  it  is  this  influence  ap- 
parently and  not  anoxia  which  causes  an  occasional 
etherized  baby  to  breathe  slowly.   Time  and  gentle 
stimulation  usually  bring  satisfactory  reaction  in 
these  babies,  and   the  prognosis  is  always  better 
than  that  of  apnea  the  result  of  profound  anoxia. 
The  most  controversial  question  in  modern  obs- 
tetrics is:    Does  the  apnea  of  the  newborn,  which 


commonly  follows  the  use  of  a  modern  analgesic 
program,  jeopardize  the  baby  enough  to  condemn 
the  employment  of  these  drugs?  The  answer  is 
that  sedatives  given  in  amnesic  doses  do  inhibit 
the  onset  of  respiration  in  40  to  60  per  cent  of 
babies.  The  duration  of  apnea  is  from  a  few 
seconds  to  half  a  minute.  Not  very  infrequently  the 
effect  of  the  analgesic  drug  has  superimposed  upon 
it  the  effect  of  inhalation  anesthesia.  The  impres- 
sion of  the  author  is  that  the  ultimate  outcome 
for  mature  babies  born  under  analgesia  intelli- 
gently administered  is  just  as  good  as  it  is  for 
those  born  under  no  analgesia.  Respiration  in  the 
premature  baby  is  at  best  a  precarious  business 
and  should  not  be  hampered  by  the  use  of  de- 
pressant drugs.  The  necessity  for  difficult  forceps 
operation  arises  less  frequently  in  the  patient  who 
has  been  given  sedation.  This  is  a  result  of  rest 
for  the  patient  and  lack  of  demand  that  the  obste- 
trician interfere. 

Anoxia — If  oxygen  determinations  are  done  on 
the  blood  from  the  umbilical  vein  at  birth,  it  will 
be  found  that  most  apneic  babies  (narcosis  ex- 
cluded) show  very  low  oxygen  levels.  Whether 
the  anoxemia  is  due  to  primary  conditions,  such 
as  prolapse  and  obstruction  of  the  umbilical  cord, 
or  to  one  of  many  other  causes  can  not  always  be 
determined:  but  the  fact  remains  that  most  apneic 
babies  are  anoxic  and  this  should  be  taken  into 
consideration  in  our  plan  of  treatment. 

Prematurity  and  Congenital  Malformations  — 
Although  prematurity  is  the  most  common  cause 
of  neonatal  death,  it  is  seldom  responsible  for 
actual  apnea  at  birth  unless  narcosis  or  cerebral 
hemorrhage  be  superimposed. 

Treatment — Eastman  and  Kreiselman  in  treat- 
ing apnea  and  anoxemia  consistently  failed  to 
get  any  satisfactory  results  with  intravenous  or 
intramuscular  injection  of  alpha-lobeline,  metrazol 
or  coramine;  on  the  other  hand,  a  few  insufflations 
of  oxygen  produced  immediate  breathing.  In  their 
opinion,  the  one  treatment  of  apnea  at  birth  is 
insufflation  of  100  per  cent  oxygen.  The  attempt 
to  stimulate  respiration  by  the  addition  of  carbon 
dioxide  is  not  only  futile  but  may  be  dangerous. 
Editor's  Comment 
The  problem  of  apnea  is  twofold — prophylactic 
and  therapeutic.  Close  observation  of  the  fetal 
heart  throughout  labor,  especially  the  second  stage, 
is  necessary.  Take  active  steps  when  indicated, 
but  do  the  mother  no  harm.  Manage  the  breech 
and  forceps  extraction  with  gentleness.  Difficult 
operations  usually  mean  ill-advised  or  ill-timed 
operations. 
Therapy: 

1.  Remove  mucus  from  mouth  and  pharynx  as 
soon  as  the  head  is  born. 

2.  Handle  baby  gently.     Do  not  use  forceful 


January  1940 


SOUTHERN  U EDWIN E  &  SURGERY 


manipulation,  swinging,  compression  of  chest,  et 
cetera. 

3.  Keep  warm — heater,  blankets,  or  warm  bath. 

4.  Remove  mucus  from  trachea  gently  with  soft 
rubber  tracheal  catheter. 

5.  Give  inhalations  of  100  per  cent  oxygen. 


GYNECOLOGY 

G.  Carlyle   Coon,  M.  D.,  Editor,  Winston-Salem,  N.  C. 


THE  MALE  MAY  HAVE  TRICHOMONAS 
INFECTION 

A  few  years  ago,  while  making  an  extempor- 
aneous dissertation  before  the  Tri-State  Medical 
Association  the  writer  made  the  statement  that 
trichomonas  vaginalis  infections  are  easily  cured. 
The  statement  drew  considerable  criticism  because 
of  the  prevailing  opinion  that  it  was  difficult  to 
handle.  After  these  years  of  experience  since  that 
statement,  it  still  holds  true.  However,  the  chance 
reinfection  at  that  time  had  not  been  duly  con- 
sidered. 

Within  the  last  year  or  two,  many  cases  have 
been  seen  to  clear  up  of  symptoms  and  organisms, 
to  return  later  with  renewed  activity.  At  first  it 
was  assumed  that  there  had  been  no  cure,  and 
faith  in  the  common  starch  treatment  was  badly 
shaken.  Recent  investigations  showed  that  the 
male  may  harbor  the  organisms  almost  as  frequent- 
ly as  the  female,  that  the  trichomonas  may  be 
found  in  the  urethra,  in  the  prostate,  in  the  seminal 
vesicles,  and  even  in  the  blood  of  the  male.  It 
then  becomes  apparent  that  these  cases  were  not 
failures  of  cure  but  failures  in  preventing  reinfec- 
tion. The  problem  of  curing  the  wife  of  venereal 
diseases  takes  in  full  consideration  the  treatment 
of  the  husband.  It  is  only  now,  however,  that 
the  importance  of  this  phase  of  treatment  of  tri- 
chomonas vaginitis  infection  is  appreciated. 

Some  of  the  failures  in  cures  in  women  have 
been  due  to  the  lack  of  consideration  of  the  areas 
of  possible  infection  —  the  urethra,  the  external 
folds  of  the  labia  majora,  and  the  rectum.  When 
these  areas  are  thoroughly  cleansed  and  the  vagina 
filled  with  common  corn  starch,  the  disease  is 
readily  eradicated  by  from  4  to  8  daily  treatments. 

These  cases  will  remain  cured  if  genital  hygiene 
is  maintained  and  the  male  partner  is  free  from 
the  organism.  In  other  words,  it  becomes  highlv 
essential  and  desirable  that  the  gynecologist  be 
alert  to  this  possibility  and  inform  his  patients 
and  insist  that  their  partners  have  treatment.  In 
other  words,  more  evidence  of  closer  cooperation 
between  gynecologist  and  urologist  or  gynecologist 
and  family  doctor,  as  the  case  may  be. 


BENIGN  GYNECOLOGIC  HEMORRHAGES 

The  author1  covers  the  subject  well  and  gives 
a  helpful  discussion  of  the  various  phases  of  benign 
uterine  bleeding.  Uterine  bleeding  other  than  nor- 
mal menstruation  is  one  of  the  most  frequent  con- 
ditions that  the  general  practitioner  has  to  contend 
with  and  it  is  important  to  make  correct  diagnosis 
as  to  whether  benign  or  malignant.  The  following 
classification  is  interesting  and  instructive: 

1.  Functional  hemorrhages  as  a  result  of  en- 
docrine dysfunction  and  imbalance  occurring  at 
puberty,  during  the  childbearing  period  and  at  the 
menopause  when  there  is  no  demonstrable  lesion. 

2.  Hemorrhages  associated  with  neoplastic  dis- 
eases, including  cervical  and  corporal  polyps, 
myomas,  adenomyomas  and  ovarian  tumors. 

3.  Hemorrhages  associated  with  inflammatory 
disease,  as  salpingitis,  oophoritis  and  tuberculosis. 

4.  Bleeding  from  retained  gestational  products 
after  abortion  or  full  term  delivery,  and  tubal  preg- 
nancy. 

5.  Intraabdominal  hemorrhage  as  a  result  of 
ectopic  pregnancy,  endometriosis  and  ruptured 
ovarian  cysts,  adenomyomas. 

6.  Uterine  bleeding  from  miscellaneous  causes, 
such  as  cervicitis  with  erosion,  subinvolution,  hem- 
ophilia, hypertension  and  postoperative  hemor- 
rhage. 

The  author  deals  at  length  with  functional  hem- 
orrhage, stressing  the  part  played  by  the  endo- 
crines,  the  importance  of  biopsies  and  early  treat- 
ment, as  indicated.  He  concludes  by  cautioning 
women  and  physicians  as  to  the  danger  of  regard- 
ing irregular  bleeding  at  the  monopause  age  as 
normal.  In  every  case  it  should  be  considered  as 
possibly  malignant  until  this  is  disproved.  It  is 
a  presentation  which  should  be  read  and  studied 
by  every  practitioner  who  deals  with  this  type  of 
patient.  Perhaps  the  most  frequent  and  the  most 
serious  errors  of  the  general  practitioner  come  from 
neglecting  to  make  certain  examinations,  especially 
vagnial  and  rectal. 


1.  G.  G.  Ward,  New  York  City,  in  /.  A.  M.  A.,  Not    9th  1940, 


GENERAL  PRACTICE 

Walter    J.    Lackey,    M.  D.,    Editor,    Fallston,    N.    C. 


TREATMENT  OFINTRACTABLE  PAIN 

Every  practitioner  has  patients  whose  pains 
have  taxed  his  mental  and  their  own  financial 
resources.  A  small-town  doctor1  in  the  Middle 
West  writes  encouragingly  (and  not  too  enthusias- 
tically) on  this  subject. 

The  conditions  treated  were  diagnosed  as  myal- 
gia, neuritis,  neuroma,  arthritis,  lumbosacral  strain, 

1.   R.  A.   Youngman,   Falls  City,   in  Neb.  Stole  Med.  Jl.,  Ja«. 


SOUTHERN  MEDICINE  &  SURGERY 


January  1940 


strain  of  dorsal  spinal  ligaments. 

Two  different  solutions  were  used.  Solution  A 
had  following  formula: 

Isoamylhydrocupreine  0.005  gm. 

Ethylaminobenzoate  0.150  gm. 

Benzyl   alcohol  0.250  gm. 

Oil   sweet   almond  5.00    c.    c. 

This  solution  produces  local  anesthesia  lasting 
as  long  as  3  months.  It  may  produce  a  slough 
if  injected  subcutaneously. 

Solution  B  is  not  a  local  anesthetic.  It  is  an 
aqueous  solution  of  the  soluble  salts  of  the  vola- 
tile bases  of  the  plant  Sarrocenia  purpurea  (pitcher 
plant.)  To  each  5  c.  c.  of  this  solution  is  added 
33  mgm.  of  crystalline  vitamin  B.  Both  of  these 
solutions  are  injected  intramuscularly,  from  1  to 
10  c.  c.  at  a  treatment.  Usually  from  3  to  5 
treatments  are  required  for  satisfactory  relief. 
Ordinarily  some  relief  is  obtained  after  the  first 
injection  if  the  case  is  one  which  is  going  to  re- 
spond to  treatment.  As  far  as  I  know  there  is 
no  definite  rationale  behind  the  use  of  this  solution. 
I  inject  the  solution  directly  into  the  tender 
areas  in  the  muscles  or  ligaments,  whichever  the 
case  may  be.  A  total  of  5  c.  c.  may  be  used  at 
one  treatment,  the  amount  given  being  divided 
among  2  or  3  points  of  injection.  If  the  area  in- 
volved is  large  and  the  nerve  supply  is  readily 
accessible  it  is  advisable  to  infiltrate  the  nerve 
also. 

Six  of  the  11  patients  were  given  nearly  com- 
plete relief;  in  the  unsuccessful  cases  not  even 
partial  relief  was  obtained.  While  the  percentage 
of  cure  in  this  series  is  not  high,  it  should  be 
pointed  out  that  attempts  had  been  made  to  treat 
some  of  these  cases  by  other  methods  without  suc- 
cess and  one  patient  who  had  become  resigned 
to  a  prolonged  period  of  suffering  was  relieved. 

After  some  experience  with  this  method  I  feel 
that  the  physician  would  soon  learn  which  cases 
respond  satisfactorily  to  this  treatment. 


OPHTHALMOLOGY 

Herbert  C.  Neblett,  M.  D.,  Editor,  Charlotte,  N.  C. 


PENETRATING  AND  NON-PENETRATING 

FOREIGN  BODIES  OF 

THE  CORNEA 

These  foreign  bodies  are  either  attached  to  or 
embedded  in  the  substance  of  the  cornea.  The 
majority  are  embedded  when  seen  by  an  oculist. 
There  are  six  common  causes  which  serve  to  drive 
a  foreign  body  into  the  substance  of  the  cornea, 
any  one  of  which  may  be  a  sufficient  cause  alone 
or  all  may  be  combined  in  the  etiology. 

The  foreign  body  may  be  driven  with  sufficient 


force  to  penetrate  the  cornea  on  contact,  may  be 
hot  enough  to  do  so,  or  its  chemistry  may  produce 
it.  It  may  become  embedded  by  forceful  closure 
of  the  lids,  by  briskly  rubbing  the  eveball  with 
the  finger  over  the  lid  or  by  the  attempt  of  a 
friend  or  a  fellow  worker  to  remove  it  by  cumber- 
some means  and  rough  manipulation. 

At  the  time  of  the  injury  the  great  majority 
of  foreign  bodies  are  simply  attached  and  because 
of  the  acute  pain  produced  by  their  presence  force- 
ful closure  of  the  lids  and  rubbing  the  globe  with 
the  finger  serves  as  the  most  important  factor  in 
causing  the  foreign  body  to  become  embedded. 
All  foreign  bodies  of  the  cornea  are  to  a  degree 
embedded,  by  virtue  of  the  above  factors  at  work, 
if  they  are  allowed  to  remain  in  situ  for  24  to  48 
hours.  For  the  most  part  these  bodies  are  from 
pinpoint  to  pinhead  in  size.  Those  almost  micro- 
scopical and  semitransparent,  before  a  brown- 
hlack  iris,  are  difficult  to  locate.  Staining  the 
cornea  and  using  the  slit  lamp  is  sometimes  needed. 
As  a  rule  these  bodies  are  diamond-shaped  with 
sharp  angles  if  of  the  cinder  or  sand  type,  emery- 
wheel  particles  and  the  like;  flat  or  semi-flat  with 
sharp  serrated  edges  if  of  shale  or  rusty  iron.  In 
recent  years  a  type  frequently  carried  by  the  wind 
into  the  eye  from  the  street,  is  a  small  chip  of 
enamel  or  paint  from  automobiles  naturally  of  any 
color  or  shape.  In  a  case  recently  seen  the  body 
was  the  spear-point,  1-6  in.  in  length,  of  a  briar 
lying  in  the  substance  of  the  cornea  of  a  huntsman. 

If  the  foreign  body  is  over  the  apex  or  the 
upper  middle  third  of  the  cornea  pain  is  greater 
because  the  upper  lid  is  in  more  or  less  constant 
contact  with  these  areas. 

In  your  own  and  the  patient's  interest,  and  that 
of  insurance  carrier  and  employer,  take  the  visual 
acuity  of  each  eye  and  do  a  fundus  examination. 
Get  the  vision  in  each  eye  upon  termination  of 
the  case,  and  if  a  refractive  error  is  present  do  a 
manifest  refraction  to  reduce  vision  to  maximum 
efficiency  with  the  proper  lenses.  This  does  not 
mean  to  prescribe  glasses.  This  is  for  the  record. 
If  the  patient  has  glasses  determine  their  measure- 
ment and  the  visual  efficiency  with  them.  Deter- 
mine the  excursion  of  the  eyes  and  the  muscle 
balance  and  any  preexisting  condition  of  either 
eye.  This  in  the  interest  of  good  work  and  a 
comprehensive  record  of  the  case. 

In  removing  the  foreign  body  the  work  is  easier 
with  patient  prone,  the  oculist  standing  behind 
the  head.  Instill  a  few  drops  of  any  good  local 
anesthetic,  cocain  excepted,  and  after  3  minutes 
the  eye  is  under  sufficient  anesthesia  to  proceed. 
Pontocain  is  to  be  preferred  because  it  causes  no 
discomfort,  no  reaction  either  on  the  mucous  mem- 
brane or  the  pupil  and  allergic  reactions  are  rare. 


January  1940 


SOUTHERN  MEDICINE  &  SURGERY 


Irrigate  ahe  sac  before  and  after  removal  of  the 
foreign  body  with  zinc  sulphate  }4  gr->  boric  acid 
and  biborate  of  soda  10  grs.,  to  1  oz.  of  distilled 
water.  Have  a  sufficient  assortment  of  good  sharp 
spuds,  gouges,  small  round  curettes  and  a  dental 
burr  to  cleanly  remove  the  foreign  body  and  the 
stain  left  in  the  cornea  from  the  presence  of  the 
embedded  foreign  body.  It  should  be  remembered 
if  a  stain  is  present  after  removal  of  the  foreign 
body  it  causes  considerable  irritation  and  the  job 
is  only  half  done.  If  the  stain  or  rust  is  firmly 
adhered  at  the  initial  operation  requiring  much 
trauma  to  the  corneal  tissue  to  remove,  it  is  best 
to  fill  the  sac  with  boric  acid  ointment  and  occlude 
the  eye.  Twenty-four  hours  later  it  will  have 
become  loosened  sufficiently  to  remove  with  ease. 
The  foreign  body  should  not  be  scraped  out.  The 
instrument  should  be  inserted  beneath  it  and  the 
body  raised  out. 

The  eye  should  be  covered  for  the  first  24  hours 
following  the  removal  of  an  embedded  foreign 
body,  longer  if  healing  is  not  complete  as  witnessed 
by  staining  the  cornea  to  prove  it.  It  is  seldom 
necessary  to  use  an  eye  speculum  or  fixation 
forceps  in  these  cases.  The  globe  can  be  held 
practically  fixed  with  the  sterile  index  and  second 
finger  of  the  operator,  using  the  index  finger  to 
elevate  the  upper  lid  and  at  the  same  time  apply 
moderate  pressure  at  the  upper  and  outer  quadrant 
of  the  sclera  as  the  second  finger  slightly  depresses 
the  lower  lid  with  pressure  applied  at  the  lower 
and  inner  quadrant  in  holding  the  right  eye  with 
the  left  hand.  The  position  of  the  fingers  on  the 
globe  is  reversed  if  on  the  left  eye. 

Children  under  12  usually  require  a  general 
anesthetic  for  safety  of  the  eye  where  the  foreign 
body  is  embedded. 

If  a  physician  has  not  the  requisite  instruments 
and  proper  lighting  and  a  foreign  body  is  embedded 
in  the  cornea  it  would  be  in  the  interest  of  all 
concerned  that  he  fill  the  eye  sac  with  any  simple 
bland  oil  or  ointment,  occlude  it  and  direct  the 
patient  where  proper  facilities  are  to  be  had. 

A  mydriatic  is  rarely  indicated  in  this  type  of 
injury  and  if  so  it  is  because  too  much  trauma 
has  been  produced  to  the  cornea  by  the  operator. 
The  writer  has  strictly  followed  these  simple 
procedures  in  these  types  of  cases,  as  outlined,  for 
the  past  16  years  without  a  single  infection  and 
in  an  industrial  area  where  this  type  of  injury  is 
frequent. 

Dr.  Wilmer  said  to  one  of  his  assistants  who 
removed  a  foreign  body  from  one  eye  and  took 
no  stock  of  the  condition  of  its  fellow,  which  later 
proved  to  also  have  a  foreign  body  in  it:  "Searc 
carefully  the  injured  eye  for  more  than  one  for- 
eign body  and  after  removal  of  one  or  all  therein 
search  the  fellow  eye  likewise;   finally,  evert  both 


lids  of  each  eye  and  inspect  the  retrotarsal  folds 
for  a  foreign  body." 


HOSPITALS 

R.  B.  Davis,  M.  D.,  Editor,  Greensboro,  N.  C. 


WHY    TAX    THE    SICK    MAN? 

For  the  last  few  months  there  has  been  con- 
siderable agitation  in  our  State  concerning  the 
taxation  of  eleemosynary  institutions.  The  hue 
and  cry  has  been  that  these  institutions  have  prop- 
erty which  is  rented  or  utilized  in  competition 
with  private  property.  It  is  to  be  admitted  in 
the  beginning  that  this  is  true;  however,  if  we 
would  take  stock  of  the  benefits  derived  by  the 
private  property  owners  because  of  the  location 
and  operation  of  such  institutions  it  can  be  readily 
seen  that  the  private-property  owners  are  much 
ahead  of  the  game. 

The  three  main  eleemosynary  institutions  which 
will  suffer  most  are  the  churches,  colleges  and  hos- 
pitals. No  sane  man  would  argue  that  property 
is  more  profitable  in  a  city  where  there  are  no 
churches.  It  is  easy  to  see  that  the  good  influence 
of  the  church  in  a  city  greatly  enhances  the  morale 
of  the  citizenship.  This  in  return  keeps  the  tax 
figure  down  much  lower  than  it  would  be  otherwise. 
Lew  making  and  law  enforcement,  coupled  with 
the  expense  of  caring  for  the  criminal,  all  wiuld 
be  greatly  increased  were  it  not  for  the  good  in- 
fluence of  the  church.  For  this  reason  the  private- 
property  owners  should  gladly  encourage  church 
activities  and  expansion. 

When  the  question  of  colleges  is  discussed  here 
again  the  private-property  owner  is  benefited.  If 
the  eleemosynary  colleges  were  all  closed  the  de- 
mand upon  the  state  for  increased  college  facilities 
would  be  so  great  that  the  tax  rate  for  this  item 
alone  would  treble  any  taxes  which  could  possibly 
be  raised  from  the  now  existing  organizations. 

This  paper  is  essentially  concerned,  however, 
with  the  taxation  of  the  hospitals  in  our  State. 
Private  capital  would  not  purchase  a  piece  of 
property  in  a  state  where  there  were  no  hospitals. 
Experience  has  shown  that  where  the  state,  city 
or  county  attempts  to  furnish  hospitalization  them- 
selves for  the  indigent  sick,  invariably  the  per 
capita  cost  exceeds  that  of  those  hospitals  operated 
outside  of  political  control.  To  anyone  who  is 
interested  a  proof  of  this  statement  can  be  had 
from  the  Duke  Endowment  report.  This  being 
true,  it  is  difficult  for  those  of  us  who  are  operating 
hospitals  in  the  State  to  understand  the  attitude  of 
the  law-makers  and  courts  of  "justice."  It  is  the 
sincere  belief  of  the  writer  that  this  matter  has 
never  been  studied  in  its  true  light  and  it  it  hoped 


SOUTHERN  MEDICINE  &  SURGERY 


January  1940 


that  effort  on  the  part  of  the  hospitals  will  be  made 
for  a  true  analysis  of  the  hospital  problem  of  tax- 
ation in  North  Carolina. 

The  foregoing  facts  would  suffice  as  reasons  for 
eleemosynary  institutions  to  operate  tax-free.  How- 
ever, in  the  case  of  the  hospitals  this  is  by  no 
means  all  there  is  to  be  put  forward  in  favor  of 
such  exemption. 

The  sick  man  goes  to  the  hospital.  It  is  the 
sick  man's  money  which  takes  care  of  the  hos- 
pitalization. The  sick  man  cannot  work.  His 
income  is  greatly  reduced  if  not  completely  cut 
off.  He  is  of  all  people  often  the  least  able  to 
pay  for  even  the  necessities  of  life.  This  fact  is 
evidenced  on  every  corner  for  jurists  and  laymen 
alike  demand  that  the  hospitals  play  the  part  of 
the  good  Samaritan  at  all  times  and  under  all 
circumstances  regardless  of  the  cost.  Therefore, 
what  taxes  are  paid  by  the  hospitals  have  to  be 
derived  from  the  income  of  the  sick  man.  If  the 
sick  man  cannot  pay  for  the  necessities  of  life 
then  it  does  seem  that  this  is  a  very  poor  source 
from  which  to  derive  taxes. 

If  a  man  gets  into  civil  or  criminal  difficulty 
and  is  not  able  to  employ  counsel  to  defend  him- 
self the  great  State  of  North  Carolina  will  employ 
such  counsel  for  him.  Further,  it  will  furnish  a 
tax-free  court  house  to  try  him  in.  This  seems 
altogether  human  and  just  and  I  find  no  fault  with 
the  system.  Nevertheless,  I  cannot  shut  my  eyes 
to  the  injustice,  the  unreasonableness  and  the  hard- 
heartedness  of  the  method  of  taxing  the  institution 
which  is  supported  by  the  sick  man's  money.  In 
the  final  analysis  this  extra  taxation  will  be  added 
to  the  hospital  bill  of  every  patient. 

I  wish  to  invite  a  careful  investigation  and 
analysis  by  those  in  authority  concerning  this 
humanitarian  problem.  No  institutions  on  the  face 
of  the  green  earth  render  a  service  to  all  mankind 
every  day  of  the  year  more  willingly  than  do  the 
hospitals  of  the  land.  The  trustees  and  the  em- 
ployees all  need  the  sympathetic  cooperation  of  the 
public  at  large  and  especially  that  of  those  having 
the  taxing  power. 

In  order  to  partly  alleviate  this  expense  of  sick- 
ness the  hospital  people  have  organized  and  are 
now  maintaining  in  the  State  of  North  Carolina 
two  good  non-profit  hospital  insurance  corpora- 
tions whose  sole  purpose  it  is  to  help  the  well  man 
prepare  to  take  care  of  himself  when  he  is  sick. 
The  great  leaders  of  our  State  will  surely  do  no 
less  than  to  sympathize  in  an  economic  way  with 
the  sick  man's  pocketbook.  I  call  upon  them  to 
use  their  influence  at  all  times  and  under  all  cir- 
cumstances to  lighten  the  burden  of  the  hospitals 
which  are  so  hard  pressed  for  money. to  meet  the 
great  emergencies  which  arise  in  the  sick  and  in- 


jured  homan  body.     I  cannot  believe  that  they 
will  do  otherwise. 


THREE-QUARTERS  OF  A  CENTURY  FOR 
PARKE,  DAVIS  &  COMPANY 
The  year  1941  marks  the  Diamond  Anniversary  of  the 
founding  of  Parke,  Davis  &  Company.  A  firm  which  had 
its  inception  in  a  small  drug  store  in  the  City  of  Detroit, 
has  become  the  world's  largest  maker  of  pharmaceutical 
and  biological  products. 

From  the  vary  beginning,  research  work  with  the  object 
of  making  available  to  pharmacists  and  physicians  medi- 
cinal preparations  of  the  highest  degree  of  accuracy  has 
been   an   important   feature  of   the  firm's  work. 

In  the  early  70's,  pharmaceutical  progress  meant  the 
discovery  of  new  vegetable  drugs.  Energetic — and  exten- 
sive— explorations  gave  to  the  medical  profession  such 
valuable  and  widely  used  drugs  as  Cascara  and  Coca. 
Then,  in  1879,  came  one  of  Parke-Davis's  greatest  con- 
tributions to  pharmacy  and  medicine — the  introduction  of 
first  chemically  standardized  extract  know  to  pharmacy. 
Desiccated  Thyroid  Gland,  the  first  endocrine  product  sup- 
plied by  the  Company,  was  introduced  in  1893.  One  year 
later,  Parke-Davis  established  the  first  commercial  bio- 
logical laboratory  in  the  United  States.  In  1897  came  the 
introduction  of  the  first  physiologically  assayed  and  stan- 
dardized extracts. 

In  the  present  century,  progress  of  the  Company  has 
continued  apace.  An  aggressive  program  of  research  has 
been  zealously  pursued,  marked  by  the  introduction  of 
such  important  medicinal  products  as  Adrenalin,  Ventri- 
culin,  Theelin,  Pitocin,  Pitressin,  Mapharsen,  Neo-Silvol, 
Antuitrin-S,  Meningococcus  Anttoxin,  Dilantin  Sodium, 
and  many  others. 

The  Company's  home  offices  and  research  and  manufac- 
turing laboratories  in  Detroit  occupy  six  city  blocks  on 
the  Detroit  Riverfront. 

A  beautiful  farm  of  700  acres,  known  as  Parkdale  and 
located  near  Rochester,  Michigan,  about  30  miles  from 
Detroit,  is  utilized  for  the  production  of  anitoxins,  serums 
and  vaccines,  and  for  the  cultivation  of  medicinal  plants. 
In  addition  to  its  Detroit  headquarters,  branches  and 
depots  are  mantained  in  important  cities  throughout  the 
country,  the  list  including  Atlanta,  Baltimore,  Boston, 
Buffalo,  Chicago,  Cincinnati,  Dallas,  Denver,  Indianapolis, 
Kansas  City,  Minneapolis,  New  Orleans,  New  York,  Phila- 
delphia, Pittsburgh,  San  Francisco,  St.  Louis,  and  Seattle. 
Branches  are  located  in  London,  England;  Sydney, 
N.  S.  W.;  Walkerville,  Ontario;  Montreal,  Quebec;  Toron- 
to, Ontario;  Winnipeg,  Manitoba;  Bombay,  India;  Havana, 
Cuba;  Buenos  Aires,  Argentina;  Rio  de  Janeiro,  Brazil; 
and   Mexico    City,   Mexico. 

Through  the  use  of  full-pages  in  leading  national  maga- 
zines Parke,  Davis  &  Company  are  carrying  on  an  adver- 
tising program  that  has  attracted  wide  attention.  As 
might  be  expected,  their  advertising  is  ethical  and  dis- 
tinctive. They  make  no  direct  attempt  to  sell  their 
products  to  the  public  by  means  of  this  publicity.  In  a 
well-considered  effort  to  render  a  valuable  service  to  the 
medical  profession,  they  are  running  a  striking  series  of 
messages  based  on  the  "See  Your  Doctor"  theme,  and 
physicians  throughout  the  country  are  constantly  experi- 
encing  evidences   of   the   results  of   this  program. 


The  Post  Graduate  Surgical  Assembly  of  the  South- 
eastern Surgical  Congress  will  be  held  at  Richmond, 
Virginia  March  10th  -  12th.  The  John  Marshall  Hotel 
will  be  headquarters. 


January  1941  SOUTHERN  MEDICINE  &  SURGERY  31 

SOUTHERN  MEDICINE  &  SURGERY 

Official  Organ  THE  TRI-STATE  MEETING  NEXT  MONTH 
TRI-STATE    MEDICAL    ASSOCIATION    OF    THE  February  24th-2Sth 

CAROLINAS  AND  VIRGINIA  Preparations  for  the  forty-third  meeting  of  this 

James  M.  Northtngton,  M.D.,  Editor  hodY  of  doctors  are  Just  about  complexed.     There 

is  every  assurance  of  the  kind  of  meeting  you  will 

Department  Editors  enjoy  while  you  are  in  attendance  and  enjoy  more 

Human  Behavior  as  you  give  your  patients  the  benefit  of  the  infor- 

Jamxs  K.  Haix,  M.D Richmond,  Va.  mation  you  received  in  exchange  for  information 

Orthopedic   Surgery  you  imparted. 

Oscar  Lee  Miller,  M.  D  I  Charlotte  N  C  G"ur  president  will  inform  us  on  the  latest  things 

John  Stuart  Gaul,  M.D. f in  obstetric  care. 

Urology  Guest   speakers   will   come   from  Lincoln,   from 

Hamilton  W.  McKay,  M.D.  I Charlotte,  N.  C.  New   Y,ork,    from    Baltimore,    from    Augusta   and 

Robert  W.  McKay,  M.D )  frorn   Rochester,  each  bringing  instruction   in   the 

Surgery  best  ways  of  getting  sick  folks  well,  then  keeping 

Geo.  H.  Bunch,  M.D _ Columbia,  S.  C.  ^        wgjj 

_  T   T  „  _,  s  e  ncs  _.      .„     ,,  A   number   of   the   men   conveniently  near  will 

Henry  J.  Langston,  M.D Danville,  Va.         .  .  .  ...         ■; 

Ivan  M.  Procter,  M.D Raleigh,  N.  C.  glve  clinics,  in  which  the  participation  of  our  guests 

Gynecology  speakers  is  anticipated. 

Chas.  R.  Robins,  M.D Richmond,  Va.  These   clinics   will   cover   a   variety   of   disease 

G.  Carlyle  Cooke,  M.D Winston-Salem,  N.  C.  conditions  encountered  in  every-day  practice,  man- 

Pediatncs  ifesting  themselves  by  a  great  diversity  of  symp- 

G.  W.  Kutscher,  Jr.,  M.D Asheville,  N.  C.  .  A     c-a-  r>         n  u  u 

'  J   '  .  toms    and    findings.     Our    Greensboro    members 

J.  L.  Hamner,  M.D.G.e.".e.rl.P.r!C.'!!! Mannboro,  Va.  have  extended   themselves   to  make   this   feature 

W.  J.  Lackey,  M.D Fallston,  N.  C.  particularly    instructive    and    attractive.       Some 

Clinical  Chemistry  and  Microscopy  original  work  will  be  presented. 

C.  C.  Carpenter,  M.D )  Addresses,  clinics  and  essays  are  arranged  with 

R.  P.  Morehead,  B.S.,  M.A.,  M.D..)'  Forest,  N.  C  tne  end  in  view  of  dealing  with  sick  persons  as 

Hospitals  wholes. 

R.  B.  Davis,  M.D Greensboro,  N.  C  Other  members  will  discourse  on  wound  healing; 

Cardiology  cancer  and  its  cure(z.  e.,  its  care);   diagnosis  of 

Clyde  M.  Gilmore,  A.B.,  M.D Greensboro,  N.  C.  bleeding   in   the   brain;    postoperative   distention; 

Public  Health  treatment   with   plasma;    pulmonary   hemorrhage; 

N.  Thos.  Ennett,  M.D Greenville,  N.  C.  blindness  prevention;    hand   injuries;    toxemias  of 

Radiology  pregnancy;  breast  tumors;  arthritis;  skin  grafting 

Wright  ClarksonM.D.,  and  Associates....Petersburg,  Va.  in  orthopedic  conditions;  gunshot  wounds  of  the 
R.  H.  Lafferty,  M.  D.,  and  Associates,     Charlotte,  N.  C.  ,,         .?      ,.  ,.x. 

pregnant     uterus;      thyroid     disease     conditions; 

r   !•   »T        „«■  ^  erapeutics  obscure    but    important    eye    conditions;    and  ,  of 

J.  F.  Nash,  M.  D., Saint  Pauls,  N.  C.  ,  ,,  .,        J 

course,  the  sulfonamides. 
Tuberculosis  „  .  ,  .  ,         ,  , 

John  Donnelly,  M.D Charlotte,  N.   C.  A11  survivors  of  the  group  that  gathered  for  the 

D     .  first  meeting  of  the  Association,  held  at  Charlotte 

J.  H.  Guion,  D.D.S Charlotte,  N.  C.  in  1899>  are  bemg  ur8ed  to  8race  the  occasion  as 

Internal  Medicine  SPedal     8UeStS-       0ne     °f     th'S     gr0UP-     Dr-     Paul 

Georce  R.  Wilkinson,  M.D Greenville,  S.  C.  Barrmger,  of  Charlottesville,  has  died  since  these 

Ophthalmology  invitations  were  sent  out. 

Herbert  C.  Neblett,  M.  D., Charlotte,  N.  C.  Another  of  them  promises  to  discuss  the  appen- 

Rhino-Oto-Laryngology  dicitis  of  43  years  ago  and  that  of  today. 

Clay  W.  Evatt,  M.  D.,  Charleston,  S.  C.  It's  easy  to  get  about  now.     You  will  want  to 

Offerings  for  the  pages  of  this  Journal  are  requested  and  *et  t0  Greensboro  taking  along  a  doctor  neighbor. 

given  careful  consideration  in  each  case.    Manuscripts  not  You  wll]  want  to  attend  all  the  sessions.     Our  in- 

found   suitable   for   our   use   will   not    be   returned   unless  fluenza  promises  to  be  past  by  the  time  of  the  meet- 

author  encloses  postage.  ;ng     Let  nothing  interfere  with  your  plan  to  attend 

As  is  true  of  most  Medical  Journals,  all  costs  of  cuts,  an(j  fake  an  active  nart 
etc.,  for  illustrating  an  article  must  be  borne  by  the  author. 


SOUTHERN  MEDICINE  &  SURGERY 


January  1940 


CANCER  OF  THE  STOMACH 

Several  of  the  recent  Reports  of  the  Staff  Meet- 
ings of  theMavo  Clinic  have  devoted  space  to  the 
kind  of  cancer  which  is  most  insidious  and  as  to  the 
male,  most  common. 

Stomach  surgery  begins  with  the  work  of 
Billroth,  so  it  is  fitting  that  this  dealing  with  the 
subject  should  be  introduced  with  a  brief  sketch  of 
that  great  surgeon. 

Charles  Albert  Theodor  Billroth  was  born  at 
Bergen.  Norway,  in  1829.  He  studied  medicine  in 
Germany  and  was  graduated  from  the  University 
of  Berlin  in  1852.  After  brilliant  service  as  assist- 
ant in  Langenbeck's  clinic  in  1860  he  was  made 
Professor  of  Surgery  at  Zurich,  where  he  became 
a  permanent  resident  for  seven  years.  He  then 
went  to  Vienna,  where  he  remained  as  professor 
of  surgery  until  his  death  in  1894. 

Billroth  was  a  master  operator  as  well  as  a  keen 
clinician;  he  did  a  vast  amount  of  research  in  the 
laboratory  and  in  the  hospital.  He  was  a  great 
teacher,  and  had  the  faculty  of  inspiring  enthusi- 
asm and  energv.  He  was  an  accomplished  musi- 
cian— the  author  of  a  large  volume  on  music. 

In  addition  to  his  many  contributions  in  the 
field  of  gastric  surgery,  he  performed  the  first  re- 
section of  the  esophagus  and  the  first  laryngec- 
tomy for  cancer.  He  trained  Mikulicz,  Wolfler,  von 
Eiselberg,  Czerny  and  many  others.  Billroth's  first 
successful  partial  gastrectomy  was  performed  on 
Teresa  Haller,  who  had  a  polypoid  cancer  in  the 
distal  portion  of  her  stomach.  One-third  of  the 
stomach  was  resected  and  gastro-intestinal  contin- 
uity was  re-established  by  the  Billroth  I  type  of 
procedure.  The  patient  was  dismissed  from  the 
hospital,  apparently  in  good  health,  22  days  fol- 
lowing her  operation.  She  succumbed  in  four 
months  from  "cancerous  degeneration  of  the  peri- 
toneum." Billroth  performed  two  similar  opera- 
tions in  1881  but  both  patients  died  during  the 
early  postoperative  period.  The  following  year 
Wolfler  made  a  gastric  resection  and  the  patient 
lived  for  1J4  years  following  the  operation. 

By  1886,  37  partial  gastrectomies  for  cancer  of 
the  stomach  had  been  reported,  with  an  operative 
mortality  rate  of  73%.  Billroth  performed  eight 
of  these,  Czerny  four,  and  25  were  done  by  25  sur- 
geons. The  mortality  rate  for  the  eight  cases  was 
37%.  It  was  thus  demonstrated  that:  one,  partial 
gastrectomy  could  be  done  and  the  patient  sur- 
vile;  two,  there  was  some  possibility  of  longevity 
following  such  removal;  and  three,  some  degree  of 
special  training  of  the  surgeon  resulted  in  lowered 
operative  mortality.  Only  patients  who  were  in  the 
most  unfavorable  condition  were  operated  on  in 
this  period.    The  early  diagnosis  of  cancer  of  the 


stomach  was  impossible. 

W.  J.  Mayo's  early  writings  on  the  subject  were 
quoted  and  requoted,  and  his  illustrations  were 
reproduced  in  most  of  the  standard  textbooks  of 
the  time.  His  first  report  was  in  1894  and  hardly 
a  year  passed  thereafter  that  he  did  not  make  ad- 
ditional reports.  That  made  in  1910,  of  627  oper- 
ations for  gastric  carcinoma,  with  resections  in 
36%  of  the  cases  and  a  mortality  rate  of  12% 
reveals  his  great  accomplishments  in  this  field  at 
this  early  date.  C.  H.  Mayo  and  Balfour  also  con- 
tributed largely.  Also  prominent  in  this  early  work 
were  Pean,  Kocher,  von  Winiwarter,  von  Eisel- 
berg, Hemmeter,  Doyen,  Witzel,  Hartmann, 
Mayo-Robson,  Bland-Sutton,  Cuneo,  Bull,  Gross, 
Keen,  Finney,  Ochsner,  Moynihan  and  a  number 
of  others. 

Cancer  of  the  stomach  is  by  far  the  commonest 
malignant  growth.  More  persons  die  as  the  result 
of  a  primary  malignant  lesion  in  this  location  than 
anywhere  else  in  the  body.  Two-and-a-half  times 
as  many  persons  died  in  this  country  from  cancer 
of  the  stomach  during  15  years  of  peace  as  were 
killed  and  died  of  wounds  in  all  of  the  wars  in 
which  the  United  States  has  participated.  Empha- 
sis must  be  placed,  therefore,  on  the  necessity  of 
early  recognition  of  this  disease,  for  which  surgery, 
early,  is  the  only  hope  of  cure.  The  possibility  of 
the  presence  of  malignant  disease  must  be  consid- 
ered whenever  a  patient  complains  of  symptoms 
referable  to  the  stomach  which  do  not  respond 
promptly  and  permanently  to  simple  remedies. 
During  the  period  1937-1939  30%  of  all  patients 
seen  with  carcinoma  of  the  stomach  underwent 
partial  resection,  whereas  15  years  previously  in 
only  20%  could  promise  be  made  of  any  reason- 
able chance  of  improvement  justifying  this  pro- 
cedure. 

The  fact  must  be  impressed  on  physicians  and 
laymen  that  there  is  no  clinical  syndrome  typical 
of  carcinoma  of  the  stomach. 

In  the  period  1907-1938,  10,890  patients  for 
whom  a  diagnosis  of  malignant  lesion  of  the 
stomach  had  been  made  were  examined  at  the 
clinic.  Of  these,  6,352  underwent  operations — 2,- 
840  were  resections.  The  mean  age  of  patients  who 
had  carcinoma  was  55.  There  were  3.5  times  as 
many  males  as  females  in  this  group.  The  lesion 
was  removable  in  44%  at  all  ages.  Dyspepsia  and 
disturbance  of  gastric  motility,  whether  only  mild 
fullness  after  meals  or  vomiting,  was  present  in 
half  of  the  cases,  regardless  of  whether  the  gastric 
lesion   was   removable  or  nonremovable. 

Eighteen  per  cent  had  had  symptoms  for  5  years. 
How  many  of  these  symptoms  were  due  to  the 
cancer  is  unknown. 

Eighty  per  cent  of  those  treated  as  ulcer  before 


January  1941 


SOUTHERN  MEDICINE  &  SURGERY 


coming  to  the  clinic,  responded  as  to  be  expected 
in  ulcer  cases.  Among  those  who  had  a  pal- 
pable abdominal  mass,  the  lesions  of  40%  were 
removable,  whereas  among  those  whose  rectal  or 
cervical  glands  found  by  the  clinician  suggested 
metastasis,  only  20%  had  resectable  gastric  les- 
ions. The  group  who  had  no  abdominal  mass,  no 
evidence  of  rectal  metastasis  and  no  evidence  of 
cervical  metastasis:  rate  of  removability  was  50%. 

Since  the  advent  of  diagnostic  roentgenologic 
study  of  the  gastro-intestinal  tract,  in  that  group 
in  which  lesions  were  removable,  a  definite  diag- 
nosis of  cancer  was  made  in  75%.  In  an  addition- 
al 13%  of  cases  there  was  some  gastric  lesion. 
In  99%  of  cases  in  which  the  lesions  could  be  re- 
moved, the  roentgenologists  reported  some  type 
of  gastric  lesion.  The  roentgenologist  should  be 
given  the  opportunity  to  examine  any  patient  more 
than  thirtv  years  old  who  presents  reasonably  in- 
dicative evidence  that  he  has  digestive  disease. 

Few  of  the  cases  the  radiologist  thought  inoper- 
able were  surgically  explored. 

In  the  period  1907-1938,  the  diagnosis  of  ma- 
lignant lesion  of  the  stomach  was  made  at  the 
Clinic  for  10,890  patients;  42%  of  these  patients 
either  could  not  be  operated  on,  or  left  the  Clinic 
without  being  operated  on;  58%  were  subjected 
to  surgical  exploration.  Of  these  the  lesions  of  45% 
proved  to  be  removable  (of  the  original  total 
group  26%).  The  hospital  mortality  rate  for  the 
2,840  patients  for  whom  resection  was  performed 
was  16%  (this  including  those  in  which  total  gas- 
trectomy was  performed).  For  16%  of  the  patients 
who  underwent  exploration,  a  palliative  operation 
only,  such  as  gastro-enterostomy,  was  performed, 
and  for  these  the  rate  was  12%.  For  those  for 
whom  exploratory  laparotomy  only,  4% — a  fig- 
ure sufficiently  low  to  warrant  operation  in  any  case 
holding  out  any  reasonable  hope  of  its  proving  of 
advantage  to  the  patient. 

The  5-year  survival  rate  after  resection  is  29% 
— adjusted  for  the  normal  death  rate,  32%;  10- 
year  rate  20% — adjusted  for  the  normal  death 
rate,  25%.  For  patients  whose  symptoms  had  been 
present  for  less  than  a  year,  the  5-year  survival 
rate  was  25%;  whereas  for  patients  with  symp- 
toms for  more  than  a  year,  the  5-year  survival 
rate  was  32%. 

This  accurate,  detailed  report  on  a  large  number 
of  cases  of  a  common  and  generally  fatal  disease 
should  stimulate  all  doctors  to  be  more  alert  to 
find  the  cases  of  stomach  cancers  of  their  patients 
early. 

The  report  appeals  as  the  most  definite  state- 
ment of  the  case  to  be  found.  The  facts  presented 
are  encouraging.  The  advice  offered  is  convinc- 
ing. 


SMALLPOX  IN  THE  UNITED  STATES 

That  there  has  occured  even  one  case  of  small- 
pox in  the  literate  world  in  the  century  just  past 
is  proof  positive  that  Carlyle's  observation  that 
people  are  "mostly  fools"  has  foundation  in  fact. 

A  Public  Health  Report  just  out  shows  that 
with  all  our  muddling  as  to  this  disease,  somehow 
we  are  having  fewer  cases. 

In  the  20-year  period  from  1900  to  1919  three- 
quarters  of  a  million  cases  of  smallpox  were  re- 
ported in  the  United  States,  and  in  the  two  suc- 
ceeding decades  the  number  totaled  700,000  cases, 
75  per  cent  of  them  1920-1929.  During  the  period 
1900-1919,  11,435  deaths  from  this  disease  were 
recorded;  from  1920  to  1939  5,337,  90  per  cent 
of  which  occurred  from  1920  to  1929.  Also  there 
has  been  a  progressive  change  in  the  type  of  small- 
pox during  the  past  four  decades.  The  mild  or 
alastrim  type  of  smallpox  may  have  originated  in 
South  Africa2.  It  appeared  in  the  United  States 
in  1896,  apparently  entering  Florida,  from  which 
locality  it  spread  rapidly  to  all  parts  of  the  country. 

The  malignant  and  mild  forms  may  represent 
two  separate  strains  of  the  virus,  and,  although 
exhibiting  some  variations,  the  mild  form  bred  true 
with  no  evidence  of  reversion  to  the  malignant 
form.  However,  both  types  have  been  reported  in 
the  same  community  at  approximately  the  same 
time. 

Smallpox  incidence  has  been  higher  in  the  North 
Central  States  and  west  of  the  Mississippi  River. 
Except  for  sporadic  cases  or  small  isolated  out- 
breaks the  disease  has  practically  disappeared  from 
the  New  England,  Middle  Atlantic,  and  the  north- 
ern tier  of  the  South  Atlantic  States.  The  incidence 
in  the  remainder  of  the  South  Atlantic  and  East 
South  Central  States  has  also  declined  to  a  very 
low  level  in  recent  years. 

In  the  eastern  part  of  the  United  States  the 
disease  has  practically  vanished.  In  many  of  the 
Eastern  States  a  large  proportion  of  the  population 
has  been  protected  by  a  continuous  program  of 
vaccination  year  after  year.  It  is  worth  noting 
that  where  laws  requiring  vaccination  for  school 
attendance  have  been  in  force  for  a  number  of 
years  smallpox  has  practically  disappeared,  while 
nearly  all  of  the  cases  reported  in  recent  years 
have  occurred  in  the  sections  where  there  are  no 
such  laws. 

An  explanation  is  offered  for  the  mkldness  of 
recent  outbreaks. 

•  It's  relieving  to  learn  that  almost  no  cases  have 
occurred  recently  in  the  South. 

1     C.    C.    Dauek,    M.    D.,    Epidemiologist,   D.    C.   Halth   Deft, 
in   Public   H.   Reports.   Dec.    '40. 

2.    Chapin,    C.    V.,    and    Smith,    J.:    Permanency    of    the    mild 
type    of    smallpox.    /.    Prev.    Med.,    6:273-320    (1932). 


SOUTHERN  MEDICINE  &  SURGERY 


January  1940 


ARTIFICIAL  INSEMINATION  IN  THE 
UNITED  STATES 

This  journal  has  received  from  the  National 
Research  Foundation  for  Eugenic  Alleviation  of 
Sterility  a  copy  of  a  recent  survey  of  Artificial 
Insemination  as  practiced  in  the  United  States. 
The  Foundation  is  desirous  of  having  all  workers 
in  this  and  related  fields  send  in  their  results  as 
they  become  available.  The  data  are  to  be  re- 
leased to  all  who  may  need  them  and  doctors  are 
urged  to  draw  upon  it  whenever  necessary. 

This  stock-taking  of  the  results  to  date  of 
attempts  at  artificial  insemination  will  prove  a 
revelation  to  most  of  us.  That  nearly  10000 
children  have  come  into  the  world  alive  in  the 
United  States  as  the  result  of  bringing  the  ovum 
and  spermatozoon  together  by  art  other  than  the 
oldest  of  arts  is  indeed  astounding  news. 

Of  the  1 50,000  doctors  in  the  United  States,  one- 
fifth  were  sent  questionnaires;  7,642  doctors  sent 
in  replies;  4,049  reported  successful  results  with 
A.  I.;  2,478  physicians  reported  that  they  had 
never  used  A.  I.;  1,115  physicians  failed  to  obtain 
pregnancies  by  A.  I. 

Census  of  children  produced  by  artificial  insemination 
in  the  U.  S.  to  June,  1940. 

Total  number  of  live  children  born  of  A.  I.,  9,238 

Total  number  of  pregnancies  initiated,  9,489 

Result   of   A.    I.    using   husband    (temporary 
sterility)    5,728 

(a)  Number    of    boys,    3,623 

(b)  Number    of    girls,    2,105 
Result  of   A.   I.   using   donor    (absolute  sterility 

of  male)    3,510 

(a)  Number   of   boys,  '2,060 

(b)  Number   of   girls,   1,450. 
Mothers  having  more   than   one   pregnancy  by 

A.  I.,  1,357 
Multiple  pregnancies  in  series,  3  sets  of  twins 
The  number  of  surgical  operations   (to  effect 

pregnancy)    avoided,  382 
Ratio  of  total  pregnancies  to  surgical  operations 

prevented,  24.8  to   1. 
The  question  "What  was  the  average  number  of  insem- 
inations   employed    to    effect   pregnancy?"    was    answered 
as  follows: 

(a)  The  1115  who  failed  to  obtain  pregnancy  by 
A.  I.  50  gave  no  specific  number  of  inseminations. 
1,065   physicians  answered   as  follows: 

740  tried  one  insemination 
111  two  inseminations 

91  three 

83  four 

7  five 

33  six 

(b)  The   4,049   successful  physicians: 

3  pregnancies  resulted  after  one  insemination 
17  two  inseminations 

409  three 

61  eight 

897  nine 

4312  12 

1916  14 


1003 
367 
139 
241 


124   physicians   reported   success  after   more   than 
21   inseminations. 
1    physician   reported  that  pregnancy  was 
effected  after  the  22nd.  insemination. 
The    greatest    number    of    physicians    reported 
pregnancies  after  twelve  inseminations  which  varied 
three  inseminations  for  four  months;   four  insemi- 
nations for  three  months;  or  two  inseminations  for 
six  months.     A  few  varied  the  procedure  slightly 
over  the  twelve  inseminations. 

Geographical  distribution  of  children  sired  by 
A.  I.  as  reported  by  physicians  was: 

Central     '  2,602 

Atlantic  2,997 

New   England  1,514 

Pacific  617 

Mountain  96 

Southern  1,663 

Analysis  of  physicians'  replies  by  geographical 
sections: 

Central  2,389 

Atlantic  2,520 

New  England  930 

Pacific  302 

Mountain  124 

Southern  1,377. 

Total  number  of  miscarriages  and  abortions,  217 

Percentage   of  total   number   of  pregnancies,   2.3 
Incidence  of  miscarriages  and  abortions  in  so- 
called   normal  patients,   10  to   20% 
Total  number    of   extra-uterine   pregnancies,   22 
Intravaginally   inseminated,   2 
Intracervically   inseminated,    11 
Intrauterinely   inseminated,   9 
Percentage  of  total  number  of  pregnancies,  0.2 
Incidence  of  extrauterine  pregnancies  in  so-called 
normal  patients,  1.3% 
Number   of  inseminations  where  some   solution  was 
added   to   specimen,   3,831 

Percentage   of  pregnancies  in  which  some  solution 
was   added   to   specimen,  40.3 
Number   of  "flare-ups"   reported  through   uterosalpingo- 
graphy, 44 
Type    of    flare-up: 

Acute  salpingitis,   11 
unitateral,   7 
bilateral,  4 
Pelvic  abscesses,  3 
Marked   abdominal   cramps,   28 
Pelvic   peritonitis,   7 
Dermatitis   venenata,   5 
Number  of   flare-ups  cited  above  requiring   operative 

interference,   9 
Other  incidents:  Retention  of  the  oil  in  diseased  salpinx,  6. 

To  many  young  couples  who  have  been  vainly 
hoping  for  children  this  will  be  encouraging  news. 
Their  doctors  will  be  stimulated  to  renewed  effort. 
This  Foundation  will  be  glad  to  supply1  further 
details. 


1.  Foundation  for  Alleviation  of  Sterility,  Nesconset,  L.  I.,  N.  Y. 


January  1941 


SOUTHERN  MEDICINE  &  SURGERY 


DEPARTMENTS 


PEDIATRICS 

G.  W.  Kutscher,  Jr.,  M.  D.,  F.  A.  A.  P.,  Editor 
Asheville,  N.   C 


DIETS  IN  ECZEMA 

The  recalcitrant  case  of  infantile  eczema  pro- 
vides a  terrifying  experience  for  the  patient  and 
all  those  in  intimate  contact  with  it.  The  essence 
of  a  valuable  article1  on  this  subject  is  passed  on 
to  readers  of  this  department. 

Note  how  many  stand-bys  are  frequent  causes 
of  eczema. 

The  first  step  in  the  management  was  to  elimi- 
nate all  sources  of  local  irritation  and  all  factors 
of  contact  dermatitis.  The  most  common  causes 
were  wool,  soap  and  feathers;  powder  and  floor 
wax  occasionally  .  In  slightly  more  than  half  the 
cases,  only  one  substance  was  causing  the  trouble; 
in  the  remainder,  2  to  4. 

Xo  skin  testing  mas  done — either  for  contact 
substances  or  foods — but  an  exceedingly  careful 
history  was  taken  in  every  case. 

The  babies'  faces  were  kept  clean  with  olive  oil, 
avoiding  soap,  and  the  lesions  were  covered  at  all 
times  with  appropriate  ointments.  The  arms  were 
splinted  at  the  elbow  so  that  the  infants  might 
not  scratch.  Restraints  were  removed  as  early  as 
possible. 

Key  to  the  treatment  was  the  use  of  only  a 
few  foods  known  to  be  innocouous  to  most  allergic 
patients.  The  infants  were  permitted  any  amount 
of  food  on  the  schedule,  but  not  even  the  most 
minute  amount  of  food  not  on  the  schedule. 

If  the  patient  improves  after  one  or  two  weeks 
he  is  considered  sensitive  to  food  allergens;  if  he 
does  not  improve,  he  is  probably  sensitive  to  some- 
thing else,  rarely  to  a  food;  more  often  to  an  un- 
identified contact  substance. 

If  the  infant  objects  to  acidified  milk  in  the 
elimination  diet,  hctic  acid  may  be  left  out  of 
the  formula.  Sometimes  it  is  necessary  to  use  a 
mi'k  substitute,  e.  g.,  soybean  emulsion.  Codliver 
oil  and  orange  juice  are  forbidden.  If  vitamins 
are  thought  necessary,  they  are  given  in  synthetic 
('  m,  c.  g.  cevitamic  acid  and  irradiated  ergosterol. 
Commercially   prepared    foods   are   not   used. 

After  the  condition  has  healed  or  materially 
improved,  other  materials  are  added,  one  at  a 
time,  at  4-day  intervals.  It  is  often  discovered 
that  the  baby  is  allergic  to  those  foods  against 
which  he  shows  an  aversion.  If  the  condition  flares 
up  after  the  addition  of  a  certain  food,  that  food 

1     A.    R.    Bin,    in    Canadian    Med.    Asso.    Jt,    Dec, 


is  withheld  indefinitely.  Milk  is  usually  the  first 
food  added;  then  bread,  fruit,  vegetables,  eggs. 
Tomatoes  and  oranges  are  among  the  last. 

Egg  was  found  to  be  the  most  common  offender; 
tomato  next;  then,  in  descending  order,  orange, 
milk,  fish,  oatmeal  and  codliver  oil.  In  some  cases, 
wheat,  celery,  lettuce,  honey,  spinach,  beans,  peas 
and  chocolate  were  the  source  of  the  trouble. 
Elimination  Diets  for  Children  from  Birth  to  Two  Years 

FOR    CHILD    FROM    BIRTH    TO    8    MONTHS 

Evaporated  milk   oz- 

Corn  syrup   tbsp. 

Water    (boiled)    °z- 

Lactic    acid    tsP- 

bottles of  each 

to   be   fed   at   a.   m p.   m. 

Method  of  preparation:  (1)  Blend  corn  syrup  and  water. 
(2)  Add  lactic  acid.  Mix  well.  Gradually  add  this  mix- 
ture to  the  evaporated  milk,  stirring  constantly.  Keep  in 
a  cool  place.  The  caloric  requirements  of  a  child  are  SO 
to  the  pound  of  body  weight.  Evaporated  milk  has  a 
caloric  value  of  42  per  ounce,  undiluted.  One  ounce  of 
corn  syrup  is  equivalent  to  120  calories.  The  formula 
for  this  elimination  diet  may  thus  be  properly  figured 
and  filled  in. 

FOR    CHILD    8    TO    12    MONTHS    OF    AGE 

6  a.   m. — Evaporated  milk  formula. 

10  a.  m.,  breakfast — Rice  or  cornmeal  cooked  two  hours 
in  double  boiler;  3  to  4  tablespoons  with  part  of  formula 
poured  over  it.  Pureed  prune  pulp  or  ripe  mashed  banana. 
Formula — rest   to    drink. 

1:30  to  2  p.  m.,  dinner — Beef  broth — may  have  added 
rice  or  rice  flour.  Strained  vegetables — carrots,  asparagus, 
beets.  Cornstarch  or  rice  pudding — made  with  evaporated 
milk   and  no   egg.     Formula. 

5:30  to   6  p.   m.,  supper — Same  as  breakfast. 

10   p.   m. — Evaporated   milk   formula. 

FOR   CHILD    1    TO   2    YEARS   OLD 

Breakfast — Rice  or  cornmeal  cooked  two  hours  in  a 
double  boiler;  3  to  4  tablespoonfuls  with  diluted  evapo- 
rated milk  poured  over  it.  Pureed  prune  pulp  or  apricots, 
ripe  mashed  banana  and  apple  sauce.  Diluted  evaporated 
milk. 

Dinner — Beef  broth( — .scraped  beef  or  chopped  liver. 
Strained  vegetables — carrots,  asparagus,  beets.  Cornstarch 
or  rice  pudding — made  with  evaporated  milk  and  no  egg. 
Diluted   evaporated   milk. 

Supper — Same   as  breakfast. 

Bedtime — Diluted  evaporated  milk  if  desired. 

FOR  CHILD  OVER  2  YEARS  OF  ACE 

No   egg,   milk   or   wheat 

Fruit — Prunes,   plums,   apples,   apricots,   ripe   bananas. 

Beverage — Grape,    apple    or   prune   juice. 

Cereal — Rice,   puffed   rice,   rice  krispies. 

Meat — Beef,  roasted,  boiled;  steak,  liver  and  beef  broth 
may  be  used. 

Vegetables — Carrots,   asparagus,   beets   and  lettuce. 

Bread — Ry-Krisp,   100%   whole  rye  bread. 

Butter — substitute   Crisco   for   baking. 

Flour    substitute — Rice    flour;    rye    flour. 

Miscellaneous:    Maple    syrup,    Karo,    brown    and    refined 
r.ugar,  salt,  baking  soda  and  gelatin   (unflavored).     Royal 
or   any    baking   powder   which   according   to   the  label   on 
I      ca.i  does  not  contain  egg. 

In  a  series  of  126  cases,  78%  were  clinically 
cured  in  an  average  of  2.8  months;  the  remaining 
24 '/i  were  considerably  improved  in  an  average  of 
4.7  months.     No  case  went  unimproved. 


SOUTHERN  MEDICINE  &  SURGERY 


January  1941 


GENERAL  PRACTICE 

Walth   J.    Laciet,   M.  D.,   Editor,   Fallston,   N.   C. 


DOING  MORE  OF  OUR  OWN  WORK  WITH 

BETTER  DRUGS  LOWERS  COST 

OF  TREATMENT 

The  recalcitrant  case  of  infantile  eczema  pro- 
In  recent  years  the  field  of  therapy  has  improved 
by  leaps  and  bounds.  Human  illness  can  now  be 
treated  with  more  scientific  methods  and  in  a  more 
humane  way.  Too  much  can  hardly  be  said  for 
what  the  sulfonamide  group  has  done  to  speed  up 
recoveries  and  save  lives.  The  cost  of  medical 
attendance  has  been  reduced  greatly,  due  to  the 
rapid  recovery  from  many  illness  after  giving  these 
drugs.  In  the  average  case  of  pneumonia,  the 
family  saves  at  least  $40  in  doctor  bills  alone. 
Before  the  Defense  Program  and  all  the  various 
other  Government  expenditures  are  paid,  the  fami- 
lies will  have  to  have  all  the  help  they  can  get 
to  meet  their  financial  burdens.  If  the  cost  of 
medical  care  is  not  kept  at  a  minimum,  that  is 
all  the  more  reason  the  people  may  want  some 
kind  of  socialized  medicine;  a  threat  all  doctors 
should  be  on  gard  against.  This  invasion  on  the 
medical  profession  is  being  kept  up  throughout  our 
free  country  in  the  remotest  corners.  The  minute 
socialized  medicine  is  put  in  effect  in  the  United 
States  the  quality  of  medical  care  will  be  lowered. 
We  will  be  treating  case  No.  405  instead  of  our 
good  friend,  Mr.  Jones.  The  red  tape  all  of  us 
would  have  to  go  through  would  take  out  the 
human  side  of  treatment  and  the  field  of  research 
would  be  neglected.  Tht  main  thing  for  the  medi- 
cal men  to  do  is  to  cooperate  and  each  man  be 
more  efficient  in  his  field.  By  doing  this,  we  shall 
keep  the  practice  of  medicine  the  most  highly  re- 
spected profession  on  earth,  with  all  due  respect 
to  the  clergvmen. 

While  I  am  on  this  subject  of  saving  the  patient 
of  being  over-run  by  medical  cost,  I  want  to  say 
again  that  the  modern  trend  is  for  many  to  go 
to  a  specialist  whether  his  illness  indicates  it  or 
not,  befre  he  consults  his  family  doctor.  If  some- 
thing unusual  come  up,  the  specialist  has  a  very 
definite  field  and  can  render  a  great  service  for 
which  he  should  be  properly  imbursed.  By  this 
method  the  cost  of  medical  care  can  be  greatly 
reduced  and  the  patient  receives  much  better  care. 
The  general  practitioner  should  follow  up  his  pati- 
ents when  they  go  to  the  hospital,  and  if  the  hos- 
pital permits,  should  treat  them  there.  Treatments 
such  as  blood  transfusion  can  be  given  by  the 
family  physician.  Blood  transfusions  have  a  wider 
scope  of  usefulness  in  the  last  few  years.  The 
methods   of   giving  blood   are   many   and    not   SO 


important.  Different  direct  methods  are  available. 
The  old  sodium  citrate  indirect  method  is  hard 
to  beat.  The  physician  should  familiarize  himself 
with  the  one  he  prefers.  Now  it  seems  that  plasma 
will  replace  whole  blood  and  make  transfusion,  as 
the  Dunkard  preacher  said  of  his  sermon,  "so 
simple  that  even  the  women  can  understand  it." 

There's  no  reason  why  family  doctors  should 
refer  everything  that  commands  a  fee  or  that  has 
legitimate   advertising   value. 

P.  S.  A  New  Year's  Resolutions:  1.  Let  us 
family  doctors  overcome  our  inferiority  complexes. 
2.  Let  us  all  resolve  to  be  more  prompt  in  filling 
out  birth  certificates  for  the  coming  year,  and 
more  accurate  in  filling  out  all  death  certificates. 


SUCCESSFUL   SUBLINGUAL  THERAPY 

IN  ADDISON'S  DISEASE 

(E.  Anderson  &  W.  Haymaker,  San  Francisco  &  E.  Henderson, 

Bloomfield,   N     J.,   in  //.   A.   M.   A.,   Dec.   21st.) 

The  ingestion  of  tablets  of  desoxycorticosterone  acetate 
is  for  practical  purposes  valueless.  Two  of  our  patients 
with  Addison's  disease  who  ingested  10  times  the  dose 
effective  by  the  subcutaneous  route  developed  symptoms  of 
adrenal   cortical  insufficiency. 

It  was  found  that  the  preparation,  dissolved  in  pro- 
pylene glycol,  administered  by  drops  under  the  tongue 
was  as  effective  in  the  6  cases  here  reported  as  when 
given  in  oil  subcutaneously  or  intramuscularly.  Each  c.  c. 
of  propylene  glycol  contained  10  mg.  of  acetate.  The 
dropper  used  by  the  patients  was  such  that  1  c.  c.  of 
the  solution  was  discharged  as  40  drops.  The  dose  was 
from  8  to  24  drops  of  the  solution,  (2  to  6  mg.  of  the 
active  substaoce)   daily  in  divided  doses. 

All  6  patients  who  have  been  receiving  desoxycorticos- 
terone acetate  sublingually  for  from  6  to  8  weeks  are  in 
excellent  condition  and  are  carrying  on  their  usual  occu- 
pations. 


THE  PREVENTION  OF  DIABETES 
(C.  H.  Best  et  al,  in  New  England  Jl  Med.,  Oct.  17th.) 
Two  schools  of  thought  have  prevailed  as  to  the  steps 
which  should  be  taken  to  prevent  the  development  of 
diabetes  in  those  who  by  heredity  appear  most  suscep- 
tible to  the  disease:  one  favoring  stimulation  of  the  islet 
cells  of  the  pancreas  by  diets  rich  in  carbohydrates;  the 
other  testing  the  pancreas  by  1)  fasting,  2)  feeding  of 
fats   and   3)    administration   of  insulin. 

Evidence  favors  the  hypothesis  that  the  full-blown 
development  of  diabetes  is  best  prevented  by  resting  the 
pancreas   rather   than   by   stimulating  it. 


RELIEF  IN  URETERAL  COLIC 

,...-.  .-son    Carroll,  et  al,   St..   Louis,   in  Miss.    Vol.   Med.   Jl,  via 

Cur.   Med.   Dig.,   Nov.) 

Morphine  gr.  %  was  found  to  increase  motility  of  the 
ureter  and  atropine  neutralized  this  action;  always  combine 
atropine   gr.    1  75,   with   morphine   for   renal   colic. 

The  release  of  ureteral  spasm  is  of  great  clinical  impor- 
tance, and  the  severe  pain  associated  with  it  may  be 
relieved  in  3  minutes  by  the  injection  of  pancreatic  tissue 
extract,  3  c.  c.  intramuscularly,  or  padutin,  3  or  4  c.  c. 
Morphine  and  atropine  relieve  the  pain  by  blocking  the 
cerebral  recognition  of  it,  but  do  not  in  themselves  release 
the  spasm,  hence   the   former  are   more  desirable. 


Attacks   of   transient   blindness   should   be   regarded   as 
a   warning    of    vascular    disease. — Minion. 


January  1941 


SOUTHERN  MEDICINE  &  SURGERY 


APPEASEMENT  FOR 


SHORT- PANTS    DICTATORS 


Little  patients,  who  snub  their  noses  at  any 
suggestion  of  medication,  eagerly  accept  the 
delicious  5 -vitamin  nutritive  tonic,  CAL-C-TOSE. 

•  Cal-C-Tose  carries  no  suggestion  of  medication.  Added  to  milk,  it  makes  a 
rich,  appetizing,  chocolate-flavored  drink  that  tickles  the  palate  of  the  most 
finicky  child.  It  is  delicious  served  either  as  a  "hot  chocolate"  or  as  a  cold, 
refreshing  milkshake. 

•  In  addition  to  its  full  protective  complement  of  the  essential  vitamins  A,  Bi, 
B2,  C,  and  D,  Cal-C-Tose  also  contains  skimmed  milk  protein,  dibasic  calcium 
phosphate,  and  other  valuable  minerals. 

•  Because  of  its  appealing  flavor,  it  encourages  an  increased  consumption  of  milk 
in  those  who  may  dislike  it;  thus  additional  amounts  of  natural  vitamins  and 
minerals  are  ingested  daily. 

•  Moreover,  it  is  economical.  Judged  on  the  basis  of  its  vitamin  content  solely 
and  disregarding  entirely  its  nutritive  value,  Cal-C-Tose  is  one  of  the  most 
economical  of  all  5-vitamin  products. 

HOFFMANN  -  LA  ROCHE,  INC.,  NUTLEY,  N.  J. 


CAL-C-TOSE— DELICIOUS    5-VITAMIN    NUTRITIVE 


SOUTHERN  MEDICINE  &■  SURGERY 


January  1941 


NEWS 


FOURTH   DISTRICT  AND   SOUTHSIDE   VIRGINIA 

MEDICAL  SOCIETY 
The  meeting  was  held  at  Petersburg,  Friday  afternoon, 
December  27.   1940. 

SCIENTIFIC  SESSION 

Sulfathiazole   and   Allied   Types   of   Chemotherapy  in 

Children,  ....  William  B.  Mcllwaine,  M.  D.,  Petersburg 
The    Cause   and   Prevention   of   Chronic   Bronchiectasis, 

Porter  Vinson,  M.  D.,  Richmond 
What   Every   Physician   Should   Know   About   the   Spread 
and   Prevention    of   Tuberculosis, 

Ramsay  Spillman,  M.  D.,  New   York 
New   and   Interesting  Phases   of   Rheumatic   Fever, 

T.  Duckett  Jones,  M.  D.,  Boston 
Abdominal  Pregnancy  With  Report  of  Two  Cases, 

J.  B.  Jones,  M.  D.,  Petersburg 
The  Heart  in  Pregnancy, 

William  B.  Porter,  M.  D.,  Richmond 
Signs   and   Symptoms   of   Brain  Tumors  That   Should  be 
Familiar   to   Every   Physician, 

C.  C.  Coleman,  M.  D.,  Richmond 
Signs  and  Symptoms  of  Certain  Important  Surgical 

Emergencies,  Isaac  A.  Bigger,  M.  D.,  Richmond 

During  the  afternoon,  the  wives  and  friends  accom- 
panying the  physicians  were  entertained  by  the  local 
Woman's  Medical  Auxiliary  headed  by  Mrs.  E.  L.  McGill, 
President. 

Immediately  following  the  program  at  the  Medical  Arts 
Building,  Dr.  and  Mrs.  Wright  Clarkson  entertained  the 
physicians  and  their  guests  at  their  home,  205  South 
Svcamore  Street. 


RICHMOND  ACADEMY  OF  MEDICINE 
Dr.  William  Branch  Porter  is  the  new  president  of  the 
Richmond  Academy  of  Medicine,  succeeded  Dr.  J.  Powell 
Williams.  Other  officers  for  the  new  year  are  Dr. 
Beverley  R.  Tucker,  president-elect ;  Dr.  T.  Dewey  Davis, 
first  vice-president ;  Dr.  John  Lyncl;,  recording  secretary ; 
Dr.  Benjamin  W.  Rawles  Jr.,  sergeant-at-arms,  and  Miss 
Mary  Martha  Nokely,  executive  secretary-treasurer.  The 
board  of  trustees  is  composed  of  Dr.  Williams,  Dr.  Portor, 
Dr.  Tucker,  Dr.  Emmett  Terrell,  Dr.  T.  Dewey  Davis, 
Dr.  C.  L.  Outland  and  Dr.  J.  L.  Tabb. 


MARLBORO  COUNTY,  S.  C,  MEDICAL  SOCIETY 

The  Twenty-First  New  Year  Meeting  and  Banquet  held 
at  the  Country  Club,  Bennettsville,  on  January  9th  was 
largely   attended   and   loudly    applauded. 

At  six  the  annual  banquet  was  served.  Afterward  excellent 
post-prandial  oratory  was  supplied  by  Dr.  W.  L.  Pressley. 
President;  Dr.  George  M.  Truluck.  P resident-Elect;  Dr. 
Julian  P.  Price.  Secretary;  and  Dr.  Joseph  I.  Waring, 
Editor  of  Journal;  of  the  South  Carolina  Medical  Associa- 
tion. 

Formal  addresses  were  made  as  follows:  Acute  Infect- 
ious Mononucleosis — Dr.  O.  B.  Mayer,  Columbia.  Pro- 
longed Labor  Due  To  Uterine  Dystocia — Dr.  Brodie  C. 
Nalle,  Charlotte.  Treatment  of  Diarrhea  and  Dehydra- 
tion— Dr.   J.   Buren   Sidbury,   Wilmington. 


APPOINTMENTS    TO    BOWMAN    GRAY    FACULTY 
Dr.  Tinsley  Harrison,  native  of  Alabama,  and  graduate 
of  Michigan  and  Hopkins  is  the  first  Professor  of  Medicine 
of  the  new  Wake  Forest  School  of  Medicine.     Dr.  Win- 
gate  Johnson  is  Professor  of  Clinical  Medicine. 


dr.  McClelland  makes  address 

At   the   recent   meeting   of   the   Association   of   Seaboard 
Air    Line    Railway    surgeons,    Dr.    J.    0.    McCIellalnd    of 


Maxton.   N.   C,   chose   as   the   subject   of   his   Presidential 
Address,   "The   Country   Doctor". 

The  meeting  was  held  at  Savannah,  and  the  papers  of 
that  city  devoted  much  space  to  the  meeting  especially 
the  President's  Address. 


An  Evacuation  Hospital  Unit  is  being  organized  from 
the  staff  of  Memorial  Hospital,  Charlotte.  Dr.  Paul  Sanger 
is  heading  the  movement. 


Dr.  Lonnie  N.  Little  has  been  elected  health  officer 
of  Iredell  County,  N.  C,  in  succession  to  Dr.  Ross  S. 
McElwee.     Both   doctors  live  at   Statesville. 


Dr.  James  Watson,  of  the  Mental  Hygiene  Bureau 
of  the  State  Department  of  Public  Welfare,  addressed 
the  Guilford  County  Mental  Hygiene  Society  in  Greensboro 
on   January    16th. 


Dr.  W.  H.  Patton,  Jr.,  of  Morganton,  has  been  elected 
health   officer   of   Burke   County. 


Dr.  Oscar  Lee  Miller,  president  the  American  Acad- 
emy of  Orthopedic  Surgery,  presided  over  the  meeting 
held  at  New  Orleans,   January   12th  to   16th. 


Dr.   Spencer   Bell,   of   Brooks   Cross   Roads,   has   been 
elected    health    officer    of   Yadkin    County. 


Dr.  Albert  A.  Kossove,  and  Dr.  Irene  L.  Kossove, 
announces  the  opening  of  offices  for  the  general  practice 
of  medicine  at  1516  Elizabeth  Avenue  Charlotte,  North 
Carolina. 


Dr.  Waxter  J.  Rein,  recent  associate  in  ophthalmology 
of  the  late  Dr.  Emory  Hill,  announces  the  continuation 
of  his  practice  at  the  same  address,  208  Professional 
Building,  Richmond,  Va. 

MARRIED 


Dr.  George  Benjamin  Fleetwood  Traylor,  of  Lumberton, 
North  Carolina,  and  Miss  Leslie  Chappell  Bradshaw,  of 
Waverly,  Virginia,  were  married  on  December  2 1st. 


Dr.  Joseph  Spurgeon  Hiatt  and  Miss  Sara  Elizabeth 
Rankin,  of  Gastonia,  were  married  on  January  3rd.  Dr. 
Hiatt  is  a  member  of  the  staff  of  Duke  Hospital. 


Dr.   Thomas   Clarkson   Worth,   of   Raleigh,  N.   C,   and 

Miss   Barbara   Donaldson   Luther,   of   Oleans,  New   York, 

were   married   on   January   4th.     Dr.   Worth  is   stationed 

at  Fort  Benning,  Georgia,  as  a  lieutenant  in  the  Medical 
Corps,   United   States  Army. 


Miss  Mary  Adelaide  Walton,  of  Morganton,  N.  C. 
and  Dr.  John  Warren  Montague,  of  Roanoke  and  Rich- 
mond, Va.,  January  4th.  Dr.  Montague  is  now  a  mem- 
ber of  the  house  staff  of  the  Medical  College  of  Virginia 
Hospital. 


Dr.  William  Alexander  Graham  and  Miss  Ermine  De- 
Graffenried  Peek,  of  Durham,  were  married  on  January 
11th. 


Dr.  Edward  Stewart  Orgain,  of  Richmond,  and  Miss 
Ann  Foreman  Lewis,  of  Durham,  were  married  on  Decem- 
ber 28th.  Dr.  Orgain  is  a  member  of  the  staff  of  Duke 
Hospital. 


January  1941 


SOUTHERN  MEDICINE  &  SURGERY 


Anal-Sed 


Analgesic,  Antipyretic  and  Sedative 

Each  (1.   oz.  contains: 

Aminopyrine    28  grains 

Caffeine    Hydrobromide    4  grains 

Potassium    Bromide    120  grains 

Adult  Dose 
One  teaspoonful  in  a  little  water. 

How  Supplied 

In  Pints,  Five  Pints  and  Gallons  to  Physicians  and 
Druggists. 


Burwell  &  Dunn  Company 


Manufacturing 
Established 


Pharmacists 
in   1887 


CHARLOTTE,  N.  C. 

Sample   sent   to    any    physician   in   the    U.    S.    on 
request 


Dr.  Hunter  McGuire  Sweaney  and  Miss  Frances  Leake 
Foushee,  of  Durham,  were  married  on  December  31st. 


Dr.  McLean  Bacon  Leath,  Jr.,  of  High  Point,  and 
Miss  Lillian  Boswell  Agnew,  of  Inverness,  Virginia,  were 
married  on  December  31st. 


Dr.  J.  S.  Chamblee  and  Miss  Willie  Elizabeth  Evans, 
both  of  Windsor,  North  Carolina,  were  married  on  Dec- 
ember 28th.  Dr.  Chamblee  is  health  officer  of  Bertie  and 
Chowan  Counties. 

DEATHS 


Dr.  Paul  Brandon  Barringer,  physician,  educator  and 
publicist  of  national  distinction,  died  at  his  home  at  Char- 
lottesville, Va.,  January  9th.  after  an  extended  illness. 
He  would  have  been  84  years  old  in  February. 
Dr.  Barringer  was  born  at  Concord,  N.  C. 
In  1877  he  was  graduated  from  the  medical  department 
of  the  University  of  Virginia,  in  the  following  year  from 
the  University  of  New  York. 

Thereafter  he  passed  a  year  or  more  of  travel  and 
study  in  Europe,  and  at  the  beginning  of  the  1889-90 
session  of  the  University  of  Virginia  was  made  Professor 
of  Psychology  and  Materia  Medica.  For  seven  years  he 
served  as  chairman  of  the  faculty. 

In  1907,  Dr.  Barringer  was  elected  president  of  the 
Virginia  Polytechnic  Institute,  where  he  remained  for 
seven  years,  returning  to  Charlottesville  where  he  had 
given  his  attention  largely  to  work  as  a  publicist,  especial- 
ly in  connection  with  Negro  problems,  and  the  agricultural 
problems  of   the   South. 


Dr.  Prentiss  Dupuy  Johnston  died  at  his  home  at  Taze- 
well, Virginia,  on  January  3rd,  of  a  heart  attack.  Dr. 
Johnston,  a  cousin  of  Dr.  George  Ben  Johnston,  was  born 
at  Goochland  Courthouse  in  1878  and  graduated  from  the 
Medical  College  of  Virginia  in  1906.  One  of  the  survivors 
is  a  daughter,  Dr.  Mary  Elizabeth  Johnston,  who  was 
associated  with   her   father  in  practice. 


Dr.  Allan  Carruthers  Banner,  of  Greensboro,  died 
suddenly  of  a  heart  attack  on  January  11th.  at  the  age 
of  45. 


Dr.  Silas  Asa  Conduff,  59,  prominent  physician  and 
civic  leader  of  Mount  Airy,  N.  C.  died  at  Martin  Memorial 
Hospital,  January  13th,  a  heart  attack  following  a  recent 
stroke  of  paralysis. 


Dr.   Manney    Rice,   of   Columbia,    South    Carolina,   died 
at  his  home  on  December  25th. 


OUR  MEDICAL  SCHOOLS 


Medical  College  or  Virginia 
The    General    Education    Board    has    made    a   grant    of 
$168,00000  for  the  further  development  of  the  St.  Philip 
School   of   Nursing,    (Negro). 

This  grant  will  add  and  furnish  approximately  seventy- 
four  rooms  to  the  nurses'  residence,  St.  Philip  Hall,  and 
will  substantially  enlarge  the  library  and  teaching  unit. 
The  estimated  cost  of  this  aspect  of  the  new  development 
is  $130,000.00;  and  provides  $38,000.00,  over  a  six-year 
period,   on   a   decreasing   basis  biennially  for  substantially 


SOUTHERN  MEDICINE  &■  SURGERY 


January  1941 


CLINICAL  ABSTRACTS 

AN  INDISPENSABLE  MEDICAL  REPORTER! 
Brings  to  every  progressive  physician: 

1.  Weekly  abstracts  of  important  articles  on  MEDICINE,  SURGERY,  PEDI- 
ATRICS, THE  SPECIALTIES  and  THE  BASIC  SCIT  NCES,  culled  from  the 
worlds'  leading  medical  journals. 

2.  "Bi-weekly  cumulative  index — the  only  one  of  its  kind  in  the  world." 

3.  Handsome,  durable  binder,  made  to  hold  about  five  years'  abstracts  in  one  easy 
reference  volume. 

4.  Free  library  service.   Reprints  of  any  paper  abstracted  by  us,  available  on  request. 

5.  An  additional  new  feature — Resume  of  weekly  issues  of  THE  BRITISH  MEDI- 
CAL JOURNAL  and  THE  LANCET  included;  also  indexed. 

FOR  A  VITAL  TIME-SAVER,  CLIP  THIS  COUPON  TODAY! 

CLINICAL    ABSTRACTS 

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strengthening  the  teaching  program,  especially  on  the  clini- 
cal side. 

The  new  hospital  was  dedicated  on  Founders'  Day, 
December  5th.  Participating  were  Governor  James  H. 
Price;  Colonel  E.  W.  Clark;  Dr.  W.  L.  Bierring;  Dr. 
Walter  B.  Martin;  Dr.  H.  E.  Jordan;  M.  Haskins  Coleman, 
Jr.;  and  Dr.  Lewis  E.  Jarrett.  President  Sanger  presided 
at  the  exercises  which  were  broadcast  over  VV.  R.  N.  L. 
Beginning  at  2  p.  m.  the  new  hospital  was  opened  for 
inspection  to  the  public  and  on  Tuesday  night,  December 
3rd,  a  reception  and  hospital  open  house  were  observed 
at  the  hospital  for  the  local  medical  profession  and  speci- 
ally invited  guests.  During  Tuesday  evening  and  Thursday- 
afternoon  and  evening  over  15,000  guests  were  shown 
through  the  new  building,  many  from  distant  points. 

Installation  ceremonies  of  Beta  Chapter  of  Virginia, 
Alpha  Omega  Alpha,  were  held  at  the  Commonwealth 
Club,  Wednesday  evening,  December  3rd.  Dr.  Walter  L. 
Bierring,  National  President,  and  Dr.  J.  J.  Moore,  National 
Secretary,  were  present,  Dr.  Bierring  conferring  the  charter 
on  the  college  and  Dr.  Moore  presenting  the  certificates 
and  keys  to  the  initiates.  Other  speakers  on  the  program 
were  Dr.  William  T.  Sanger,  President  of  the  college; 
Dr.  Lee  E.  Sutton,  Jr.,  dean  of  the  school  of  medicine; 
Dr.  William  B.  Porter,  professor  of  medicine,  and  Dr. 
J.  Shelton  Horsley.  General  Hugh  S.  Cumrrring  aind 
General  Merritte  D.  Ireland  were  also  among  the  dis- 
tinguished guests  present.  Dean  H.  E.  Jordan  of  the 
department  of  medicine.  University  of  Virginia,  brought 
greetings   from   his  institution.     Dr.   Stuart   McGuire  was 


made  honorary  and  charter  member.  Faculty  initiates 
were:  Drs.  Frank  L.  Apperly.  C.  C.  Coleman,  Harvey 
B.  Haag,  William  B.  Porter.  Harry  Walker,  and  H.  H. 
Ware,  Jr.  Students  of  the  senior  medical  class  initiated 
were:  Messrs.  Herbert  C.  Allen,  Jr.,  William  E.  Daner, 
George   A.    Stewart,   Jr.,   and  Adney   K.   Sutphin. 

Dr.  Porter  P.  Vinson  was  recently  elected  president  of 
the   alumni   association    of   the   Mayo    Foundation. 

President  W.  T.  Sanger  was  made  an  honorary  member 
of  Alpha  (Virginia)  chapter  of  Phi  Beta  Kappa  at  the 
College   of   William    and   Mary   on   December   5th. 

Dr.  Walter  E.  Vest  and  Dr.  R.  J.  Wilkinson  of  the 
Chesapeake  and  Ohio  Hospital,  Huntington,  West  Vir- 
ginia, and  Dr.  J.  M.  Emmett  of  the  Chesapeake  and 
Ohio  Hospital,  Clifton  Forge.  Virginia,  were  recent  visitors. 

Dr.  Walther  Riese  reported  for  work  at  the  college 
as  research  associate  in  psychiatry  on  January  6th.  A 
grant  for  Dr.  Riese's  work  here  was  made  by  the  Rocke- 
feller   Foundation    of    Xew    York. 

Dr.  R.  D.  Hushes.  Assistant  Professor  of  Biology  in 
the  School  of  Pharmacy,  has  been  called  to  active  duty 
in  the  navy.  Doctor  Hughes'  wife  will  carry  on  his 
teaching   duties   while   he   is   away. 

Due  to  the  prevalence  of  influenza  the  sixth  floor  of 
the  new  college  hospital  was  opened  for  patients  on 
January  15th.  It  is  expected  the  entire  hospital  will  be 
occupied   by   February    1st. 

Lectures  scheduled  for  the  spring  months  at  the  college 
are: 


January  1941  SOUTHERN  MEDICINE  &  SURGERY 


CLINICAL  ABSTRACTS 

IS  THE 

IDEAL  CHRISTMAS  GIFT 

THE  FIRST  LINE  OF  MEDICAL  DEFENSE  IS 

RELIABLE,  UP-TO-DATE  KNOWLEDGE 

OF 

IMPORTANT,  WORLD-WIDE  DEVELOPMENTS 

REPORTED  WEEKLY 

IN 
CLINICAL  ABSTRACTS 

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January  1941 


SOUTHERN  MEDICINE  &  SURGERY 


February    14th   Alpha    Omega    Alpha    Lectureship    Dr. 
Fuller   Albright,   Massachusetts   General   Hospital, 
Boston. 
March    14    Phi   Beta   Pi    Lectureship    Dr.    Walter   E. 
Vest,  Chesapeake  and  Ohio  Hospital,  Huntington, 
West  Virginia. 
April  24-25  Stuart  McGuire  Lectures  Dr.  Alfred  Bla- 
lock,    Yanderbilt    University,   Nashville. 
The  annual  spring  postgraduate  clinics  will  be  held  in 
conjunction   with   the   Stuart   McGuire   lectures. 

Dr.  William  B.  Porter,  Professor  of  Medicine,  has  been 
elected  president  of  the  Richmond  Academy  of  Medicine. 


BOOKS 


Duke 


On  Nov.  29th.-30.  1940,  the  Tenth  Anniversary  of  the 
opening  of  the  School  of  Medicine  and  Hospital  was  cele- 
brated and  the  new  Department  of  Neuropsychiatry  was 
dedicated.  One  hundred  and  twenty  medical  alumi  and 
former  members  of  the  house  staff  were  present.  Dr. 
Adolf  Meyer,  Henry  Phipps  Professor  of  Psychistry  of 
the  Johns  Hopkins  University  School  of  Medciine,  ad- 
dressed the  staff,  students  and  alumni  on  Considerations 
on  Psychiatry  or  Ergasiatrics  as  an  Essential  and  Natural 
Part  of  All  Medical  Training  and  Practice.  Special  clinics 
and  talks  were  given  by  Drs.  R.  L.  Flowers,  F.  M.  Hanes, 
D.  T.  Smith,  Deryl  Hart,  Bayard  Carter  and  W.  C. 
Davison. 

On  Nov.  29th.  1940  the  Duke  University  School  of 
Medicine  Alumi  Association  was  organized  with  the  fol- 
lowing officers:  J.  M.  Arena,  president,  R.  N.  Graves, 
vice-president,  J.  L.  Callaway,  secretary-treasurer,  L.  D. 
Baker,  corresponding  secretary. 

On  December  11th.  1940,  Dr.  Lee  E.  Farr,  Director  of 
Research  of  the  Alfred  I.  duPont  Institute  of  the  Namours 
Foundation  held  a  clinic  on  the  Treatment  of  Nephritis. 

At  the  beginning  of  the  winter  quarter,  there  were  239 
medical  students — 66  first  year,  65  second  year,  65  juniors, 
and  43  seniors.     140  pupil  nurses  were  enrolled. 

Dr.  Laurence  H.  Snyder,  Professor  of  Medical  Genetics 
at  Ohio  State  University  School  of  Medicine,  is  giving 
a  series  of  weekly  lectures  on  Medical  Genetics  in  January, 
Feburary,  and  March. 

At  the  meeting  of  the  Duke  Medical  Society  on  Jan- 
uary 14th,  Dr.  Tinsley  R.  Harrison,  newly  appointed 
Professor  of  Medicine  at  the  Bowman  Gray  School  of 
Medicine  of  Wake  Forest  College,  spoke  on  Hypertension. 
Dr.  Wingate  Johnson,  Professor  of  Clinical  Medicine  at 
the  Bowman  Gray  School  of  Medicine  of  Wake  Forest 
College,  discussed   the  paper. 


University   of  Virginia 

On  January  9th,  Dr.  Byrd  S.  Leavell  spoke  before  the 
Fredericksburg  Medical  Society  on  the  subject  of  Anemia. 

Dr.  Oscar  Swineford,  Jr.,  participated  in  the  Third 
Annual  Forum  on  Allergy  in  Indianapolis.  His  subject 
was  Asthma   and  Heart   Disease. 

Dr.  Robert  V.  Funsten  attended  the  meetings  of  the 
American  Academy  of  Orthopedic  Surgery  in  New  Orleans 
from  January  12.  to  16th.  He  presented  a  paper  on 
Experimental  Studies  in  the  Use  of  the  U  Clamp  For 
Fixation  of  the  Spinous  Processes  in  Fractures  of  the 
Spine. 

DO  YOU  WRITE? 

Book  Manuscripts  Wanted  —  All  subjects 
for  immediate  publication.  Booklet  sent  free. 
Meador  Publishing  Co.,  324  Newbury  St., 
Boston,   Mass.     Established    1925. 


STRANGE  MALADY:  The  Story  of  Allergy,  by 
Warren  T.  Vaughan,  M.  D.,  line  drawings  by  John  P. 
Tillery.  Doubleday,  Doran  &  Co.,  Inc.,  New  York  City. 
1941.  $3.00. 

The  author  has  written  textbooks  on  this  sub- 
ject for  his  fellow-doctors.  Now  he  fills  the  need 
and  the  call  for  a  trustworthy  book  from  which 
those  we  call  the  intelligent  laity  may  learn  things 
to  counter-act  the  pernicious  influence  of  the  ex- 
aggerations and  distortions  as  to  allergy  appearing 
in  lay  publications. 

Dr.  Warren  Vaughan  has  a  broad  knowledge  of 
this  subject,  and  he  has  much  of  the  robust  sense, 
the  scientific  training  and  habit,  and  the  literary 
ability  of  his  distinguished  father,  Dr.  Victor 
Vaughan;  all  which  means  that  a  book  of  his  will 
meet  the  most  exacting  tests. 


THE  1940  YEAR  BOOK  OF  GENERAL  SURGERY, 
edited  by  Evarts  A.  Graham,  A.  B.,  M.  D.,  Professor 
of  Surgery,  Washington  University  School  of  Medicine; 
Surgeon-in-Chief  of  the  Barnes  Hospital  and  of  the  Child- 
ren's Hospital,  St.  Louis.  The  Year  Book  Publishers,  Inc., 
304  S.   Dearborn  St.,   Chicago.  $3.00  postpaid. 

Few  realize,  and  most  of  us  did  not  know,  that 
this  series  of  Year  Books  have  been  covering  pro- 
gress in  medicine  and  surgery  for  40  years.  The 
current  series  constitute  conspicuous  evidences  of 
evolution  in  its  best  sense,  and  the  volume  on 
General  Surgery  covers  its  field  with  such  discrim- 
nation  as  to  merit  the  highest  praise. 


THE  MEDICAL  REPORTS  OF  JOHN  Y.  BASSETT, 
M.D.,  THE  ALABAMA  STUDENT,  with  an  introduction 
by  Daniel  C.  Elkin,  M.  D.,  Joseph  B.  Whitehead, 
Professor  of  Surgery,  Emory  University.  Charles  C. 
Thomas,   Springfield,   111.    1941. 

Osier  found  Bassett's  writings  in  issues  of  a  long- 
discontinued  and  never  widely-circulated  medical 
publication;  and  this  discovery,  in  the  words  of 
the  introduction,  "rescued  John  Y.  Bassett  from 
the  oblivion  to  which  he  seemed  otherwise  doomed." 
Here  is  a  happy  illustration  of  the  value  to  a 
doctor's  name  and  fame  of  writing  for  the  journals. 

Thirty  years  ago  the  volume  of  Osier's  discourses 
published  under  the  title  An  Alabama  Student  was 
given  this  reviewer  by  a  doctor  friend.  It  was  a 
matter  for  marveling  how  this  doctor's  craving  for 
the  best  made  him  impose  the  sternest  privations 
on  his  family  as  well  as  himself,  when  his  patients 
would  have  been  just  as  well  satisfied  and  have 
paid  him  just  as  much  for  the  skill  he  had  already. 

These  Reports  cover  the  topography,  climate 
and  diseases  of  the  author's  county  of  Madison, 


SOUTHERN  MEDICINE  6-  SURGERY 


January  1941 


Alabama:  and  the  climate  and  diseases  of  Hunts- 
ville  and  its  vicinity  in  the  year  1850.  One  report 
is  numbered  I,  the  other  III,  suggesting  that  an 
insignificant  II  may  have  been  forgotten,  as  in  the 
Xapoleanic  succession. 

An  appendix,  which  is  a  letter  from  a  Dr. 
Mastin  to  Dr.  Osier,  sheds  a  new  and  interesting 
light  on  Bassett's  life,  and  gives  his  work  new 
meaning. 

This  booklet  of  Reports  affords  delightful,  in- 
structive and  inspiring  reading.  In  all  probability 
Osier's  style  was  improved  by  his  running  across 
those  forgotten  sentences  of  pungently  expressed 
observations. 


The  work  is  truly  encyclopedic.  For  instance, 
for  cystitis  73  remedies  are  listed;  for  diarrhea, 
62. 


THE  MERCK  MANUAL  OF  THERAPEUTICS  AND 
MATERIA  MEDICA.  Seventh  edition.  Merck  and  Com- 
pany,  Inc.,   Rahway,   N.   J.   1940. 

The  sixth  edition  was  published  in  1934.  The 
present  edition  continues  the  plan  expressed  at 
that  time:  "when  the  best  remedy  is  wanted  .  .  . 
it  is  difficut  to  recall  the  whole  array  .  .  .  and 
pick  the  best  .  .  .  The  Merck  Manual  is  in- 
tended to  supply  just  the  needed  reminder."  And 
the  developments  during  the  interval  have  supplied 
many  valuable  additions  to  our  therapeutic  arma- 
mentarium. 


MODERN  DRUG  ENCYCLOPEDIA  AND  THERA- 
PEUTIC GUIDE:  11,114  modern  nonpharmacopeial, 
ethical  medicinal  preparations  in  15,629  forms, — 3,421 
drugs  and  chemicals,  663  biologicals,  691  endocrines,  2,270 
ampoule  medicaments,  3.190  individual  and  group  allergens 
and  879  miscellaneous  products,  by  Jacob  Gutman,  M.  D., 
Phar.  D.,  F.  A.  C.  P.,  Director.  Brooklyn  Diagnostic 
Institute;  Formerly  Professor  of  Materia  Medical,  College 
of  Dentistry,  University  of  the  State  of  New  Jersey; 
Professor  of  Clinical  Chemistry,  Jersey  City  College  of 
Pharmacy;  Instructor  of  Medicine,  New  York  Post-Grad- 
uate  Medical  School  and  Hospital.  2nd.  edition.  New 
Modern  Drugs.    New  York.   1941.    $7.00. 

This,  the  second,  edition  gives  much  space  to 
endocrine  products,  vitamin  therapy  and  chemo- 
therapy. Preparations  advertised  to  the  laity  are 
not  carried,  but  such  helpful,  ethical  drugs  avail- 
able throughout  the  United  States.  A  glossary  is 
provided,  wisely,  to  make  clear  what  is  meant  by 
certain  terms  not  to  be  found  in  even  good  dic- 
tionaries. 

There  are  700  pages  of  information  on  popular 
propriety  drugs;  80  on  endocrine  preparations  (30 
of  these  on  pluriglandular  products) ;  170  on  hypo- 
dermic medicaments;  100  on  biologicals;  50  on 
allergens.  Then  comes  a  distributors'  and  manu- 
facturers' index  of  10  pages,  then  a  therapeutic 
guide  and  index  of  160  pages  presenting  all  the 
drugs  and  preparations  described  in  previous  chap- 
ters from  the  standpoint  of  composition,  effects 
and  application  in  treatment.  Last  there  is  a  good 
drug  and  general  index  of   180  pink  pages. 


THE  1940  YEAR  BOOK  OF  PEDIATRICS:  edited  by 
Issac  A.  Abt,  D.  Sc,  M.  D.,  Professor  of  Pediatrics, 
Northwestern  University  Medical  School;  with  the  collabo- 
ration of  Arthur  F.  Abt,  B.  S.,  M.  D.,  Assistant  Professor 
of  Pediatrics,  Northwestern  University  Medical  School. 
The  Year  Book  Publishers,  Inc.,  304  S.  Dearborn  St., 
Chicago.  $2.50  postpaid. 

The  book  for  this  year  carries  some  photographs. 
That  of  Dr.  Abt,  Sr.,  looks  like  Dr.  J.  H.  Mc- 
intosh; that  of  Dr.  John  Ridlon  like  Dr.  Osier; 
that  of  Dr.  G.  P.  Head  like  Dr.  M.  H.  Todd; 
while  Dr.  E.  W.  Ryerson  resembles  Dr.  C.  C.  Orr 
and  Dr.  Cloyd  J.  Head  reminds  of  this  year's  Tri- 
State  president,   Dr.  C.  J.  Andrews. 

The  treatment  of  pneumonia  is  reviewed  from 
a  long  way  back  all  the  up  to  sera,  sulfonamides, 
oxygen  and  transfusions.  Much  attention  is  de- 
voted to  disease  and  nutrition  in  the  first  year. 
The  attitude  toward  the  use  of  vitamines  is  soundly 
conservative.  Repeated  Schick  tests  during  child- 
hood are  advised  to  detect  possible  lapses  of  im- 
munity. A  mother  who  acquires  measles  in  the 
last  days  of  pregnancy  or  during  the  time  of  de- 
livery may  transmit  the  diesase  to  her  baby.  Pro- 
gress is  noted  all  along  the  line  in  the  management 
of  infectious  diseases. 

Pectin-agar  mixtures  have  been  found  useful  by 
G.  W.  Kutscher  and  Alfred  Blumberg,  Asheville. 
Other  doctors  from  this  section  whose  articles  are 
reviewed  are:  Wyndham  R.  Blanton,  Richmond; 
X.  W.  Beach,  Charleston;  Angus  McBryde,  Dur- 
ham;   R.   \Y.   McKay,   Charlotte. 

An  unusually  gobd  covering  of  an  unusually 
good  year  for  pediatries. 


THE  EUGENICS  OF  PRESIDENT  ABRAHAM  LIN- 
COLN: His  German-Scotch  Ancestry  Irrefutably  Estab- 
lished from  Recently  Discovered  Documents,  by  James 
Caswell  Cogclns,  A.  M„  S.  T.  D.,  Ph.  D.,  LL.  D.,  Good- 
will Press,   Elizabethton,   Tenn.    1940.   $2.00. 

All  authorities  consulted  agree  that  Lincoln's 
mother,  Nancy  Hanks,  was  a  ''woods-colt." 

Building  on  the  foundation  laid  by  J.  H.  Cathey, 
Professor  Coggins  has  provided  this  generation  with 
a  cogent,  convincing  case  for  North  Carolina  as 
the  birthplace  and  Abraham  Enloe  as  the  father 
of  Abraham  Lincoln.  A  number  of  unfortunate 
errors  mar  the  work;  but  they  in  no  way  weaken 
the  case  made  out.  Evervthing  considered,  it  is 
as  laughable  that  the  late  Senator  Beveridge  should 
appear  as  "Beverage,"  as  that  it  should  be  stated 
of  A.  Lincoln  that  "he  became  a  loaf  in  New 
Salem;"  and  that  pompous  ass,  Edward  Everett 
Hale,  would  not  rest  easy  in  his  grave  could  he 
see  himself  appearing  as  '"Evert." 


January  1941 


SOUTHERN  MEDICINE  &  SURGERY 


45 


Southern  Railway's  Six  Streamlined 
Diesel-operated  Coach  Trains 

Six  such  trains  are  to  be  put  in  service  early  in  1941  between  New  York  and  New  Orleans, 
via  Atlanta,  Birmingham  and  Meridian :  and  between  Washington  and  Memphis,  via  Knoxville 
and  Chattanooga. 

The  New  York-New  Orleans  all-coach  trains  will  be  operated  in  conjunction  with  the  Penn- 
sylvania Railroad  between  New  York  and  Washington  and  the  Memphis  trains  in  cooperation 
with  the  Norfolk  &  Western  between  Lynchburg  and  Bristol,  Va. 

Each  of  the  six  trains  will  consist  of  an  observation-lounge-tavern  car,  48-seat  dining  car, 
baggage-dormitory  chair  car,  chair  car  coaches  and  Diesel-powered  locomotive,  all  of  light-weight 
construction  with  ultramodern  streamline  effects,  with  a  hostess  assigned  to  each  train.  The  chair 
cars  have  soft,  upholstered  reclining  seats,  individual  lights  that  may  be  dimmed  at  night  and 
unusually  broad  windows.  The  trains  will  be  air-conditioned  throughout  and  all  seats  will  be 
reserved  at  no  additional  cost  over  the  regular  coach  fares. 

The  New  York-New  Orleans  trains  will  be  an  entirely  new  daily  service,  operating  exclusively 
over  the  lines  of  Southern  Railway  between  Washington  and  New  Orleans,  while  the  Memphis 
trains  will  replace  existing  trains  Nos.  25  and  26,  the  Memphis  Special,  and  will  handle  sleeping 
cars  between  Knoxville,  Chattanooga  and  Memphis,  in  addition  to  the  coach  equipment. 

Tentative  schedules  between  New  York  and  New  Orleans  are  announced  as  follows: 
Southbound:  Northbound: 

4:30  PM  Lv.  New  York  Ar.  12:50  PM 

8:30  PM  Ar.  Washington  Lv.  9:00  AM 


8:45 

PM 

Lv.  Washington 

Ar. 

8:40  AM 

8:57 

PM 

Lv.  Alexandria 

Lv. 

8:28  AM 

11:02 

PM 

Lv.  Charlottesville 

Lv. 

6:23  AM 

12:17 

AM 

Lv.  Lynchburg 

Lv. 

5:08  AM 

1:32 

AM 

Lv.  Danville 

Lv. 

3:53  AM 

2:32 

AM 

Lv.  Greensboro 

Lv. 

2:53  AM 

3:32 

AM 

Ar.   Salisbury 

Lv. 

1:53  AM 

4:28 

AM 

Lv.  Charlotte 

Lv. 

12:57  AM 

5:59 

AM 

Lv.  Spartanburg 

Lv. 

11:26  PM 

6:40 

AM 

Lv.  Greenville 

Lv. 

10:45  PM 

9:45 

AM 

ET 

Ar.  Atlanta 

Lv. 

ET 

7:40  PM 

11:15 

AM 

CT 

Lv.  Anniston 

Lv. 

CT 

4:10  PM 

12:35 

PM 

Ar.  Birmingham 

Lv. 

2:50  PM 

3:30 

PM 

Ar.  Meridian 

Lv. 

12:15  PM 

7:45 

PM 

Ar.  New  Orleans 

Lv. 

8:00  AM 

Tentative 

schedules   of   the   streamlined   Memphis 

Special   will 

be: 

Southbound 

Northbound: 

9:00 

AM 

Lv.  Washington 

Ar. 

9:45  PM 

9:12 

AM 

Lv.  Alexandria 
Lv.  Charlottesville 

Lv. 
Lv. 

9:30  PM 
7:30  PM 

12:45 

PM 

Ar.  Lynchburg 

Lv. 

5:45  PM 

1:50 

PM 

Lv.  Roanoke 

Lv. 

4:40  PM 

2:55 

PM 

Lv.  Radford 

Lv. 

3:15  PM 

5:45 

PM 

ET 

Ar.   Bristol 

Lv. 

ET 

12:40  PM 

7:00 

PM 

CT 

Lv.   Morristown 

Lv. 

CT 

9:20  AM 

8:05 

PM 

Ar.   Knoxville 

Lv. 

8:20  AM 

9:30 

PM 

Lv.  Athens 

Lv. 

6:45  AM 

10:55 

PM 

Ar.  Chattanooga 

Lv. 

5:25  AM 

1:15 

AM 

Lv.  Huntsville 

Lv. 

2:50  AM 

1:45 

AM 

Lv.  Decatur 

Lv. 

2:15  AM 

3:05 

AM 

Lv.  Sheffield 

Lv. 

1:05  AM 

4:30 

AM 

Lv.  Corinth 

Lv. 

11:45  PM 

6:55 

AM 

Ar.  Memphis 

Lv. 

9:25  PM 

These  schedules  ; 

is  contemplated  will  make  all  important  connections  at 

New  York,  Washing- 

ton,  Atlanta, 

Birmingham,  New  Orleans,  Chattanooga 

and  Memphis 

,  in  boi 

:h  directions,  and  will 

provide  substantially 

faster  train  service  than  the  existing  schedules 

SOUTHERN  MEDICINE  Sr  SURGERY 


January  1941 


There  are  pictures  bearing  the  titles: 
Nancy  Hank's  Log  Cabin  in  North  Carolina; 
Wesley  Enloe,  half-brother  of  Lincoln;  Nancy 
Hollifield,  aged  107  years;  Scroop  Enloe,  half- 
brother  of  Lincoln;  Abraham  Lincoln's  Mother  in 
the  Ox-wagon;  Lincoln's  Birthplace;  Trees  Used 
as  Brakes;  A  Paul  Revere  Ride;  Grave  of  Nancy 
Hanks;  Tom  Whipped  Both  Nancy  and  Little 
Abe;  Little  Abe's  Father  Fights  Tom  Lincoln; 
Camping  at  Night  in  the  Wilderness;  Meeting 
With  Indians;  Taking  Little  Abe  to  Kentucky. 

THE  CELLULAR  ORIGIN  AND  GROWTH  OF  MEN- 
TALITY, OR  THE  SOUL:  (Researches  for  the  University 
of  Paris),  by  James  Caswell  Coggdjs,  A.  M.,  S.  T.  D., 
Ph.  D.,  LL.  D„  for  many  years  principal  of  schools  in 
North  Carolina;  pastor  First  Christian  Church,  Ottawa, 
Kansas,  Decatur,  111.,  Augusta,  Ga.;  founder  and  first 
president  of  Atlantic  Christian  College,  Wilson,  N.  C. 
The   Biltmore  Press,  Asheville,  N.   C.   $2.00. 

This  reviewer  finds  difficulty  in  following  the 
reasoning  of  the  author;  and  in  many  instances 
in  which  the  meaning  seems  clear  he  is  entirely 
unable  to  agree  with  the  author's  conclusions.  Some 
of  the  statements  made  as  statements  of  general 
fact  are  not  true  in  the  reviewer's  experience.  For 
examples:  the  statements  are  made  (1)  that  it  is 
not  the  brain  that  does  the  thinking;  and  (2)  that 
science  believes  in  nothing  that  it  cannot  see  under 
a  microscope.  The  author  appears  to  labor  under 
the  delusion  that  his  own  abuse  brings  the  abusee 
under  the  condemnation  of  Jehovah.  The  reviewer 
dissents. 

NOT  TOO  OLD  FOR  SURGERY 

(C  R  Robins,  Richmond,  in  Bui.  Stuart  Circle  Hosp.,  Dec.) 
From  January  1st,  1939,  to  October  1st,  1940,  a  period 
ef  21  months,  I  preformed  22  operations  on  21  persons 
whose  ages  ranged  from  60  to  80  years.  There  were  no 
operative  deaths.  The  patient  with  sarcoma  of  the  groin 
died  some  months  later  from  an  extension  of  the  disease. 
All  these  patients  were  very  greatful  and  they  took  pride 
in  their  operations.  They  were  relieved  of  conditions 
that  caused  them  apprehension,  discomfort,  or  pain,  or 
actually  threatened  their  lives;  consequently  they  seemed 
to  take  a  new  lease  on  life  and  a  new  joy  in  living. 
What  could  cause  more  despair  than  to  be  told  that  one 
is  too  old  for  operation  and  that  his  only  relief  is  in 
death  ? 

PHYSICIAN'S  EQUIPMENT  FOR  SALE 

COST  ASKING 

G     E    Yiolet-rav    lamp  $295.00  $150.00 

G.  E.  Diathermy  Outfit  329.00  50.00 

Office  Desk  and  Chair  Extra  Good 

Two   Examining  Tables  200° 

Two  Lamps  J°-°° 

Microscope   (E.  Leitz,  Wetzlar) 

Otoscope  35.00   or40.00  15.00 

Filling  Cabinet  ls  °° 

Instrument   Cabinet  150° 

Dr.   James   Alexander's   death   causes   the   offer   for   sale 

of  the  following  items;  all  in  No.  1  condition: 

MRS.  JAMES  ALEXANDER 

117   N.   Mulberry   St. 

Statesville,  N.   C. 


JOHN  BROWNE  AND  HIS  TREATISE 

ON   THE  MUSCLES 

(K.    F.    Russell,    Melbourne,    in   Aust.   &   New  Zealand 

Jl   of  Surg.   Oct.) 

John  Browne  held  the  post  of  Surgeon  in  Ordinary  to 
both  Charles  II  and  William  III.  He  was  the  author 
of  a  number  of  books  on  surgery   and  one  on  anatomy. 

He  was  born  in  1642  at  Norwich,  the  birthplace  of 
the  Sir  Thomas  Browne  who  wrote  Raligio  Medici.  They 
were  not  related. 

His  medical  career  started  at  Saint  Thomas's.  After 
a  brief  service  as  surgeon  in  the  Navy  he  settled  at  Nor- 
wich. Apparently  coming  under  the  notice  of  the  King 
he  came  to  London  in  1677  and  was  appointed  Surgeon 
in  Ordinary.  A  vacancy  occurred  on  the  surgical  staff 
of  Saint  Thomas's,  and,  armed  with  a  letter  of  recom- 
mendation from  His  Majesty,  Browne  applied  for  the 
position.  The  governors  wished  to  fill  the  vacancy  with 
an  Edward  Rice,  who  had  given  good  service  to  the 
hospital  during  the  great  plague,  but  because  of  the  King's 
letter  they  could  not  refuse  Browne  and  he  was  elected 
on    June    21st.    16S3. 

The  governor's  turn  came  in  1691  when  all  the  surgeons, 
including  Browne,  were  asked  to  resign  and  others  were 
appointed  in  their  place.  Browne  appealed  to  the  Lords 
Commissioners  of  the  Great  Seal,  who  called  on  the 
governors  for  an  explanation,  and  when  this  was  forth- 
coming,  they  gave  a   decision  aginst  Browne. 

After  the  death  of  Charles  II,  Browne  was  appointed 
Surgeon  in  Ordinary  to  William  III,  which  position  he 
held  until  his  death  in   1700. 

His  treatise  on  the  muscles  first  appeared  in  1681.  It 
is  interesting  to  note  that  the  1687  edition  was  the  first 
book  ever  to  appear  in  which  the  names  were  printed 
on  the  muscles. 


DIAGNOSIS   OF  TUMORS  OF  THE   BREAST 

(E.   T.    Bell,    Minneapolis,   in  Minn.   Med.,   Dec.) 
The   clinical   features   are   shown   in   the   following   out- 
lines: 

I.  Single  Tumor 

1.  Adherent.  The  great  majority  are  malignant,  but 
in  rare  instances  an  adherent  growth  proves  to  be  fat 
necrosis  or  mastitis.  Palpable  axillary  lymphnodes 
strengthen  the  diagnosis  of  malignant  tumor.  Unless 
the  diagnosis  is  obvious  one  should  remove  the  lump 
and  examine  it  before  proceeding  with  radical  operation. 

2.  Non-adherent.  In  young  women  the  majority  are 
benign,  in  older  women  most  are  malignant.  Deeply 
placed  scirrhous  carcinomas  are  not  adherent  and  medul- 
lary carcinomas  do  not  adhere.  Tumors  unusually  mov- 
able are  apt  to  be  fibroadenomas.  Cystic  disease  frequent- 
ly appears  as  a  single  non-adherent  tumor.  In  this  group 
is  is  imperative  that  the  tumor  be  removed  and  examined 
before  the  operation  is  decided  upon.  An  aspiration 
biopsy  may  be  made  if  one  is  reasonably  sure  the  growth 
is   a   cyst. 

II.  Multiple  Tumors 
Multiple   tumors  in  one  or  both  breasts  are   malignant 
when    adherent    and    nearly    always    benign    when    non- 
adherent.     In    rare    instances    a    medullary    or    gelatinous 
carcinoma  appears  as  non-adherent   masses. 

Non-adherent  multiple  tumors  usually  represent  cystic 
disease,  but  rarely  they  may  be  fibro-adenomas.  It  is 
usually  satisfactory  to  remove  the  most  conspicuous  mass 
for  microscopic  examination.  If  cystic  disease  is  found 
no   further  operation  is  indicated. 

III.  Single  or  Multiple  Ill-defined 
Non-adherent  Masses 
These  usually  represent  uneven  involution  of  the  breast. 


January  1941 


SOUTHERN  MEDICINE  &  SURGERY 


47 


After  repeated  pregnancies  some  lobules  do  not  regress 
as  much  as  others.  Varying  proportions  of  fibrous  tissue 
in  different  parts  may  also  give  the  impression  of  tumors. 
A  clinical  diagnosis  can  usually  be  made  and  operation 
is  seldom  indicated. 

IV.  Acute  Carcinoma 
This  produces  diffuse  induration  of  the  breast  with  ad- 
hesion to  the  skin,  redness,  tenderness  and  local  heat  and 
the  patient  may   have  a   low   fever.     Incurable   and  best 
palliation  is  obtained  by  radiation. 
V.  Mastitis 

1.  Mastitis  of  Puberty.  In  boys  or  girls  near  puberty 
there  may  develop  a  tender  indurated  area,  small  and 
circular,   the   nipple   is   in   its   center,   self-limited. 

2.  Exudative  Mastitis.  Inflammatory  lesions,  usually 
during  lactation  or  pregnancy,  exhibit  the  features  of 
inflammation  and  are  treated  accordingly. 

3.  Chronic  Fibrous  Mastitis.  Masses  of  fibrous  tissue 
sometimes  develop  in  the  breast,  patchy  distribution  or 
the  entire  breast  may  be  converted  into  a  firm  mass. 

VI.  Discharge  From  The  Nipple 

1.  With  a  Palpable  Tumor.  Whenever  a  palpable  tumor 
is  found  it  should  be  removed  and  examined,  it  may  be 
papilloma  or  a  carcinoma. 

2.  Without  a  Palpable  Tumor.  Discharge  may  be 
bloody  or  serous,  a  small  duct  papilloma  more  often  a 
cyst  communicating  with  a  large  duct. 

In  the  diagnosis  of  cystic  disease  of  the  breast  it  is 
important  to  distinguish  the  adenomatous  type  from  car- 
cinoma. Under  low  magnification  benign  lesions  always 
show  a  definite  lobulation.  Under  high  magnification 
these  adenomatous  areas  appear  malignant.  Adenocystic 
disease  is  neither   a  cancer  nor  a  precancerous  lesion. 


CHUCKLES 


Smart  Little  Waitress  to  Customer:  "I've  got  deviled 
kidneys,  calves'  brains,  pigs'  feet,  chicken  livers,  and  .  . ." 

"Forget  it  sister,"  growled  the  cantankerous  diner.  "I've 
a  headache,  eczema,  fallen  arches,  corns,  bunions,  three 
warts  and  an  empty  stomach.  Tell  your  troubles  to  some- 
one  else,   and   bring   me   some   ham   and   eggs." 

Head  Clerk:  "I  am  very  sorry  to  hear  of  your  partner's 
death.     Would   you   like   me   to   take   his  place?" 

Senior  Partner:  "Very  much,  if  you  can  get  the  under- 
taker to  arrange  it." 

Little  Mary  Jane  awoke  about  3  o'clock  one  morning. 
She  asked  her  mother  to  tell  her  a  story.  Her  mother 
said,  "If  you  wait  a  little  longer  your  father  will  be 
home   and  tell   us  both  a  story." 

"Your  vegetables  cost  more   than   they   used  to,"  com- 
plained the  buyer. 
"Yes,"  replied  the  farmer,  "when  a  farmer  is  supposed 
tt>   know  the   botanical   name   of   what  he's  raisin',   and 
the   zoological   name   of   the   insect   that   eats   it,   and   the 
chemical  name  of  what  will  kill  it,  somebody's  got  to  pay." 

He:    "Billy    the    Kid,    the    famous    Arizona    desperado, 
killed    nineteen   men   before   he   was   twenty-one." 
She:   "What  kind  of  a  car  did  he  drive?" 

A  lady  of  30  entered  the  office  in  an  agitated  state. 
The  evening  before  she  and  her  fiance  had  patronized  a 
palmist,  who  had  told  her  that  the  lines  of  her  hand 
indicated  she  would  have  but  one  child.  This  seemed 
to   displease    her   young   man,    although    he   said    nothing. 

"Doctor,"  pleaded  the  woman,  "please  change  the  lines 
on  my  palm  so  I  can  have  more  than  one  child!" 


A  public-minded  woman  had  been  contributing  her  time 
as  a  supervisor  in  a  WPA  sewing  room.  One  night  she 
looked  over  the  weary  women,  many  of  whom  showed 
they  would  soon  need  an  obstetrician,  and  delivered  her- 
self  of   this   immortal   peroration: 

"Ladies,  you  have  been  neglected.  No  one  has  had 
the  courage  to  talk  to  you  about  birth  control  and  you 
need  it !  I  am  going  to  help  you.  I  am  not  afraid.  Now, 
this  is  what  you  do.  When  it  is  time  to  go  to  bed,  do 
not  be  afraid.  Let  your  husband  get  in.  Then  you  take 
a  blanket,  wrap  it  securely  around  yourself,  and  sleep  on 
the  floor!" 

Her  husband  has  recently  moved  his  business  to  another 
town. 

An  enema  was  ordered  for  a  gentleman  patient  and  a 
nurse  went  in  to  prepare  the  patient.  She  explained.  "I'm 
going  to  give  you   an  enema." 

Patient:    "I   don't   want   any   enema." 

Nurse:    "But   it's  the   doctor's  order." 

Patient:  "Well,  you  can't  make  me  take  it.  I  won't 
open  my  mouth." 

Called  to  attend  a  young  divinity  student;  during  the 
examination  the  physician  asked  to  "see  the  unruly  mem- 
ber." The  student  looked  at  the  doctor  curiously  and 
began  to  remove  the  covers  from  the  lower  portion  of 
his  body. 

"No,  no,"  said  the  doctor,  "let  me  see  your  tongue." 
A  few  weeks  later  the  physician  was  called  to  see  the 
young  student's  wife  and,  during  the  examination,  asked 
the  same  question.  She  promptly  responded  by  extending 
her  tongue  and  drew  it  back  to  say:  "You  see,  doctor, 
I  know  my  theology." 

On  completing  a  lecture  on  obstetrics  to  student  nurses, 
a  doctor  gave  an  examination.  This  was  one  of  the 
questions:     "Give   some   positive   signs   of   pregnancy." 

One  of  the  answers  read:  "One  of  the  signs  of  preg- 
nancy  is   a   far-away   look  in   her   eye." 

A  staff  physician  on  his  rounds  was  told  by  a  patient 
that  her  right  ear  was  aching.  He  wrote  an  order  direct- 
ing that  a  hot  water  bag  be  placed  against  the  ear  and 
continued  on  his  way.  When  he  returned  later  that  day, 
he  was  amazed  to  find  the  patient  sitting  on  a  hot  water 
bag.     Calling  in  a  nurse,  he  requested  an  explanation. 

"But  that's  What  you  ordered,"  was  the  aggrieved 
answer. 

Unbelievingly,  the  doctor  picked  up  the  chart  to  check 
the  order  and  read,  "Hot  water  bag  to  patient's  r.  ear." 

A  young  sailor  cast  away  on  a  desert  island,  after  nine 
years,  spied  a  figure  on  a  neighboring  island.  Braving  the 
sharks,  he  swam  there  to  find  a  sweet  young  woman. 
Approaching   her,   he  said: 

"How   long  have   you   been   here?" 

"Why,   I've   been   here   six   years,"  she  said. 

"Six  years.  Why,  I've  been  on  my  island  for  nine 
long   years." 

"Why,  you  poor  man,  all  alone  for  nine  years.  I'm 
going  to  give  you  something  you've  been  wanting  for  a 
long   time." 

"Lady,  you  don't  mean  to  tell  me  you've  got  beer  on 
ice?" 

— Milwaukee   Med.    Jl. 

"Oh,  your  husband  has  a  new  suit,  hasn't  he?" 

"No." 

"But   he   looks   different,   somehow." 

"He's  a  new  husband." 


PROFESSIONAL   CARDS 


January  1941 


GENERAL 


Nail*  Clinic  Building 


THE  NALLE  CLINIC 

Telephone — 3-2141    (//  no  answer,  call  3-2621) 


412  North   Church   Street,  Charlotte 


General  Surgery 

BRODIE  C.  NALLE,  M.D. 
Gynecology  &  Obstetrics.. 
EDWARD    R.    HIPP,   M.D. 

Traumatic   Surgery 

PRESTON  NOWLIN,   M.D. 

Urology 


Consulting   Staff 

DRS.   LAFFERTY,   BAXTER   &   PARSONS 
Radiology 
BARRET   LABORATORY 
Pathology 


General  Medicine 


LUCIUS   G.   GAGE,   M.D. 
Diagnosis 


LUTHER   W.   KELLY,   M.D. 
Cardio-Respiratory   Diseases 


J.  R.  ADAMS,  M.D. 
Diseases  of  Infants  &  Children 


W.  B.  MAYER,  M.  D. 
Dermatology  &  Syphilology 


C— H— M   MEDICAL   OFFICES 

DIA  GNOSIS— SURGER  Y 

X-RAY— RADIUM 

Dr.   G  Carlyle  Cooke — Abdominal  Surgery 

&  Gynecology 
Dr.  Geo.  W.  Holmes — Orthopedics 
Dr.  C.  H.  McCants — General  Surgery 
222-226  Nissen  Bid.  Winston-Salem 


WADE   CLINIC 

Wade  Building 
Hot  Springs  National  Park,  Arkansas 


H.  King  Wade,  M.  D. 
Charles  S.  Moss,  M.D. 
Jack  Ellis,  M.D. 
Frank  M.  Adams,  M.D. 


Urology 

General  Surgery 

General  Medicine 

General  Medicine 


N.  B.  Burch,  M.D.  Eye,  Ear,  Nose  &  Throat 
Raymond  C  Turk,  D.D.S.  Dental  Surgery 
A.  W.  Scheer  X-ray  Technician 

Etta  Wade  Clinical  Palholoty 

Marjorie  Wade  Bacteriology 


INTERNAL  MEDICINE 


ARCHIE  A.  BARRON,  M.  D.,  F.A.  CP. 

JOHN  DONNELLY,  M.D. 

INTERNAL    MEDICINE— NEUROLOGY 

DISEASES  OF  THE  LUNGS 

Professional  Bldg.                                 Charlotte 

324^4  N.  Tryon  St.                              Charlotte 

CLYDE    M.    GILMOrE,    A.  B.,    M.D. 
CARDIOLOGY— INTERNAL    MEDICINE 
Dixie  Building  Greensboro 


JAMES   M.  NORTHINGTON,  M.D. 
INTERNAL    MEDICINE— GERIATRICS 
Medical  Building  Charlotte 


ORTHOPEDICS 


HERBERT   F.   MUNT,   M.D. 

ALONZO    MYERS,    M.  D.,    F.  A.  C.  S. 

ACCIDENT  SURGERY  &  ORTHOPEDICS 

ORTHOPEDIC  SURGERY  and 

FRACTURES 

FRACTURES 

Nissen  Building                          Winston-Salem, 

Professional   Bldg.                                 Charlotte 

January  1941 


PROFESSIONAL  CARDS 


NEUROLOGY  and  PSYCHIATRY 


J.  FRED  MERRITT,  M.D. 

NERVOUS  and  MILD  MENTAL 
DISEASES 

ALCOHOL  and  DRUG  ADDICTIONS 

Glenwood   Park   Sanitarium  Greensboro 


EYE,  EAR,  NOSE  AND  THROAT 


H.  C.  NEBLETT,  M.D. 

OCULIST 

Phone  3-58S2 

Professional  Bldg.  Charlotte 


AMZI  J.  ELLINGTON,  M.D. 

DISEASES  of  the 
EYE,  EAR,  NOSE  and  THROAT 

Phones:   Office  992— Residence  761 

Burlington  North   Carolina 


UROLOGY,   DERMATOLOGY  and   PROCTOLOGY 

THE  CROWELL  CLINIC  of  UROLOGY  and  UROLOGICAL  SURGERY 

Hours — Nine  to  Five  Telephones — 3-7101 — 3-7102 

STAFF 

Andrew  J.  Crowell,  M.  D. 

(1911-1938) 

Angus  M.  McDonald,  M.  D.  Claude  B.  Squires,  M.  D. 

Suite  700-711  Professional  Building  Charlotte 


Dr.  Hamilton  W.  McKay 


DOCTORS  McKAY  and  McKAY 

Practice  Limited  to   UROLOGY  and  GENITO-URINARY  SURGERY 
Hours  by  Appointment 
Occupying  2nd  Flood  Medical  Arts  Bldg. 


Dr.  Robert  W.  McKay 


Charlotte 


Raymond  Thompson,  M.  D.,  F.  A.  C.S.  Walter  E.   Daniel,   A.  B.,   M.D. 

THE  THOMPSON  -  DANIEL  CLINIC 
of 

UROLOGY  &  UROLOGICAL  SURGERY 

Fifth  Floor  Professional  Bldg.  Charlotte 


C.  C.  MASSEY,  M.D. 

PRACTICE  LIMITED 
TO 

DISEASES   OF   THE   RECTUM 

Professional  Bldg.  Char 


L.  D.  McPHAIL,  M.  D. 
RECTAL  DISEASES 


Professional   Bldg. 


WYETT   F.   SIMPSON,   M.D. 

GENITO-URINARY   DISEASES 

Phone  1234 

Hot  Springs  National  Park  Ark; 


PROFESSIONAL   CARDS 


January  1941 


SURGERY 


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JAMES   M.   NORTHINGTON,   M.  D.,   Editor 


CHARLOTTE,  N.   C.  FEBRUARY,   1941 


Acidosis  —Physiological  Basis  and  Treatment* 

Frank  B.  Marsh,  M.  D.,  Salisbury,  North  Carolina 


BECAUSE  of  its  far-reaching  effects  and  the 
multiplicity  of  its  associations,  Acidosis  has 
received  for  a  long  time  considerable 
thought  and  attention.  With  the  better  under- 
standing of  the  principles  of  normal  and  disturbed 
fluid  balance,  the  subject  has  commanded  even 
more  consideration. 

Acidosis  is  usually  the  result  of  either  one  of 
two  different  types  of  disturbed  body  metabolism. 
It  may  result  from  an  imbalance  of  electrolytes  in 
the  body  fluids  such  as  is  seen  in  the  excessive  loss 
of  the  sodium  ion  under  certain  disease  conditions. 
It  may  result,  on  the  other  hand,  from  the  produc- 
tion of  an  excessive  amount  of  ketones,  as  in  the 
disturbed  metabolism  of  an  uncontrolled  diabetes. 
While  either  of  these  disturbances  may  result  in 
the  development  of  acidosis,  it  is  indeed  seldom,  if 
ever,  that  the  acidosis  is  produced  solely  by  the 
depleted  sodium  ion  store  or  only  by  the  presence 
in  the  body  of  an  excessive  quantity  of  ketone  sub- 
stances. Practically  always  there  is  a  combination 
of  these  two  factors  operating  in  the  production  of 
the  acidotic  state,  as  it  is  met  with  in  practise.  For 
example,  in  the  acidosis  occurring  in  children  in 
whom  the  disturbance  develops  as  a  result  of  the 
depletion  of  the  sodium  ion  through  diarrhea,  the 
nausea  and  vomiting  bring  about  the  ejection  and 
rejection  of  food  and  fluid  (including  carbohy- 
drate) to  such  an  extent  that  the  combustion  of 
the  stored  fats  is  no  longer  complete.  The  result  is 
the  accumulation  of  an  excessive  quantity  of  the 
ketone  bodies. 


In  operative  cases  of  which  excessive  bile  drain- 
age, diarrhea,  profuse  sweating,  or  nausea  and 
vomiting  is  a  feature,  exactly  the  same  condition 
may  result.  If  dextrose  in  distilled  water  is  ad- 
ministered without  taking  into  consideration  the 
electrolyte  loss,  the  production  of  an  excess  of 
ketone  substances  may  be  prevented  even  in  the 
presence  of  acidosis  due  to  electrolyte  imbalance. 

In  the  severe  acidosis  of  diabetes  there  is  prac- 
tically always  depletion  of  the  sodium  ion  as  well  as 
the  presence  of  the  large  amount  of  the  ketone  sub- 
stances. The  recognition  of  this  fact  is  important 
if  the  proper  treatment  of  such  a  patient  is  to  be 
carried  out. 

There  are  rarer  conditions,  the  presence  of  which 
predisposes  to  or  results  in  acidosis.  They  are 
so  seldom  encountered,  however,  that  they  do  not 
warrant  detailed  consideration  in  this  type  of  dis- 
cussion. One  variety  of  this  group  of  conditions  is 
illustrated  by  the  two  cases  reported  in  1938  by 
Dr.  Alexis  Hartman.  The  acidosis  in  those  in- 
stances was  the  result  of  the  inability  of  the  renal 
tubules  to  reabsorb  the  bicarbonate  in  the  process 
of  urine  formation.  The  loss  of  base  in  that  man- 
ner predisposed  to  the  frequent  occurrence  of  aci- 
dosis and  required  an  almost  constant  ingestion  of 
the  sodium  ion  to  prevent  the  development  of  the 
acidotic  state. 

As  a  preliminary  to  the  discussion  of  the  sub- 
ject of  acidosis,  it  may  be  worth  while  to  review  a 
few  of  the  basic  principles  governing  the  fluid  bal- 
ance of  the  body. 


•Read    before    the    Rowan    County    (N.    C.)     Medical    Society,  Salisbury,  Dec.    12th,  1940. 


ACIDOSIS— Marsh 


February    1941 


It  is  well  to  remember  that  about  70  per  cent 
of  the  body  weight  is  made  up  of  water.  Approxi- 
mately 25  to  35  per  cent  of  this  amount  constitutes 
the  extracellular  fluid,  while  the  balance  makes  up 
the  intracellular  fluid.  The  extracellular  fluid  in- 
cludes the  plasma  portion  of  the  blood,  the  lymph, 
and  the  cerebrospinal  and  interstitial  fluids.  The 
intracellular  portion  is  the  fluid  medium  within  the 
cell  bodies.  These  two  fluids  lie,  so  to  speak,  in 
different  compartments  which  are  separated  by  a 
semipermeable  membrane.  The  extra-  and  intra- 
cellular fluids  have  the  common  functions  of  help- 
ing to  maintain  a  normal  osmotic  pressure  in  the 
body,  conveying  nutritive  elements  and  internal 
secretions  to  and  from  the  tissue  cells  of  various 
parts  of  the  organism,  carrying  waste  products  and 
poisons  from  the  cells  to  the  eliminative  organs 
and  participating  in  the  regulation  of  the  body 
temperature. 

These  fluids,  however,  do  differ  in  one  important 
respect.  This  difference  has  to  do  with  the  elec- 
trolyte content  and  the  concentration  of  protein  in 
the  two  fluids.  The  intracellular  fluid  contains 
principally  potassium,  magnesium,  phosphate  and 
protein,  while  the  extracellular  portion  contains 
very  largely  bicarbonate,  chloride  and  sodium.  It 
is  by  means  of  osmotic  pressure  that  the  inter- 
change of  fluids  and  the  substances  in  solution  is 
brought  about  between  the  cells  and  the  intercel- 
lular spaces.  Under  normal  circumstances  this 
pressure  is  held  in  a  state  of  equilibrium  to  a  very 
great  extent  by  the  equal  concentration  of  the 
monovalent  ions,  potassium  within  and  sodium  out- 
side the  cell  bodies. 

The  additional  factor  playing  its  part  in  the 
maintenance  of  the  normal  osmotic  pressure  within 
the  body  is  the  proper  concentration  of  the  other 
crystalloids  and  the  proteins  in  solution. 

For  the  purpose  of  discussion  one  can  illustrate 
the  changes  occurring  in  the  body  fluids  in  the 
various  types  of  disturbed  fluid  balance  by  the 
accompanying  diagrams.  There  is  represented  in 
these  figures  a  vessel  divided  into  two  compart- 
ments by  a  semipermeable  membrane.  The  fluids 
in  the  two  sections  of  the  vessel  are  thus  separated 
by  that  membrane  which  permits  the  forces  of 
osmosis  to  operate.  The  chamber  A  may  be  al- 
lowed to  represent  the  intracellular  and  the  cham- 
ber B  to  represent  the  extracellular  spaces,  while 
the  fluids  in  these  compartments  represent  the  in- 
tracellular and  extracellular  fluids,  respectively. 

As  one  sees  in  Diagram  1,  there  are  in  solution 
on  one  side  of  the  semipermeable  membrane  po- 
tassium, magnesium,  phosphate  and  protein,  while 
on  the  other  side  of  the  membrane  are  bicarbonate, 
chloride  and  sodium.     With  the  equal  concentra- 


tion of  the  potassium  and  sodium  the  normal  water 
balance  is  established.  If.  however,  the  amount  of 
sodium  is  reduced  by  a  given  amount  of  the  nor- 
mal store,  two  very  definite  things  occur.  First, 
the  amount  of  water  in  the  chamber  marked  ex- 
tracellular fluid  is  decreased,  and  second,  th2 
amount  of  water  in  the  chamber  marked  intra- 
cellular fluid  is  increased  (Diagram  2).  This  is 
true  because  of  the  fact  that  the  potassium  ion, 
being  practically  incapable  of  permeating  the  ce!l 
wall,  is  held  within  the  cell  body,  and  therefore 
does  not  vary  in  concentration  to  any  appreciable 
degree.  The  sodium  ion  in  the  extracellular  fluid, 
however,  is  subject  to  great  variation  in  concen- 
tration under  several  different  circumstances. 

For  practical  purposes  and  particularly  for  the 
aim  of  this  discussion,  after  assuming;  the  existence 
of  a  normal  serum  protein,  we  may  postulate  that 
it  is  by  reason  of  a  normal  sodium  ion  concentra- 
tion in  the  extracellular  fluid  that  the  state  of  nor- 
mal hydration  is  maintamer'.  We  may  sav,  too, 
that  when  the  sodium  chWide  in  the  body  is  low, 
a  state  of  dehydration  is  present,  and  when  there 
is  an  excess  of  sodium  chloride  in  the  body  the 
converse  of  dehydration,  edema,  exists.  (Diagram 
3.)  We  must  now  conclude  also,  that  in  order  to 
overcome  or  remedy  dehydration  it  is  just  as  neces- 
sary to  administer  sodium  chloride  as  it  is  water, 
otherwise  the  water  passes  out  through  the  kid- 
neys, none  remaining  in  the  blood  vessels,  the  in- 
terstices, or  the  lymph  spaces  to  help  restore  the 
normal  fluid  balance.  It  becomes  evident,  too, 
that  in  the  presence  of  edema  resulting  from  salt 
retention,  such  as  in  nephritis,  large  quantities  of 
water  are  necessary;  but  salt  should  not  be  admin- 
istered lest  the  edema  be  increased  thereby. 

It  must  be  stated  at  this  juncture  that  by  no 
means  do  the  sodium  and  chloride  ions  bear  a  fixed 
relation  as  to  the  extent  of  loss  or  the  constancy  of 
the  amount  in  concentration  under  certain  patho- 
logical circumstances.  (Diagram  4). 

Deficiency  of  sodium  may  result,  of  course, 
from  a  long-continued  inadequate  ingestion  of  the 
sodium  salts;  however,  the  most  frequent  cause  for 
this  disturbance  in  hydration  results  from  pro- 
longed and  copious  drainage  from  the  body  of  the 
various  salt-containing  fluids.  When  one  considers 
the  composition  of  the  gastric  and  intestinal  secre- 
tions, the  bile,  the  urine  and  the  sweat,  he  can 
clearly  see  how  great  loss  of  any  of  these  fluids 
might  result  in  electrolyte  denletion.  These  excre- 
tions and  secretions  may  be  looked  upon  as  modi- 
fied extracellular  fluids,  the  first  three  of  which  are 
normally  reabsorbed,  the  loss  of  the  electrolyte 
thereby  being  prevented. 

In  the  event  of  a  considerable  loss  of  any  of 


February    1941 


ACIDOSIS— Marsh 


these  fluids,  there  is  a  significant  diminution  in 
the  store  of  the  necessary  and  effectual  chloride 
and  sodium  ions,  the  loss  of  which  will  result  in 
dehydration  unless  these  elements  are  replaced  in 
the  equal  or  greater  quantity. 

In  this  connection  it  should  be  recalled  that,  de- 
pending upon  the  location  in  the  alimentary  tract 
from  which  the  fluid  loss  occurs,  will  be  determined 
the  particular  electrolyte  which  is  depleted  thereby. 
For  example:  prolonged  emesis  from  pyloric  ob- 
struction or  a  considerable  loss  of  hydrochloric  acid 
by  gastric  intubation  frequently  results  in  an  alka- 
losis as  a  result  of  the  relatively  larger  amount  of 
chlorides  in  the  gastric  juice.  On  the  contrary, 
obstructive  lesions  in  the  upper  part  of  the  small 
bowel  (duodenal  or  jejunal)  will  result  in  the  loss 
of  the  acid  and  base  elements  in  approximately 
equal  quantities.  Tn  the  fluid  loss  of  diarrhea  or 
in  the  copious  drainage  from  an  ileostomy,  the 
base  depletion  is  greater  and  acidosis  follows.  In 
the  surgical  drainage  of  the  gall  bladder  or  bile 
ducts,  the  alkali  loss  predominates  with  the  pre- 
disposition toward  an  acidosis.  In  heat  prostration, 
the  result  of  excessive  sweating  over  long  periods 
of  time,  there  is  a  significant  loss  of  water  as  well 
as  of  sodium  and  chlorine  ions. 

It  becomes  evident  then  that  either  acidosis  or 
alkalosis  may  result  from  the  imbalance  of  elec- 
trolytes, the  determining  factor  being  the  predomi- 
nant loss  of  sodium  in  the  former  and  the  more 
marker]  loss  of  the  chlorine  ion  in  the  latter.  We 
must  recognize  the  fact  that  the  acidosis  originat- 
ing primarily  as  a  result  of  the  sodium  ion  loss  is 
merely  one  phase  of  dehydration.  (Diagram  5). 

The  organic  type  of  acidosis  arises  from  an  en- 
tirely different  type  of  disorder.  Underlying  this 
type  k  the  fact  that  "fats  burn  in  the  fire  of 
carbohydrate  combustion."  Tn  any  condition  in 
which  the  oxidation  of  the  carbohydrates  is  con- 
siderably limited  or  slowed,  as  in  carbohydrate 
starvation  or  in  uncontrolled  diabetes  of  the  severe 
type,  the  fats  are  incompletely  burned  and  organic 
acid  bodies  are  produced.  These  substances  are 
the  ketones,  the  chief  ones  being  acetone,  diacetic 
acid  and  beta-hvdroxybutyric  acid.  In  the  at- 
tempt of  the  protective  forces  of  the  body  to  coun- 
teract this  disordered  state  much  of  the  base  may 
be  l^st  and  the  buffer  reserve  decreased  to  a 
sufficient   degree   to  cause  serious  consequences. 

The  normal  pH  of  the  blood  (about  7.41  is  pro- 
tected by  three  agencies:  (J)  The  buffer  systems 
of  the  body:  (2)  the  elimination  of  CO>  by  the 
lungs:  and  (3)  the  excretion  of  the  fixed  acids  by 
way  of  the  kidneys  and  the  bowels.  The  base  bi- 
carbonate, the  alkaline  phosphate  and  the  alkaline 
proteinate   perform   the   buffer   or    tampon   action 


and  neutralize  the  several  acid  substances  formed 
in  or  introduced  into  the  body,  thereby  maintain- 
ing the  normal  pH  of  the  body  in  health.  It  is  the 
quantity  of  the  sodium  ion  existing  in  the  extra- 
cellular fluids  which  determines  very  largely  the 
amount  of  bicarbonate  present  and  the  total  alkali 
reserve.  Tn  any  instance  in  which  the  quantity  of 
disassociated  sodium  ion  is  considerably  reduced 
the  chloride  shift  occurs,  releasing  more  of  the 
sodium  element  for  the  formation  of  additional 
base  bicarbonate.  The  carbonic  acid  concentra- 
tion in  the  blood,  on  the  other  hand,  may  be  raised 
or  lowered  as  the  situation  demands,  thereby  taking 
care,  up  to  a  certain  point,  of  any  excess  of  base 
obtained  in  the  body  fluids. 

Treatment 

Tn  the  treatment  of  the  disturbance  of  electrolyte 
balance  now  under  discussion,  it  usually  suffices  to 
-administer  large  quantities  of  sodium  chloride  in 
the  form  of  normal  saline  solution.  The  normal 
kidney  has  no  difficulty  eliminating  large  excesses 
of  either  the  sodium  or  the  chloride  ion,  provided 
sufficient  water  be  administered  therewith.  Ex- 
perimental studies  have  proven  that  healthy  kid- 
neys can  eliminate  as  much  as  twelve  to  fifteen 
times  the  average  normal  body  requirement  of 
sodium  chloride  when  accompanied  by  copious 
quantities  of  water.  However,  in  those  cases  in 
which  there  has  been  a  pronounced  loss  of  the 
sodium  element,  as  indicated  bv  a  considerable  de- 
crease in  the  plasma  00=  combining  power,  it  is 
often  advisable  to  replace  this  deficiency  by  ad- 
ministering either  a  sterile  solution  of  sodium  bi- 
carbonate or  a  preparation  of  sodium  r-lactate 
intravenously.  Bv  basing  one's  calculation  on  the 
plasma  CO'  combining  power  and  the  weight  of 
the  patient,  the  amount  of  the  sodium  bicarbonate 
or  sodium  r-lactate  necessary  to  replace  the  sodium 
inn  deficiency  may  be  easily  determined. 

FTartm^nn  advocates  the  nsp  of  cndinm  r-lactate 
usually  in  the  1  '6  molar  strength  in  the  treatment 
of  all  types  of  acidosis,  as  well  as  in  its  prevention 
under  certain  circumstances.  The  formula  sug- 
gested bv  TTnrtmann  for  determinm1?  the  quantity  of 
normal  sodium  r-lacfate  renuired  for  a  given  indi- 
vidual is: 

mM  =   (60  -  COO   0.7  W 


2.24 

Tn  this  equation  mM  represents  millimolars, 
CO»  represents  the  plasma  CO-  rending,  and  W  the 
weight  of  the  patient  in  kilograms. 

Tt  must  be  remembered  that  in  all  such  cases 
large  ounntities  of  fluid,  in  some  instances  as  much 
as  5000  c.c.  in  the  twenty-four  hours,  are  required 
to  restore  the  flird  bnkirce. 


ACIDOSIS— Marsh 


February   1941 


The  quantity  of  sodium  chloride  required  in  any 
given  case  of  dehydration  may  be  estimated  by  the 
formula  of  Collar  and  Maddock: 

(560  -  PC)  x  .5gm  x  Kilo  BW  =  Gms.  NaCl. 

100 
In  this  equation  PC  represents  the  plasma  chroride 
determination   and   BW   the   body   weight   of   the 
patient  at  the  time  of  the  examination. 

All  the  fluid  required  for  the  given  individual  for 
the  day,  except  that  containing  the  estimated 
amount  of  NaCl  needed,  should  be  administered  in 
the  form  of  either  a  five  or  ten  per  cent  solution 
of  glucose  in  distilled  water,  intravenously.  Inas- 
much as  this  type  of  acidosis  is  a  part  and  parcel 
of  dehydration,  this  same  rule  holds  good  for  the 
treatment  of  the  dehydrated  patient  under  ordi- 
nary circumstances. 

In  the  treatment  of  diabetic  acidosis,  one  strives 
to  obtain  several  different  results.  As  suggested 
by  Dr.  Hartmann,  they  may  be  considered  as: 

1.  Relief  of  the  disturbed  body  pH  and  HCO>. 

2.  Relief  of  anhydremia  and  dehydration. 

3.  Restoration  of  the  normal  electrolytes. 

4.  Abolition  of  the  ketosis. 

5.  The  restoration  of  the  glycogen  reserve. 

6.  The  reduction  of  hyperglycemia  and  of  glyco- 
suria. 

It  is  important  that  at  least  some  of  these  aims 
be  accomplished  rather  rapidly,  and  preferably  as 
rapidly  as  possible.  This  statement  applies  prin- 
cipally to  the  relief  of  the  disturbed  body  pH 
which  embraces  the  relief  of  the  dehydration,  the 
restoration  of  the  normal  electrolytes  and  the 
restoration  of  a  normal  plasma  CO>  combining 
power.  With  these  objects  attained,  the  ketosis, 
the  depletion  of  the  glvcogen  reserve,  the  hyper- 
glycemia and  the  glycosuria  becomes  less  signifi- 
cant, in  that  the  patient's  condition  has  been  made 
much  less  precarious  by  that  accomplishment. 

As  we  analyze  the  various  objects  of  the  treat- 
ment as  outlined,  we  see  that  the  first  three  are  at- 
tained as  a  result  of  the  administration  of  a  suf- 
ficient quantity  of  fluid  (water)  and  the  sodium  ion 
in  an  available  form.  The  fourth  is  accomplished 
by  the  administration  of  insulin  with  or  without 
glucose,  and  plenty  of  water  with  which  the  ke- 
tones may  be  washed  from  the  bodv. 

The  fifth  and  sixth  aims  can  be  accomplished 
only  bv  the  administration  of  a  sufficient  quantity 
of  insulin  to  convert  the  dextrose  into  glvcogen 
and,  later,  of  a  sufficient  quantity  of  glucose  to 
permit  of  the  production  of  enough  glvcogen  to 
meet  the  body's  requirements.  With  the  proper 
regulation  of  the  dose  of  insulin  and  the  dietary 
requirements    of    the    patient,    the    hyperglycemia 


and  the  glycosuria  can  be  satisfactorily  controlled. 
In  order  to  simplify  and  abbreviate  the  matter 
of  treatment  as  much  as  possible  and  at  the  same 
time  present  a  type  of  routine  procedure  which  has 
been  proved  to  be  quite  effective,  I  shall  outline 
for  vou  a  method  of  treatment  which  was  suggested 
recently  by  Dr.  Alexis  Hartmann  of  St.  Louis. 

After  the  history  is  taken  and  a  careful  physical 
examination  is  done  to  make  certain  the  diagnosis 
of  diabetic  acidosis,  the  patients  are  given:  First, 
two  units  of  plain  insulin  for  each  kilogram  of  body 
weight;  second,  30  c.c.  of  1/6  molar  sodium  r-lac- 
tate  per  kilo  intravenouslv:  third,  50  to  100  c.c. 
per  kilo  of  fortified  lactate  Ringer's  solution  sub- 
cutaneously. 

The  two  units  of  insulin,  according  to  the  ob- 
servation made  by  Dr.  Hartmann,  are  sufficient  for 
complete  metabolism  of  the  sodium  r-lactate  ad- 
ministered and  to  reduce  the  blood  sugar  by  300 
mgm.  per  100  c.c.  of  blood.  The  fortified  lactate 
Ringer's  solution  will  produce  8  grams  of  NaHCO 
per  liter,  and  the  total  amount  of  the  sodium  r-lac- 
tate should  increase  the  plasma  CO»  content  by  30 
to  40  volumes  per  cent. 

After  six  hours  the  second  dose  of  insulin  may 
be  necessary.  The  dose  is  to  be  governed  by  the 
blood  sugar  level  or  urinary  sugar  estimation.  The 
dose  is  usually  l/2  unit  per  kilogram  of  body 
weight. 

At  this  point,  in  exceptional  cases  of  acidosis  of 
the  greatest  severity,  30  c.c.  more  of  the  isotonic 
sodium  r-lactate  solution  may  be  administered. 

As  the  blood  sugar  level  approaches  normal,  if 
the  general  condition  warrants  it.  the  patient  is 
started  on  easily  digested  food,  the  dose  of  insulin 
being  estimated  from  the  previous  requirements 
and  the  condition  of  the  patient  and  generally  be- 
ing about  one  unit  of  insulin  for  each  two  grams  of 
available  dextrose. 

Symptoms  of  shock  indicate  the  immediate  ad- 
ministration of  blood  plasma  intravenously  in  suf- 
ficient quantities  to_  be  effective.  This  measure 
may  prove  life-saving  in  the  more  desperate  cases. 

It  has  been  shown  that  by  the  use  of  the  sodium 
r-lactate  and  insulin,  the  plasma  CO  combining 
power  in  severe  acidosis  can  be  raised  as  much  as 
15  to  16  volumes  per  cent  in  two  hours,  while  with 
saline  and  insulin  it  often  requires  many  hours 
more  to  obtain  the  same  amount  of  rise.  Such  a 
significant  difference  in  effectiveness  can  leave  no 
question  as  to  the  type  of  solution  indicated  by 
the  condition  under  discussion. 

In  most  instances  the  change  in  the  patient's 
condition  is  very  striking  under  the  suggested 
treatment.  However,  it  must  be  remembered  that 
if  the  patient  is  not  given  enough  sodium  chloride 


February   1941 


ACIDOSIS— Marsh 


SS 


A 

B 

NORMAL 



WATER  BALANCE 

K 

Na 

% 

BHCOj 

Prot. 

CI. 

Phos. 

v 

A 

B 

A 

B 





Na  + 

1 

Na 

Na 

1 

* 

) 

FIG.  1    NORMAL        2. 1  NTRACELLULAR     3.  EXTRACELLULAR. 
HYDRATION  OEDEMA  OEDEMA 


A 

B 

NORMAL      > 

_K_ 

i 

WATER    BALANCE 

i 

Sa 

ct. 

/ 

A 

B 

Ji. 

I 

"lei 

Na  ! 

^ 

i        ' 

FIG.     4 
ALKALOSIS 


FIG.    5 
ACIDOSIS 


Figure  1 — The   equal    concentration    of   the  Na  and    K   ions    results    in   the   state    of   normal    hydration. 

figure  2 — The  loss  of  sodium  ion  results  in  an  intracellular  edema  and  an  extracellular  dehydration. 
This  may  result  from  a  localization  of  sodium  in  a  pathological  lesion,  i.e.  pneumonia  or  an 
extensive   burn,    or  as   a  consequence  of   the   unreplaced    loss    of   the  electrolyte    from    the   body. 

Figure  3 — The  presence  of  an  excess  of  the  Na  ion  in  the  body  brings  about  the  retention  of  an  ab- 
normal   amount    of    water    in    the    extracellular    spaces,    instituting    a    state    of    general    edema. 

Figure  A — In  the  development  of  dehydration,  the  loss  of  a  relatively  larger  quantity  of  the  Na  ion 
gives  rise  to  a  relatively  larger  amount  of  the  CI  ion  in  the  extracellular  fluid.  The  result 
is  a  state  of   acidosis. 

Figure  5 — The  loss  of  relatively  larger  amount  of  the  CI  ion  result*  in  the  development  of  a  state  of 
alkalosis,    being    the    counterpart    of    the    condition    illustrated    in    Figure    4. 


there  is  likely  to  be  retained  in  the  blood  an  excess 
of  HCOj.  Should  the  degree  of  dehydration  in  a 
given  patient  not  be  considerable,  the  sodium  r- 
lactate  should  be  given  in  more  concentrated  form; 
i.e.,  in  one-third  to  one-half  molar  strength,  and 
the  total  quantity  of  fluid  administered  reduced 
proportionately.  On  the  other  hand,  in  conditions 
of  great  dehydration  sodium  r-lactate  in  a  hyper- 
tonic solution  is  prone  to  cause  high  fever,  the 
re  ull  of  rapid  oxidation  of  the  sodium  d-lactate. 
In  the  presence  of  dehydration,  it  should  be  given 
as  an  isotonic  solution,  which  is  the  1  '6  molar 
strength. 

SUMMARY 

/.  Acidosis  usually  arises  (1)  from  an  electrolyte 
imbalance  in  which  there  is  a  significant  sodium  ion 
depletion;  (2)  as  a  result  of  an  arrested  or 
markedly  limited  carbohydrate  metabolism  in  the 
body;  and,  (3)  as  a  consequence  of  the  existence 
mbination  of  these  two  conditions. 

//.  A  clear  understanding  and  the  proper  treat- 
ment of  acidosis  are  dependent  upon  an  intelligent 


conception  of  the  basic  principles  of  normal  and 
disturbed  fluid  balance. 

///.  The  treatment  of  the  mineral  type  of  aci- 
dosis consists  usually  of  the  intravenous  adminis- 
tration of  sufficient  normal  saline.  Ringer's  solu- 
tion, or  sodium  r-lactate  to  restore  the  fluid  bal- 
ance and  the  depleted  sodium  ion  concentration  of 
the  body  fluids.  In  cases  of  the  milder  form  and 
for  prevention  either  of  the  first  two  solutions  may 
be  employed.  In  the  severer  form  of  the  disturb- 
ance, however,  sodium  r-lactate  solution  is  prefer- 
able. 

IV.  In  the  treatment  of  the  organic  type  of  aci- 
dosis arising  from  an  uncontrolled  diabetes,  the 
orinciples  involved  are:  (1)  the  administration  of 
insulm  to  reestablish  the  arrested  or  depressed  car- 
bohydrate metabolism:  (2)  the  intravenous  injec- 
tion of  sodium  r-lactate  followed  by  the  intra- 
muscular injection  of  fortified  Ringer's  solution  to 
restore  the  fluid  balance  and  the  sodium  ion  deficit, 
and,  (3)  the  subserji"*nt  idministration  of  the 
(To   >■ 


SOUTHERN  MEDICINE  &  SURGERY 

Thyroidectomy* 

Paui    McBee,  M.  D..  Marion,  North  Carolina 


February   1941 


THYROIDECTOMY,  the  most  dramatic  of 
all  operations,  is  a  well  standardized  surgi- 
cal procedure.  There  are  several  minor 
variations  in  operative  technique  which  are  of 
interest  to  those  of  us  who  are  surgeons,  but  the 
purpose  of  this  paper  is  to  show  what  we  may 
reasonably  expect  to  accomplish  by  the  operation. 

Disease  of  the  thyroid  gland  is  fairly  prevalent 
in  this  section.  The  diagnosis,  as  a  rule,  is  not 
difficult.  My  six-year-old  ■  daughter  says  that  "a 
goiter  is  a  lump  in  your  neck  which  makes  you 
nervous."  Nervousness  is  an  important  symptom 
in  certain  types  of  goiters.  Some  make  the  patient 
nervous,  others  make  the  family  and  friends  nerv- 
ous and  still  others  make  the  doctor  nervous.  Few 
conditions  are  more  frightening  than  a  violently 
active  exophthalmic  goiter. 

Thyroid  diseases  tend  to  run  in  cycles  and  to 
chronicity.  Even  the  most  toxic  goiters  generally 
have  at  least  relative  remissions  and  exacerbations. 
This  should  make  us  temper  our  anxiety  for  prompt 
cure  with  some  caution. 

The  treatment  of  goiter  does  not  begin  or  end 
with  operation.  A  great  many  goiters  never  require 
any  sort  of  operation.  They  are  purely  medical. 
The  ones  which  do  require  surgery  need  well- 
studied  medical  care  before  and  after  operation.  I 
prefer  to  think  of  thyroidectomy  as  an  incident  in 
the  treatment  of  certain  kinds  of  goiters. 

Occasionally  a  thyroidectomy  is  justifiable  for 
cosmetic  reasons.  There  are  two  main  groups  of 
goiters  which  should  be  operated  upon. 

(1)  Hyperthyroidism,  regardless  of  whether  the 
overactivity  is  primary  or  secondary,  nearly  always 
requires  operation.  Subtotal  thyroidectomy  should 
be  performed  early  in  the  course  of  the  disease 
before  there  is  damage  to  vital  organs. 

Most  patients  with  hyperthyroidism  can  be  got- 
ten into  condition  for  operation  by  quiet,  rest  in 
bed,  sedatives,  and  the  administration  of  Lugol's 
solution.  They  should  be  operated  upon  while  the 
metabolism  is  falling  and  while  they  are  gaining 
weight.  When  the  metabolism  is  rising  and  they 
are  losing  weight  surgery  is  risky.  In  this  connec- 
tion I  want  to  go  on  record  as  being  decidedly 
opposed  to  pole  ligations  and  meddlesome,  mincing 
operations  upon  patients  with  violentlv  toxic  goiter. 
Occasionally  a  patient  with  complications  other 
than  those  of  thyroid  origin  can  be  better  handled 
by  a  thyroidectomy  in  two  stages.  As  a  rule  if  a 
patient  can  not  be  prepared  for  a  subtotal  thyroid- 
ectomy in  one  stage,  I  much  prefer  to  wait  for  a 

•Presented    to    the    January    meeting   of    the   Thermal    Belt    Medic 


neous  remission.  These  remissions  are  cer- 
tain to  occur  and  it  is  better  for  the  patient  to  get 
along  for  several  years  with  some  badly  damaged 
organs  than  to  die  from  a  premature  attempt  at 
radical  cure. 

(2)  Adenomatous  goiters  should  be  operated 
upon  while  they  are  still  quiet.  A  great  many  of 
them  become  hyperactive  later  in  life,  and  not  a 
few  undergo  malignant  degeneration.  Operation  is 
usually  very  safe  in  this  group  and  they  do  not 
require  extensive  preparation. 

Thyroidectomy  in  the  hands  of  competent  sur- 
geons does  not  entail  a  high  mortality.  When  per- 
formed adequately,  and  at  the  proper  time,  the 
mortality  is  about  one  per  cent.  This  compares 
favorably  with  other  elective  major  surgery.  I 
would  define  adequate  thyroid  surgery  as  the  re- 
moval of  an  amount  of  gland  sufficient  to  get  the 
patient  well  in  the  shortest  possible  time  and  to 
insure  as  nearly  as  possible  a  permanent  remission 
in  the  disease.  This  may  require  the  removal  of 
one-half,  five-sixths,  nineteen-twentieths  or  in  rare 
cases  even  all  of  the  thyroid  gland.  In  young, 
adults  with  severe  hyperthyroidism,  I  usually  re- 
move all  of  the  gland  except  a  tiny  piece  of  the 
posterior  capsule  on  each  side.  Patients  beyond 
middle  life  do  not  require  such  extensive  removal 
and  children  mav  fail  to  grow  properly  if  too  much 
is  removed.  Hvperthvroidism  should  not  recur  in 
more  than  five,  or,  at  the  outside,  ten  per  cent  of 
cases  following  this  type  of  operative  treatment.  I 
feel  that  it  is  better  for  a  few  of  these  patients  to 
require  some  thyroid  feeding  after  operation  than 
for  us  to  have  very  many  recurrences. 

Every  patient  with  a  goiter  requiring  surgery 
presents  an  individual  problem  which  must  be 
worked  out  in  the  light  of  the  teaching  and  the  ex- 
perience of  the  physician  and  the  surgeon  in  charge 
of  the  patient.  A  vast  store  of  useful  information 
is  available  in  the  writings  of  the  many  great  sur- 
geons who  have  developed  goiter  surgery  to  its 
present  state. 

Basal  metabolism  reports  should  not  be  taken 
too  seriously  in  the  diagnosis  or  treatment  of  goiter. 
The  test  is  a  valuable  help  and  should  not  be  neg- 
lected, but  one  should  rely  upon  the  patient's  his- 
tory and  physical  signs  to  make  the  diagnosis,  and 
use  the  metabolism  reading  to  help  decide  just  how 
bad  the  goiter  is. 

The  essential  steps  in  the  technique  of  thyroid- 
ectomy are  shown  in  a  short  moving  picture  of  one 
of  my  operations. 

.1    Society    held    at    Rutherfordton. 


February   1941 


SOUTHERN  MEDICINE  &  SURGERY 


Ablatio  Placentae 

With  Report  Of  A  Case  Treated  By  Abdominal  Cesarean  Section 
E.  J.  Cathell,  M.  D.,  and  J.  M.  Andrews,  M.  D.,  Lexington,  North  Carolina 


ABLATIO  PLACENTAE  generically  exists 
when  the  placenta,  implanted  upon  the  wall 
of  the  upper  uterine  segment,  becomes 
practically  or  entirely  detached  in  pregnancy,  or 
in  labor  before  the  completion  of  the  second  stage. 
Hemorrhage  and  its  sequelae  are  dominant  symp- 
toms. The  line  of  demarcation  between  placenta 
praevia  and  ablatio  is  the  site  of  the  retraction 
ring. 

The  primitive  conception  of  placenta  praevia  was 
that  the  placenta  was  invariably  attached  high 
within  the  uterine  cavity,  was  separated  with  hem- 
orrhage and  prolapse,  and  was  born  before  the 
child.  As  it  became  universally  conceded  that 
praevia  means  a  primary  attachment  of  the  nor- 
mal placenta  in  the  lower  segment  of  the  uterus, 
the  fundamentally  important  fact  that  a  placenta, 
normally  situated,  might  prematurely  become  de- 
tached with  an  alarming  hemorrhage  was  entirely 
ignored,  or  ardently  denied,  by  various  authorities. 
In  the  early  statistics  the  condition  was  included 
under  the  general  term  of  placenta  praevia.  The 
development  of  knowledge  on  this  subject  in  this 
last  generation  has  given  it  its  due  place  among 
obstetric  complications. 

The  frequency  of  premature  separation  of  the 
placenta  varies  a  great  deal.  In  private  practice 
clinic  ablatio  will  be  found  once  in  500  births. 

Eclampsia  has  often  declared  to  be  a  disease 
of  theories  when  considering  the  etiology.  The  same 
may  be  said  of  ablatio,  for  other  than  traumatic 
influences,  the  etiology  is  wrapped  in  numerous 
hypotheses,  some  of  which  are  highly  logical,  while 
others  are  well  within  the  realm  of  chimerical  spec- 
ulation. Numbers  of  earnest  investigators  have 
described  diverse  pathological  alterations  of  the 
uterus,  placenta  and  other  organs,  which  are  so 
characteristically  variant  one  from  the  other  as  to 
lead  to  the  belief  that  distinctive  etiologic  influences 
have  been  operative.  The  symptomatology  in  dif- 
ferent cases  shows  extremely  different  manifesta- 
tions, which  again  would  thoroughly  substantiate 
the  opinion  that  ablatio  is  not  a  specific  entity; 
they  all  have  one  conspicuous  sign — hemorrhage, 
the  result  of  placental  separation.  Finally,  the 
etiology  may  be  divided  into  the  indirect  or 
anatomic,  and  the  direct,  factors.  In  the  former, 
the  conception  held  by  most  authorities  is  that  the 
cause  of  placental  separation  is  the  result  of  loss 
of   continuity   of   the   walls  of   the   maternal-fetal 


blood  streams,  the  extravasated  blood  initiating 
the  dehiscence.  The  bleeding  is  secondary,  a  result 
of  uterine  contraction.  The  later  or  direct  factors 
may  be  divided  into: 

1.  Traumatic 

2.  Pathologic   (inflammatory) 

3.  Toxemic. 

The  resistance  of  the  body  in  different  individ- 
uals varies  greatly  in  the  reaction  to  injury,  large 
and  small.  In  one,  a  seemingly  trivial  accident 
may  be  of  serious  import,  while  in  another  great 
violence  may  be  followed  by  no  ill  effects.  Inflam- 
matory and  degenerative  changes  are  usually  as- 
sumed to  be  responsible  for  nontoxic  or  pathological 
types  of  separation. 

Toxemia  as  a  cause  results  from  faulty  metabol- 
ism, endocrine  dysfunction  and  from  biochemical 
incompatabilities  between  the  maternal  blood  con- 
tent and  the  new  emanations  originating  within  the 
ovum.  The  complex  presented  by  those  patients 
who  have  organic  disturbances  (nephritic,  hepatic 
etc.)  with  their  premature  separation,  gives  proof 
that  at  least  one  third  of  all  examples  of  ablatio 
conform  to  the  principles  which  dictate  that  they 
shall  be  classified  with  other  obstetric  toxemias, 
hyperemesis,  eclampsia  etc. 

Pathology 

Separation  of  the  placenta  is  always  accompanied 
by  hemorrhage  unless  the  fetus  has  been  dead  long 
enough  to  allow  thrombosis  to  occur  in  the  uterine 
sinuses.  De  Lee  states  that  in  all  his  cases  ex- 
ternal hemorrhage  followed  internal;  so  the  rule  in 
his  cases  is  that  the  bleeding  in  abruptio  placentae 
is  first  internal  or  concealed,  then  combined,  ex- 
ternal and  internal.  The  macroscopic  appearance 
of  the  uterine  peritoneum  is  characteristic  of  a 
toxic  apoplexy.  The  widespread  infiltration  of  the 
muscularis  reflects  the  hemorrhagic  deposits  of  the 
surface.  The  feel  of  the  uterine  wall  has  been 
aptly  described  as  comparable  to  that  of  soaked 
sole  leather.  Its  contractile  and  retractile  power 
is  reduced  to  a  minimum.  The  suffusion  of  the 
placenta  with  feeble  attempts  to  form  hematomas 
and  the  acute  or  subacute  extensive  thromboses  of 
the  villi  are  so  typical  that  they  harmonize  with 
the  uterine  changes.  Infarcts  and  frequently  ad- 
vanced degeneration  will  be  found  in  the  placenta. 
Symptomatology 

A  typical  picture  of  ablatio  is  as  follows.  The 
woman  is  seized  with  a  severe  pain,  feels  the  ab- 


ABLATIO   PLACENTAE— Cathell  &  Andrews 


February   1941 


domen  distended;  becomes  dizzy  or  faints;  gives 
evidence  of  shock,  pulse  thready  and  weak;  skin, 
conjunctival  membrane  and  prolabia  pallid;  fetal 
movements  suddenly  become  tumultuous,  then 
quickly  cease;  internal  hemorrhage  continues  and 
eventually  some  blood  passes  the  vulva.  Such  a 
symptom-complex  is  the  exception  not  the  rule. 
And  the  diversity  of  these  symptoms  is  controlled 
by: 

1.  The  response  of  the  sensorium 

2.  The  nature  of  the  etiologic  factor 

3.  The  location  of  the  placental  site 

4.  The  degree  of  placental  separation 

5.  The  tonicity  of  the  uterus 

6.  The  condition  of  the  blood. 

Prognosis 
The  mortality  rate  is  influenced  by  various  ele- 
ments which  are  reflected  in  mathematical  terms: 

1.  Early  diagnosis 

2.  Segregation  of  cases  into  mild  and  severe 

3.  Whether  absolutely  or  relatively  concealed 

4.  The  etiology 

5.  The  method  of  treatment. 

Treatment 
The  integrals  which  control  the  selection  of  the 
appropriate  treatment  are: 

1.  The  condition  of  the  mother  (degree  of  ane- 
mia, shock  and  the  presence  of  potential 
sepsis) 

2.  The  condition  of  the  fetus  (dead  at  the  time 
of  intervention,  or  premature  beyond  the  hope 
of  saving) 

3.  The  condition  of  the  cervix  (os  dilatable,  or 
tightly  closed  by  rigidity  etc.) 

4.  The  contractility  of  the  uterus. 

The  indications  and  the  consraindications  must 
be  weighed  in  selecting  the  appropriate  treatment. 
The  methods  of  treatment   may  be  divided   into 
conservative  and  surgical. 
Conservative: 

1.  Spontaneous 

2.  Rupture  of  membranes 

3.  Low  forceps,  breech  extraction  when  condi- 
tion permits 

4.  Rupture  of  membranes,  cervicovaginal  tam- 
ponade, and  use  of  the  eventual  forceps 

5.  Hystereurysis. 
Surgical: 

1.  Vaginal  cesarean  section 

2.  Classical  section 

3.  Low  cervical  section 

4.  Eventual  hysterectomy  (Parro) 

5.  Manual  dilatation. 

Report  Of  Case 
A  white,  married  woman,  aged  23,  gravida  II, 
para  I,  eight  months  pregnant,  was  admitted   to 


the  hospital  12  hours  after  initial  profuse  hemor- 
rhage, which  awakened  her  at  8  a.  m.  She  was 
severely  shocked.  Pulse  160  per  minute,  irregular 
and  weak,  b.  p.  90/80.  There  was  moderate  con- 
stant vaginal  bleeding  through  vaginal  pack.  The 
abdomen  was  the  size  of  an  8  months  pregnancy. 
No  fetal  heart  tones  or  placenta  souffle  was  heard. 
When  the  pack  was  removed  the  patient  was  bleed- 
ing moderatelv.  Cervix  not  effaced,  thick,  hard 
and  dilated  2^2  cm.     Presenting  part  not  felt. 

Patient  was  delivered  at  full  term,  normally, 
two  years  previously.  Appendectomy  and  left 
oophorectomy  one  year  ago.  Mother  died  with 
eight  pregnancy  following  three  weeks  hemorrhage 
and  still  birth.     No  previous  serious  illness. 

Well  developed  and  fairly  well  nourished  woman 
lying  in  bed,  acutelv  aware  of  surroundings,  com- 
plaining of  thirst  and  in  severe  shock.  Pulse  160, 
b.  p.  90  80,  pulse  weak  and  irregular  at  times,  face 
and  mucous  membranes  pallid.  Extremities  cold 
and  clammv.  Abdomen  enlarged  to  about  8 
months  pregnancy-  No  contraction  elicited.  Fetal 
heart  tones  and  uterine  souffle  not  heard.  Patient 
was  bleeding  from  vagina  through  vaginal  pack  in- 
serted in  home.  On  removing  pack  hemorrhage  was 
severe  and  constant  from  cervix.  Cervix  was  thick, 
hard  and  not  effaced  and  was  dilated  l^/i  cm.  The 
presenting  part  was  not  felt. 

A  diagnosis  of  premature  separation  of  the  pla- 
centa of  unknown  etiology  was  made.  The  lower 
uterine  cavity,  cervix  and  vagina  were  packed,  foot 
of  bed  elevated,  morphine  gr.  J4  given  and  infusion 
o"!  1000  c.c.  saline  and  glucose  begun.  Ice  caps 
were  placed  to  abdomen  and  blood  taken  for  match- 
ing. 

As  soon  as  a  satisfactory  donor  was  obtained  the 
patient  was  given  500  c.c.  citrated  blood.  Her  con- 
dition improved  until  the  pulse  was  130  per  min- 
ute, regular  and  stronger,  b.  p.  110/80.  At  this 
time  a  high  cesarean  section  was  done  under  gas 
anesthesia  with  a  small  amount  of  ether.  A  dead 
fetus  was  delivered.  As  soon  as  the  patient  was  re- 
turned to  room  she  was  given  500  c.c.  more  of  ci- 
trated blood. 

The  patient's  temperature  in  the  second  post- 
operative day  was  101  3/5.  There  was  a  gradual 
decline  thereafter  to  normal.  She  was  given  sul- 
fanilamide beginning  the  first  and  continuing 
through  the  eighth  day.  Otherwise  the  course  was 
uneventful.  She  was  dismissed  from  the  hospital 
on  the  eleventh  day. 

Summary  and  Conclusion 
Premature  separation  is  a  grave  emergency.  Con- 
servative treatment  is  the  procedure  of  choice  when 
possible  and  the  mortality  is  less  than  in  drastic 
surgical  procedure.    In  choosing  the  type  of  treat- 


February   1941 


ABLA T10   PLACENTAE— -Cathell 


Andrews 


59 


ment  ail  conditions  and  circumstances  must  be 
weighed. 

Abdominal  section  is  probably  the  major  surgi- 
cal procedure  of  choice. 

Surgical  Procedure. — Vaginal  cesarean  section 
has  never  been  very  popular  for  the  treatment  of 
ablatio.  Hemorrhage  obscures  the  field.  The  mor- 
tality rate  is  as  high  or  exceeds  that  of  abdominal 
section.  One  cannot  inspect  the  uterus,  which 
alone  is  the  means  of  recognizing  the  main  indica- 
tion for  a  hysterectomy,  the  Couvelaire  uterus. 

Abdominal  cesarean  section  must  be  considered 
a  makeshift  until  a  rational  procedure  for  the  con- 
duct of  ablatio  shall  be  devised.  The  nontoxic  types 
are  not  appropriate  for  the  operation  for  anemia  is 
not  conducive  to  good  results.  Toxemia  patients, 
likewise,  are  not  suitable  for  an  abdominal  opera- 
tion. In  external  hemorrhage  cesarean  section  is 
2.6  times  more  fatal  than  conservative  means.  In 
internal  hemorrhage  this  formidable  operation  is 
five  times  as  dangerous  as  the  conservative  meas- 
ures. Cesarean  section  requires  the  following  con- 
ditions. 

1.  The  cervix  shall  be  tightly  closed,  and  not 
readily  dilatable. 

2.  There  shall  be  contributory  obstetric  compli- 
cations which  render  vaginal  delivery  difficult 
or  impossible. 

Low   cervical   cesarean   section   has   become   the 
operation  of  choice  by  a  few.  The  time  required  in 
rotating  the  head  and  applying  forceps  has  some 
disadvantage  over  the  abdominal  section. 
Reference 

1.  Gynecology  &  Obstetrics   (Carl  Henry  Davis).  W.  R. 
Prior  Company,  Inc. 

2.  Anesthesia   in   Cesarean   Section.   S.,   G.   &■  0.,   March, 
1940. 

3.  Cyclopedia  of  Med.,  1938. 

4.  Prin.  &  Prac.  oj  Obs.,  De  Lee. 


BETTER    MEDICATION   FOR    ASTHMA   ETC. 

(E.  A.  BROWN  in  New  Eng.  JI  oj  Med.,  Nov.  21st) 

Capsules  containing  %  grain  of  ephedrine  sulfate,  ri 
grain  of  sodium  phenobarbital  and  3  grains  of  theophylline 
sodium  acetate  were  dispensed  over  a  period  of  18  months 
to  189  patients  in  private  practice  and  in  an  Allergy 
Clinic.  All  patients  here  reported  on  had  bronchial 
a?thma:   extrinsic  80;   intrinsic  50;   mixed   10  cases. 

In  every  case  in  which  the  usual  doses  of  ephedrine  and 
phenobarbital  were  adequate,  the  capsule  described  was 
equally  or  more  efffective.  All  patients  were  receiving 
treatment  aimed  at  the  causes.  All  except  those  who  had 
side  reactions  agreed  that  the  relief  came  on  more  quickly 
and  was  more  complete  than  that  given  by  other  medica- 
tions. 

Ol  the  total  number,  13  complained  of  tremor,  palpita- 
tion and  headaches  due — as  proved  experimentally — to  the 
ephedrine  in  it.  Six  complained  of  nausea  and  indiges- 
tion. This  was  found  to  be  due  to  the  theophylline  so- 
dium acetate.  Four  complained  of  nausea,  but  continued 
to  take  the  capsules  containing  theophylline.  No  case  of 
sensitivity    to   phenobarbital    was    encountered.     Two    pa- 


tients complained  that  all  gelatin  capsules  caused  pyrosis. 

Five-hour  enteric-coated  tablets  were  given  to  a  total 
of  117  patients,  of  whom  61  also  received  the  plain  cap- 
sule, since  asthma  occurred  either  during  the  day  or  during 
the  first  four  hours  following  retiring.  The  remaining  56 
patients  had  no  asthma  during  the  day  but  usually  had 
symptoms  arising  four  or  more  hours  after  retiring,  and 
were  given  the  enteric-coated  capsules  only.  The  61 
patients  therefore,  who  received  both  capusles  and  tablets 
were  those  whose  asthma  might  occur  during  either  period 
of  th  night  or  both. 

Of  the  117  patients,  S  awakened  6  hours  following  medi- 
cation free  of  asthma,  but  unable  to  fall  asleep  again. 
This  state  was  attributed  to  the  theophylline,  and  either 
this  drug  was  omitted  or  additional  phenobarbital  was 
given. 

Not  all  patients  got  relief  at  all  times. 


CHEMOTHERAPY  IN  ACUTE  BACILLARY 
DYSENTERY 
1.    G.    M.    Lyon,    Huntington,    in    W.    Va.   Med,   JL,   Feb. 

Twenty-three  patients  with  severe  cases  of  acute  bacil- 
lary  dysentery  were  treated  with  sulfanilylguanidine,  and 
21  alternate  patients  with  the  same  disease  of  a  similar 
severity  were  taken  as  untreated  controls. 

The  patients  not  receiving  sulfanilylguanidine  had  tem- 
peratures of  102  to  105°  the  first  week,  bloody  diarrhea, 
nausea,  vomiting,  cramps,  tenesmus,  prolapsus  ani;  in  the 
second  week  ,a  lower  temperature,  diarrhea  more  purulent 
and  a  loss  of  strength  and  body  weight;  in  the  third  week, 
a  convalescence  of  varying  degrees  of  severity  and  tardi- 
ness, accompanied  by  indigestion  and  loss  of  strength. 

Of  the  patients  receiving  sulfanilylguanidine  five  were 
not  influenced  by  the  drug.  Of  these,  two  had  accompany- 
ing pyogenic  infections  of  importance.  The  other  18  all 
received  great  benefit  from  the  drug.  Generally,  within 
24  to  48  hours,  a  rather  rapid  fall  in  the  temperature  and 
in  the  leucocyte  count,  marked  reduction  in  the  number 
of  diarrheal  stools  and  remarkable  improvement  in  con- 
sistency, and  as  to  blood,  pus,  or  mucus.  This  occurred 
in  24  to  72  hours  after  institution  of  the  chemotherapy  in 
all  of  the  18.  There  is  reason  to  believe  that  sulfanilyl- 
guanidine is  most  efficacious  in  the  first  three  or  four 
days.  Its  use  is  attended  with  less  toxic  side  effects  than 
that  of  the  related  compounds. 


BANANA  DIET  IN  BACILLARY  DYSENTERY 
(L.  H.  BLOCK,  Chicago,  &  A.  TARNOWSKI,  Dixon  in 
Dig.  Dis.  Jan.) 
Of  127  patients,  65  on  banana  diets  and  62  on  control 
diets  which  consisted  of  the  us  al  institutional  dietary  re- 
gme,  symptoms,  weight,  temperature,  appearance  of  the 
rectu  mand  sgmoid,  and  the  mortality  and  morbidity  rate 
ot  the  patients  in  comparable  groups  indicate  that  the  use 
of  bananas  is  advantageous  in  bacillary   dysentery. 


If  Protamine  Zinc  Insulin  Fails  to  give  the  desired  re- 
sults, supplement  regular  insulin  rather  than  increasing 
the  dose  of  the  protamine  zinc  insulin.  Regular  insulin, 
mixed  with  protamine  zinc  insulin,  apparently  is  converted 
more  or  less  completely  into  the  latter.  Care  in  the  ma- 
nipulation of  the  double  syringe  and  the  deposition  of 
the  insulins  in  Afferent  areas  with  the  one  injection  avoids 
the  insulins  in  different  areas  with  the  one  injection  avoids 
their  admixture  in  the  subcutaneous  tissues. — Watson. 


Mazzini  Test — In  our  opinion  the  Mazzini  test  is  an 
excellent  test  for  the  laboratory  diagonosis  of  syphilis  — 
Breageale  et  al.,  Tucson,  in     Jl.  Lab.  &  Clin.  Med.,  Jan.) 


SOUTHERN  MEDICINE  &  SURGERY 


February   1941 


Gonorrheal  Vaginitis  in  Girls* 

Robert  A.  Moore,  M.  D.,  Charlotte,  North  Carolina 


GONORRHEAL  VAGINITIS  has  come  to 
be   recognized  as  an  important  disease  of 
:hildhood.    Its  possible  physical  effects  are 
serious,  and  even   more  serious  is   the  danger  of 
causing  lasting  feeling  of  guilt  and  shame  and  of 
giving  rise  to  abnormal  sex  habits. 
Frequency 

It  is  difficult  to  estimate  the  frequency  because 
so  few  of  the  cases  are  reported,  and  many  go  un- 
recognized. Vonderlehr ,  of  the  United  States  Pub- 
lic Health  Service,  estimates  that  there  are  over  a 
million  cases  of  active  gonorrhea  in  the  United 
States.  Considering  this  number  of  possible  foci,  it 
is  not  unlikely  that  Jean's  report  of  5.3  per  cent 
positives  in  262  girls  at  dispensary  clinics  in  St. 
Louis  is  not  far  from  the  right  figure  for  this  group 
in  large  cities.  The  incidence  is  probably  much 
lower  for  private  patients,  and  among  children  gen- 
erally in  smaller  communities. 

The  condition  is  infrequent  in  the  newborn,  even 
when  the  mother  at  confinement  has  acute  gonor- 
rhea. This  is  in  contrast  to  gonorrheal  ophthalmia. 
It  is  most  prevalent  between  the  ages  of  five  and 
seven.  Abt  states  that  70  to  80  per  cent  of  all 
cases  of  vaginitis  are  gonorrheal;  Spalding  says 
79  per  cent.  Brenett  et  al.  of  241  clinic  cases  found 
79  per  cent  positive,  14  suspicious  and  7  gonor- 
rheal. 

Etiology 

The  undeveloped  state  of  the  vulva  and  the  ab- 
sence of  pubic  hair  exposes  the  vagina  of  the  child 
to  infection.  The  gonococcus  is  implanted  on  the 
vulva  through  indirect  contact  with  an  infected 
individual.  An  important  source  of  infection  is  the 
toilet  seat,  usually  so  constructed  that  the  vulva 
of  the  little  girl  comes  in  contact  with  its  surface. 
Contaminated  bed  linen,  towels,  wash  cloths,  tubs 
and  underclothes  are  other  sources  of  infection. 
Careless  or  uncleanly  handling  bv  the  nurse,  maid 
or  playmate  is  responsible  for  some  cases.  Benson 
found  an  infected  parent  was  the  source  of  infec- 
tion in  50  per  cent  of  a  series.  Reichert  found  the 
disease  oftener  transmitted  from  an  adult  member 
of  the  family  than  from  one  child  to  another. 
Studies  of  121  cases  disclosed  genital  infection  in 
other  members  of  the  family  in  108  cases. 
Symptoms 

The  acute  state  is  characterized  by  a  purulent 
greenish-yellow  discharge,  not  conspicuous  in  the 
cleanly  girl,  or  just  after  voiding.    Greenish  stiff 

"Presented    to    the    meeting    of    the    Mecklenburg    County    Medic 


spots  on  the  underclothes'  commonly  arrest  the 
mother's  attention.  The  vulva,  the  surrounding 
skin,  and  frequently  the  thighs,  are  inflamed;  the 
inguinal  glands  are  palpably  enlarged;  the  labia, 
clitoris  and  hymen  are  reddened,  swollen  and  ten- 
der. Some  investigators  state  that  urethral  involve- 
ment has  no  part  in  determining  the  course  of  the 
disease;  Stein  and  others  state  that  urethritis  is 
an  inevitable  complication;  while  Le  Tinde  found 
no  urethritis  in  the  vast  majority  of  his  cases.  The 
vagina  and  the  vaginal  cervix  show  inflammation 
and  often  ulceration,  and  in  the  submucosa  the 
organisms  are  found.  Bartholin's  glands,  undevel- 
oped, are  infrequently  involved.  In  all  young  girls 
the  cervical  os  is  tightly  closed  and  the  endocervical 
glands  are  immature  and  not  often  involved.  The 
relatively  long  cervix  and  tightly  closed  lumen 
usually  prevent  entrance  of  the  gonococci.  My 
search  reveals  reports  of  only  57  cases  of  periton- 
itis complicating  gonorrheal  vaginitis. 

The  rectum  may  also  be  infected  by  vaginal  se- 
cretions; but,  there  are  usually  no  symptoms,  and 
as  the  rectal  tissues  are  resistant  to  this  organism  it 
is  unlikely  that  proctitis  plays  anv  part  in  causing 
recurrence  of  vaginitis. 

Diagnosis 

The  physical  findings,  examination  of  gram- 
stained  smears,  with  use  of  the  culture  method 
when  in  doubt  furnish  the  evidence.  The  culture 
gives  a  higher  percentage  of  positives  than  the 
smear;  and  differentiates  micrococcus  catarrhalis, 
frequently  present  in  the  vagina,  and  the  meningo- 
coccus. All  leucorrheal  discharges  of  girls  should 
be  considered  of  gonorrheal  origin  until  proven 
otherwise.  The  complement-fixation  test  is  only 
about  50  per  cent  reliable. 

Specimens  from  the  vagina  can  be  taken  by  cot- 
ton swabs,  or  by  inserting  an  ordinary  glass  cathe- 
ter containing  a  y2  inch  of  saline  to  the  upper 
limit  of  the  vagina.  Culture  media  may  be  inocu- 
lated, smear  made  and  the  discharge  tested  for  its 
reaction  with  liquid  nitrazene.  Positive  cases 
usually  show  a  pH  above  6.  I  have  used  the  cathe- 
ter method  for  several  months  and  find  it  much 
better  than  the  swab  method.  In  case  cultures  and 
smears  are  repeatedly  negative,  yet  the  mother 
continues  to  find  a  spotting  on  the  child's  under- 
clothes, the  mother  is  shown  how  to  make  a  smear 
and  is  given  slides  and  swabs  with  instructions  to 
obtain  a  specimen  from  the  vaginal  opening.     A 

al    Society,    on    the   first    Tuesday   in    October,    1940. 


February   1941 


GONORRHEA  L    1  ".-1 G1XIT1S— Moore 


provocative  test — 2  to  4  per  cent  silver  nitrate  so- 
lution instilled  into  the  vagina  and  washed  out 
with  saline  after  a  few  minutes  and  smears  and 
cultures  made  the  following  day — may  make  the 
diagnosis. 

Prognosis 
It  is  difficult  to  predict  the  duration  of  the 
disease.  In  less  virulent  infections  it  may  subside 
in  5  to  4  weeks:  but  as  a  rule  untreated  or  insuffi- 
cienily  treated  cases  last  for  months,  even  years, 
with  frequent  exacerbations.  It  is  hard  to  say 
when  a  case  is  cured.  Some  say  after  three  weekly 
negative  smears;  others,  as  Mueller,  say  examine 
even-  two  weeks  for  the  first  year,  and  every  three 
months  during  the  second  year.  Stein  believes  that 
frequent  negative  smears  must  be  obtained  for  six 
months  before  calling  a  case  cured.  One  case  I 
thought  I  had  cured  with  sulfanilamide  gave  twen- 
ty negative  smears  during  two  months;  then  the 
twenty-first  was  positive.  The  reason  for  so  many 
smears  was  because  of  a  slight  mucous  discharge. 
The  disease  is  seldom,  if  ever,  carried  over  the  age 
of  puberty. 

Prevention 

Gynecologists,  urologists  and  general  practition- 
ers— all  who  treat  gonorrhea — should  warn  the 
adult  and  instruct  him  or  her  in  measures  neces- 
sary for  the  protection  of  the  children.  Taussin 
recommends  U-shaped  toilet  seats  in  public  lava- 
tories used  by  children.  Infected  girls  should  be 
kept  from  school  until  at  least  four  weekly  nega- 
tive smears  have  been  made.  I  diagnose  all  cases 
of  gonorrheal  vaginitis  as  pyuria  for  the  benefit 
of  the  girl  and  for  protection  against  inquisitive 
neighbors.  The  parents  are  duly  appreciative. 
Treatment 

Until  the  past  few  years  numerous  reports  of 
various  methods  showed  failure  to  obtain  satisfac- 
tory results  with  any  method.  Silver  salts,  mercu- 
rochrome,  potassium  permanganate  and  picric 
acid  were  used.  Perhaps  better  results  could  have 
been  obtained  with  any  of  the  antiseptics  had  the 
treatment  been  more  persistent.  Vaccine  therapy 
has  been  used  extensively  but  without  much  result. 
Gonococcus  filtrate  has  apparently  had  its  day. 
Fever  therapy  with  bacterial  vaccine,  malarial  in- 
fections, and  hypertherm  gave  fair  results;  but 
this  method  of  treatment  in  children  is  often  worse 
than  the  disease. 

In  1933  Lewis  developed  the  idea  that  as  gon- 
orrheal vaginitis  usually  ceases  spontaneously  at 
puberty,  treatment  of  children  with  estrogenic  ma- 
terial might  be  of  value.  The  child's  vaginal  epi- 
thelium is  five  or  six  layers,  that  of  the  adult 
twenty  to  thirty  layers  and  resistant  to  the  gono- 
coccus. Lewis,  using  theelin,  caused  thickening  of 
the  mucosa  and  acidification  of  the  vaginal  secre- 


tions— pH  4.8  to  6.  Six  of  his  first  eight  cases  were 
apparently  cured.  In  vitro  the  gonococci  grow  best 
in  a  slightly  alkaline  medium;  if  the  pH  falls  be- 
low 6  they  invariably  die.  It  is  likely  that  thick- 
ening and  acidity  have  their  parts  in  the  cure. 

Many  others  have  used  this  estrogen  treatment. 
TeLinde  treated  159  cases  with  1000-unit  amniotin 
suppositories,  and  obtained  recovery  in  every  case. 
A  follow-up  of  his  first  100  from  two  months  to 
two  and  one-half  years  showed  98  of  them  well. 
The  average  time  for  epithelial  response  was  two 
weeks  and  negative  smears  a  few  days  later.  Re- 
sults were  not  obtained  when  given  large  doses  of 
amniotin  orally,  nor  was  there  an  epithelial  re- 
sponse from  estrogen  in  aqueous  solution  hypo- 
dermically,  though  sixteen  out  of  twenty-two  re- 
sponded when  theelin  in  oil  was  given.  Matzer  and 
Shector  reported  on  118  cases  admitted  to  Phila- 
delphia General  Hospital  ('35-'37)  with  eighty-one 
treated  with  progynon  B  hypodermically,  34  with 
vaginal  suppositories  and  three  given  progynon 
orally.  Three  of  the  eighty-one  cases  failed  to  re- 
spond, and  a  follow-up  of  sixty-one  from  three  to 
twenty-three  months  showed  10  per  cent  recur- 
rence; of  the  thirty-four  treated  with  suppositories 
one  failed  to  respond  and  twenty-six  of  thirty-three 
followed  from  three  to  fifteen  months  without  re- 
currence. The  three  treated  orally  did  not  respond. 
The  suggestion  is  made  that  treatment  be  con- 
tinued for  eight  weeks  to  safeguard  against  recur- 
rence. 

Lewis  and  Adler  in  treatment  of  eighty-two 
cases  with  1,000-unit  theelin  suppositories  obtained 
only  67  per  cent  permanent  cures. 

Matzer  and  Israel  with  ninety-three  cases  ob- 
tained 81  per  cent  cures. 

Burpee,  Robinow  and  Leslie  had  apparent 
cures  in  41  of  47  cases  with  intramuscular  in- 
jections of  theelin  in  oil.  They  observed  that  acute 
gonorrhea  required  longer  treatment  than  chronic, 
and  regularity  and  duration  of  treatment  appeared 
to  be  more  important  than  the  amount  given  in  a 
single  or  total  dose. 

During  the  past  five  years  the  sulfonamides  have 
proved  effective.  The  reported  percentage  of  cures 
has  been  lowered,  due  to  late  recurrences.  Pelouze 
says  that  with  sulfanilamide  and  sulfapyridine 
there  is  prompt  cure  in  25  to  40  per  cent  of  dispen- 
sary cases,  in  45  to  50  per  cent  of  private  and  in  75 
to  85  per  cent  of  bed  patients;  and  that  sulfapyri- 
dine is  25  to  50  per  cent  more  effective.  The  newer 
sulfathiazol  gives  a  slightly  higher  percentage  of 
cures  than  sulfapyridine.  It  has  been  found  that 
where  one  strain  of  gonococcus  is  resistant  to  sulfan- 
ilamide change  to  one  of  the  other  drugs  may 
bring  about  a  cure.   The  results  to  be  obtained  are 


GONORRHEAL    VAGINITIS— Moore 


February   1941 


usually  manifested  in  a  few  days,  rarely  after  ten 
days  or  two  weeks  of  treatment. 

In  childhood  vaginitis  treated  with  these  drugs 
the  percentage  of  cures  is  somewhat  lower,  but 
when  effective  the  cure  is  just  as  dramatic.  Some 
give  much  larger  dosage  than  others.  The  majority 
give  half  to  J4  adult  dose,  or  24  grain  per  pound 
per  day  for  the  first  few  days,  then  cutting  to  }4 
grain  per  pound.  A  working  plan  in  gonorrheal 
vaginitis  in  children  is  to  begin  with  a  sulfonamide 
and  if  cure  is  not  obtained  in  ten  days  or  two 
weeks,  to  change  to  another  of  this  group;  and  if 
still  no  cure,  to  use  estrogenic  substance,  prefer- 
ably in  vaginal  suppositories  of  1,000  units  for 
eight  weeks.. 

A  personal  communication  from  Dr.  TeLinde 
states  that  he  still  considers  ammniotin  supposito- 
ries the  treatment  of  choice,  and  that,  except  for 
some  experimental  work  with  stilbestrol,  he  has 
used  it  exclusively. 

The  parent  should  be  informed  of  the  dangers 
of  infection  of  the  child's  eyes,  and  of  other  mem- 
bers of  the  family,  and  given  instructions  somewhat 
as  follows:  (1)  genitalia  to  be  cleaned  several 
limes  dailv  with  mild  antiseptic  solution:  (2)  pad 
to  be  worn  when  there  is  anv  discharge:  (3)  sep- 
arate care  and  boiling  of  underclothes:  (4)  taught 
proper  use  of  or  separate  commode;  (5)  scalding 
of  bathtub  after  use;  (6)  separate  bed. 
Cases 

I  am  reporting  seventeen  cases  of  gonorrheal  va- 
ginitis treated  within  the  past  three  vears.  There 
were  three  other  cases,  two  in  negroes,  not  included 
because  of  lack  of  cooperation. ' 

Eight  were  between  the  ages  of  four  and  seven, 
three  under  four,  six  between  eight  and  ten.  Thir- 
teen occurred  in  patients  of  the  better  class,  four 
in  average,  none  in  lowest.  Only  two  of  these  chil- 
dren were  undernourished,  in  ten  instances  the  pa- 
tient was  the  only  child,  two  patients  had  one  sister 
each,  and  in  the  other  four  there  were  brothers, 
but  no  sisters.  Eleven  cases  were  acute.  Two  of 
the  chronic  cases  were  found  on  routine  examina- 
tion. One  of  the  acute  cases  was  allowed  to  drift 
into  the  chronic  stage  before  diagnosis.  This  girl 
was  treated  six  months  previously  for  urethritis 
which  responded  to  simple  treatment. 

In  an  attempt  to  find  the  source  of  infection,  all 
mothers  and  maids  were  examined  bv  their  doc- 
tors; two  were  so  chagrined  that  they  were  exam- 
ined in  another  citv.  One  mother  and  two  maids 
were  reported  positive.  The  fathers,  unfortunately, 
were  not  asked  to  be  examined.  One  source  of  in- 
fection was  at  a  girl's  camp,  as  discharge  appeared 
four  davs  after  attending  the  camp.  One  other 
source  was  probably  at  school.    This  girl  was  seen 


with  an  acute  attack  and  later  a  classmate  was  seen 
with  an  antedating  chronic  case.  In  only  two  of 
the  chronic  cases  was  there  complaint  of  symptoms, 
and  these  only  those  of  mild  irritation  of  the  labia. 

One  case  was  complicated  by  urethritis,  one  by 
bleeding  from  ulceration  posterior  to  the  urethra, 
which  cleared  in  two  weeks.  A  three-year-old  girl 
had  the  most  profuse  discharge  and  she  fought  like 
a  little  tiger  when  she  was  treated.  Her  grand- 
mother spanked  her  one  day  while  treating  her  and 
so  spattered  pus  into  her  own  eyes.  Three  days 
later  she  had  a  severe  gonorrheal  ophthalmia,  which 
cleared  under  treatment  with  sulfanilamide. 

Vaginal  cleanliness  was  attempted  in  all  the 
cases  with  potassium  permanganate  or  chlorozene, 
either  by  douches  or  simple  sponging  of  the  labia. 
For  the  last  two  years  douches  have  been  omitted. 

Sulfapyridine  was  used  on  three  of  the  girls  but 
all  vomited  after  first  few  doses  and  sulfanilamide 
was  substituted. 

Neoprontosil  was  used  on  two  occasions  without 
results. 

Sulfanilamide  was  used  on  thirteen.  The  dosage 
approximated  three-fourths  grain  per  pound  per 
day  for  the  first  few  days,  sometimes  as  long  as  a 
week,  and  never  under  the  third  day  and  then 
dropped  to  one-half  grain  per  pound,  and  was  con- 
tinued from  ten  days  to  as  long  as  a  month,  two 
weeks  being  the  average.  Two  developed  rashes  on 
the  tenth  and  eleventh  days,  and  two  became  short 
of  breath  and  moderately  cyanotic,  but  were  able 
to  continue  the  treatment.  All  were  ambulatory 
and  little  disturbed  by  the  medication.  No  attempt 
was  made  to  determine  the  blood  concentration. 
There  were  no  results  in  eleven,  though  six  had 
the  course  of  the  drug  repeated.  In  two  the  results 
were  doubtful,  but  sulfanilamide  received  the 
credit. 

One  of  these  was  a  case  which  had  been  treated 
bv  a  physician  in  a  nearby  town  for  four  months 
with  500  units  of  theelin  hypodermically  biweekly 
and  potassium  permanganate  douches.  This  case 
was  treated  with  1.000  units  of  amniotin  dailv  for 
twelve  weeks  and  during  this  time  had  20.000  units 
of  theelin.  Six  weeks  after  stopping  the  treatment 
she  had  a  clinical  recurrence  with  spotting  of  pan- 
ties, redness  of  labia,  and  pus  in  the  mouth  of  va- 
gina, but  with  no  organisms  being  found.  She  was 
eiven  sulfanilamide  for  two  weeks  and  the  theelin 
and  amniotin  for  a  month.  The  condition  cleared 
promptly  and  has  been  cured  for  two  and  one-half 
vears. 

In  the  other  case  neoprontosil  had  been  used  for 
a  month  without  effect,  and  theelin  used  for  six 
weeks  with  no   visible   thickening  of   the   vaginal 

(To   Page   fig) 


February   1941 


SOUTHERN  MEDICINE  &  SURGERY 


Physiology  of  the  First  Portion  of  the  Digestive  Tract 

J.  van  de  Erve,  M.  D.,  Charleston,  South  Carolina 
Professor  of  Physiology.  Medical  College  of  the  State  of  South   Carolina 


THE  fundamental  functional  purpose  of  the 
alimentary  tract  is  to  make  foodstuffs 
absorbable,  then  to  carry  them  into  the 
lymph-  and  bloodstreams  and  eliminate,  via  the 
feces,  the  indigestible  and  undigested  remainders. 

Of  the  six  foodstuffs,  three  (the  vitamins,  in- 
organic salts  and  water)  are  already  in  a  form 
easily  transferred  across  the  intestinal  wall.  The 
other  three  (proteins,  carbohydrates  and  fats) 
must  undergo  extensive  changes  before  they  can 
be  absorbed  and  metabolized. 

Five  factors,  coordinately  and  interdependently, 
interweave  their  effects  upon  the  foodstuffs  men- 
tioned as  these  pass  through  and  out  of  the  ali- 
mentary canal  —  mechanical,  chemical,  nervous, 
hormonal,  bacterial. 

Because  these  forces,  to  a  greater  and  lesser 
local  degree,  act  conjointly  and  concurrently,  it 
becomes  a  difficult,  if  not  impossible,  task  to  dis- 
cuss each  separately.  Textbooks  on  physiology 
must  perforce  do  so,  but  they  cannot,  of  course,  be 
consistent.  Much  of  needed  emphasis  on  func- 
tional unity  is  sacrificed  to  diversity  of  presenta- 
tion. 

It  is  indeed  quite  practicable,  avoiding  too 
flagrant  distortion  and  fragmentary  delineation, 
to  give  an  account  of  the  mechanical  movements 
noted  in  the  alimentary  canal,  and  then  dwell  on 
the  chemical  changes,  since  hormonal  and  bacterial 
effects  are  quite  altogether  chemical  in  nature.  .  . 
.  .  .  .and,  in  the  newer  physiology  of  nerve  stimula- 
tion, a  chemical  mediation,  certainly  of  the  auto- 
nomic system,  is  definitely  posited. 

Perhaps  the  most  logical  and  sequential  consid- 
eration of  activities  in  the  digestive  tract  is  to  des- 
cribe all  that  happens  consecutively  in  each  of  the 
larger  anatomical  divisions  and  subdivisions — the 
mouth  the  esophagus,  the  stomach,  the  duodenum, 
the  remainder  of  the  small,  and  the  large  intestines. 

Let  me  say,  in  a  parenthesis,  that  it  would  be 
highly  interesting  to  write  a  textbook,  first  detailing 
the  physiology  of  all  organs;  then  short,  separate 
chapters  on  the  nine  systems;  and  finally,  briefly 
interrelating  and  unifying  organic  and  systemic 
functions  from  the  viewpoint  of  the  organism  as 
a  whole. 

The  process  of  breaking  down  nutrient  material 
for  body  use  begins  in  the  mouth.  It  really  begins 
in  the  market  and  the  kitchen,  where  food  is  pre- 
pared for  ingestion,  by  cooking  it,  making  it  pala- 
table, appetizing   etc. 


If  one  percent  of  the  thought  and  energy 
expended  in  seductive  advertising  of  foods  and 
preparing  it  temptingly,  if  not  scientifically,  for 
our  consumption,  were  devoted  to  a  quantitative 
and  qualitative  selection  and  ingestion  of  a  pro- 
per and  adequate  diet,  simple  and  satisfying,  our 
digestive  systems  would  not  be  so  outrageously  and 
fatally  overworked.  Also  we  would  have  more 
money  for  income  taxes  and  defence  preparations. 
What  economic  and  physiological  jays  we  be, 
stuffing  our  longsuffering  intake  and  uptake  and 
eliminating  organs  with  unacceptable  volumes,  and 
non  -  metabolizable  and  highly  uneconomical  so- 
called  edibles. 

Once  in  the  mouth  foods  are  subjected  to  a 
vigorous  process  of  comminution — the  pulverizing 
process  of  mastication.  Teeth,  tongue,  lips  and 
cheeks,  and  the  appropriate  powerful  muscles  co- 
operate in  grinding  into  small  pieces  the  bolus  of 
food  (which  should  not  be  larger  than  five  cubic 
centimeters — about  a  teaspoonful). 

Lifting  and  lowering,  forward  and  backward, 
and  also  sideward  movements  of  the  lower  against 
the  upper  jaw  crush  the  food  into  small  particles, 
not  much  larger  than  two  mm.  in  diameter,  pro- 
vided a  sufficient  length  of  time  is  allowed.  Too 
often  our  hurrying  Americans  bolt  inordinately  big 
masses  and  wellnigh  dam  (add  an  n  if  you  like) 
the  pharyngeal  passage,  the  tongue  vainly  trying 
to  throw  it  back  for  more  extensive  chewing. 

Contrawise  it  is  well  to  accent  the  futility  of 
chewing  our  food  excessively  long.  Gladstone  used 
to  say:  "We  have  32  teeth,  therefore  each  mouth- 
ful should  be  chewed  32  times,  to  and  fro  and 
sidewise."  This  is  masticating  zeal,  without  physi- 
ological knowledge.  There  is  a  golden  mean- 
between  the  bolting,  impatient  American,  and  the 
placid,  unhurried,  great  Englishman. 

The  tongue,  cheeks  and  gums  are  richly  supplied 
with  very  sensitive  nerve  endings  to  determine  the 
desirable  size  of  food  divisions.  The  tongue  is 
endowed  with  extremely  delicate  touch  sensation 
— as  any  dentist  will  tell  you,  who  cannot  feel 
with  the  highly  responsive  fingertip  a  slight  un- 
evenness  on  the  teeth,  easily  discerned  by  the  tip 
of  the  tongue. 

The  intricate  and  graduated  movements  of  the 
masticating  organs  demand  a  corresponding  effec- 
tive innervation — they  all  correlated  by  the  inferior 
maxillary  branch  of  the  fifth  cranial. 

(To  Page  gQ) 


SOUTHERN  MEDICINE  &■  SURGERY 


February   1941 


SURGICAL  OBSERVATIONS 


thyroid  cases  will  usually  prevent  the  necessity  for 
ligations. 


DAVIS  HOSPITAL  STAFF 
Statesville 


THE  MANAGEMENT  OF  SEVERE  CASES 
OF  HYPERTHYROIDISM 
In  severe  cases  of  hyperthroidism  it  is  often 
difficult  to  bring  the  basal  rate  down  rapidly,  and 
to  get  them  in  condition  for  a  thyroidectomy.  How- 
ever, any  extensive  surgical  procedure  in  some  cases 
entails  a  great  risk  and,  for  this  reason,  occasion- 
ally it  is  necessary  to  treat  these  patients  differ- 
ently from  the  treatment  of  the  average  case  of 
hyperthyroidism. 

Primarily,  we  depend  upon  the  use  of  iodine  in 
some  form,  usually  Lugol's  solution,  prolonged  rest 
in  bed  and  the  administration  of  large  amounts  of 
fluids.  Where  the  metabolic  rate  continues  high 
and  does  not  come  down  as  rapidly  as  it  should, 
even  when  preparatory  treatment  is  prolonged,  it 
is  best  to  do  a  ligation  of  one  pole,  possibly  both. 
Usually  it  is  very  satisfactory  to  ligate  one  pole, 
wait  a  few  days,  then  ligate  the  opposite  pole. 
Following  this,  the  hyperthyroidism  should  decrease 
more  rapidly  and  the  patient  will  usually  get  in 
condition  for  thyroidectomy  much  more  rapidly 
than  otherwise. 

The  question  arises  as  to  how  long  we  should 
wait  after  ligation  of  the  upper  poles  of  the  gland 
before  doing  a  thyroidectomy.  Usually  about  two 
weeks  is  sufficient,  although  anywhere  from  one  to 
four  weeks  may  be  necessary. 

In  any  event  the  patient  should  have  a  contin- 
uation of  the  preparatory  treatment.  Absolute  rest 
in  bed  and  repeated  basal  metabolic  rate  deter- 
minations are  necessary  in  order  to  determine  the 
exact  time  the  patient  is  ready  for  operation.  It 
is  better  in  these  cases  to  wait  a  longer  time  than 
is  ordinarily  thought  necessary,  rather  than  rush 
into  operation  too  soon. 

Where  the  superior  poles  have  been  ligated,  there 
is  a  tremendous  decrease  in  the  blood  supply  to 
the  gland  and  consequent  reduction  in  the  toxemia. 
This,  together  with  the  general  preparatory  treat- 
ment, is  usually  sufficient  to  get  the  patient  in 
condition   for  operation. 

A  careful  study  of  each  patient  from  every  angle 
should  be  made.  We  must  not  depend  entirely 
upon  the  basal  rate  help  or  any  other  one  sign  or 
symptom.  Experience  over  a  long  period  of  years 
with  many  thousands  of  thyroid  patients  has  shown 
over  and  over  again  that  a  complete  and  careful 
study  of  the  patient  must  be  done,  in  addition  to 
the  usual  preparation  for  thyroidectomy. 

Earlv  diagnosis  and  early  treatment  of  hyper- 


THE  ADVANTAGE  OF  STEREOSCOPIC 

OVER  FLAT  X-RAY  FILMS 

OF  THE  CHEST 

Anyone  who  has  examined  flat  x-ray  films  of 
the  chest  showing  pathologic  changes,  and  then 
stereoscopic  films  of  the  same  chest,  has  been  im- 
pressed by  the  remarkable  additional  information 
that  may  be  derived  from  stereoscopic  examination. 

In  many  cases,  of  course,  only  a  flat  film  is 
necessary,  but  we  have  found  stereoscopic  films  ex- 
tremely helpful  in  making  an  accurate  diagnosis  in 
obscure  conditions,  as  well  as  those  in  which  no 
film  shows  disease. 

In  making  a  careful  study  of  the  chest,  after  the 
physicial  examination  is  completed,  a  supplementary 
examination  or  a  stereoscopic  x-ray  film  will  reveal 
manv  things  which  ordinarily  cannot  be  found  by 
a  physicial  examination,  also  some  things  which  are 
not  ordinarily  seen  so  readily  on  a  single  flat  film. 
In  every  obscure  chest  condition  there  is  need  for 
stereoscopic  x-ray  examination  of  the  chest.  Where 
there  is  demonstrable  disease  on  physical  examina- 
tion, a  stereoscopic  x-ray  examination  also  is  most 
helpful. 


THE  TREATMENT  OF  KELOID  SCARS 
Keloid  scars  are  sometimes  painful  and  distress- 
ing and  may  give  considerable  trouble,  from  their 
size  and  location.  Some  patients  are  prone  to  have 
keloids.  Even  a  scratch  mav  start  the  formation 
of  a  keloid,  which  is  thick,  painful  and  distressing. 
Colored  people  are  more  prone  to  this  disease  than 
white,  but  a  large  number  of  white  people  have 
keloids. 

Simple  excision  of  any  growth  of  this  kind  usually 
results  in  a  recurrence  in  a  few  months. 

We  find  that  simple  excision,  using  the  greatest 
care  to  approximate  the  skin  edges,  afterwards  giv- 
ing x-ray  treatment  to  this  area,  greatly  reduces 
the  number  of  recurrences. 


VITALLIUM  BONE  PLATES 

After  using  vitallium  bone  plates  and  vitallium 
screws  over  a  period  of  several  years,  we  have  found 
them  most  satisfactory  for  bone  work  generally. 

The  composition  of  vitallium  is  such  that  there 
is  no  electrolytic  reaction  and,  apparently,  no  irri- 
tation of  the  bone.  Usually  we  find  on  removing 
vitallium  bone  plates,  even  months  after  they  are 
applied,  that  the  screws  have  not  come  loose,  as 
they  would  often  do  when  steel  plates  and  screws 
were  used. 

It  has  been  shown,  where  ordinary  steel  plates 


February    1941 


SOUTHERN  MEDICINE  &  SURGERY 


o5 


and  screws  were  used,  that  an  electrolytic  reaction 
caused  the  screws  to  become  loose,  often  interfering 
seriously  with  the  progress  of  healing. 

Xot  only  does  vitallium  seem  not  to  interfere 
with  healing  but  in  a  number  of  instances  where 
vitallium  plates  have  been  removed,  especially  in 
younger  people,  they  have  been  almost  covered  with 
a  firm  growth  of  bone.  Usually  also  there  is  no 
discoloration  of  the  bone  tissue,  as  in  the  case  of 
steel  plates. 

A  number  of  times  in  this  department,  we  have 
mentioned  the  use  of  vitallium  plates  and  screws 
and  the  fact  that  it  was  extremely  satisfactory. 
After  more  than  three  years  of  use,  it  has  been 
found  to  be  a  satisfactory  method  of  internal  fixa- 
tion. 

Due  to  the  non-irritating  qualities,  it  is  usually 
possible  to  leave  vitallium  plates  on  for  an  indefi- 
nite period  of  time  and  in  slow-healing  fractures 
this  is  an  enormous  advantage  over  steel  plates  and 
screws. 

With  the  rapidly  increasing  number  of  fractures 
of  the  various  bones  of  the  body,  for  which  internal 
fixation  is  necessary,  the  use  of  vitallium  is  an  enor- 
mous help  and  a  great  satisfaction  to  those  who  do 
bone  surgery  and  handle  fractures  generally. 


SURGERY  OF  THE  KNEE  JOINT 
The  knee  is  a  very  complicated  joint,  susceptible 
to  many  disabling  conditions.  One  of  the  most 
common  conditions  we  have  to  deal  with  is  a  loose 
internal  cartilage.  When  a  knee  joint  becomes  lock- 
ed from  a  loose  cartilage  the  pain  is  severe.  Spasm 
of  the  muscles  which  move  the  joint  causes  the 
joint  to  become  locked  or  fixed.  Sometimes  when 
patients  who  have  had  this  condition  for  some  time 
they  can  jerk  the  leg  in  such  a  way  as  to 
unlock  the  joint,  but  very  often  they  cannot  do  so. 
Loose  particles  of  cartilage,  sometimes  present  in 
the  knee  joint,  are  called  joint-mice.  They  mav 
vary  in  size  from  a  small  piece  that  can  hardly  be 
seen  up  to  a  size  as  large  as  the  end  of  the  thumb. 
These  also  cause  a  lot  of  trouble.  Fat  pads  about 
the  joint,  especially  anterior  fat  pads,  sometimes 
become  hypertrophied  and  elongated  and  may  cause 
trouble. 

The  internal  semilunar  cartilage  becomes  dislo- 
cated more  often  than  the  external^  This  disloca- 
tion usually  comes  from  great  strain  on  the  knee. 
With  the  fat  firmly  fi"-ed  the  body  twists  and  there- 
by pulls  loose  the  internal  cartilage.  Sometimes 
people  who  play  basketball  develop  trouble  with 
the  semilunar  cartilage,  especially  the  internal. 

The  mo=t  satisfactory  treatment  is  surgical  re- 
moval of  the  offending  body.  This  usually  gives 
immediate  and  permanent  relief.  Proper  surgical 
care  of  the  elongated  or  hypertrophied  fat  pads  is 


important  also  and  careful  attention  to  this  is  nec- 
essary. 

Any  patient  with  trouble  with  the  knee  joint 
should  receive  a  thorough  examination,  including 
x-ray.  The  history  of  the  case  should  be  carefully 
investigated.  Often  a  history  of  long-continued 
trouble  with  frequent  recurrences  will  be  brought 
out. 

The  joint  must  be  carefully  handled  and  any 
loose  bodies  or  cartilage  should  be  removed  with 
extreme  care.  In  years  past  there  has  been  a  belief 
common  among  doctors  that  to  open  any  joint 
would  invite  infection  and  disaster.  Our  experience 
in  many  operations  on  the  knee  joint  has  been  very 
satisfactory  and  the  danger  of  infection  is  no  greater 
than  that  of  infection  in  the  abdomen  following  a 
carefully  prepared  abdominal  section. 


AN  UNUSUAL  CASE  OF  PERFORATION  OF 
DUODENAL  DIVERTICULUM 

Recently  a  man  was  admitted  here  with 
symptoms  suggestive  of  a  perforated  pyloric  ulcer. 
Immediate  operation  revealed  a  perforation  through 
a  duodenal  diverticulum  which  arose  from  the  sec- 
ond portion  of  the  duodenum  and  extended  back- 
ward and  upward.  It  was  necessary  to  mobilize 
the  duodenum  in  order  to  locate  and  free  up  the 
duodenal  diverticulum  and  close  the  opening  into 
the  duodenum.  The  diverticulum  was  of  medium 
size  and  the  entire  end  had  sloughed  off  through 
acute  inflammation — probably  very  much  like  that 
of  a  perforated  or  gangrenous  appendix. 

A  small  longitudinal  incision  was  made  through 
the  pyloric  end  and  through  this  a  suction  tube 
was  passed  and  a  large  amount  of  liquid  material 
removed  from  the  stomach.  A  careful  exploration 
was  made  of  the  internal  opening  from  the  duo- 
odenum  into  the  diverticulum  and  of  the  duodenum 
for  other  diverticula,  possible  ulcerations,  or  sources 
of  possible  hemorrrhage  after  operation.  The 
liquid  material  in  the  stomach  could  have  been 
removed  by  aspiration,  but  the  distention  was  so 
great  that  it  was  thought  advisable  to  do  this  by 
suction  rather  than  to  risk  an  attempt  to  remove 
it  by  a  stomach  pump  through  the  mouth.  This 
seemed  to  be  a  happv  solution  of  the  problem  of 
emptying  the  stoimch.  The  longitudinal  incision 
in  the  duodenum  wa*  closed  vertically,  which  made 
it  wider  and  tended  to  prevent  any  possible  con- 
striction later  on. 

In  this  case,  owing  lo  (he  peculiar  nature  of 
the  perforation,  it  was  thought  advisable  to  drain. 
Soft-rubber  tissue  tubular  drains  were  placed  high 
up  and  brought  out  through  a  stab  wound  to 
protect  this  area. 

Accurate  knowledge  of  the  anatomy  of  the  duo- 


SOUTHERN  MEDICINE  &  SURGERY 


denum  at  this  point  is  important  because  of  the 
relationship  between  the  duodenum,  the  perito- 
neum, the  right  kidney  and  the  posterior  peritoneal 
structures. 

The  patient  was  not  in  good  physical  condition 
since  he  had  not  been  well  for  manv  years,  but 
he  did  make  an  excellent  recovery.  It  is  interest- 
ing to  note  the  history  of  this  perforation.  While 
it  occurred  twelve  hours  before  admission  to  the 
hospital  and  the  rigidity  of  the  abdomen  was  char- 
acteristic of  a  perforated  intestine,  especially  a 
pyloric  ulcer,  vet  the  general  physical  condition 
was  not  one  that  you  would  expect  in  a  condition 
of  this  kind.  This  was  due  to  the-  fact  that  a 
diverticulum  had  become  perforated  and.  being 
some  little  distance  from  the  pyloric  end  of  the 
stomach,  there  was  evidently  a  pylorospasm:  and 
while  some  material  had  escaped  through  this  pas- 
sage vet  not  nearly  so  much  had  escaped  as  would 
have  had  the  perforation  been  alone  the  anterior 
wall  of  the  first  part  of  the  duodenum,  or  the 
anterior   wall   of   the   stomach. 

The  maioritv  nf  perforated  ulcers  found  in  this 
clinic  have  been  in  the  pyloric  area,  usually  on 
the  duodenal  side  and  on  the  anterior  wall.  Where 
a  perforation  of  this  kind  occurs,  especially  if  it 
is  of  the  usual  size,  it  allows  the  gastric  contents 
and  also  the  back  flow  of  bile  to  nass  directely 
into  the  peritoneal  cavity  and  sets  up  a  violent 
peritonitis,  the  mortality  of  which  increases  about 
ten   per  cent  with   eirh   hour  of  delav. 

In  removing  material  from  the  abdomen  which 
has  escaped  from  the  stomach'  duodenum,  or  in- 
testine, bv  using  suction,  which  operates  without 
trauma  to  the  peritoneal  surface,  we  can  save  manv 
patients  who  would  nerish  if  the  abdominal  cavitv 
was  mopped  out  with  gauze,  as  was  the  custom 
manv  years  ago. 

The  management  of  perforated  ulcers  consists 
of  immediate  oneration.  removal  of  all  the  escaped 
flnirt  and  inflammatory  products  present  in  the  ab- 
domen bv  means  of  suction  and  careful  closure 
nf  thp  perforation.  Following  thk  the  abdomen 
is   usually   closed   without    drainage. 


TRAOFnTF,'?  AND  CAT.AMTTTF.S  OF  SWRGERY 

I  \  W  TTrW-Jr,  Prnvirlen™.  j„  p  J  Wed.  Jl.  TanA 
A  hov  of  in  rears  old  had  a  eunshot  wound.  He  wa? 
riven  tetanus  antitoxin :  wound  cleaned  and  dressed  bv 
hi<  familv  nhvsician.  Ten  davs  bter  severe  infection  of 
the  hand  with  cellulitis  to  shoulder.  No  story  was  ob- 
tained of  his  havine  tetanus  anti-toxin.  He  was  riven 
a  second  dose  of  tetanus  antitoxin  without  beine  tested  for 
sensiti%itv  to  horse  serum;  and  died  of  anaphylactic  shock 
before  aid  could  reach  him. 

A  laborer  sustained  a  bruise  of  his  foot  from  falline  cob- 
blestones. His  wound  was  dressed  by  his  family  doctor. 
A  week  later  he  was  admitted  to  the  hospital  with  a  black 


gangrenous  foot,  generalized  rigidity  and  fixed  jaws.  A 
man  working  in  a  road  gang  should  have  received  prophy- 
lactic tetanus  antitoxin. 

A  man  45  years  old  had  a  simple  cholecystectomy  done, 
and  was  given  an  intravenous  saline  infusion.  This  was 
followed  by  chills,  shock,  and  death  in  two  hours.  In- 
\  estigation  proved  that  he  died  from  impurities  in  the 
solution. 

An  emaciated  male  of  60  had  a  small  cancer  of  the 
lower  lip.  It  was  decided  to  excise  under  evipal  anes- 
thesia. A  minimum  dose  was  started  intravenously,  slow- 
lv.  Before  2  3rds  was  administered  the  patient  became 
unconscious,  cyanotic,  pulseless  and  respiration  ceased. 
This  operation  could  have  been  done  under  local  novo- 
caine  block. 

A  woman.  46.  came  for  operation  for  hemorrhoids.  She 
was  given  nitrous-oxide-ether  anesthesia.  When  I  com- 
menced to  dilate  the  sphincter  in  preparation  for  the 
hemorrhoidectomy  I  was  told  by  the  anesthetist  that  the 
patient  was  pulseless  and  that  respiration  had  ceased.  A 
post-mortem  examination  was  performed.  The  cause  of 
death  was  given  as  pulmonary  collapse. 

A  man  with  epithelioma  of  the  hand  was  prepared  for 
excision  and  for  skin  graft.  Given  nitrous  oxide  followed 
by  ether,  during  the  ether  induction  he  commenced  to 
vomit  and  drowned  in  his  food.  He  had  been  given  no 
breakfast,  but  as  dinner  time  had  arrived  and  there  was 
no  order  for  withholding  dinner,  he  had  been  given  his 
dinner. 

A  woman  45,  with  an  acute  upper  respiratory  infection 
had  an  acute  cholecystits.  Operation  was  deemed  urgent, 
150  mg.  of  potocaine  was  given  spinally.  The  day  fol- 
lowing operation  she  developed  paralysis  of  her  legs  as- 
cended to  involve  the  respiratory  center.  She  was  in  a 
Drinker  respiratory  for  5  weeks  and  then  expired.  No  au- 
topsy was  obtained.  She  died,  no  doubt,  from  sequelae  of 
spinal  anesthesia. 

An  elderly  man  suffering  from  empyema  was  booked 
for  a  thoracotomy  under  local  anesthesia.  En  route  to  the 
operating  floor  he  became  cyanotic  and  died  before  help 
could  get  to  him.  At  post-mortem  his  upper  set  of  teeth 
was  found  jammed  tight  in  his  posterior  pharynx  causing 
complete  obstruction.  Because  he  was  to  have  a  local 
anesthetic  his  false  teeth  were  not  removed  on  the  ward. 
A  tiny  woman  72  had  all  the  signs  of  intestinal  obstruc- 
tion. Her  abdomen  was  immense.  The  diagnosis  of 
avarian  tumor  was  made.  Oophorectomy  was  done  in 
creat  haste,  tumor  54  lbs.  removed.  The  patient  remained 
unconscious  for  72  hours  until  her  death.  No  urine.  At- 
tempt made  to  catheterize  her  ureters  did  not  go  far  into 
the  ureters.  While  no  postmortem  was  obtained  in  this 
case  I  feel  that  her  ureters  were  tied  off  in  the  haste  of 
the   operation. 

Man  of  30  had  a  gangrenous  appendix  removed.  On  en- 
tering the  peritoneum  the  operator  accidentally  cut  into 
small  bowel.  Because  of  bad  condition  of  patient  the  in- 
cised gut  was  closed  over  with  only  a  single  layer  of  fine 
silk  and  the  appendix  immediately  removed.  The  wound 
was  just  as  hastily  closed  up  tight.  Death  of  general 
peritonitis  in  8  days.  At  autopsy  the  perforated  small 
gut  was  found  wide  open  pouring  out  its  contents. 

Woman.  45.  said  to  have  an  inguinal  hernia.  The  sur- 
geon decided  that  a  piece  of  tissue  he  grasped  in  his  for- 
ceps must  be  the  sac.  Incision,  exodus  of  large  quantities 
of  feces.  He  had  cut  into  the  sigmoid.  This  rapidly  closed 
with  three  layers  of  sutures  but  the  b.  coli  had  spread 
far   and   wide.      Death. 

My   teachers   cautioned  care   about   the   urinary   bladder. 
I  have   cautioned   my   pupils.     One   of   my   internes   said 
(To  Page  S8~> 


SOUTHERN   MEDICINE  &   SURGERY 


CLINIC 


Conducted  By 

Frederick    R.    Taylor,   B.S..   M.D..   F.A.C.P. 

High   Point.  North   Carolina 


SHOWING   A   CERTAIN"   AMOUNT   OF   STU- 
PIDITY OF  THE  PHYSICIAN  IN  CHARGE. 
THE  SAME  BEING  MYSELF 

The  patient  was  under  my  observation  for  a 
number  of  years  for  a  variety  of  troubles.  My 
falling;  in  the  trap  occurred  during  the  last  episode 
recounted  in  this  history.  What  had  gone  before 
should  have  made  me  wary.  A  partial  extenuation 
might  be  found  in  the  fact  that  the  chief  diagnostic 
error  was  made  "in  the  wee  sma'  hours  o'  the 
nicht"  when  one's  faculties  are  somewhat  at  ebb. 
Fortunately,  the  error  was  not  fatal. 

On  January  1st,  1932,  a  51-year-old  minister 
complained  of  pain  in  the  lower  right  abdominal 
quadrant.  He  had  had  his  first  such  attack  in 
July.  1931,  with  sharp  pain  in  the  lower  right 
quadrant,  and  had  had  recurrent  attacks  of  in- 
creasing severity.  Two  of  these  had  been  attended 
with  fever,  nausea  and  vomiting.  There  was  no 
other  symptom  except  some  frontal  headache. 

His  past  history  threw  no  light  on  his  trouble. 
He  had  had  the  common  diseases  of  childhood, 
and  had  suffered  from  sciatica  at  intervals  during 
the  past  few  years.  He  had  had  a  varicocele  oper- 
ation at  the  age  of  20. 

His  habits  were  good  except  for  the  fact  that  he 
was  highly  emotional  and  worked  at  unduly  high 
tension  and  couldn't  relax  as  well  as  he  should. 

His  father  died  at  the  age  of  60  of  an  abdom- 
inal cancer,  his  mother  at  62  of  brain  tumor;  1 
sister  well;  2  died  of  influenza.  1  of  heart  disease 
at  age  of  25:  3  brothers  died  of  influenza,  one  of 
tuberculosis  aged  21.    Wife  well,  no  children. 

He  was  a  man  of  heavy  build.  His  head  and 
neck  were  negative,  chest  rather  barrel-shaped  and 
showed  a  moderate  degree  of  emphysema,  lungs 
otherwise  normal.  Abdomen  showed  2  spots  of 
tenderness,  one  at  McBurnev's  point  and  one  close 
to  right  costal  margin  at  the  midclavicular  line. 
There  was  moderate  right-rectus  rigidity.  Genitals 
and  extremities  negative.  Temperature  before  ad- 
mission to  hospital  was  98.6,  pulse  76,  respiration 
18.  b.  p.   150  70. 

Diagnosis:  Appendicitis,  subacute,  with  possi- 
ble associated  gallbladder  disease. 

He  was  operated  nn  promptly  by  Dr.  J.  T.  Bur- 
rus.  through  a  right-rectus  incision,  and  a  kinked, 
adherent,  subacutely  inflamed  appendix  was  re- 
moved. On  palpating  the  gallbladder,  the  surgeon 
reported  that  it  seemed  normal.  The  wound  was 
closed  without  drainage. 


On  January  8th,  1932,  while  still  in  hospital, 
the  laboratory  reported  an  eosinophilia.  Stool  ex- 
amination showed  cysts  of  Entamoeba  histolytica. 
It  now  develops  that  in  1916  one  of  his  brothers, 
who  had  been  in  the  British  army  in  Saloniki,  had 
had  an  "enteritis"  lasting  6  months,  and  that  the 
patient  had  been  closely  associated  with  this  broth- 
er during  this  time,  helping  in  the  nursing  etc. 
Also,  the  same  brother  had  worked  for  a  while  in 
a  military  infectious  hospital  center  near  Cairo, 
Egypt.  The  patient  himself  had  never  had  any 
chronic  or  recurrent  diarrhea  or  any  blood  in  his 
stools. 

Supplementary  Diagnosis:  Amebiasis,  carrier.  T 
ordered  some  stovarsol  for  him,  but  he  would  never 
come  around  to  the  office  for  further  treatment 
after  leaving  hospital. 

In  October,  1932,  he  had  a  brief  attack  of  what 
seemed  pretty  obviously  to  be  acute  cholecystitis 
with  jaundice.    Magnesium  sulfate  gave  relief. 

April  1st,  1936.  Patient  was  seized  with  epigas- 
tric pain  of  moderate  severity  about  10:30  last 
night.  He  refused  to  have  me  called.  The  pain 
lasted  some  hours,  and  then  he  vomited.  Then  the 
pain  got  severe  and  I  was  called  at  4:00  a.  m.  I 
found  him  sitting  up  in  bed,  stock  still,  with  a 
rather  typical  anginoid  facies.  He  seemed  to  be  in 
extreme  pain.  A  hypodermic  of  J/>  gr.  morphine 
sulfate  and  1/75  gr.  atropine  sulfate  gave  only 
partial  relief.  His  abdomen  was  tender  deep  in  the 
epigastrium,  but  nowhere  else.  The  right  hypochon- 
drium  was  not  particularly  tender.  There  was  no 
muscular  rigidity.  He  had  some  gaseous  disten- 
tion. He  said  he  had  a  little  precordial  pain,  but 
the  pain  started  and  was  most  severe  in  the  abdo- 
men. B.  p.  184/100.  Nitroglycerin  1/100  gr., 
under  the  tongue  broueht  the  blood  pressure  down 
to  154/90  and  seemed  to  give  very  transient  relief. 
The  pain  soon  recurred.  He  was  then  given  an  in- 
halation of  trichlorethvlene.  This  was  followed  by 
more  relief  than  all  other  measures  afforded,  and 
seemed  to  relieve  permanently.  I  staved  about  1 l/?. 
hours  and  then  left  him  comfortable  with  instruc- 
tions to  stay  in  bed. 

Diagnosis  undetermined,  but  probably  an  ab- 
dominal type  of  angina  following  moderate  abdom- 
inal pain  and  gaseous  distention  perhaps  due  to 
amebiasis. 

The  patient  was  advised  to  stay  in  bed  and  to 
have  another  stool  examination  for  E.  histolytica, 
also  an  electrocardiogram. 

The  stupidity  referred  to  in  the  title  is  the  lack 
of  emphasis  placed  at  this  time  on  the  very  definite 
history  of  recurrent  attacks  of  gallbladder  disease. 
Because  the  pain  was  epigastric,  rather  than  right 
hypochondriac,  and   the   tenderness  likewise,  and 


6S 


SOUTHERN  MEDICINE  &  SURGERY 


February   1941 


because  of  the  patient's  general  appearance,  sit- 
ting up  stock-still  with  a  rather  ashen  face,  and 
because  of  his  hypertension,  the  gallbladder  history 
was  disregarded  and  abdominal  symptoms  of  an- 
gina pectoris  considered  as  the  likely  diagnosis.  A 
closer  analysis  of  the  symptoms,  however,  would 
make  one  consider  the  following  factors  as  of  sig- 
nificance: recurrence  of  pain  after  the  effect  of 
the  nitroglycerin  had  worn  off.  while  possible,  in 
angina  pectoris,  is  unlikely  with  the  patient  at  rest 
in  bed;  prolonged  relief  following  trichlorethylene 
excludes  coronary  thrombosis  as  the  diagnosis. 
These  points  should  have  led  to  a  more  serious 
consideration  of  gallbladder  disease,  especially  a 
ball-valve  stone,  as  the  cause  of  the  symptoms. 

The  following  day,  April  2nd,  the  patient  be- 
came very  tender  in  the  right  hypochondrium,  and 
the  diagnosis  was  revised  to  that  of  probable  gall- 
bladder disease,  and  the  patient  taken  to  the  hos- 
pital. A  slight  jaundice  was  now  noticeable.  Under 
sodium  amytal-ether  anesthesia  a  right  rectus  in- 
cision was  made  and  2  gallstones  were  removed 
from  the  common  duct  by  Dr.  Burrus.  These 
stones  were  the  size  of  filberts,  but  rather  elongat- 
ed. Then  a  cholecystectomy  was  done.  Dr.  Burrus 
noted  at  this  time  that  the  pancreas  felt  a  little 
thick  and  edematous.  The  wound  was  closed  with 
a  cigarette-and-wick  drain  and  the  patient  recov- 
ered uneventfully  and  has  been  in  good  health  ever 
since.  Curiously,  no  evidence  of  amebiasis  was 
found  during  this  stay  in  hospital,  though  the 
search  was  made.  The  patient  had  never  accepted 
prolonged  treatment  for  it. 

Final  Diagnosis:   Gallstones. 

The  diagnostic  error  has  been  discussed  already. 
Of  course,  it  such  an  error  has  to  be  made,  it  is 
safer  to  treat  the -patient  for  coronary  disease  till 
proved  otherwise  than  to  subject  a  patient  with 
serious  coronary  disease  to  an  unnecessary  laparo- 
tomy. The  fact  that  I  had  developed  rather  more 
interest,  perhaps,  in  cardiology  than  in  gastro- 
enterology, may  have  been  an  additional  factor  in 
leading  me  astray.  Moreover.  I  had  heard  very 
shortly  before  encountering  this  case  of  coronary 
pain  being  relieved  by  trichlorethylene.  and,  hav- 
ing some  with  me.  trie'd  it.  and  failed  to  realize 
that  it  might  relieve  any  kind  of  pain  due  to  in- 
voluntary muscle  spasm.  We  are  constantly  warn- 
ed, and  rightly  so.  to  beware  of  treating  coronary 
disease  with  abdominal  symptoms  as  primary  ab- 
dominal disease.  This  case  illustrates  the  reverse 
error,  far  less  dangerous,  but  an  error  none  the 
less. 

I  cons'der  it  more  important  to  publish  our  diag- 
nostic errors,  than  our  successes.  We  learn  more 
by  our  errors.    My  revered  teacher,  Dr.  M.  How- 


ard Fussell,  used  to  say.  Acknowledge  your  mis- 
takes, but  do  not  make  the  same  mistake  twice!" 
The  very  acknowledgment  helps  to  avoid  a  repeti- 
tion of  a  mistake,  and  acknowledging  it  in  print 
may  help  someone  else  to  avoid  making  that  mis- 
take even   the  first  time. 


TRAGEDIES— from    p.    66 
this   never  could  happen.     The  very  next  day  as  he  was 
doing  an  inguinal  hernia  operation  urine  spurted  after  he 
had  made  an  incision  into  what  he  thought  was  the  her- 
nial sac. 

I  have  seen  3  cases  of  coronary  thrombosis  following 
operation. 

Post-operative  hemorrhage  today  is  due  to  carelessness 
or  accident.  I  have  seen  6  such  cases.  Saved  if  immedi- 
ately explored. 

Tragedies  caused  by  emboli,  we  have  no  way  of  com- 
batting and  no  way  of  foretelling. 

Volkmann's  contracture — bandage  had  been  entirely 
too  tight. 

Cellulitis  of  the  scalp — he  was  given  ether;  the  sutures 
were  removed  and  the  wound  was  laid  wide  open,  this  was 
found  to  contain  dirt  and  gravel. 

In  a  wound  which  had  been  dressed  for  6  mos.  after 
removal  of  a  splinter,  x-rays  disclosed  a  piece  of  wood 
3  in.  i  Y-2  in.  in  a  child's  thigh. 

In  applying  a  dressing  with  a  drainage  tube  see  that 
the  tube  is  fastened  securely  to  the  skin  with  sutures,  as 
well   as   to   the   outside   dressing. 

Two  cases  of  left  wrist  drop  following  operations  for 
inguinal  hernia.  The  elbow  perhaps  was  leaned  on  during 
the  operation,  the  arm  of  the  patient  not  placed  properly 
on  the  table.  It  might  have  been  caused  by  the  rigid  band 
that  is  used  to  fasten  the  diaphragm  of  the  blood-pres- 
surt  stethoscope  to  the  patient's  arm. 

A  foot  drop  followed  a  simple  cholecystectomy  on  one 
of  my  patients  a  year  ago.  He  had  to  wear  a  brace  3 
months  and  it  was  6  months  before  he  recovered.  The 
leg  strap  may  have  been  applied  too  tightly,  or  the  bed 
clothes  may  have  betn  tucked  down  too  tightly  so  as  to 
bring  pressure  on  his  foot  hyperextending  it  while  he  was 
recovering   from   ether. 


THE  SEX  HORMONES  AND  THE 
ENDOCRINE   BALANCE 

(W.  Cramer,  St.  Louis,  in  Bui.  N.  Y.  Acad,  of  Med.,  Jan.) 
There  is  a  possibility  of  inducing  profound  changes  in 
tlie  pituitary  and  the  other  endocrine  organs  by  prolonged 
administration  of  estrogenic  hormones.  This  is  more  likely 
than  the  more  remote  chance  of  inducing  cancer  of  the 
mamma.  The  therapeutic  value  of  the  estrogenic  hormones 
is  so  high  that  their  use  should  not  be  discredited  by 
either  overrating  or  underrating  the  rangers  resulting 
from  their  use.  There  is  no  danger  in  the  therapeutic 
administration  of  an  estrogenic  preparation  over  periods 
of  several  months,  in  doses  just  sufficient  to  produce  the 
desired  effects.  When  this  hormone  has  to  be  given  over 
a  year  or  several  years,  the  danger  of  inducing  endocrine 
changes  can  be  avoided  by  giving  the  doses  in  courses 
of  three  or  four  months,  interrupted  by  periods  of  rest. 
The  administration  of  estrogenic  hormones  by  the  inocula- 
tion of  pellets  is,  I  believe,  dangerous  and  inadvisable. 

In  many  cases  more  than  one  endocrine  organ  is  in- 
volved. Examination  of  a  case  of  an  endocrine  disease 
fhould.  therefore,  involve  the  examination  of  every  endo- 
crine organ. 


February    1941 


SOUTHERN  MEDICINE  &■  SURGERY 


DEPARTMENTS 


HUMAN  BEHAVIOUR 

James   K.   Hall,  M.  D.,  Editor,   Richmond,   Va. 


DOCTOR  PAUL  BRANDON  BARRINGER 
I  thought,  as  Dr.  H.  C.  Henry  and  I  looked 
upon  the  flower  -  covered  casket  rolled  into  the 
chapel  of  the  University  of  Virginia  at  mid-after- 
noon of  January  10th,  that  a  link  binding  the  day 
with  distant  days  had  been  broken.  The  dead 
body  of  Dr.  Paul  B.  Barringer  lay  in  the  casket. 
His  students — and  there  must  be  thousands  of  them 
— call  him  "Paul  B.,"  if  they  do  not  call  him  "old 
Paul  B."  I  thought  of  the  vicissitudes  through 
which  he  had  lived  since  that  day  of  his  birth 
in  Cabarrus  County  in  North  Carolina  in  1857. 
Even  in  quiet,  monotonous  times  eighty-three  years 
is  a  long  time  for  a  human  being  to  live.  And 
existence  is  more  hazardous  when  the  times  are 
perturbed;  and  in  such  times  a  year  may  be  in 
the  number  and  in  the  quality  of  the  deeds  done 
in  it  the  equal  of  many  years.  I  thought,  too, 
as  I  looked  upon  the  flower-covered  casket,  that 
back,  far  back,  in  the  years  I  could  see  a  little 
boy  being  ridden  on  the  foot  of  a  grim,  bewhis- 
kered,  solemn-looking  soldier-man,  and  that  the 
little  boy,  three  years  old  in  1860,  was  Paul  B. 
Barringer,  and  that  the  silent,  professor-soldier 
had  become,  two  years  later,  the  immortal  Stone- 
wall Jackson. 

The  infancy  and  the  childhood  of  Paul  B.  Bar- 
ringer were  all  entangled  in  warfare.  His  father, 
Rufus  Barringer,  a  Confederate  cavalryman,  came 
out  of  the  Civil  War  a  brigadier-general,  whose 
life  had  remained  in  his  body  throughout  almost  a 
hundred  engagements.  Though  he  escaped  death 
on  the  field  of  battle,  and  lived  into  old  age,  he 
did  not  escape  frequent  wounds.  The  mother  of 
Paul  B.  Barringer  was  Eugenia  Morrison,  whose 
father,  a  Presbyterian  minister  and  a  teacher,  was 
the  first  president  of  Davidson  College.  Another 
daughter  of  the  minister  became  the  second  wife 
of  Stonewall  Jackson.  And  in  the  home  of  that 
maternal  aunt  the  child  and  the  boy,  left  mother- 
less himself  in  infancy,  spent  manv  happy,  inspir- 
ing days.  The  wife  of  General  D.  B.  Hill  was 
another  maternal  aunt,  and  so  also  was  the  first 
wife  of  Judge  A.  C.  Avery,  of  North  Carolina's 
Supreme  Court.  And  Judge  Avery  had  been  a  Con- 
federate officer.  And  the  paternal  grandfather  of 
Paul  B.  Barringer  was  a  brigadier-general  in  the 
War  of  1812.  When  Appomattox  came.  Paul  B. 
Barringer  was  a  lad  of  eight  years.    He  lived  also 


through  the  Spanish-American  War,  the  first 
World  War,  and  Europe  had  been  ravaged  again 
by  warfare  before  his  casket  was  rolled  into  and 
out  of  the  University  Chapel. 

Though  he  had  heard  in  infancy  the  roll  of  the 
drums,  and  though  warrior-blood  coursed  through 
his  vessels,  he  was  a  genial,  peaceable  man,  inter- 
ested throughout  his  long  life  in  education  and  in 
conservation,   rather   than   in  warfare. 

Had  Dr.  Cyrus  Thompson  gone  back  to  the  Uni- 
versity of  Virginia  after  his  one  year  in  medicine 
there  instead  of  to  Tulane,  I  believe  he  and  Dr. 
Paul  B.  Barringer  would  have  been  graduated  to- 
gether in  1877.  When  Randolph-Macon  was  cele- 
brating, a  few  years  ago,  the  hundredth  anniver- 
sary of  its  beginning,  Dr.  Cyrus  Thompson,  a 
member  of  the  Academic  Class  of  1875,  was  one 
of  the  Nestors  of  the  occasion.  On  the  Saturday 
of  that  joyous  week  in  his  long  life,  I  put  him  in 
my  car  and  sent  him  up  to  the  University  of  Vir- 
ginia, where  he  had  not  been  since  1876.  On  that 
night,  in  my  home,  he  told  me,  with  deep  satisfac- 
tion, that  the  best  thing  he  had  seen  on  that  day 
of  many  memories  was  old  "Paul  B.",  as  they  met, 
by  chance,  on  the  University's  Lawn.  And  Dr. 
Thompson  chuckled,  as  he  remarked  that  they 
recognized  each  other  from  afar,  though  they  had 
not  seen  either  the  other  for  almost  a  hundred 
years ! 

By  1884  Dr.  Barringer  was  established  at  Da- 
vidson College  as  college  and  as  village  physician. 
He  had  got  back  to  the  home  of  his  maternal 
grandfather,  the  Rev.  Robert  H.  Morrison.  But 
his  coming  to  Davidson  had  been  preceded  by  a 
few  years  of  practice  in  Texas  and  by  studies  in 
New  York  and  abroad.  He  was  probably  uncon- 
sciously preparing  for  teaching,  for  he  was  a  nat- 
ural-born teacher.  At  Davidson  College  he  soon 
found  himself  tutoring  students  in  medicine — the 
old  style  preceptorial  work.  And  most  of  those 
students  were  sent  bv  him,  of  course,  to  the  Uni- 
versity of  Virginia.  Though  I  do  not  think  Dr. 
Barringer's  preparation  of  students  for  the  study 
of  medicine  was  done  as  a  member  of  the  faculty 
of  Davidson  College,  vet  his  teaching  there  must 
have  been  the  first  teaching  of  medicine  done  at 
or  in  a  college  in  North  Carolina.  In  that  sense 
Dr.  Barringer  was  a  pioneer — and  a  youthful 
pioneer,  too,  as  Dr.  Richard  H.  Whitehead  was 
when  he  became  the  head  of  the  medical  school  at 
the  University  of  North  Carolina  in  1890.  Dr. 
Barringer  had  had  the  proffer  of  the  headship 
of  the  medical  school  at  Chapel  Hill  in  1889,  but 
he  declined  it,  because  he  sensed  that  he  was  going 
to  receive  a  call  to  the  medical  school  of  the  Uni- 
versity of  Virginia.   He  was  called  to  that  school, 


70 


SOUTHERN  MEDICINE  &  SURGERY 


February  1941 


and  he  went  to  it,  in  1889,  and  there  he  remained 
most  of  the  rest  of  his  long  life.  There  he  taught 
physiology,  and  materia  medica;  and  he  probably 
could  have  taught  anything  else  in  the  medical 
curriculum,  so  universal  was  his  knowledge. 

Until  Edwin  Anderson  Alderman  came  from 
Tulane  in  1904  to  the  presidency  of  the  University 
of  Virginia,  that  institution  had  never  had  a  presi- 
dent. Its  executive  officer  had  been  known  as  the 
Chairman  of  the  Faculty.  For  several  years  prior 
to  Dr.  Alderman's  coming  Dr.  Barringer  had  been 
Chairman  of  the  Faculty. 

For  almost  seventy-five  years,  ever  since  its  be- 
ginning, the  University's  medical  teaching  had 
been  almost  wholly  didactic.  There  were  no  hos- 
pital beds  at  the  University  of  Virginia.  Clinical 
medicine  was  not  known  there.  Dr.  Barringer  was 
a  practical  man,  and  he  believed  that  patients  were 
a  necessary  part  of  a  medical  school.  He  assem- 
bled the  first  fund  and  built  about  1900  the  first 
unit  of  the  University's  hospital — now  a  magnifi- 
cent institution  of  several  hundred  beds.  Dr.  Bar- 
ringer encountered  objections  and  he  experienced 
difficulties  in  providing  clinical  material  for  the 
medical  school.  But  in  that  effort  he  was  again  a 
pioneer.  It  is  well  that  his  name  has  been  at- 
tached to  a  division  of  the  present  University  Hos- 
pital.  He  made  it  possible. 

Soon  after  1900,  Dr.  Barringer  purchased  an 
old  plantation  near  Charlottesville,  and  on  it  he 
established  a  private  sanitarium  for  nervous  and 
mental  patients.  Dr.  O.  C.  Brunk,  of  Richmond, 
was  taken  from  his  staff  to  the.  Superintendency  of 
the  Eastern  State  Hospital  at  Williamsburg.  Dr. 
H.  C.  Henry,  now  the  Director  of  State  Hospitals 
of  Virginia,  and  for  several  years  Superintendent 
of  the  Central  State  Hospital  of  Petersburg,  be- 
came his  assistant  at  Hillcrest  Sanitarium.  That 
private  sanitarium  would  doubtless  be  continuing 
its  good  work  today  had  not  Dr.  Barringer  been 
called,  perhaps  about  1907,  to  the  presidency  of 
the  Virginia  Polytechnic  Institute.  There  he  re- 
mained until  about  1912.  During  the  first  World 
War  he  lent  himself  to  the  government,  but  he  had 
made  his  home  again  at  the  University  of  Vir- 
ginia, and  there  he  remained,  until  the  Boatman 
came  for  him. 

Have  you  inferred  from  his  manner  of  life  the 
degree  of  his  versatility?  His  mind  ranged  and 
roamed  throughout  the  universe  in  search  of  the  va- 
ried knowledge  that  would  satisfy  his  innate  yearn- 
ing to  know.  He  was  constantly  sending  his  soul 
into  the  invisible,  that  is  true.  He  was  interested 
in  the  earth  and  in  what  grows  out  of  it;  but  most 
of  all,  in  his  fellow-mortals,  who  lives  upon  the 
spheroid  terra — in  his  origin,  in  his  behaviour,  in 


his  aspirations,  and  in  his  destiny.  The  roll  of  the 
years  did  not  enroll  him  amongst  the  decrepits: 
he  remained  forever  young,  and  his  spirit  dwelt 
always  amongst  the  young  and  their  unfolding 
minds. 

At  first  he  taught  in  a  school  of  medicine,  but 
soon  he  was  the  administrative  officer  of  a  great 
University;  his  developing  interest  in  psychiatry, 
before  the  term  had  come  into  use,  was  interrupted 
by  his  call  to  the  presidency  of  Virginia's  great 
school  of  technology,  and  in  that  function  he  was 
entirely  at  home,  because  he  was  unceasingly  insist- 
ent that  the  youth  of  the  South  have  opportunities 
for  scientific  training.  For  several  years  he  was  a 
member  of  the  State  Board  of  Agriculture.  He 
was  enormously  interested  in  the  lives  of  those  who 
till  the  soil,  and  he  laboured  to  make  their  lives 
more  abundant.  He  was  also  a  member  of  the 
State  Board  of  Health — a  field  of  peculiar  useful- 
ness for  his  wide  knowledge  of  medicine.  He  was 
once  president  of  the  State  Medical  Society.  He 
wrote  not  a  little — about  cholera  and  syphilis  and 
typhoid  fever;  and  much  about  his  study  of  the 
Negro,  in  whose  destiny  he  was  profoundly  inter- 
ested. He  spoke,  publicly,  not  often,  but  well 
always.  He  manifested  his  inner  self  most  appeal- 
ingly  in  intimate  conversation  with  a  friend  or  two, 
or  with  a  small  group.  He  loved  his  fellowman, 
and  he  was  much  beloved  by  those  who  knew  him 
well  He  was  a  loyal,  a  stimulating  and  an  inspir- 
ing friend,  who  had  brought  by  inheritance  and  by 
inculcation  all  that  was  best  of  the  ante-bellum 
South  into  the  raucous  and  self-assertive  new  day. 
But  he  did  not  repine,  he  did  not  express  any 
yearning  for  the  dear  old  dead  days;  his  heart  was 
in  the  present  and  in  the  unfolding  future,  in  the 
vestibule  of  which  he  was  always  standing,  wait- 
ing eagerly  for  the  door  to  be  opened. 

His  kind  is  gone,  not  to  be  again.  He  knew  his 
fellowman  and  his  student.  The  college  student 
who  occupied  no  place  in  "old  Paul  B's"  charitable 
esteem  did  not  belong  in  college  life.  And  the  boys 
knew  that  in  his  they  had  a  firm  friend  to  whom 
they  could  come  about  all  their  digressive  conduct 
— whether  they  had  stepped  over  the  boundary 
line,  or  whether  the  fault  lay  in  failure  to  measure 
up.  The  relationship  existing  between  him  and  his 
students  was  highly  personal — a  spiritual  state — 
that  is  disappearing  from  all  school  life,  to  the 
impoverishment  of  the  student  and  the  teacher. 

North  Carolina  birthed  him  and  afforded  him 
his  first  pabulation.  But  Virginia  later  nourished 
him  and  inspired  him  and  was  stimulated  and  suc- 
coured by  him.  Both  states  may  exult  in  their 
pride  in  him. 

The  wife  of  the  many  years  and  their  children 


February   1941 


SOUTHERN  MEDICINE  &■  SURGERY 


are  comforted  by  sweet  memories  of  happy  days 
with  him  and  by  the  satisfying  realization  that  in 
them  and  in  hundreds  of  former  students  living 
all  'round  the  earth  the  spirit  of  "Paul  B."  will 
abide  as  a  noble  influence  forever  and  forever — 
for  the  good  teacher  becomes  always  one  of  the 
world's  immortals. 


OBSTETRICS 

Ivan   Marriott  Procter,  M.D.,   F.A.C.S.,   Editor 


MATERNAL  MORTALITY  IN  SOUTHERN 
STATES 

An  article  recently  published1  is  of  such  import- 
ance as  to  warrant  abstraction  in  this  department. 
For  ten  years,  maternal  mortality  rates  have 
gone  progressively  downward.  Among  the  factors 
responsible  are:  economic  status  of  the  mother; 
educational  environment;  adequate  prenatal  care; 
availability  of  well-staffed  and  organized  hos- 
pitals; race  of  the  mother;  public  health  nursing, 
and  the  ability  to  obtain  the  services  of  medical 
attendants  with  obstetric  training.  The  greatest 
number  of  deaths  from  puerperal  causes  occur  in 
the  Southern  States.  In  the  United  States,  in  1938, 
there  were  2,286,962  live  births  recorded,  and  9,953 
maternal  deaths.  The  maternal  mortality  for 
1938  was  53.5  per  10,000  live  births.  However, 
in  the  South,  comparing  the  mortality  rates  of 
1936-1937  with  those  of  1934-1935,  there  has  been 
no  significant  decrease  in  maternal  mortality  rates, 
except  in  North  Carolina,  Florida  and  Texas. 

The  fundamental  difference  between  the  high 
southern  and  lower  northern  rates  is  a  matter  of 
obstetric  care.  In  the  South  a  great  number  of 
women  do  not  have  adequate  care  during  preg- 
nancy and  labor.  We  have  a  large  Negro  popula- 
tion; there  is  great  lack  of  maternity  care  at.  the 
hands  of  physicians  and  there  are  too  few  planned 
hospital  confinements. 

In  1938,  more  than  233,000  of  the  267,700 
Negro  live  births  were  in  the  South:  Mississippi 
29,505;  Georgia  25,723;  North  Carolina  24,665; 
Alabama  23,207:  South  Carolina  20,754  and  Louisi- 
ana 20,070.  There  were  262,462  Negro  births  in 
the  United  States  in  1937.  Midwives  delivered  54 
per  cent  of  these.  Of  the  46  per  cent  of  Negro 
births  attended  by  physicians,  19  per  cent  were 
in  hospitals  and  27  per  cent  in  the  homes.  In 
Mississippi,  South  Carolina  and  Georgia,  midwives 
delivered  83.9,  82.4  and  75.8  per  cent  of  the  Negro 
babies,  respectively.  Figures  on  the  amount  and 
type  of  prenatal  care  received  by  Negro  mothers 
are  not  available.  Practically  none  of  those  at- 
tended by  midwives  and  only  a  few  of  those  at- 


tended by  physicians  could  have  been  expected 
to  have  received  rr^ire  than  care  at  the  actual 
time  of  delivery.  The  latest  figures  for  1938  re- 
veal that,  in  29  states  with  500  or  more  Negro  live 
births,  the  white  and  Negro  maternal  mortality 
rates  were  38  and  86  per  10,000  live  births,  respec- 
tively—the rate  among  Negroes  more  than  dou- 
ble that  of  white  women. 

The  advantages  of  prenatal  and  delivery  care  by 
physicians,  those  able  and  willing  to  render  it,  are 
selfevident.  The  records  of  well  organized  ob- 
stetric clinics  reveal  that  it  is  possible  to  obtain 
excellent  results  in  prenatal  and  natal  work.  Un- 
fortunately, in  rural  districts  of  the  South  such  do 
not  exist.  However,  the  best  of  prenatal  care,  no 
matter  how  carefully  and  intelligently  adminis- 
tered, cannot  offset  the  results  of  faulty  judgment 
or  poor  technic  at  the  time  of  delivery.  Physicians 
delivered  approximaely  90  per  cent  of  the  2,203,- 
337  babies  born  in  the  United  States  in  1937,  half 
of  these  in  the  homes.  Midwives  delivered  the  re- 
maining 10  per  cent  in  the  homes.  Of  the  1,928,- 
437  white  births,  midwives  delivered  4.5  per  cent; 
of  the  262,462  Negro  births,  midwives  attended  55 
per  cent.  Taking  for  granted  that  the  average 
doctor  is  adequately  prepared  to  render  maternity 
services,  there  is  a  scarcity  of  physicians  in  rural 
areas  and  small  towns.  The  midwife,  limited  in 
experience,  intelligence  and  training,  falls  heir  to 
the  burden  of  an  immense  rural  maternity  prac- 
tice. 

In  1937  47.3  per  cent  of  white  deliveries  and 
19.8  per  cent  of  Negro  were  in  the  hospitals.  In 
Northern  States  hospital  confinements  were  half  of 
the  total — from  a  low  of  37  per  cent  in  Maine  to 
a  high  of  82.7  per  cent  in  Connecticut.  In  South- 
ern States  the  incidence  of  hospital  confinement 
was  12  per  cent. 

The  number  of  maternal  deaths  in  the  United 
States  in  1938  was  nearly  10,000.  Of  the  1,163 
in  three  Southern  States,  sepsis  was  the  cause  of 
29.3,  toxemia  of  pregnancy  31.2,  hemorrhage  19.7 
per  cent.  Infection  caused  fewer  deaths  while  tox- 
emia and  hemorrhage  each  caused  6  per  cent  more 
deaths  in  Southern  States  than  in  the  Nation  as  a 
whole.  The  maternal  mortality'  rate  among  Ne- 
groes (86  per  10,000  live  births)  during  1938  was 
more  than  double  that  for  white  women.  The  mor- 
tality rate  from  sepsis  was  higher  among  Negroes 
than  among  whites.  The  deaths  from  toxemia  in 
Negroes  more  than  doubled  the  figures  in  white 
women  and  the  deaths  from  hemorrhage  are  more 
frequent  among  Negro  than  white  women.  The 
brunt  of  the  battle  for  the  control  of  the  cause  of 
maternal  mortality  rests  upon  the  shoulders  of  the 
physician  in  attendance. 


SOUTHERN  MEDICINE  &■  SURGERY 


February  1941 


Deaths  from  sepsis  are  largely  preventable,  pro- 
vided all  the  ordinary  precautions  are  exercised  in 
every  confinement.  Rectal  examinations,  rather 
than  repeated  vaginal  investigations  through  an 
unprepared  introitus,  will  materially  reduce  the 
number  of  infections.  Surgical  cleanliness  in 
preparation  for  delivery  is  of  paramount  import- 
ance. 

In  the  United  States  as  a  whole  sepsis  leads  as 
the  cause  of  maternal  deaths.  In  the  South  tox- 
emia leads.  There  has  been  no  significant  change 
in  the  number  of  women  dying  as  a  result  of  tox- 
emia in  the  United  States  during  the  last  five 
years.  It  is  the  only  serious  complication  which 
is  not  showing  a  reduction.  Adequate  prenatal  ob- 
servation and  intelligent  interpretation  of  develop- 
ing signs  and  symptoms  will  prevent  the  final 
eclamptic  state  of  toxemia  of  pregnancy.  The  high 
incidence  of  eclampsia  in  the  South  is  due  to  the 
large  percentage  of  pregnant  women  (60-75  per 
cent  in  rural  districts)  who  do  not  receive  prenatal 
care.  The  symptoms  and  signs  of  toxemia  are 
usually  present  early.  The  problem  is  the  failure 
on  our  part  to  interpret  the  symptoms  and  signs 
and  to  apply  successful  treatment.  Conservatism 
in  the  management  of  labor  is  the  keynote  of  the 
modern  treatment  of  toxemia.  The  medical  induc- 
tion of  labor  or  induction  by  simple  rupture  of  the 
membranes  is  the  accepted  method.  The  aban- 
donment of  traumatizing  methods  and  the  adop- 
tion of  the  modern  method  of  controlling  toxemia 
of  pregnancy,  especially  eclampsia,  before  attempt- 
ing delivery  would  materially  -reduce  our  death 
rate. 

In  1938,  13.3  per  cent  of  all  maternal  mortali- 
ties were  due  to  hemorrhage.  Prompt  recognition 
of  the  cause  and  immediate  active  treatment  will 
reduce  these  deaths.  In  the  presence  of  active 
bleeding,  whatever  the  cause,  the  attendant  must 
not  procrastinate.  Placenta  praevia  has  always  been 
one  of  the  bugbears  of  obstetrics.  Hospitalization 
is  required  by  all  means.  Vaginal  examinations 
are  contraindicated,  unless  we  are  thoroughly  pre- 
pared to  carry  out  treatment  immediately.  The 
first  sudden,  causeless  and  painless  hemorrhage 
justifies  immediate  hospitalization.  In  planning 
treatment  for  premature  separation  of  the  placenta 
it  is  important  to  keep  in  mind  the  cause — toxemia 
— as  well  as  the  control  of  bleeding.  Adequate 
prenatal  care  will  prevent  this  condition  in  the  ma- 
jority of  cases — a  fact  to  be  kept  in  mind  while 
following  a  course  of  watchful  expectancy  during 
the  treatment  of  the  toxemia  of  late  pregnancy. 
In  postpartum  hemorrhage  preventive  measures 
are  of  most  value.  Slow  emptying  of  the  uterus 
and  judicious  use  of  oxytocics  will  prevent  many 


cases  of  postpartum  hemorrhage.  An  intravenous 
dose  of  pitocin  will  prevent  the  necessity  of  uterine 
packing  in  the  majority  of  cases  due  to  atony. 
Preventive  treatment  of  hemorrhage  by  proper 
conduct  of  labor,  intelligent  use  of  oxytocics  and 
avoidance  of  operative  procedures  through  an  in- 
completely dilated  cervix  should  be  our  practice. 

It  has  been  shown  that  a  high  percentage  of 
women  who  do  register  with  a  physician  receive  in- 
adequate or  poor  prenatal  care.  There  can  be  no 
excuse  for  this.  The  fault  lies  in  poor  training  or 
failure  to  keep  up  with  medical  progress  in  the 
physician.  Postgraduate  education,  in  the  form  of 
refresher  courses,  lectures  and  postgraduate  study, 
is  the  solution  of  our  part  of  the  problem. 


TUBERCULOSIS 

J.   Donnelly,   M.  D ,  Editor,   Charlotte.   N    C. 


TUBERCULO-ASEPSIS 
A  new  term  is  suggested1  to  designate  a  termi- 
nal result  in  many  cases  of  tuberculous  disease. 
One  frequently  sees  patients,  particularly  among 
the  elderly,  with  all  the  symptoms  of  active  tuber- 
culous disease  but  in  whose  sputum  there  is  never 
a  tubercle  bacillus.  Some  of  these  cases  have  never 
been  diagnosed  as  tuberculous,  while  others  have 
had  such  a  diagnosis  and  have  spat  up  tubercle 
bacilli  at  various  periods  in  their  lives.  The  x-ray 
films  usually  show  calcification  and  fibrosis*,  with 
pulmonary  contraction,  and  evidence  of  varying 
degrees  of  emphysema.  The  belief  is  expressed 
that  tuberculosis  going  on  to  asepsis  places  this 
disease  on  a  basis  similar  to  that  of  other  infectious 
diseases,  and  that  this  process  is  the  rule  rather 
than  the  exception. 

Several  case  histories  are  introduced  to  illustrate 
the  condition.  Following  are  short  synopses  of  two 
of  these  histories. 

Case  I:  White  man,  born  1856  and  died  in 
4937.  No  family  history  of  tuberculosis  and  no 
known  contact.  He  had  "inflammation  of  lungs" 
in  1864,  pneumonia  in  1888,  cough  since  1875. 
Pulmonary  hemorrhages  in  1915,  1919  and  1920, 
last  one  a  month  before  admission  to  Sanatorium 
November  12th,  1920.  Patient  dated  present  ill- 
ness from  1918  with  loss  of  weight,  fatigue,  dysp- 
nea, cough  and  sputum  frequently  positive  for  the 
bacilli.  Patient  remained  in  sanatorium  until  June 
12th,  1923,  and  remained  in  fair  health  until  sec- 
ond admission  seven  years  later. 

Complaints  on  second  admission  in  1930  were 
dyspnea  and  chest  pain.    Patient  had  had  eight- 

}.    J.    M.    McMillan,    Am.    Rev.    of    Tub. 


February    1941 


SOUTHERN  MEDICINE  &  SURGERY 


ounce  pulmonary  hemorrhage  in  October,  1927, 
followed  by  two  smaller  ones  a  week  later.  88 
consecutive  sputum  examinations,  including  a  con- 
centration and  two  guinea  pig  tests,  were  negative 
for  tubercle  bacilli.  The  course  of  his  disease  in 
the  sanatorium  was  more  like  that  of  cardiac  than 
pulmonary  disease  and  he  died  a  cardiac  death  in 
1937.  From  the  autopsy  report  the  pathological 
diagnosis  was  bronchiectasis  with  cavitation  at 
apices  of  lungs;  chronic  fibrosis;  pleuritis  with 
marked  calcification  of  pleura  on  the  right;  pul- 
monary edema;  focal  pulmonary  fibrosis;  and 
chronic  mitral  endocarditis.  No  microscopic  evi- 
dtnce  of  tuberculosis  anywhere  in  lungs. 

Case  II:  White  man  born  1907  and  died  1939. 
His  contact  was  with  an  uncle  who  died  of  tuber- 
culosis in  1926  or  1927.  He  had  a  mild  bronchitis 
in  1927,  influenza  in  1929,  and  a  mild  bronchial 
catarrh  for  the  past  nine  years.  He  gave  the  onset 
of  his  present  illness  as  September,  1930,  with  a 
severe  pulmonary  hemorrhage,  and  a  diagnosis  of 
moderately  advanced  pulmonary  tuberculosis  was 
made  at  that  time.  His  sputum  was  positive  for 
tubercle  bacilli  on  several  different  examinations. 
Patient  was  in  a  tuberculosis  sanatorium  from  Oc- 
tober, 1930,  to  August,  1933.  After  a  right  phren- 
icectomy  in  December,  1930,  his  sputum  remained 
negative  for  tubercle  bacilli.  After  another  pul- 
monary hemorrhage  in  July,  1932,  artificial  pneu- 
mothorax was  induced  and  continued  until  August, 
1939.  Increasing  dyspnea  in  the  summer  of  1939 
led  his  physician  to  advise  a  cardiac  study.  He 
was  admitted  to  a  general  hospital  December  30th, 
1939,  and  died  suddenly  within  24  hours  from  what 
was  diagnosed  acute  cardiac  dilatation. 

The  pathological  diagnosis  was:  post-inflamma- 
tory fibrosis  of  the  lungs;  hypertrophy  and  dilata- 
tion of  the  right  heart;  pronounced  atherosclerosis 
of  the  pulmonary  artery  and  its  branches.  Micro- 
scopic examination  showed  no  evidence  of  tuber- 
culous granuloma,  and  no  areas  of  healed  or  calci- 
fied tuberculosis.  No  evidence  at  all  of  tuberculous 
reaction  was  found. 

These  case  reports  serve  to  illustrate  the  event- 
ual possibilities  of  pathological  change  in  certain 
cases  whose  original  disease  was  known  to  be  tu- 
berculous. They  are  almost  invariably  permanent- 
ly labeled  as  tuberculous,  and  are  repeatedly  ad- 
mitted to  sanatoria,  although  they  derive  very  little 
if  any  benefit  from  such  treatment.  Fortunately 
for  their  contacts,  these  patients,  having  become 
negative  for  tuberculosis,  are  no  longer  capable  of 
transmitting  the  disease,  but  it  is  necessary  to  be 
certain  that  they  are  aseptic.  As  a  rule  emphyse- 
ma, bronchiectasis,  fibrosis  and  calcification  are 
the  x-ray  evidences  of  pulmonary  disease,  but  the 


possibility  of  tuberculosis  being  the  original  causa- 
tive factor  should  be  thoroughly  investigated.  For 
this  reason,  admission  to  a  hospital  where  such  a 
thorough  examination  can  be  more  readily  com- 
pleted is  advisable.  The  following  is  the  author's 
routine  procedure:  (1)  a  detailed  history,  partic- 
ularly as  to  lung  abscess,  pneumonia  or  any  sup- 
purative pulmonary  process;  (2)  study  of  all  past 
and  present  roentgenograms;  (3)  oblique  roentgen- 
ograms for  the  purpose  of  studying  the  tracheo- 
bronchial areas;  (4)  tuberculin  tests  and  frequent- 
ly repeated  sputum  examinations  for  tubercle  ba- 
cilli or  other  bacterial  agents;  (5)  complete  cardiac 
and  blood  studies.  Although  little  can  be  done  in 
the  way  of  satisfactory  treatment  for  these  pa- 
tients, it  is  important  to  find  out  whether  or  not 
their  cases  are  aseptic.  Prevention  of  infection  is 
the  most  important  phase  of  tuberculosis  work. 
According  to  the  author  the  most  frequent  symp- 
tom in  this  type  of  case  is  pulmonary  hemorrhage 
in  an  apparently  well  individual,  frequently  fol- 
lowing some  acute  respiratory  infection.  Chronic 
cough  and  sputum  of  many  years'  duration  may 
be  present,  but,  as  the  author  states,  such  symp- 
toms are  frequently  denied,  even  though  the  films 
show  extensive  pulmonary  damage. 

Death  in  this  type  of  case  probably  most  fre- 
quently is  due  to  the  overloading  of  the  right  heart 
with  resulting  cardiac  dilatation.  Since  the  condi- 
tion is  non-infectious  from  a  tuberculosis  view- 
point, long  periods  of  hospitalization  in  a  tubercu- 
losis sanatorium  are  not  necessary,  although  rest 
will  relieve  somewhat  the  cardiac  load  and  prolong 
life.  If  the  necessity  for  hospitalization  becomes 
immediate,  they  can  be  cared  for  in  general  hos- 
pitals, with  no  danger  of  infection  to  the  hospital 
personnel.  The  unfortunate  phase  of  the  condition 
is  that  it  usually  produces  a  state  of  chronic  in- 
validism, and  the  victims,  because  of  chronic  cough 
and  dyspnea,  are  unable  to  follow  any  lucrative 
occupation  for  any  reasonable  length  of  time. 


INJECTION    OF    PILES    WITH   PSYLLIATE 

(T  .F.  Reuther  &  C.  O.  Almquist,  Gary,  Ind.,  in  III.  Med. 

Jl,  Jan.) 

The  use  of  S%  sodium  psylliate  solution  is  reported  in  a 
series  of  50  patients. 

The  patients  were  selected  as  suitable  for  injection  treat- 
ment, or  were  treated  to  control  bleeding  while  awaiting 
operation. 

The  control  of  bleeding  was  more  prompt  and  effective 
with  injections  of  sodium  psylliate  than  with  phenol  or 
quinine  and  urea  hydrochloride  solutions. 

The  amount  of  fibrous  tissue  produced  was  satisfactory. 

Fewer  injections  were  necessary  to  produce  a  clinical 
cure  than  with  the  other  solutions  used. 

Reactions  which  occurred  were  chiefly  those  of  local 
pain  following  injections.  There  were  two  general  re- 
actions noted,  neither  of  which  proved  to  be  severe. 


SOUTHERN  MEDICINE  &  SURGERY 


February   1941 


RHINO-OTO-LARYNGOLOGY 

Clay  W.  Evatt,  M.  D.,  Editor,  Charleston,  S.  C. 


INDICATIONS  FOR  TONSILLECTOMY 
The  indications  for  tonsillectomy  have  been  de- 
bated for  the  past  ten  years.  It  is  easy  enough  to 
understand  why  this  issue  is  so  controversial  when 
one  considers  that  the  physiology  both  normal  and 
pathological  of  the  tonsil  is  only  recently  being 
well  studied  and  understood.  Even  the  fundamen- 
tal, basic  facts  concerning  the  tonsil  have  been  dis- 
puted. It  is  not  wholly  agreed  upon  whether  the 
tonsils  play  a  role  in  combatting  infections  around 
the  throat  and  posterior  pharynx. 

At  the  present  time  the  pendulum  is  swinging 
away  from  indiscriminate  tonsillectomies.  Physi- 
cians are  looking  into  the  results  of  the  past  ten  to 
twenty  years  of  such  practice.  The  statistics  thus 
obtained  are  revealing. 

Kaiser  wrote  on  the  results  of  his  thorough  in- 
vestigation of  this  problem  and  his  conclusions 
follow. 

1.  The  value  of  removal  of  the  tonsils  and  ade- 
noids cannot  be  definitely  established  in  a  few 
years.  Apparent  benefits  during  the  first  few  years 
are  not  so  evident  over  a  ten-year  period. 

2.  Benefits  are  apparent  in  rendering  individuals 
less  susceptible  to  diphtheria  and  scarlet  fever. 

3.  Acute  head  colds  and  otitis  media,  though 
lessened  over  a  three-year  period,  are  not  essenti- 
ally influenced  over  a  ten-year  period. 

4.  Cervical  adenitis  is  decidedly  reduced  in 
tonsillectomized   children   over   a   ten-year  period. 

5.  Respiratory  infections  occur  more  frequently 
in   tonsillectomized   children. 

6.  First  attacks  of  rheumatic  infections  occur 
about  30%  less  often  after  a  tonsillectomy.  Ton- 
sillectomy has  no  effect  on  recurrences. 

7.  Incomplete  tonsillectomies  do  not  offer  the 
same  protection. 

8.  The  hazards  of  tonsillectomy  must  be  con- 
sidered in  the  evaluation  of  the  problem. 

These  conclusions  seem  to  have  an  important 
bearing  on  the  problem  of  whether  and  when  to 
remove  tonsils,  but  it  is  evident  that  there  is  some 
confusion  here.  For  example,  it  would  seem  advis- 
able to  remove  tonsils  and  to  remove  them  early 
to  lower  the  incidence  of  rheumatic  fever,  scarlet 
fever,  diphtheria  and  cervical  adenitis.  Conversely, 
the  tonsillectomy  makes  one  more  liable  to 
pneumonia,  bronchitis  and  laryngitis.  It  is  believed 
that  the  solution  lies  in  not  removing  tonsils  until 
the  fifth  year  or  later. 

The  size  of  the  tonsils  means  nothing,  unless 


actually  causing  respiratory  or  swallowing  difficul- 
ties. Tonsils  almost  meeting  in  the  midline,  may 
be  entirely  free  from  infection  and  very  probably 
have  hypertrophied  to  combat  infections  in  that 
region.  Conversely,  small  tonsils  may  be  the  seat 
of  gross  infection  and  should  without  doubt  be 
removed. 

Probably  the  most  definite  of  all  indications  for 
tonsillectomy  is  recurrent,  chronic  tonsillitis.  In 
this  condition  there  seems  to  be  no  doubt  that  the 
tonsil  has  lost  its  usefulness  and  is  harboring  organ- 
isms potentially  dangerous  locally  and  systemically. 
It  is  well  to  remember  that  this  disease  does  not 
commonly  produce  sore  throat  in  young  children. 

Chronic  enlargement  of  the  upper  deep  cervical 
lymphatic  glands  on  either  or  both  sides  of  the 
neck  without  enlargement  of  other  glands  indicates 
a  tonsillar  infection.  Very  often  these  glands  are 
tuberculous  and  it  is  probable  that  the  portal  of 
entry  was  the  tonsil.  This,  therefore,  constitutes 
another  very  strong  indication  for  tonsillectomy. 
The  great  decrease  in  incidence  of  tuberculous 
glands  in  the  past  thirty  years  may  be  due  in  part 
to  the  better  treatment  of  throat  conditions,  and 
not  entirely  to  the  use  of  better  milk  and  general 
hygienic  measures. 

Otitis  media,  with  its  sequelae,  mastoiditis  and 
deafness,  are  in  the  majority  of  instances  the  result 
of  nasopharyngeal  catarrh  secondary  to  infected 
tonsils  and  adenoids.  Tonsillectomy  in  these  cases 
will  often  prove  very  beneficial.  It  has  been  the 
rule  in  rheumatic  patients.  The  tonsils  should  be 
removed  unless  it  can  be  definitely  shown  that  no 
infection  lurks  within.  There  seems  to  be  definite 
improvement  after  tonsillectomy  in  cases  of  chronic 
sepsis  in  children;  although  malnutrition,  weak- 
ness and  constitutional  inferiority  probably  lowers 
the  resistance  to  organisms  which  under  better 
conditions  would  be  unable  to  produce  disease. 
Tonsillectomy  for  those  who  have  recurrent  colds 
is  very  questionable,  except  for  those  whose  colds 
always  started  with  a  sore  throat. 

With  well-meaning  social  workers,  school  teach- 
ers, public  health  examiners  et  al  referring  children 
for  tonsillectomy  because  of  every  symptom  con- 
ceivable, there  is  no  doubt  that  many  healthy 
tonsils  have  been  removed.  However,  let  us  not 
err  in  the  opposite  direction  by  denying  the  bene- 
fits of  properly  executed  tonsillectomy  when  indi- 
cated. Medicine  is  making  great  strides  in  chemo-, 
electro-  and  other  forms  of  therapy,  but  concerning 
the  tonsil  nothing  takes  the  place  of  good  surgery 
when  indicated.  Whether  or  not  to  remove  the 
tonsils  should  be  carefully  determined  in  the  indi- 
vidual case. 


February   1941 


SOUTHERN  MEDICINE  &  SURGERY 


75 


OPHTHALMOLOGY 

Herbert  C.  Neblett,  M.  D.,  Editor,  Charlotte,  N.  C. 


THE  MEDICAL  QUOTIENT  IN 
REFRACTION 

The  ignorance  of  the  layman  in  regard  to  his 
visual  problems,  in  regard  to  who  are  and  who  are 
not  medical  refractionists,  and  his  trust  placed  in 
the  capabilities  of  the  "doctor"  to  whom  he  ap- 
plies for  help  in  that  particular  makes  him  the 
recipient  of  whatever  brand  of  ''medical  practice" 
is  imposed.  Upon  the  "doctor"  to  whom  he  applies 
is  imposed  the  duty  and  responsibility  to  use  all 
the  ability  he  has,  and  all  the  means  he  can  enlist 
to  aid  in  determining  a  diagnosis  and  in  prescrib- 
ing the  proper  treatment. 

In  a  refractive  error,  great  or  small,  it  is  not 
enough  to  summarily  prescribe  a  corrective  lens 
for  that  error  and  conclude  the  case.  Such  a 
method  leaves  out  the  medical  problem  which  is 
part  and  parcel  of  every  patient  presented  for  re- 
fraction. It  is  conservative  to  say  that  40  to  SO 
per  cent  of  all  children  of  pre-school  and  school 
age,  representing  all  phases  of  economic  life,  who 
are  presented  for  refraction  or  for  an  investigation 
of  this  problem,  have  no  refractive  error  of  conse- 
quence; that  their  eye  symptoms  are  dependent 
upon  dietary  deficiency,  allergic  conditions,  physi- 
cal depletion  from  whatever  cause,  nervous  debil- 
ity, and  psychic  disturbances.  The  busy-every- 
minute  schedule  of  our  institutions  of  learning  and 
the  keen  competitive  spirit  in  all  walks  of  life 
impose  too  great  a  burden  upon  the  formative 
period  of  childhood  and  adolescence  with  the  result 
that  eye  symptoms — headache,  pain  in  the  eye- 
balls, irritated  lids,  light  discomfort,  loss  of  eye 
muscle  tone  as  witnessed  by  deficient  convergence 
and  lessened  accommodation,  digestive  disturban- 
ces and  emotional  trends,  simply  reflect  the  physi- 
cal and  nervous  status  of  the  individual.  Then  the 
bugaboo  "eye  strain"  with  all  its  implications  and 
fixed  viewpoint  of  the  individual  and  his  well- 
meaning  advisers  that  glasses  should  cure  all  of 
his  ills.  Then,  if  without  a  basic  reason  glasses 
are  prescribed,  they  are  a  further  imposition  upon 
the  child  because  of  their  handicap,  an  economic 
waste  to  his  sponsors.  Thus  are  the  standards  of 
ophthalmological  practice  lowered,  the  patient 
diverted  to  those  not  best  qualified. 

Eye  strain  is  a  misnomer.  It  is  improbable  that 
an  eye  can  be  strained.  It  can  become  fatigued 
by  excessive  use  to  the  point  where  the  individual 
can  no  longer  accomplish  his  work  because  of 
blurring  of  vision,  pain  in  the  eyes  and  head  and 
a  sensation  of  burning  of  the  lids.    This  can  occur 


with  or  without  a  refractive  error  and  is  predi- 
cated upon  any  eye  anomaly,  general  physical  or 
nervous  depletion  or  adverse  external  factors.  The 
intrinsic  and  extrinsic  muscles  of  the  eye  in  a 
normal  eye  in  a  normal  healthy  individual  are  so 
geared  in  unison  that  eye  strain  (fatigue)  is  never 
experienced  except  under  the  prolonged  effect  of 
the  most  adverse  external  conditions. 

Vision  is  an  involuntary  function  of  the  eye.  An 
attempt  to  increase  visual  capacity  beyond  the 
ability  of  any  eyes  to  see  causes  fatigue  of  more 
or  less  degree,  but  there  has  been  no  strain  placed 
upon  the  intrinsic  and  extrinsic  muscles.  Strain 
of  a  muscle  or  a  group  of  muscles,  as  in  the  eye, 
implies  impairment  or  injury  to  the  tensile  strength 
of  the  muscle  or  tendon  by  overstretching  causing 
a  mechanical  deformation  in  its  structure.  It  is 
hardly  conceivable  that  this  can  happen  in  a  nor- 
mally coordinating  eye  musculature.  The  refrac- 
tionist  should  thoroughly  investigate  the  medical 
possibilities  in  every  case  presented,  especially  in 
children,  and  should  not  rely  upon  the  prescription 
of  glasses  as  a  routine  measure  either  in  the  pres- 
ence of  small  or  large  errors  of  refraction. 

In  children,  and  in  adults  prior  to  the  age  of 
presbyopic  changes,  for  a  simple  spherical  error 
of  refraction  of  one  diopter  or  less  or  an  astigmatic 
error  alone  of  less  than  l/2  diopter  glasses  should 
better  not  be  prescribed  in  the  great  majority  of 
cases.  Instead,  if  symptoms  of  eye  discomfort  are 
present  a  careful  investigation  into  the  daily  habits 
of  the  patient,  and  proper  advice  and  medical  treat- 
ment would  solve  the  eye  problem  with  a  great 
deal  more  satisfaction  to  the  patient  and  less  strain 
upon  his  finances. 

In  the  attempt  to  rehabilitate  the  indigent  pati- 
ent, to  prescribe  for  correction  of  the  amount  of 
refractive  error  specified  is  an  economic  waste, 
because  it  does  not  rehabilitate,  to  prescribe  glasses 
where  one  eye  is  normal  or  comes  within  the  speci- 
fications above  named  and  the  fellow  eye  grossly 
deficient  in  vision,  or  otherwise  defective.  This 
reasoning  is  obvious  and  applies  as  well  to  those 
economically  secure. 

In  the  frank  presbyope,  the  aged  and  infirm 
whether  indigent  or  otherwise,  the  vocation,  the 
economic  and  social  status  of  the  individual  should 
be  a  strong  directing  influence  in  the  prescribing 
of  corrective  glasses  as  to  whether  or  not  a  straight 
reading  glass  is  need  or  bifocals.  The  weight  of 
evidence  is  in  favor  of  the  simplest  type  of  correc- 
tion which  meets  the  need  of  the  individual  case. 
Here,  too,  a  thorough  knowledge  of  the  medical 
aspects  of  the  case,  as  well  as  the  special  problems 
presented  in  each  eye,  is  essential  in  directing  the 
treatment  to  be  prescribed. 


76 


SOUTHERN  MEDICINE  &  SURGERY 


February  1941 


It  is  estimated  that  85  per  cent  of  all  children 
of  school  and  pre-school  age  have  some  defect  of 
the  visual  apparatus.  The  great  majority  of  these 
defects  are  of  little  importance  per  se,  they  cause 
no  economic  loss,  and  require  no  special  treatment 
except  that  which  may  be  necessary  for  the  general 
wellbeing  of  the  individual  that  lowered  physical 
vitality  may  not  be  reflected  in  the  eyes  augment- 
ing the  defects  present.  In  other  words  a  normal 
healthy  body  will  compensate  for  the  great  majori- 
ty of  these  deficiencies  holding  in  abyance  what 
otherwise  might  become  a  detrimental  factor  in 
visual  efficiency. 


NONSPECIFIC    PROTEIN   THERAPY    IN   OCULAR 
DISEASE 

(T.  E.   Sanders,  St.  Louis,  in  11.  Iowa  State  Med.  Soc.  Feb.) 

A  typhoid  vaccine  in  vials  of  2.5  c.c,  each  c.c.  contain- 
ing 1,000  million  organisms  is  used.  With  a  tuberculin 
syringe,  doses  as  small  as  SO  million  of  this  preparation 
can  easily  be  given  without  dilution.  In  smaller  doses  it  is 
well  to  dilute  with  saline. 

One  of  the  chief  problems  of  foreign  protein  therapy  has 
been  the  lack  of  an  agent  that  would  give  a  satisfactory 
reaction,  yet  could  still  be  used  safely  in  office  and  clinic. 
Such  a  substance  is  now  available  in  Typhoid  Antigen  H. 
After  intravenous  injection,  typhoid  antigen  H  causes  a 
prompt  rise  in  temperature,  but  there  is  usually  no  chill 
and  the  patient  does  not  feel  as  debilitated  as  after  typhoid 
vaccine.  Dosage  and  method  of  administration  are  the 
same  as  for  typhoid  vaccine,  although  a  slightly  larger 
dose  may  be  used. 

Foreign  protein  therapy  is  very  effective  in  ocular  in- 
flammation, particularly  of  iridocyclitis  and  ocular  trauma; 
it  is  easy  to  use  and  not  dangerous,  large  enough  doses 
should  be  given  to  cause  definite  general  reactions ;  typhoid 
vaccine  is  the  most  effective  agent,  although  typhoid  anti- 
gen H  is  effective  and  offers  advantages  in  office  practice. 

(This  is  a  valuable,  but  neglected,  treatment  in  sluggish 
disease  conditions  of  organs  and  parts  other  than  the  eye. — 
J.  M.  N.) 


GENERAL  PRACTICE 

Walter   J.   Lackey,   M.  D.,   Editor,   Fallston,   N.   C. 


DIAGNOSIS  AND  TREATMENT  OF 

PAROXYSMAL     TACHYCARDIA 

LN  GENERAL  PRACTICE 

Paroxysmal  tachycardia  in  most  cases  is  benign. 
The  predominant  sign  is  heart  rate  of  150  to  220 
per  minute. 

Sinus  tachycardia  rarely  goes  higher  than  130 
per  minute,  increases  during  physical  exercise. 

Auricular  flutter  rate  higher — 200  to  400  per 
minute — although  a  partial  block  can  be  deceptive. 
Exercise  never  changes  the  rate  in  paroxysmal 
tachycardia  while  in  case  of  flutter  it  often  tem- 
porarily retards  the  ventricular  rate  to  one-half  or 
one-third.  In  paroxysmal  tachycardia  the  carotid 
arteries  are  visibly  pulsating;  seldom  seen  in  auri- 


cular flutter.  There  is  strict  rhythmicity  in  par- 
oxysmal tachycardia  and  absolute  arrhythmia  in 
auricular  fibrillation.  In  cases  of  auricular  fibril- 
lation the  carotid  arteries  show  only  a  very  slight 
pulsation,  if  any,  and  that  always  irregular. 

Assure  the  patient  that  he  is  not  suffering  from 
a  severe  heart  ailment,  ask  him  for  his  cooper- 
ation. Apply  carotid  sinus  pressure,  never  on  both 
sides  simultaneously.  With  the  three  middle  fingers 
palpate  the  rt.  carotid  artery,  the  middle  finger 
being  at  the  height  of  the  angle  of  the  jaw,  press 
the  artery  suddenly  and  strongly  against  the  ver- 
tebrae for  5  to  10  seconds;  if  not  successful,  try 
on  the  other  side.  If  not  successful,  next  use  eye 
pressure — painful,  but  can  do  no  harm.  The  pati- 
ent flat,  eyes  closed,  ask  him  to  look  downward, 
let  him  hold  stethoscope  on  his  chest.  With  our 
palms  on  his  head  in  the  temporal  region  apply 
a  slowly  increasing  pressure  with  our  thumbs  on 
his  eyeballs;  sometimes  a  stronger  pressure  is 
necessary.  We  need  not  be  afraid  of  injuring  his 
eyes.  Many  times  when  carotid  sinus  pressure 
fails,  eye  pressure  will  stop  the  attack.  The  strang- 
est case  we  saw  was  a  patient  who  claimed  to 
stop  his  attacks  only  by  going  into  a  doorway 
and  turning  a  somersault. 

The  attack  not  ended  by  pressure,  morphine 
sometimes  relieves,  harmless  l/8th  to  3/8th  grains. 

The  remedy  of  choice  in  stopping  as  well  as 
in  preventing  the  attacks  is  quinidine.  After  a 
trial  dose  of  0.2  gm.  to  exclude  an  allergy  against 
derivatives  of  quinine,  we  start  2  hours  later  with 
doses  of  0.4  to  0.6  gm.,  every  2  to  3  hours  until 
the  attack  has  subsided.  Keep  in  bed  and  use 
cold  application  on  the  precordium.  A  few  long- 
lasting  cases  have  responded  to  digitalis  intra- 
venously (2  to  4  c.  c.  once  to  twice  a  day). 

In  a  limited  number  of  cases  we  must  be 
careful  lest  the  management  of  the  tachycardia 
interfere  with  the  treatment"  of  another  pathologic 
condition  of  the  heart — : 

1.  Mitral  stenosis  with  auricular  fibrillation. 
In  this  case  we  are  careful  in  prescribing  quini- 
dine because  the  slower  normal  rhythm  may  bring 
about  a  loosening  of  thrombi  in  the  auricles.  Small 
doses  of  quinidine  should  be  combined  with  digi- 
talis, after  the  two  mechanical  treatments  are  tried 
unsuccessfully*- 

2.  Coronary  occlusion.  Quinidine  weakens  the 
heart  already  impaired  by  the  infarction.  Mor- 
phine is  especially  useful  since  the  attacks  of  tachy- 
cardia are  usually  of  short  duration  when  due  to 
coronary  occlusion. 

3.  Marked  hypertension.  Combine  not  too  large 
doses  of  quinidine  with  barbital  or  chloral  hydrate 
in  the  usual  doses.  Commonly  the  attacks  can  be 
stopped  by  carotid  sinus  pressure.   The  preventive 


February   1941 


SOUTHERN  MEDICINE  &  SURGERY 


77 


dose  of  0.2  gm.  of  quinidine  4  i.  d.  should  not 
be  increased. 

Paroxysmal  tachycardia  diagnosis  and  differen- 
tial diagnosis  can  be  made  without  the  electro- 
cardiograph. The  treatment  of  the  attacks  consist 
of  the  carotid  sinus  pressure,  the  eye  pressure  and 
administration  of  quinidine;  these  methods  should 
be  tried  in  the  order  named. 

A  helpful  article1  on  a  common  and  distressing 
condition  tells  us  how  to  diagnose  and  treat  at 
the  bedside. 


1.    Otto   Neurath,    Sigourney,    in   //  Iowa   State   Med.   Soc.,    Dec. 


DENTISTRY 

J.   H.   Guion,   D.  D.  S.,   Editor,   Charlotte,   N.   C. 


NEW  PLAN  OF  DENTAL  EDUCATION 
Harvard  will  inaugrate  in  1941  an  entirely  new 
five-year  course  in  dental  education1.  The  course, 
which  will  combine  the  basic  knowledge  of  both 
medicine  and  dentistry,  is  designed  to  train  new 
types  of  scientific  workers  for  the  attack  on  dental 
disease.  The  new  development  has  been  made 
possible  by  the  gift  of  $650,000  from  the  Carne- 
gie Corporation,  $400,000  from  the  Rockefeller 
Foundation,  and  $250,000  from  the  John  and 
Mary  R.  Markle  Foundation.  A  balance  of 
$250,000,  bringing  the  total  of  $1,550,000,  is  re- 
quired to  fulfil  the  program.  The  President  and 
Fellows  of  Harvard  College  have  also  transferred 
to  the  resources  of  the  Harvard  school  of  dental 
medicine  $1,000,000  tentatively  placed  at  the  dis- 
posal of  the  dental  school  ten  years  ago.  The 
dental  school  will  be  renamed  the  Harvard  School 
of  Dental  Medicine. 

Dental  students  will  register  in  both  the  School 
of  Dental  Medicine  and  in  the  Harvard  Medical 
School,  taking  three  and  one-half  years  of  the 
same  medical  courses  as  other  students  in  the 
Harvard  Medical  School,  and  in  addition  one  and 
one-half  years  of  specific  dental  training.  Grad- 
uates will  receive  both  the  M.  D.  and  D.  M.  D. 
degrees.  Admissions  to  the  school  of  dental  medi- 
cine will  be  governed  by  the  same  standards  and 
the  same  committee  which  governs  admissions  to 
the  Harvard  Medical  School.  The  last  class  to 
enter  the  present  four-year  dental  curriculum  at 
Harvard  was  admitted  in  September  1940, 
and  the  new  program  will  go  into  operation  in 
the  autumn  of  1941.  Harvard,  the  first  univer- 
sity in  America  to  establish  a  dental  school,  thus 
becomes  the  first  university  to  institute  this  par- 
ticular plan  in  the  development  of  dental  and 
medical  education. 

The  plan  being  put  in  force  at  Harvard  seems 


to  have  as  its  purpose  the  training  of  men  for 
public  health  work,  teaching  and  scientific  work. 
It  will  be  fine  for  that  purpose  but  at  the  present 
the  general  opinion  seems  to  be  that  too  much 
time  and  expense  are  involved  for  the  man  who 
is  going  to  do  general  practice  of  dentistry. 

I.     The   Diplomate,    Oct. 


SURGERY 

Geo.   H.   Bunch,   M.  D.,   Editor,   Columbia,   S.   C. 


CANCER  OF   THE  THYROID 

The  tendency  of  adenoma  of  the  thyroid  or 
nodular  goiter  to  become  malignant,  if  not  surgi- 
cally removed,  is  of  especial  interest  in  the  South- 
eastern States  where  adenoma  is  the  prevailing 
type  of  thyroid  disease.  It  is  estimated  that  from 
80  to  90  per  cent  of  all  cases  of  cancer  of  the 
thyroid  develop  from  benign  nodular  goiter  and 
Means,  in  his  monograph  on  the  thyroid,  says  that 
carcinoma  has  been  proven  to  be  present  in  3.2 
per  cent  of  clinically  nodular  goiters.  In  Berne, 
Switzerland,  where  there  is  a  high  incidence  of 
thyroid  disease,  cancer  of  the  thyroid  was  found 
in  one  of  every  96  post  mortem  examinations, 
whereas  in  the  United  States  it  is  noted  once  in 
every  928  post  mortems. 

Unfortunately,  early  malignancy  in  benign  ade- 
noma cannot  be  recognized  clinically.  Rapid  in- 
crease in  the  rate  of  growth  is  suggestive  but  sud- 
den enlargement  may  be  caused  by  hemorrhage 
into  the  tumor.  Palpable  change  of  consistency 
of  the  growth,  increasing  hardness,  is  significant 
but  not  conclusive.  Pressure  symptoms  may  em- 
barrass respiration  and  alter  the  voice.  Metasta- 
tic involvement  of  the  cervical  lymph  glands  is 
a  late  manifestation.  The  basal  metabolic  rate  is 
of  no  value  in  determining  malignancy.  Most  often 
characteristic  clinical  changes  occur  only  after  the 
confining  capsule  has  ruptured  and  the  surrounding 
gland  becomes  infiltrated  by  cancer. 

Treatment  of  cancer  of  the  thyroid  is  most 
effective  before  the  condition  can  be  recognized 
clinically.  Although  malignancy  may  undoubtedly 
bea;in  as  a  primary  disease  in  an  apparently  normal 
gland,  as  a  rule  it  develops  in  glands  that  are  ob- 
viously diseased.  It  behooves  the  clinician  to  have 
adenomatous  masses  removed  from  the  thyroid  as 
soon  as  they  are  recognized.  Simple  removal  of 
the  encapsulated  growth  is  all  that  is  necessary. 
Wide  evasion  need  not  be  done.  After  infiltration 
of  the  gland  has  begun  the  affected  lobe  and  the 
isthmus  should  be  removed  completely. 

When  the  juglar  vein  has  been  invaded  by  can- 
cer it  should  also  be  removed.   Cases  in  which  the 


SOUTHERN  MEDICINE  &  SURGERY 


February   1941 


growth  is  fixed  to  the  trachea,  and  there  are  no 
lines  of  cleavage  to  guide  dissection,  should  be 
considered  inoperable.  In  them  palliative  tracheo- 
tomy mav  prolong  life. 

In  every  case  of  malignant  tumor  a  biopsy  ex- 
amination should  be  made  to  learn  the  radio-sensi- 
tivity of  the  growth.  This  affects  the  prognosis 
and  is  helpful  to  the  radiologist  in  determining  the 
method  of  application  and  the  proper  dosage. 
Everv  case  of  cancer  of  the  thyroid  should  have 
radiation  after  operation.  In  inoperable  cases  ra- 
diation holds  promise  of  prolonging  life  by  lessen- 
ing the  activity  of  the  tumor,  and,  by  removing  the 
incubus  of  the  growth  and  in  other  ways,  making 
the  sfflicted  one  much  easier  for  his  remaining 
time. 

Metastases  should  be  treated  by  radiation. 

PeM'3erton:  Diseases  of  the  Thyroid  Gland.  Christo- 
pher's Text  Book  of  Surgery,  Edition  1936. 

Lahey:  Carcinoma  of  the  Thyroid.  Annals  of  Surgery, 
Dec,  1940. 


THERAPEUTICS 

J.  F.  Nash,  M.  D.,  Editor,  Saint  Pauls,  N.  C. 


GONORRHEA  IN  THE  MALE 

Reports  on  the  new  "cures"  for  gonorrhea  were 
first  so  encouraging  and  of  late  have  been  so  con- 
flicting as  to  make  gladly  welcome  a  statement  on 
which  we  may  rely.  Such  a  report1  is  here  ab- 
stracted.    It  is   comforting  and   reassuring. 

Sulfanilamide  does  one  of  three  things:  1)  It 
either  produces  a  cure  within  two  weeks;  2)  it 
eradicates  the  obvious  signs  of  the  disease  and 
leaves  the  patient  as  an  asymptomatic  gonococcus 
carrier,  or  3)  it  does  not  in  any  way  change  the 
course  of  his  disease. 

How  many  does  it  cure?  One  has  to  be  generous 
to  say  30%,  which  is  far  from  those  romantic 
figures  of  from  60  to  91%. 

How  many  asymptomatic  carriers  does  it  make? 
20%  or  much  higher. 

Some  sulfanilamide  failures  may  be  cured  by 
some  of  our  later  sulfonamides  and  those  who  are 
not  should  be  treated  as  before  these  drugs  came 
into  use. 

How  about  those  who  become  asymptomatic 
carriers?  A  virile  male  who  falsely  believes  him- 
self cured  is  a  social  menace.  He  may  go  months 
without  symptoms,  despite  alcohol  and  sexual 
intercourse  which,  in  the  presulfonamide  days  sel- 
dom left  him  in  much  doubt  as  to  cure.  When 
he  transmits  his  infection  to  a  female,  she  usually, 

1.  P.  S.  Pelouze,  Univ.  of  Perm.,  in  Bui.  N.   Y.  Acad,  of  Med., 
Jan. 


becomes  a  totally  asymptomatic  carrier  who  has 
not  the  slightest  suspicion  that  she  has  such  an 
infection  until  she  transmits  it  to  a  third  party. 
He  has  a  profuse  urethral  discharge  containing 
countless  gonococci.  This  third  party  usually  re- 
sponds promptly  to  sulfanilamide  medication.  He 
has  an  equal  chance  with  the  party  of  the  first 
part  of  becoming  an  asymptomatic  carrier. 

Thus  could  the  shaking-down  process  be  con- 
tinued. 

The  point  reached  by  the  essayist  and  many  of 
his  friends  is  that  sulfanilamide  should  be  aban- 
doned for  the  far  more  efficient  sulfapyridine  and 
sulfathiazole,  or  whatever  the  future  may  develop 
that  may  be  improvements  upon  them.  They,  too, 
produce  some  asymptomatic  gonococcus  carriers 
who  can  produce  others  of  the  same  stripe.  Pati- 
ents return  whom  we  were  sure  were  cured  by  both 
drugs  some  months  before;  these  had  been  sub- 
jected to  all  of  our  so-called  tests  of  cure,  their 
secretions  repeatedly  subjected  to  the  most  careful 
microscopic  and  cultural  studies. 

So  far  our  story  has  been  gloomy,  it  is  time 
to  get  out  into  the  sunshine,  for  there  is  much  of 
it.  A  number  of  careful  clinicians  report  apparent 
cure  rate  of  both  sulfapyridine  and  sulfathiazole 
runs  between  80  and  91% ;  there  is  little  to  suggest 
that  the  carrier  rate  among  these  apparently  cured 
patients  is  high.  Even  if  as  high  as  10%,  we  must 
view  the  introduction  of  these  drugs  into  the  treat- 
ment of  gonorrhea  as  the  most  glorious  thing  that 
has  ever  happened  for  its  victims. 

Except  perhaps  in  metastatic  gonorrhea,  large 
doses  are  not  needed. 

If  the  patient  is  not  symptom-free  by  the  end 
of  5  days,  further  administration  of  the  same  sul- 
fonamide is  useless. 

Change  to  another  may  produce  results.  This  is 
particularly    so    where    sulfanilamide    has    failed. 

Sulfanilamide,  where  the  others  have  failed, 
is  useless. 

Continuation  of  the  same  drug  for  longer  than 
10  days  is  of  no  value. 

The  cure  rates  of  sulfapyridine  and  sulfathia- 
zole are  about  the  same  for  both  early  and  late 
cases. 

The  toxic  bv-effects  of  sulfapyridine  are,  dose  for  dose, 
about  equal  to  those  of  sulfanilamide.  For  sulfathiazole 
thev   are   far   less. 

As  many  of  these  toxic  symptoms  appear  after  the  first 
week  of  medication,  some  doctors  continue  the  drugs  for 
only  7  days.  The  cures  are  no  less  than  for  10  days  or 
more. 

In  the  presence  of  any  toxic  symptoms  of  moment,  these 
drugs  should  be  stopped  and  the  patient  instructed  to 
drink  large  quantities  of  water  to  aid  elimination. 

Short  dosage  period  and  a  fluid  intake  of  at  least  1500 


February   1941 


SOUTHERN  MEDICINE  &  SURGERY 


79 


c.  c.  in  the  24  hours  will  prevent  sulfonamide  urinary  cal- 
culosis. 

Patients  seemingly  cured  have  no  urethral  discharge. 
Prostatic  and  Cowper's  gland  secretions  offer  the  only 
means  of  revealing  carrier  states  microscopically. 

Properly-dose  cultures  of  carefully  collected  secretions 
have  twice  the  diagnostic  value  of  the  most  careful  micro- 
scopic studies.  Both  can  fail  to  reveal  persisting  infection 
;ind  should  be  repeated  two  or  more  times. 

No  patient  should  be  dismissed  from  observation  in  less 
than  two  months  during  which  at  least  three  cultural 
studies  have  been  made. 

Under  even  the  best  of  circumstances  it  is  best  to  in- 
sist that  the  patient  employ  rubber  sheaths  in  his  sexual 
pursuits  for  three  months  after  supposed  cure. 

At  least  30  %  oj  all  urethral  discharges  are  non-gonor- 
rheal  and  a  miscroscopic  diagnosis  of  gonorrhea  should  be 
made  before  any  patient  is  started  on  sulfonamide  drugs. 
They   are   practically    useless   in   non-specific   cases. 


PYRETHRUM   IX   MEDICINE 

Why  would  not  the  idea  have  occurred  to  every 
one  of  us  to  use  pyrethrum  against  pestiferous 
insects  other  than  flies  and  mosquitoes?  The  op- 
portunity that  presented  itself  to  all  has  been  im- 
proved by  at  least  one1. 

Pyrethrum  for  killing  insect  pests  has  been  used 
for  years.  It  is  harmless  to  warm-blooded  animals, 
but  extremely  toxic  to  the  cold-blooded. 

The  medical  literature  on  pyrethrum  is  meager. 
However,  those  who  have  investigated  its  use  have 
found  its  action  spectacular,  both  as  an  anthelmin- 
tic and  in  the  treatment  of  scabies. 

A  recent  survey  of  prisoners  committed  to  jail 
in  the  District  of  Columbia  reveals  that  nearly 
1%  of  those  admitted  suffer  from  one  or  more 
forms  of  parasitic   infestation,   2%    from  scabies. 

The  cooperation  of  Dr.  Alfred  Week  and  a 
manufacturer  furnished  a  product  containing  2% 
pyrethrins,  called  A-200  compound.  This  oint- 
ment is  non-poisonous  to  man. 

Almost  as  soon  as  this  A-200  was  applied  the 
lice  would  die  within  a  few  moments.  Even  when 
spread  lightly  over  infested  areas  the  parasites  that 
had  burrowed  into  the  skin  would  back  out  from 
their  retreats  and  might  be  seen  to  convulse  with 
paralysis.  The  eggs  immediately  became  detached 
from  the  hairs;  in  more  than  200  cases  a  single 
application  has  been  sufficient  to  delouse  the  pati- 
ent and  there  is  not  one  instance  of  contact  der- 
matitis or  skin  irritation   to  report. 

A  total  of  1,213  cases  of  scabies  treated  by  others 
with  .75%  pyrethrum  oint.,  878  requiring  from 
5  to  7  days,  283  requiring  from  7  to  14  days  to 
complete.  In  52  cases  they  found  it  necessary  to 
use  Wilkinson's  (sulfur)  ointment,  either  on  ac- 
count of  pustular  involvement  or  poor  cooperation. 
The  pustular  cases  were  not  recommended  by  them 

JanW'  K'  Angevine'  Washington,  in  Med.  Ann.  of  Med.  D.  C, 


for  treatment  with  pyrethrum  ointment. 

In  more  than  70  cases  of  scabies  treated  by  the 
writer  with  A-200  compound,  it  has  been  deter- 
mined that  scrubbing  and  bathing  are  not  essential 
to  successful  treatment,  with  no  contraindications 
in  pustular  conditions.  The  most  severe  cases  re- 
quired no  more  than  3  applications  of  A-200  com- 
pound, and  in  most  instances  the  lesions  were 
found   to  heal  after  a  single  treatment. 


THERAPY   IN  PNEUMONIA 
(R.    H.    Major,    Kansas    City,   in   //.    Kansas  Med.    Soc,    Dec.) 

Sulfapyridine  is  antipyretic,  bactericidal;  fall  of  t.  may 
coincide  with  its  specific  effect  upon  the  infection. 

Hematuria  in  the  course  of  sulfapyridine  therapy  is 
caused  by  the  formation  of  acetylsulfapyridine  calculi  in 
the  renal  tubules  and  pelvis.  The  drug  should  be  discon- 
tinued. It  has  been  suggested  that  the  administration  of 
sodium  bicarbonate  will  alkalinize  the  urine  and  prevent 
the  formation  of  calculi.  This  complication  is  relatively 
rare,  and  there  is  no  positive  proof  that  soda  will  prevent 
it. 

The  most  annoying  and  most  common  complication  of 
sulfapyridine  therapy  is  nausea,  often  with  vomiting  and 
hiccoughing.  The  most  effective  drug  for  this  complication, 
in  our  experience,  is  nicotinic  acid,  50  to  100  mg.  by  mouth 
3  or  4  times  daily. 

The  nausea  may  make  it  impossible  for  the  patient  to 
take  tablets  of  sulfapyridine  by  mouth.  In  such  instances 
we  employ  50  c.c.  of  a  5%  solution  of  the  sodium  salt 
intravenously  2  to  3  i.  d.,  and  have  also  used  30%  solutions 
intramuscularly  in  doses  of  5  c.c.  or  more. 

Sulfathiazole  gives  promise  of  being  even  more  valuable 
than  sulfapyridine.  Extensive  laboratory  tests  indicate  that 
sulfathiazole  is  quite  as  effective  as  sulfapyridine  against 
pneumococcus,  meningococcus  and  hemolytic  streptococcus, 
while  it  is  more  effective  than  sulfapyridine  in  staphylococ- 
cal  infections. 

Blake  at  New  Haven  has  had  100  cases  of  pneumonia 
treated  with  sulfathiazole  with  a  mortality  of  only  3%, 
these  3  elderly  patients.  It  only  rarely  produces  nausea 
and  vomiting. 


GARLIC  THERAPY  IN  DISEASE  OF  THE 
DIGESTIVE  TRACT 
(,E.  E.  MARCOVICI,  New  York,  in  Med.  Rec,  Jan.  15(A) 
Two  investigators  found  that  the  excretion  of  bile  wa* 
markedly  increased. 

Beneficial  effects  obtained  with  garlic  in  nervous  diar- 
rhea, flatulence,  distention  are  probably  due  to  action 
similar  to  that  of  the  simple  stomachics  and  carminatives; 
increase  of  appetite  frequently  is  observed. 

A  wider  use  of  this  harmless  and  effective  drug  avail- 
able in  the  odorless  and  tasteless  form  of  allistin  is  recom- 
mended. 


THE    TREATMENT   OF   OXYURIASIS 

(J.  S.  D'Antoni  &  Willi  Sawitz,  New  Orleans,  in  Amer.  Jl 
Trap.   Med.,   via   Current   Med.    Dig.,   Nov.) 

Drugs  thought  to  be  specific  have  not  proved  efficient, 
nor  have  purgatives  or  prophylactic  measures. 

Using  gentian  violet  (medicinal)  l/2  gr.  tab.  with  a 
coating  supposed  to  dissolve  in  4  hours  in  the  cecal  region. 
Medical  treatment  with  gentian  violet  was  shown  to  have 
an   efficacy   of   90%,   given   an   hour   before   meals. 

Vomiting  occurred  more  often  in  females  than  in  males, 
suggesting  that  a  smaller  dosage  in  girls  be  recommended. 

In  groups  in  institutions  a  single  infected  individual 
represents  a  probable  source  of  reinfection. 


SOUTHERN  MEDICINE  &  SURGERY 


February    1941 


PEDIATRICS 

G.  W.  Kutscher,  Jr.,  M.  D.,  FA.  A.  P.,  Editor 
Asheville,  N.  C 


THE   NEED   FOR   TYPING   PNEUMONIAS 

The  sulfonamide  drugs  are  bactericidal  and  bac- 
teriostatic for  pneumococci  (regardless  of  type), 
for  some  varieties  of  streptococci  and  for  some 
other  organisms;  but  they  are  not  equally  effective 
against  some  organisms  responsible  for  consolida- 
tion of  the  lung,  so  the  etiology  of  a  consolidation 
must  be  determined  to  prevent  the  administration 
of  an  often  disagreeable  and  sometimes  dangerous 
drug,  and  to  permit  the  application  of  other  avail- 
able specific  therapy  where  indicated. 

To  determine  the  cause  of  a  consolidation  may 
require  repeated  examinations  of  the  sputum  with 
inoculation  of  mice,  an  examination  of  the  blood 
and  of  the  urine  for  organisms  and  for  their  spe- 
cific products  of  metabolism,  and  the  blood  and 
tissues  for  specific  antibodies  produced  by  the 
patient.  It  is  preferable  to  examine  the  sputum 
for  organisms  before  these  drugs  are  administered, 
but  the  prior  administration  of  the  drug  is  no 
excuse  for  failure  to  examine  the  sputum  should 
a  favorable  response  not  be  made  promptly.  Pneu- 
monias due  to  B.  Pertussis  are  said  not  to  be 
benefited  by  sulfonamide  drugs,  but  pneumococci 
are  responsible  for  the  pulmonary  consolidation  in 
more  than  10  per  cent  of  patients  suffering  from 
pertussis. 

A  blood  culture  is  to  be  made  in  every  case  of 
pneumonia  because  a  bacteremia  may  exist  and 
the  etiology  of  the  pneumonia  may  be  thus  deter- 
mined. Pneumococci  found  in  the  spetum  in  the 
presence  of  a  consolidation  are  responsible  for  the 
pneumonia  in  only  93  per  cent  of  cases. 

Pneumococci  may  become  fast  to  sulfapyridine 
and  this  fastness  may  be  retained  by  them  after 
passage  to  another  patient.  Such  sulfapyridine- 
fast  pneumococci  are  susceptible  to  serum  because 
it  neutralizes  their  capsular  substance  and  sensi- 
tizes them  for  phagocytosis. 

Specific  serum  augments  the  action  of  sulfapyri- 
dine. 

If  antibody  is  already  detectable  in  ample 
amount,  it  is  useless  to  continue  administration 
of  the  serum.  In  that  case,  the  antibody  may 
have  been  incomplete  or  unsuitable  because  of 
errors  in  typing  or  in  the  collection  of  the  material, 
or  there  may  be  additional,  different  invaders.  It 
may  be  wise  then,  to  add  chemotherapy  while  the 
patient  is  restudied.  Even  when  there  is  an  effec- 
tive concentration  of  the  drug  in  the  blood,  the 
temperature  may  continue  to  be  elevated.    In  such 

1.  J.  G.  M.  BULLOWA,  New  York  City,  in  Jl  Mt.  Sinai  HosP., 
Jaiu-Frf) 


a  case,  the  organisms  may  not  have  become  fast 
to  the  drug;  there  may  be  ample  immunity  re- 
sponse, and  the  blood  may  have  been  made  bac- 
tericidal for  the  incitant  of  the  consolidation.  The 
drug  itself  may  be  responsible  for  the  fever  and, 
if  continued,  may  produce  shock  and  death  of 
the  patient. 


SULFAMETHYLTHIAZOLE  AND  SULFA- 
THIAZOLE  IN  GONOCOCCAL  INFECTIONS. 

(J.   F.  MAHONEY  et  al.,  U.  S.  Pub.  Health  Strvice,  in 
Amer.  Jl.  Syphilis,  Sept.) 

Report  is  made  of  experience  with  sulfamethylthiazole  in 
the  treatment  of  gonococcal  infections  in  115  mtn  and  21 
women.  For  all  the  men  the  dosage  was  4  gm.  on  the 
first  day  ,in  4  doses.  In  99  of  the  115  men,  then  2  gm. 
per  day  for  6  to  9  days.  The  rtmaining  16  were  given  * 
gm.  per  day  for  2  to  6  days  before  being  reduced  to  1 
gm.  per  day.  In  no  case  was  the  drug  containued  for 
more  than  12  days.  In  women  3  gm.  for  one  day,  then 
2  gm.  per  day  for  6  to  11  days.  Cures  were  obtained  for 
91  of  the  115  men  of  whom  39  had  previously  failed  to 
respond  to  one  or  more  courses  of  sulfanilamide  or  allied 
sulfonamide,  and  only  21  of  this  number  obtained  cures 
with  sulfamethylthiazole.  None  of  the  21  women  had  re- 
ceived previous  sulfonamide  therapy.  In  19  sulfamethyl- 
thiazolt  treatments  was  followed  bu  cure. 

With  one  exception,  the  complications  responded  rapid- 
ly. In  this  gonorrheal  arthrtis  neither  it  nor  the  initial 
urethritis  was  affected  by  the  trtatment. 

Of  the  total  group  of  136  patienti  36  showed  mild  evi- 
dences  of   toxicity. 

Sulfathiazole  n  the  treatment  of  gonococcal  inftctions: 
day,  then  2  gm.  per  day  for  5  to  11  days;  in  34  patients 
In  71  patients  the  dosage  was  4  gm.  per  day  the  first 
the  initial  dose  was  6  or  8  gm.  during  the  first  day,  then 
4  gm.  per  day  to  a  maximum  total  of  10  days  of  medica- 
tion. Of  the  79  patients  on  which  ths  report  is  based, 
47  had  received  no  previous  treatment  and  43  of  these  re- 
sponded favorably.  The  32  remaining  patients  had  failed 
to  benefit  from  sulfanilamide:  29  of  the  32  were  cured. 
There  were  7  failures  in  this  series.  Larger  doses  did  not 
appear  to  be  more  efftctive  than  the  usually  employed; 
i.  e.,  4  gm.  for  one  day  and  2  gm.  for  6  to  9  days  more. 
The  duration  of  the  obvious  nfection  before  starting  sul- 
fathiazole treatment  did  not  apptar  to  influence  the  the- 
rapeutic response. 


SULFAPYRIDINE   COMBATS   FRIEDLANDER   TYPE 

OF  PNEUMONIA 
(S.  SOLOMON,  New  York,  in  Jour.   A.  M.  A.  for  Nov.  2nd) 

The  first  reported  use  of  sulfapyridine  for  chronic  pneu- 
monia due  to  the  Friedlander  bacillus  brought  about  the  re- 
covery of  the  four  cases  in  which  it  was  used. 

The  Friedlander  bacillus,  is  rod-shaped  and  is  respon- 
sible for  from  1  to  3%  of  all  adult  cases  of  acute  pneu- 
monia. The  incidence  of  the  chronic  type  of  Friedlander 
pneumonia  is  less  than  that  of  the  acute  type.  No  case 
has  yet  been  observed  in  childhood. 

He  reports  27  chronic  cases.  Four  of  them  were  given 
sulfapyridine  and  one  who  was  bacteremic  was  given 
sulfanilamide  amide.  All  5  recovered.  Among  the  12  pati- 
ents, who  were  given  other  treatment   there  were  4  deaths. 


Currently   employed   liver   function   tests   leave   much 
to  be  desired. — Morrison. 


February    1941 


SOUTHERN  MEDICINE  &  SURGERY 


SOUTHERN  MEDICINE  &  SURGERY 

Official  Organ 

TRI-STATE    MEDICAL    ASSOCIATION    OF    THE 

CAROLINAS  AND  VIRGINIA 

James   M.   Northincton,   M.D.,   Editor 
Department  Editors 

Human    Behavior 
James    K.    Hall,    M.D _ Richmond,    Va. 

Orthopedic    Surgery 

Oscar  Lee  Miller,  M.  D  I  --..     ,  ...   XT    n 

c  „       '.  ,.   / Charlotte,  N.  C. 

John  Stuart  Gaul,  M.D.I 

Urology 

Hamilton  W.  McKay,  M.D.  t  Charlotte,  N.  C 

Robert  W.  McKay,  M.D J 

Surgery 

Geo.  H.  Bunch,  M.D Columbia,  S.  C. 

Obstetrics 

Henry  J.  Langston,  M.D Danville,  Va. 

Ivan  M.  Procter,  M.D Raleigh,  N.  C. 

Gynecology 

Chas.  R.   Robtns,  M.D Richmond,  Va. 

G.  Carlvle  Cooke,  M.D Winston- Salem,  N.  C. 

Pediatrics 

G.  W.  Kutscher,  Jr.,  M.D AshevUle,  N.  C. 

General  Practice 

J.   L.  Hamner,   M.D Mannboro,   Va. 

W.  J.  Lackey,  M.D Fallston,  N.   C. 

Clinical  Chemistry  and  Microscopy 

C.  C.  Carpenter,  M.D j 

r.    n    »»  t.  o     ■««■  «     -wt.    /Wake  Forest,  N.  C. 

R.  P.  Morehead,  B.S.,  M.A.,  M.D.. ) 

Hospitals 
R.  B.   Davis,  M.D Greensboro,  N.   C. 

Cardiology 
Clyde  M.  Gtlmore,  A.B.,  M.D Greensboro,  N.  C. 

Public  Health 
N.  Thos.  Ennett,  M.D Greenville,  N.  C. 

Radiology 
Wright  Clarkson,  M.D.,  and  Associates.... Petersburg,  Va. 
R.  H.  Lafferty,  M.  D.,  and  Associates,     Charlotte,  N.  C. 

Therapeutics 
J.  F.  Nash,  M.  D., Saint  Pauls,  N.  C. 

Tuberculosis 
John    Donnelly,   M.D Charlotte,   N.    C. 

Dentistry 
J.  H.   Guion,  D.  D.  S Charlotte,   N.   C. 

Internal  Medicine 
George  R.  Wilkinson,  M.  D Greenville,  S.  C. 

Ophthalmology 
Herbert  C.  Neblett,  M.  D., Charlotte,  N.  C. 

Rhino-Oto-Laryngology 
Clay  W.  Evatt,  M.  D.,  Charleston,  S.  C. 

Offerings  for  the  pages  of  this  Journal  are  requested  and 
given  careful  consideration  in  each  case.  Manuscripts  not 
found  suitable  for  our  use  will  not  be  returned  unless 
author  encloses  postage. 

As  is  true  of  most  Medical  Journals,  all  costs  of  cuts, 
etc.,  for  illustrating  an  article  must  be  borne  by  the  author 


LOOSE  THINKING  AS  TO  CAUSE 

The  implications  of  the  term  cause  are  seldom 
fully  grasped.  Generally  a  cause  is  thought  of  as 
a  single  thing,  a  bacterium  or  a  poison  commonly. 
A  cause,  however,  may  be  contributory,  primary 
or  secondary,  immediate  or  ultimate.  The  discovery 
of  an  inciting  cause  of  a  disease  is  an  exciting 
event  but  such  a  discovery  represents  merely  the 
beginning  of  a  parturition  of  a  new  chapter  in 
science.  In  order  to  bring  the  child  to  full  term, 
a  host  of  contributory  mechanisms  must  be  un- 
covered, the  invasive,  immunological,  pathogenetic, 
allergic,  constitutional  deficiency  factors  and  so 
forth.  For  example,  Laveran  discovered  the  cause 
of  malaria  but  it  remained  a  sterile  fact  until  Ross 
discovered  the  host  in  the  mosquito.  Hansen  dis- 
covered the  sause  of  leprosy  a  half-centruy  ago, 
but  the  mechanism  of  invasion  is  still  a  mystery. 
There  are  only  a  few  diseases  of  which  we  have 
the  composite  picture  of  etiology,  so  that  our  cur- 
rent lore  concerning  the  cause  of  diseases  represents 
mostly  a  series  of  variously  developed  embryos. 

This  subject  is  engagingly  discussed  in  a  book 
of  600  pages  which  is  supplied  as  the  current  issue 
of  the  journal1  of  a  great  hospital. 

The  cause  of  disease  it  is  pointed  out  must  not 
be  confused  with  the  mechanism  whereby  the  dis- 
ease, like  the  embryo,  attains  its  fruition.  Hyper- 
thyroidism and  the  resulting  changes  in  the  thyroid 
gland  are  the  dominant  mechanisms  of  Graves' 
disease,  but  the  cause  lies  behind  these-  mechan- 
isms. The  changes  in  the  islands  of  Langerhans 
represent  the  mechanism  of  glycosuria  but  these 
changes  are  not  the  cause  of  diabetes. 

One  wonders  whether  distinction  between  cause 
and  effect  is  not  tht  most  difficult  accomplishment 
of  human  thought.  The  Dark  Ages  were  dark 
because  this  accomplishment  was  clouded  by  dogma 
and  tradition.  Comets  portended  plagues,  diseases 
were  a  dispensation  of  the  Almighty,  and  scrofula 
was  cured  by  the  King's  touch.  It  was  not  igno- 
rance but  a  lack  of  mental  discipline  that  led  to 
these  distortions.  Effects  are  regarded  as  causes, 
and  vice  versa.  Arteriosclerosis  was  regarded  as 
one  of  the  main  causes  of  hypertension  until  All- 
butt  and  others  proved  the  reverse  to  be  the  rule. 
Achlorhydria  was  once  held  to  be  the  result  of 
pernicious  anemia;  we  now  know  that  it  precedes 
by  years  the  clinical  evidences  of  pernicious  ane- 
mia.    Cause  and  effect  are  much  confused. 

"What  constitutes  a  disease?"  Moschocowitz 
pertinently  asks.  And  he  offers  an  answer:  "a 
morbid  process  that  has  a  consistent  background 

1.    Eli    Moschocowitz,    New    York   City,    in   Jl   lit.   Sinai  Hasp., 
Jan. -Feb. 


SOUTHERN  MEDICINE  &■  SURGERY 


February   1941 


in  morbid  anatomy;"  adding,  "but  we  are  forced 
to  classify  certain  symptom  complexes,  syndromes 
and   functional  disturbances  as  diseases." 

"The  problem  of  etiology  must  be  concerned  not 
with  the  discovery  of  a  cause  of  a  disease,  but  of 
the  causes — of  a  how,  and  a  when,  and  a  why." 
In  this  sense,  there  is  hardly  a  disease  in  which 
the  complete  etiology  has  been  fully  elaborated; 
and,  on  the  other  hand,  there  are  few  diseases  in 
which  at  least  part  of  the  etiology  is  not  well 
known.  Even  in  cancer,  our  knowledge  of  some 
of  the  contributory  factors  is  considerable. 

A  cause  that  has  received  little  consideration 
until  the  last  few  years,  but  which  furnishes  vast 
opportunitites  for  study,  is  the  psyche.  It  is  slowly 
dawning  upon  us  that  the  impact  of  reiterated 
emotional  influences  upon  a  personablity  that  is 
compounded  largely  of  environmental  and  gene- 
tic influences  can  actually  cause  organic  disease. 
An  evidence  of  the  new  faith  is  a  journal  devoted 
to  the  psychosomatic  diseases.  The  genesis  of 
these  maladies  subsumes  the  proposition  that  func- 
tion may  sometimes  precede  anatomy  instead  of 
reversely. 

The  summation  of  our  argument  is  this:  that 
in  the  study  of  etiology,  more  particularly  than  in 
almost  any  other  chapter  of  medicine,  the  most 
important  attribute  of  our  thought,  as  in  stroking 
the  ball  in  tennis  or  in  golf,  is  the  follow  through. 

The  thoughtful  article  from  which  so  much  has 
been  taken  has  immense  practical  bearing.  The 
loose  thinking  and  loose  writing  so  characteristic 
of  our  time  is  manifested  only  a' little  less  by  medi- 
cal men  than  by  laymen.  Within  the  past  week  a 
radio  spieler  introduced  a  young  woman  as  of 
Norwegian  ancestry,  and  so,  well  qualified  to  sing 
in  that  language.  By  the  same  token  the  late 
Vice  President  Curtis  could  have  sung  sweetly  in 
the  dialect  of  the  Kaw  Indians. 

It  is  a  stock  statement  regarding  certain  dis- 
eases that  we  can  not  hope  to  master  them  until 
we  learn  their  causes;  although  all  of  us  know  we 
have  had  the  mastery  of  smallpox  in  our  hands 
for  nearly  ISO  years,  and  still  its  cause  remains 
a  dark  secret. 

The  essayist  has  sown  good  seed.  It  is  to  be 
hoped  they  will  fall  in  good  ground  and  bring 
forth  fruit. 


Recent  investigations'   bear  this  out. 

In  1933  a  virus  pathogenic  for  ferrets  was  ob- 
tained from  the  throat  washings  of  patients  with 
influenza  and  it  was  proved  that  antibodies  against 
this  virus  were  produced  during  convalescence 
from  the  disease. 

This  virus  has  caused  many  epidemics  of  influ- 
enza in  the  last  seven  years;  this  virus  has  not 
caused  all  epidemics  of  the  disease  during  the  same 
period.  No  signs  or  symptoms  have  been  estab- 
lished which  would  serve  to  distinguish  cases  of 
influenza  of  known  cause  from  cases  of  influenza 
of  unknown  cause. 

It  is  suggested  that  two  primary  divisions  be 
made: 

( 1 )  Clinical  Influenza  —  A  symptom-complex 
characterized  bv  sudden  onset,  fever,  headache, 
chills,  muscular  pains  and  cough. 

(2)  Influenza  A — A  specific  disease  caused  by 
infection  with  any  strain  of  the  virus  discovered  by 
Smith,  Andrewes,  and  Laidlaw. 

If  hitherto  undescribed  viruses  are  isolated  and 
shown  to  be  causes  other  specific  diseases  in  the 
group  could  be  labeled  influenza  B,  C  and  so  on. 

Influenza  A  cannot  yet  be  diagnosed  certainly  at 
the  bedside. 

The  recovery  and  identification  of  influenza  A 
virus  from  a  given  throat  washing  cannot  yet  be 
accomplished  in  less  than  3  weeks.  Serologic  diag- 
nosis, under  ideal  conditions,  requires  from  10  days 
to  2  weeks  after  the  beginning  of  an  epidemic. 

It  has  been  found  that  a  complex  vaccine  pre- 
pared from  chick  embryos  infected  simultaneously 
with  both  influenza  A  virus  and  canine  distemper 
virus  was  effective  in  stimulating  the  production 
of  additional  antibodies  against  influenza  A  virus 
after  a  single  subcutaneous  injection  in  man.  The 
efficacy  of  a  possible  prophylactic  agent  can  be 
determined  accurately  only  by  the  study  of  com- 
parable vaccinated  and  control  groups  of  human 
beings  exposed  to  an  epidemic  of  proven  influenza 
A. 


OUR   KNOWLEDGE   CONCERNING 
INFLUENZA 

The  great  difference  of  degree  of  severity  in 
different  epidemics  has  caused  many  to  believe  that 
what  we  call  influenza  is  fore  than  one  disease. 

1     F.   L.   Horsfall,  Jr.,   New   York,   in  Dig.  of  Treatment,   Feb. 


PREVENTION  OF  ABDOMINAL  ADHESIONS 

Excepting  the  cases  in  which  something  as 
clearly  demonstrable  as  a  fibrous  cord  binding 
down  and  so  obstructing  passage  through  a  portion 
of  intestine,  most  of  us  are  rather  skeptical  of  a 
diagnosis  of  postoperative  adhesions,  and  slow  to 
advise  operation  for  breaking  down  adhesions  with 
a  view  to  relieving  the  patient  of  miscellaneous 
abdominal  discomforts. 

That  symptom-producing  adhesions  do  form 
and  that  such  formation  should  be  prevented  if 
possible  all  agree. 


February   1941 


SOUTHERN  MEDICINE  &  SURGERY 


An  Arkansas  surgeon'  has  looked  into  the  mat- 
ter and  written  convincingly.  His  approach  is  ex- 
perimental and  clinical. 

Substances  which  are  now  being  rather  widely 
instilled  to  prevent  adhesion  formation  are  papain, 
amniotic  fluid  and,  to  less  extent,  isotonic  saline 
solution.  Work  with  papain  has  convinced  that  it 
is  of  no  value  in  preventing  adhesions.  The  only 
case  of  postoperative  obstruction  which  the  essay- 
ist has  had  in  private  practice  resulted  following 
an  appendectomy  when  the  peritoneal  cavity  was 
full  of  amniotic  fluid  at  the  time  of  operation.  He 
knows  of  no  proof  of  amniotic  fluid  being  of  value 
in  preventing  adhesion  formation.  If  the  gut  is 
unusually  dry  when  it  is  placed  back  into  the  ab- 
dominal cavity,  instillation  of  saline  can  do  no 
harm  and  mav  be  of  some  value. 

Gonococci  and  staphylococci,  we  are  reminded, 
are  prolific  fibrin  producers,  prone  to  produce  per- 
manent adhesions.  Colon  bacilli  and  streptococci 
are  very  poor  fibrin  producers.  In  a  case  of  pure 
streptococcus  or  colon  bacillus  peritonitis  the  prog- 
nosis is  practically  hopeless  since  these  toxins  do 
not  call  forth  sufficient  fibrin  to  permit  walling  off 
the  infection.  Fortunately,  however,  such  periton- 
itis is  usually  mixed  also  with  staphylococcus  in- 
fection, which  produces  much  fibrin.  The  forma- 
tion of  adhesions  in  the  peritoneal  cavity  is  to  an 
extent  in  inverse  proportion  to  acuteness  of  the 
pyogenic  infection.  In  other  words,  one  may  have 
a  peritoneal  cavity  almost  full  of  pus  and  yet 
have  an  amazingly  small  amount  of  permanent  ad- 
hesion formation  after  subsidence  of  the  infection. 
Wherever  the  serosal  covering  within  the  abdom- 
inal cavity  is  permitted  to  remain  broken,  adhe- 
sion formation  is  almost  sure  to  occur.  Of  impor- 
tance are  drains,  suture  materials  and  packs. 

Chemically  irritating  substances  as  urine,  bile, 
gastric  juices  even  though  sterile  produce  adhe- 
sions, also  chemicals  in  suture  materials. 

Whenever  practicable  an  incision  should  be 
made  parallel  with  lines  of  tension  of  the  abdo- 
men-parallel with  the  fibers  of  the  internal  oblique. 
To  hold  the  bowel  out  of  the  field  of  the  suture 
during  closure,  one  of  the  most  useful  implements 
is  the  ordinary  tablespoon,  placed  close  against 
the  under  surface  of  the  peritoneum,  sewing  in  the 
bowl  of  the  spoon.  As  the  peritoneum  is  sutured 
use  the  thumb  forceps  to  evert  the  edges  as  the 
suture  line  is  drawn  taut. 

Contrary  to  popular  belief  sponging  and  packing 
if  properly  carried  out  do  not  appear  to  cause  ad- 
hesions, but  bacteria  dragged  in  from  the  abdom- 
inal wall  onto  the  surface  of  the  gut  may  cause 
adhesions.    Keep  drapes  arranged  so  that  the  skin 

1.  J.    K.    DonaW: 


of  the  abdominal  wall  is  entirely  protected.  In 
almost  100  per  cent  of  the  cases  there  is  permanent 
adhesion  where  a  knot  is  left  exposed. 

The  following  conclusions  regarding  suture  ma- 
terials seem  warranted: 

Plain  catgut  is  about  the  poorest  of  all  sutures, 
even  in  closure  of  the  peritoneum.  When  catgut  is 
used  in  the  abdomen  the  finest  chromicized,  suffi- 
ciently strong  to  withstand  the  tension  upon  it, 
should  be  used — rarely  indeed  stronger  than  00  for 
closing  the  peritoneum.  The  chemicals  used  to 
cbromicize  catgut  are  in  themselves  irritating, 
every  manufacturer  does  not  use  the  same  methods 
The  Davis  and  Geek  brand  has  been  found  uni- 
formly strong  and  dependable. 

The  increased  use  of  silk  seems  warranted,  many 
use  it  throughout  in  all  types  of  abdominal  oper- 
ations. In  the  course  of  a  few  months  a  fine  un- 
treated suture  will  have  disappeared.  Black  silk 
(the  10c  store  kind)  is  excellent  except  that  it  will 
not  stand  repeated  sterilization.  Ordinary  fine  cot- 
ton thread  is  a  good  suuture  material  for  use  in 
the  Deritoneal  cavity. 

Postoperative  distention  is  an  important  factor 
in  tearing  the  peritoneum  along  the  suture  line  and 
thereby  causing  adhesions.  Enemas  are  used  too 
promiscuously  postoperatively  and  preoperatively. 
We  rarely  give  an  enema,  then  a  very  small  one  to 
assist  in  removing  what  has  accumulated  in  the 
rectum. 

Dehydration  of  the  bowel  may  predispose  to- 
ward loops  of  gut  sticking  together  and  to  adhesion 
formation.  It  is  important  to  maintain  a  satisfac- 
tory fluid  balance  postoperatively. 

The  appendix  stump  is  to  be  buried  unless  in- 
accessible, the  serosa  about  the  appendix  base 
will  not  hold  suture  material  well,  or  the  opera- 
tor be  inexperienced.  The  author  used  the  ligation- 
and-drop  method  for  ten  years  before  becoming 
convinced  of  the  superiority  of  the  inversion  tech- 
nique. Ordinary  untreated  black  silk  is  used  for 
the  inversion  suture,  next  preference  being  fine 
00  or  000  chromic  catgut,  or  linen.  Warning  is 
sounded  against  the  use  of  present  Deknatel  silk 
for  burying  the  stump  since  adhesions  are  more 
prone  to  form  about  this  latter  suture  than  any  of 
the  others  mentioned. 

A  similar  expression  as  to  suture  is  made  by 
another  contributor  to  the  same  issue. 

Spool  cotton  has  been  used  extensively,  it  pro- 
duces less  cellular  reaction  and  earlier  healing  than 
catgut,  silk  or  linen.  When  placed  in  tissues,  cot- 
ton loses  10  per  cent  of  its  tensile  strength  in  14 
days,  while  silk  loses  35  and  catgut  50  to  70  per 
cent.    Living   fascia  as  a  suture  material  is  indi- 


Little   Rack,    in  Jl.   Ark.    Med.   Soc,   Feb.  2.   J.    B.   Wharton,   E]    Dorado,    in    //.    Ark.   Med.   Soc,   Feb. 


SOUTHERN  MEDICINE  &  SURGERY 


February   1941 


cated  especially  in  those  individuals  with  hernia 
as  a  result  of  an  extremely  weakened  floor  of  the 
inguinal  canal  and  in  the  repair  of  unusually  large 
hernias.  Steel  wire  has  a  few  followers  in  suturing 
abdominal  wounds,  particularly  hernias. 

It  would  seem  that  the  evirences  of  adhesions  of 
consequence  are  so  plain,  and  the  number  of  ab- 
dominal operations  so  great,  that  all  doubts  as  to 
the  technique  least  liable  to  produce  adhesions 
would  be  soon  resolved. 


WRONG  GLASSES  WILL  NOT  INJURE  EYES 
Very  welcome  is  the  appearance  of  a  refutation 
of  a  lot  of  superstitions  as  to  eyeglasses  and  what 
they  will  do.  A  Harvard  man1  who  has  gone  to 
Iowa  to  practice  ophthalmology  tells  us  plainly 
that  you  don't  strain  eyes  in  reading  in  dim  light 
any  more  than  you  strain  your  ears  in  listening  to 
soft  music. 

Many  a  patient  have  I  told  this:  You  don't 
strain  your  eyes  a  bit  more  when  you  try  to  read 
in  too-dim  light,  than  you  strain  your  gun  when 
you  shoot  at  a  bird  beyond  the  gun's  range.  In 
one  instance  you  fail  to  get  the  meaning;  in  the 
other  you  fail  to  get  the  bird;  but  there's  nothing 
straining  about  either  procedure. 

We  must  counteract  some  old  adages  which  are 
as  prevalent  as  measles:  "Don't  read  too  much, 
you'll  ruin  your  eyes."  "You  mustn't  read  in  such 
poor  light,  you'll  injure  your  eyes."  "You  must 
have  your  glasses  changed  every  two  years."  The 
treatment  must  also  counteract  a  recent  commer- 
cial advertising  campaign  which  is  attempting  to 
sell  light  by  instilling  fear  in  the  customers'  minds, 
rather  than  on  the  basis  of  their  comfort;  also  the 
fear  of  the  man  who  drives  a  car  at  night,  of  the 
person  who  must  work  under  bright  or  dim  arti- 
ficial light  and  who  is  unfortunate  enough  to  be- 
lieve the  advertising  copy  which  suggests  that  in- 
sufficient light  will  cause  injury  to  the  eyes. 

It  is  not  sufficient  to  tell  the  person  who  experi- 
ences pain  when  he  is  forced  to  look  at  a  bright 
light  that  no  harm  is  being  done,  because  he  will 
not  believe  it.  You  must  tell  him:  "Hurts!  Of 
course  it  hurts!  You  should  be  glad  that  a  bright 
light  causes  pain.  If  it  did  not  when  you  were  a 
year  old,  your  mother  could  not  have  been  able  to 
make  you  understand  that  you  must  not  look  at 
the  sun."  There  are  some  lights  that  are  too  hot 
the  sun,  a  blast  furnace,  a  glass  blower's  flame — 
from  which  the  eyes  should  be  protected  by  a  heat 
absorbing  glass.  But  if  vou  must  drive  a  car  at 
night  or  work  before  footlights,  do  it  without  fear, 
and  disregard  the  discomfort  which  is  only  a  nor- 
mal reflex  provided  for  your  safety. 

There  can  be  no  more  injury  to  the  retina  or 

1.  A.  M.  Dean,  Council  Bluffs,  in  Jl.  Iowa  State  Med.  Soc,  Feb 


optic  nerve  produced  by  a  weak  light  stimulus  than 
there  is  caused  to  the  ear  or  hearing  nerve  by  lis- 
tening to  soft  organ  music.  Some  with  normal  eyes, 
or  suitable  lenses  complain  of  pain  after  using 
their  eyes.  Assuming  adequate  fusion  and  that  we 
are  dealing  with  a  functional  problem,  this  is  unim- 
portant. The  eye  neither  knows  nor  cares  whether 
it's  looking  at  the  end  of  a  short  ray  of  light  com- 
ing from  a  book  or  a  piece  of  cloth,  or  a  long  ray 
of  light  coming  from  a  tree  a  mile  down  the  road. 
To  read,  since  we  have  two  eves,  we  must  turn 
them  in  to  the  same  word,  and  we  must  pull  on  the 
muscles  which  focus  the  rays.  Such  muscle  work 
carried  on  hour  after  hour  will  naturally  tire  the 
eye  muscles  just  as  the  leg  muscles  will  be  tired 
after  hours  and  hours  of  standing;  but  neither  eye 
nor  leg  will  be  injured. 

Another  fear  is  that  of  not  wearing  the  magic 
glasses  and  of  wearing  the  wrong  glasses.  Office 
workers  want  glasses  to  protect  their  eyes.  This 
idea  has  been  sold  to  them  bv  glasses  salesmen 
and  word  of  mouth  advertising  for  so  long  that  it 
amounts  almost  to  a  fetish.  An  office  in  a  nearby 
city  has  a  complement  of  26  young  people  between 
the  ages  of  25  and  35,  24  of  whom  are  wearing 
classes!  The  half-diopter  spheres  and  cylinders 
for  relief  of  symptoms  of  so-called  asthenopia  af- 
ford no  relief  in  a  vast  majority  of  cases.  The 
wearer  tries  someone  else  who  prescribes  slightly 
different  but  equally  worthless  lenses,  and  he  still 
obtains  no  relief,  because  his  trouble  is  fear,  not 
ocular  abnormalitv.  Such  a  person  goes  through 
life  with  a  pocketful  of  glasses  and  no  confidence 
in  anyone. 

The  treatment  for  such  a  "no-glass"  or  "wrong- 
glass"  fear  which  we  have  found  most  effective  is 
to  make  the  statement  "You  must  wear  a  certain 
glass."  and  then  proceed  to  show  the  patient  how 
ridiculous  the  statement  is.  All  anv  lens  can  do  is 
to  change  the  direction  of  light  rays.  If  one  can 
say  that  ravs  of  light  must  enter  the  eye  in  one 
specific  direction  and  no  other,  it  is  equivalent  to 
saying  that  vou  must  never  move  your  eyes.  It 
makes  no  difference  to  the  eve  whether  you  wear 
the  right  glasses,  or  anv  glasses  at  all.  The  only 
thing  that  matters  is  that  vou  see  well  enough  to 
suit  vou.  You  don't  have  to  wear  glasses  because 
vou  do  close  work,  or  because  vou  work  under  an 
artificial  light,  and  vou  don't  have  to  change  your 
glasses  every  two  years  because  someone  tells  you 
to. 

The  fear  of  blindness  felt  bv  children  and  grand- 
children of  someone  who  went  blind  must  be  han- 
dled individually.  Tf  the  cause  of  blindness  be  not 
familial  the  ophthalmologist  should  simply  say  the 
individual's  chances  of  having  a  similar  condition 


February    1941 


SOUTHERN  MEDICINE  &  SURGERY 


8? 


are  those  of  the  general  public,  just  like  the  chances 
of  being  struck  bv  an  automobile. 

The  flat  way  in  which  this  thoroughly  trained 
eve-doctor  brands  as  false  the  propaganda  of  cer- 
tain of  those  with  something  to  sell  plainly  shows 
that  he  is  indignant  at  the  way  our  people  are 
being  held  up. 

The  whole  of  the  article  should  be  printed  in 
every  Public  Health  Bulletin  and  everv  dailv  news- 
paper in  the  United  States. 


DOCTOR  ALBERT  HOUCK 

Nobility  consists  of  virtue. — Don  Quixote 
That  he  was  "one  of  Nature's  noblemen"  can 
be  truly  said  of  Dr.  Albert  Houck.  For  more  than 
fifty  vears  he  was  active  in  his  chosen  profession, 
bringing  health,  joy,  comfort  and  sunshine  into  the 
lives  of  those  who  were  so  fortunate  as  to  come 
under  his  benign  influence.  A  rare  gentleman  typi- 
cal of  the  finest  and  best  traditions  of  the  old 
South,  his  long  and  useful  life  was  devoted  to 
service  to  mankind.  He  was  a  good  doctor.  In  the 
practice  of  medicine,  his  arrival  at  the  home  of  a 
patient  brought  relief  to  everv  member  of  the 
family.  His  presence  inspired  even  the  desperately 
ill  with  new  courage  and  hope,  factors  which  often 
tipped  the  scales  in  favor  of  the  patient. 

Xature  endowed  Doctor  Houck  with  a  fine  phy- 
sique, a  distinguished  apnea ranee  and  when  ad- 
vancing years  made  it  difficult  for  him  to  set  about, 
his  carriage  remained  as  upright  as  his  character. 
His  appearance  was  still  commanding  and  distin- 
guished. Always  was  he  the  perfect  gentleman.  No 
one  could  talk  with  him  even  for  a  few  minutes 
without  realizing  he  was  in  the  presence  of  one  of 
the  Lord's  elect. 

Albert  Houck  was  born  in  Rowan  Countv,  De- 
cember 15th,  1855.  He  was  educated  in  the  county 
schools,  at  Catawba  College — then  at  Newton, 
Davidson  College,  and  was  graduated  in  medicine 
from  the  College  of  Phvs'n'ans  and  Surgeons.  Bal- 
timore, in  1884.  Post-graduate  courses  were  later 
taken  at  Bellevue  Hospital.  New  York  City.  He 
did  his  first  professional  work  in  Ashe  County, 
later  moving  to  Caldwell.  He  settled  at  Lenoir  in 
1891  and  spent  most  of  his  professional  career 
there,  except  six  years  in  Statesville  and  nine  years 
as  a  member  of  the  staff  of  the  State  Hospital  at 
Morganton.  He  was  a  member  of  the  Caldwell 
County  Medical  Society,  the  Tri-County  Medical 
Society,  The  Ninth  District  Medical  Society,  the 
Medical  Societv  of  the  Stat^  of  North  Carolina, 
the  American  Medial  Association.  He  was  a  mem- 
ber of  the  Iredell-Alevander  County  Medical  So- 
ciety while  located  at  Statesville.  and  of  the  Burke 
County  Medical  Society  while  at  Morganton, 


DOCTOR  HOUCK 

He  retired  in  January,  1939,  when  he  removed 
to  Virginia  to  make  his  home  with  his  children. 
He  died  suddenly  of  a  heart  attack  on  December 
4th,  1940,  at  the  home  of  his  daughter  at  Chiles- 
burg,  Virginia.  Surviving  Doctor  Houck  are  one 
son.  W.  A.  Houck  of  Beaverdam.  Virginia,  and  a 
daughter.  Mrs.  Arthur  Cowles  of  Chilesburg,  Vir- 
ginia. His  body  lies  in  the  cemetery  at  the  Chapel 
of  Rest,  in  Happy  Valley,  Caldwell  County,  under 
the  shadow  of  the  mountains  he  loved  so  well. 

In  addition  to  his  professional  services.  Doctor 
Houck  was  a  great  asset  to  the  civic,  religious  and 
educational  life  of  the  community.  On  his  retire- 
ment he  presented  to  the  Caldwell  County  Library 
Lis  medical  library  of  more  than  300  volumes,  the 
accumulation  of  a  life-time. 

Doctor  Houck  was  a  close  observer  of  nature. 
He  loved  the  country,  the  woods  and  the  open  sky. 
He  was  fascinated  by  a  beautiful  sunrise  or  sunset, 
and  watching  the  approaching  twilight  and  the  for- 
mation of  tinted  clouds  in  the  western  sky  was  a 
favorite  pastime.  Flowers  were  his  hobby  in  later 
vears.  He  loved  them,  especially  dahlias  and  roses, 
and  spent  much  of  his  time  working  with  them. 


SOUTHERN  MEDICINE  &■  SURGERY 


February    1941 


He  collected  poems  and  committed  many  of  them 
to  memory.  He  liked  to  collect  pictures,  especially 
historical  and  humorous.  His  taste  for  books  ran 
in  much  the  same  channel — history,  biography  and 
humor.  He  had  a  wonderful  way  of  retaining  what 
he  read  and  could  repeat  it  accurately,  even  after 
a  long  period  of  time.  He  was  a  faithful  student 
of  the  dictionary  and  encyclopedia,  and  when 
he  could  not  be  outside,  he  loved  to  study 
words  for  their  exact  meanings,  studying  the 
encyclopedia  for  odd  bits  of  information.  The 
unusual  had  a  strong  appeal  for  him.  He  had 
stored  in  memory  a  vast  amount  of  unusual  and 
interesting  knowledge,  which  made  him  an  excep- 
tionally good  conversationalist. 

He  was  a  man  who  did  not  mind  being  alone. 
He  could  be  as  happy  alone,  with  his  own  thoughts 
and  in  his  own  company,  as  he  could  surrounded 
by  his  fellows.  As  long  as  he  lived,  he  felt  that  he 
was  fortunate  in  being  able  to  be  up  and  doing 
the  things  that  were  of  service  to  others. 

It  is  not  fitting  that  a  great  doctor  should  pass 
without  recognition  of  his  services  to  mankind, 
especially  one  who  has  labored  so  long  and  so 
faithfully. 

There  should  be  a  memorial  to  the  memory  of 
every  doctor  who  has  well  and  ably  ministered  to 
the  sick  and  distressed,  day  and  night,  until  ad- 
vancing years  and  infirmities  have  made  it  impossi- 
ble for  him  to  go  longer  about  his  daily  work. 

Memorials  of  marble  and  stone  will,  in  time,  be 
obliterated  and  forgotten;  but  faithful  service  to 
one's  fellowmen  remains  green  in  the  memory  of 
the  human  race  and  earns  immortality  for  every 
good  doctor. 

After  a  man  is  gone  the  kind  things  that  are 
said  about  him  do  him  no  good.  He  never  sees  the 
flowers  that  are  sent.  Eulogies  to  him  mean  noth- 
ing. His  family,  friends  and  colleagues  appreciate 
such  remembrances  which  come  out  of  respect  and 
affection  to  one  who  has  labored  well  and  faith- 
fully. Others  are  thereby  encouraged  to  perform, 
even  more  valiantly,  in  the  field  of  service  to  man- 
kind when  they  feel  that  their  efforts  are  appreci- 
ated, even  though  the  appreciation  may  come  late 
— often  too  late. 

Tn  the  passing  of  a  doctor,  there  is  a  note  of  ex- 
treme sadness.  There  is  a  tremendous  loss  to  the 
community  in  which  he  lived  and  worked.  The 
humblest  doctor,  in  the  most  out-of-the-way  place, 
who  lives  up  to  the  ideals  of  his  profession,  is  a 
great  man. 

Seldom  are  doctors  appreciated  at  their  real 
worth  until  they  are  gone  and  there  is  no  one  left 
to  perform  their  labors,  or  those  who  take  up  the 
work  not  be  able  to  fill  the  place  so  satisfactorily 


as  the  man  of  long  experience  and  an  intimate 
knowledge  of  his  people  and  the  community  he 
serves.  An  experienced  doctor  usually  has  a  wise 
and  tolerant  understanding  of  human  behavior.  He 
knows  his  people  as  only  a  physician  can. 

Gallantry  on  the  field  of  battle  is  often  reward- 
ed with  medals  but  those  who  know  what  the  real 
doctors  go  through  with  in  their  daily  work  realize 
that  they  earn,  every  day  of  their  lives,  by  their 
fortitude,  bravery,  devotion  to  duty — gallantry  in 
the  face  of  the  enemy — such  as  few  soldiers  have 
ever  exhibited. 

Here  again  it  is  not  out  of  place  to  mention 
that  the  medical  profession  is  the  only  altruistic 
profession — has  as  its  highest  aim  elimination  of 
the  very  cause  for  its  own  existence. 

The  true  doctor  enjoys  doing  things  which  pre- 
vent disease,  the  things  which  make  people  live 
longer  and  the  things  which  make  them  happier. 

In  the  passing  of  Doctor  Albert  Houck.  a  great 
man  is  gone  from  among  us.  but  his  memory  will 
ever  be  green  in  the  minds  of  those  who  knew  him. 
A  gallant  soldier  is  gone  from  the  field  of  battle. 
There  is  no  medal  which  can  be  bestowed  which 
could  adequately  portray  the  gratitude  and  appre- 
ciation of  those  he  served  so  well,  so  long  and  so 
faithfully. 

—JAMES  W.  DAVIS. 


DOCTOR  GEORGE  WITXIAM  PRESSLY 

In  mid-December  Dr.  Presslv  died  in  the  home 
of  his  ancestors  in  Greenwood  County,  South  Caro- 
lina. Almost  the  whole  of  his  professional  life 
was  spent  in  Mecklenburg  County.  North  Carolina. 

To  Charlotte  Dr.  Presslv  was  largely  instrumen- 
tal in  bringing  the  blessines  of  modern  surgery. 
But  acceptance  of  his  abilities  as  a  surgeon  never 
caused  him  to  withhold  his  skill  as  an  all-round 
doctor. 

Soon  after  my  coming  to  Charlotte  a  well-in- 
formed and  accurate  citizen,  in  my  presence,  paid 
the  highest  tribute  to  Dr.  Pressly  that  I  ever  heard 
paid  a  man.  Dr.  Pressly's  worth  I  had  had  no 
opportunity  to  know.  This  citizen  said:  "There 
is  a  doctor  in  this  city  who,  if  he  were  to  come 
into  his  office  and  find  two  calls  for  his  services, 
one  from  the  richest  man  in  the  city,  the  other 
from  the  poorest,  would  go  to  see  the  poorest  man 
first,  knowing  the  rich  man  could  easily  get  another 
doctor.     And  that  doctor  is  George  Pressly." 

After  coming  to  know  the  doctor  for  whom  so 
much  had  been  said,  it  was  easy  to  see  why  such 
words  were  spoken  of  him. 

In  a  court  trial  in  which  the  propriety  of  his 
conduct  of  a  surgical  case  was  brought  into  ques- 
tion. Dr.  Pressly,  on  the  stand,  showed  such  trans- 


February    1941 


SOUTHERN  MEDICINE  &  SURGERY 


37 


parent  honesty,  readily  admitting  that  he  might 
have  been  at  fault,  as  to  utterly  confuse  and  con- 
found the  prosecuting  attorney:  who  was  heard 
to  say  that  he  did  not  know  how  to  proceed. 

A  great  store  of  knowledge,  excellent  judgment 
and  nimble  fingers  gave  him  great  capacity  for 
dealing  with  illness.  A  compassionate  nature  made 
this  capacitv  available  at  all  times  to  all  persons. 
It  may  be  said  of  him  as  of  a  Virginia  doctor  of 
a  hundred  years  ago:  He  possessed  that  blessing 
to  others,  but  often  curse  to  himself,  a  tender 
heart. 

His  always  rather  frail  body  worn  out  in  work 
beyond  his  strength,  his  last  few  years  were  spent 
in  the  quiet  and  restfulness  of  life  on  the  farm 
on  which  he  and  many  another  of  his  name  had 
been  born. 

He  thought  no  evil,  spoke  no  evil,  did  no  evil, 
understood  no  evil.  The  Devil  must,  long  since, 
have  given  up  trying  to  tempt  him. 

To  all  these  gifts,  there  was  added  the  gift  of 
glowing  expression.  Pity  it  is  that  this  tribute 
could  not  be  penned  by  one  as  skilled  as  himself 
in  celebrating  high  desert. 

He  has  his  good  part  with   the  pure  in  heart. 
The    soil    out    of   which    such    men    as    he    are 
made   is   good   to   be   born    on,    good   to    live    on, 
good   to   die   for   and   to   be   buried   in. —   Lowell 


DOCTOR  THOMAS  W.  M.  LONG 
The  night  of  February  3rd.  the  doctor  who  held 
the  offices  of  Secretary-Treasurer  of  the  Medical 
Society  of  the  State  of  Xorth  Carolina  and  Senator 
from  the  two  counties  of  Northampton  and  Hali- 
fax died  suddenly  at  the  home  of  a  brother  in 
our  capital  city  of  Raleigh. 

Dr.  Long  was  only  55  years  of  age.  but  he  had 
served  long  and  in  various  capacities.  He  had  been 
a  member  of  the  Board  of  Medical  Examiners  of 
his  State,  President  of  the  State  Sanatorium  Board, 
member  of  the  Board  of  Directors  of  the  State 
Hospital  at  Raleight  and  of  the  Executive  Com- 
mittee of  the  State  Medical  Society.  This  was  not 
his  first  term  of  service  as  State  Senator. 

His  many  officers  had  given  him  unusual  oppor- 
tunity to  serve  his  people,  particularly  to  serve 
in  the  way  of  improving  health  and  saving  life. 
Many  a  health  measure  of  the  fir=t  importance  is 
on  the  Statute  Books  of  North  Carolina  because 
of  him.  He  had  introduced  a  b;l!  before  the  Legis- 
lature now  sitting  to  provide  that  a  sum  b  e 
raided  to  the  charge  for  licensing  each  automobile 
to  be  run  in  the  Stale,  the  nvney  so  raised  to  be 
used  to  pay  for  hosrvtal  and  medical  services  to 
those  injured  in  automobile  accidents.  It  is  a 
meritorious  bill  and  should  he  enacted  into  law; 
not,  as  some  would  obscure  the  issue,   in   loyalty 


to  its  dead  sponsor,  but  because  of  the  bill's  in- 
trinsic merit.  Probably  the  bill  would  be  the 
better  for  a  little  amending,  but  it  should  neither 
be  tabled  nor  defeated. 

Dr.  Long's  services  as  a  doctor,  as  an  officer 
of  various  medical  bodies,  as  a  hospital  adminis- 
trator and  as  a  legislator  have  entitled  him  to  high 
place  among  his  professional  brethren — among  all 
his  people. 


ACIDOSIS— From  P.  55 
proper  amount  of  glucose  and  insulin  to  restore  the 
carbohydrate  metabolism. 

References 

1.  Marsh,  F.  B.:  Disturbed  Fluid  Balance,  Industrial 
Medicine,  Vol.   9,  No.    11,  Nov.   1940. 

2.  Hartmann,  A.  F.:  Clinical  Studies  in  Acidosis  and  Alka- 
losis.  Ann.   Int.  Med.,  Vol.   13,  No.   6,   Dec.   1939. 

3.  McLeod.  J.  J.  R.:  Physiology  in  Modern  Medicine, 
C.  V.  Mosby,  St.  Louis,  Mo.   1935. 

4.  Bert,  C.  H..  and  Taylor,  N.  B.:  The  Physiological 
Basis  of  Medical  Practise,  Williams  and  Wilkins  Co., 
Baltimore,  Md.   1939. 

3.  Coller,  F.  A.,  and  Maddox,  W.  G.:Water  and  Elec- 
trolyte Balance,  S.  G.  &  0.,  Vol.  70,  340-354,  Feb.  15, 
1940. 

6.  Newbitrch,  L.  H.:  Round  Table  Discussion:  Metabolic 
Disorders,  A.  C.  P.  Post-Graduate  Course,  University 
of   Michigan,    1940. 

7.  Hartmann,  A.  F.:  The  Treatment  of  Diabetic  Acidosis, 
Symposium  on  Metabolic  Disorders,  Duke  Medical 
School,   Nov.   2,    1940. 


CHEST  FLUOROGRAPHY  WITH  PORTABLE  X-RAY 

EQUIPMENT  ON  VA-TNCB.  FILM 

(W.   P.   DEARING   &   A.   E.   TURNER,   in   Pub.   Health 

Rep.,  Dec.  27th) 

Results  from  the  standpoint  of  clinical  significance  arc 
encouraging.  Additional  refinement  of  technique  should 
produce  better  and  more  uniform  pictures.  Experience  in 
reading  the  small  films  will  reduce  errors  in  interpreta- 
ton. 

The  place  of  the  X-ray  in  mass  testing  is  emphasized 
by  the  experience  of  the  Metropolitan  Life  Insurance 
Company  with  preemployment  examinations.  Of  200 
clinically  significant  discovered  only  by  means  of  X-ray, 
after  a  history  and  physical  examination  had  failed  to  in- 
dcate  disease. 

Although  there  is  need  for  further  development  of 
techniques  and  materials,  fluorography  with  35  mm.  film 
and  portable  X-ray  equipment  offers  promise  as  a  prac- 
ticable procedure  and  for  large-scale  tuberculosis  case  find- 
in  gin  rural  areas  at  reasonable  cost. 


A  Low-protein  Diet  (7%)  increased  the  susceptibility 
of  rats  to  orally  administered  sulfanamide,  increasing  the 
mortality  rate  and  the  incidenct  of  anemia  as  compared 
with  similarly  treated  rats  on  a  diet  containing  30%  pro- 
tein.— M.  T.  Smith  et  al.,  in  P.  H.  Reports. 


Broadly  stated,  the  general  health  of  self-supporting 
students  is  inferior  to  the  health  of  non-self-supporting 
students;  however,  to  further  increase  the  accuracy  of  this 
final  conclusion,  a  larger  study  of  a  greater  sample  of  stu- 
dents in  both  groups  should  be  made.  —  Perlman,  Ann 
Arbor,  Michigan. 


SOUTHERN  MEDICINE  &  SURGERY 


February   1941 


GONORRHEAL  VAGINITIS— From  P.  62 
mucosa.  The  mother  could  not  insert  the  capsules 
because  of  the  struggles  of  the  child.  Sulfanilamide 
was  given  for  two  weeks  and  theelin  continued. 
Two  weeks  after  discontinuing  sulfanilamide  the 
smear  was  still  positive,  but  the  mucosa  was  chang- 
ing and  the  mother  could  now  use  the  supposito- 
ries. Theelin  was  continued  and  sulfanilamide  re- 
peated for  ten  days.  The  discharge  ceased  and  six 
smears  were  negative. 

Results  of  treatment  with  estrogenic  substance 
have  been  good.  Vaginal  suppositories  of  1,000 
units  were  used  nightly  with  2,000  units  theelin 
hypodermicallv  twice  weekly  for  two  or  three 
weeks,  and  sometimes  longer.  Perhaps  theelin  is 
superfluous,  with  amniotin,  but  T  think  it  gives  a 
quicker  response. 

Four  children  were  given  this  treatment  alone. 
Two  responded  to  first  course  of  seven  to  eight 
weeks,  two  required  four  to  eight  weeks'  additional 
treatment. 

In  five  cases  it  was  used  after  failure  with  sul- 
fanilamide. In  four  of  these  cases  cure  resulted 
from  six  weeks  of  theelin  and  amniotin;  the  fifth, 
one  of  vaginal  ulceration  with  bleeding,  required 
eight  weeks'  additional  treatment. 

In  two  cases  with  continued  evidence  of  infection 
after  six  weeks  of  amniotin  and  theelin  and  two 
weeks  of  sulfanilamide,  the  addition  of  floraquin 
suppositories  to  aid  in  vaginal  acidification,  with 
continuation  of  theelin  for  four  and  nine  weeks, 
resulted  in  cure. 

In  one  case  in  spite  of  complementary  courses 
of  sulfanilamide,  it  was  necessary  to  give  two 
courses  of  theelin  and  amniotin  of  six  and  eight 
weeks. 

In  another  in  spite  of  two  courses  of  sulfanila- 
mide it  was  necessarv  to  give  three  courses  of 
theelin  and  amniotin. 

In  another,  after  a  vear's  treatment  including 
thirtv-two  weeks  of  theelin  and  amniotin  and  two 
courses  of  sulfanilamide,  clinical  evidence  of  the 
disease  persisted,  but  this  cleared  spontaneously 
several  months  later. 

Three  of  the  children  developed  enlargement  of 
the  breasts,  which  subsided  after  medication  was 
stopped  and  in  three  there  was  early  appearance 
of  pubic  hair,  otherwise  there  were  no  ill  effects  of 
the  rather  large  doses  of  the  estrogenic  substances. 

Vaginal  mucosa  response  occurred  in  fifteen  of 
the  cases  in  from  one  to  two  weeks,  while  in  the 
remaining  two  there  was  no  response  for  ten  weeks. 
The  mucosa  returned  to  normal  appearance  in 
average  of  two  weeks  after  stopping  the  treatment. 
Criteria  tor  Cure 

The  criteria  for  cure  were  freedom  from  dis- 
charge and  at  least  four  negative  smears  and  one 


negative  culture.  Most  of  the  cases  had  smears  at 
weekly  intervals  for  four  weeks,  then  four  at  two- 
week  intervals.  Nine  patients  have  been  well  for 
over  two  years;  three  for  over  a  year;  two  for  over 
six  months,  and  three  for  over  four  months. 

Normal  menstruation  has  occurred  in  three  of 
the  girls  since  treatment. 

Summary 

A  brief  review  is  made  of  the  incidence,  etiology, 
symptoms,  diagnosis  and  treatment  of  gonorrheal 
vaginitis.  Seventeen  cases  are  reported.  No  results 
were  obtained  in  the  two  cases  treated  with  neo- 
prontosil.  Sulfapvridine  was  tried  on  three  of  the 
older  girls,  but  all  had  gastric  upsets  before  effect 
of  the  medication  could  be  determined.  Sulfan- 
ilamide was  used  in  fourteen  cases,  the  course  re- 
peated in  six.  Possible  cures  were  obtained  in  only 
two. 

Amniotin  suppositories  and  theelin  hypodermi- 
cally  were  used  in  the  seventeen  cases,  of  which 
sixteen  were  cured.  In  five  of  the  cases  the  course 
had  to  be  repeated,  and  in  four  it  had  to  be  given 
for  the  third  time.  In  one  there  was  no  apparent 
cure. 

Conclusions 

1.  Neoprontosil  and  sulfanilamide  are  disap- 
pointing drugs  in  the  treatment  of  gonorrheal  vag- 
initis of  children. 

2.  Sulfapyridine,  more  effective  in  the  disease, 
is  prone  to  cause  gastric  disturbances  in  children. 

3.  Cures  can  be  effected  in  90  per  cent  of  the 
cases  by  the  use  of  amniotin  and   theelin  in  oil. 

4.  Treatment  should  be  continued  for  at  least 
eight  weeks. 


ADDENDUM 
Since  presenting  this  paper,  one  6-year-old  girl  who  had 
been  treated  with  sulfanilamide  and  theelin  and  amniotin 
and  reported  as  cured  after  31  negative  smears  or  cultures 
had  a  recurrence  with  a  more  profuse  discharge  that  at 
the  onset.  She  was  re-treated,  using  sulfathiazole,  for  10 
days  at  which  time  gonococci  were  still  present.  Amnio- 
tin and  theelin  was  repeated  for  eight  weeks  and  to  date 
seven  smears  have  been  negative.  Three  other  girls  were 
treated  with  sulfathiazole  alone,  all  responding  within  a 
week  and  have  had  four  or  more  negative  smears.  Sul- 
fathiazole was  well  tolerated  though  one  developed  a 
profuse   rash   on  the  seventh  day. 


GONOCOCCAL  VAGINITIS  OF  CHILDREN 
(R.  M.  Lewis,  Yale,  in  Bull.  N.  Y.  Acad.  Med.,  Jan.) 
Cohn  and  his  associates  recently  reported  the  results  of 
their  long  study  of  this  troublesome  disease.  In  a  large 
group  of  untreated  children  75%  recovered  in  6  months 
or  less.  Vaginal  suppositories  of  estrogens,  which  have  b«en 
widely  used,  were  found  to  give  apparently  good  clinical  re- 
sults with  smears  which  early  became  negative.  That  these 
results  are  more  apparent  than  real  is  shown  by  the  faet 
that  cultures  taken  from  the  infected  children  so  treated 
remained  positive  about  as  long,  and  as  often,  as  in  the 
untreated  controls.  Sulfapyridine  given  at  4-hour  inter- 
vals 4  i.  d.  cured  90%  of  a  series  of  cases  in  which  it  wa 
given  The  dose  for  a  child  should  not  exceed  0.43  gram 
per  pound  of  body  weight  daily,  and  shouW  net  total 
more  than  2   grams  per  day. 


February    1941 


SOUTHERN  MEDICINE  &■  SURGERY 


PHYSIOLOGY— From  P.  63 
It  must  not  be  forgotten  that  mastication  serves 
a  much  larger  purpose  than  merely  finely  dividing 
food. 

The  chewing  movements  cause  intimate  contact 
of  food  pai tides  (properly  salivated,  of  course) 
with  the  gustatory  organs.  Then,  too,  fragrant 
odors  are  set  free  that  stimulate  the  nerves  of 
smell;  and,  most  important  of  all,  inaugurate  the 
flow  of  psychic  gastric  secretion,  or  appetite  juice. 
Pari  passu  with  mastication  runs  salivation.  In 
order  of  importance  saliva  subserves  a  half  dozen 
purposes.  It  has  a  small  but  not  negligible 
chemical  action;  it  keeps  the  mouth  clean,  ex- 
cretes certain  substances,  lubricates  and  above 
all  it  liquefies.  And  liquefaction  is  the  increasingly 
and  cumulatively  needed  agent,  as  food  moves 
down  the  digestive  tract,  to  act  as  the  indispensable 
solvent  for  its  mechanical  and  chemical  break-up. 
In  fact,  unless  sufficiently  liquefied,  nothing  can 
be  swallowed,  as  witness,  "trial  by  ordeal"  in  the 
Dark  Ages,  when  a  suspected  criminal  was  made 
to  eat  drv  flour.  The  fear  of  detection  inhibited 
salivary  flow,  making  swallowing  wellnigh  impos- 
sible. 

The  flow  of  saliva  is  attributed  to  reflexes  both 
unconditioned  and  conditioned  by  way  of  afferent 
sensory  fibers  through  the  chorda  tympani,  glosso- 
pharyngeal, lingual  and  sympathetic  nerves. 

Stimulation  of  any  sensory  nerve  in  the  body 
may  occasion  secretion  of  saliva. 

Anything  put  into  the  mouth  will  cause  saliva- 
tion, and,  indeed,  produce  a  saliva,  as  Pavlov  has 
pointed  out,  that  suits  the  nature  of  the  substance 
ingested:  e.  g.,  for  dry  material  a  watery  secretion; 
for  acid  a  saliva  rich  in  protein  because  of  its 
buffering  reaction.  Milk  evokes  a  saliva  loaded 
with  mucin,  etc. 

Conditioned  reflexes  originating  from  visual, 
auditory,  olfactory  and  cutaneous  impulses  are 
very  numerous  in  man. 

The  sight  of  savory  food,  the  smell  of  a  broiling, 
juicy  beefsteak,  hearing  the  dinner  bell,  will  make 
the  "mouth  water." 

The  ptyalin  content  of  saliva  initiates  the  chemi- 
cal changes,  affecting,  however,  only  certain  carbo- 
hydrates. Raw  starch  is  not  altered,  only  boiled 
starch  is  converted  into  maltose  and  isomaltose. 
It  is  noteworthy  that  ptyalin  activity  continues 
for  a  good  while  in  the  stomach  so  that  under 
favorable  conditions  three-fourths  of  potato-starch 
is  actually  split  into  the  above  mentioned  products 
before  the  acidifying  action  of  gastric  juice  inhibits 
further  action. 

The  lubricating  action  of  saliva  inheres  largely 
in  its  mucin  content — needed  where  little  mastica- 


tion or  digestion  occurs.  But  the  whole  mouth, 
especially  the  mucous  membrane,  the  tongue  and 
lips,  must  be  kept  smooth  and  slippery  to  make 
them  resilient  and  supple,  so  that  coarse  particles 
shall  not  irritate  and  will  be  readily  moved  around 
and  finally  coated  with  mucin  for  easy  swallowing. 

By  washing  out  food  detritus,  bacteria,  eroded 
epithelial  cells  etc.  from  gums  and  teeth,  and 
slushing  them  down  into  the  esophagus,  saliva 
maintains  excellent  oral  hygiene — as  suppression  of 
salivary  flow  occurring  in  some  fevers,  occasioning 
bad  breath  and  coating  of  teeth  with  sordes, 
testifies. 

The  excretory  function  of  the  salivary  glands 
is  evidenced  by  their  elimination  of  certain  drugs 
and  some  organic  and  inorganic  substances. 

A  high  content  of  urea  is  found  in  the  saliva 
in  cases  of  chronic  nephritis;  diabetics  excrete 
sugar,  overactive  parathyroids  calcium,  by  this 
route. 

The  clinically  well-known  "blue,  or  gray  line" 
marking  the  gums  in  lead  poisoning  is  essentially 
a  chemical  combination  of  lead,  excreted  with  the 
saliva,  and  sulphur  obtained  probably  from  tartar 
deposits  on   teeth,   or   from   decaying   teeth. 

Inorganic  iodides  absorbed  from  the  intestines 
appear  in  the  saliva  in  four  to  six  minutes  —  a 
striking  exercise  given  medical  students  in  every 
pharmacological  laboratory,  and  clinically  valuable 
for  the  iodide  gastric-motor-function  test. 

Straub's  startling  mouse  test  for  morphine  in 
the  saliva  of  race  track  horses;  the  stomatitis  and 
excessive  salivation  caused  by  mercury  etc.,  fur- 
ther emphasize  the  excretory  power  of  the  salivary 
glands. 

On  good  grounds  it  is  stated  that  the  virus  of 
infantile  paralysis  has  been  demonstrated  in  saliva, 
so  that  by  injecting  such  saliva  in  rats  or  monkeys 
this  disease  can  be  reproduced. 

Since  mumps  is  now  diagnosed  not  primarily  as 
a  parotid  affection  but  a  systemic  invasion,  the 
secondary  involvement  of  the  parotid  glands  must 
be  ascribed  to  an  infection  in  them  that  attacks 
their  tissues  while  passing  through  and  out  in  the 
salivary  secretions. 

Pathological  reflexes  (gastro-esophago-salivary 
reflex);  e.  g.  in  spasm  of  cardiac  sphincter,  duo- 
denal ulcer,  carcinoma  etc.,  produce  pronounced 
salivation  and  the  so-called  postprandial  water- 
brash. 

The  effect  of  saliva  on  the  prevention  of  dental 
caries  particularly  when  produced  by  acidophilic 
bacteria  or  the  presence  of  a  rich  content  of  mucin 
in  the  secretion  is  not  now  attributed  to  its  alka- 
linity (for  it  is  normally  more  usually  faintly  acid 
in  reaction),  but  to  its  marked  buffering  power. 


90 


SOUTHERN  MEDICINE  &  SURGERY 


February   1941 


This  buffering  effect  is  much  lessened  by  ingest- 
ed sweets  and,  of  course,  acid  foods  or  drinks; 
much  increased  by  bitter  substances. 


NEWS 


SIGMUND  FREUD 
(I.  S.  WECHSLER,  in  Jl.  Mt.  Sinai  Hosp.,  Jan.-Feb.) 
It  i?  dfficult  to  appraise  the  worth  of  Freud's  contri- 
bution, to  say  what  is  of  permanent  value  and  what  is 
ephemtral,  or  what  is  likely  to  remain  as  the  heritage  of 
human  knowledge  and  what  wil  lyield  to  the  corrosve 
effect  of  time.  If  I  should  dare  to  become  a  prophet,  I 
would  say  that  psychoanalysis  will  not  survive  best  as  a 
method  of  treatment,  despite  the  acknowledgement  that 
certain  neuroses  are  best  treated  by  it.  I  would  venture 
the  guess  that  analysis  will  bt  remembered  longest  for  the 
insight  into  normal  and  abnormal  behavior  which  it  has 
vouchsafed  and  for  its  excellence  as  a  metho  dof  investi- 
gation. I  am  not  so  sure  that  it  will  survive  as  a  body  of 
psychology,  although  one  can  only  feel  grateful  for  its 
hontst  approach  to  the  study  of  sex  instincts.  But  if  one 
membered  or  how  much  of  them  will  survive,  one  can 
cannot  predict  how  long  Freud's  contributions  will  be  re- 
state with  assurance  that  no  man  of  his  generation  has  had 
wider  nffluenct  or  stamped  his  personality  more  deeply 
on  the  thinking  of  his  age. 

THE  USE   OF   BURBOT-LIVER   OIL 

INTRAMUSCULARLY 

For   Ocular   Avitaminosis   A 

(H    C    Kluever  et  at.   Fort   Dodge,   in  Jl  Iowa  State 

Med.   Soe.,   Dec.) 

One  c.  c.  of  fortified  burbot-liver  oil  intramuscularly  on 
June  1st  and  June  3rd;  no  other  treatment;  repeated 
on  June  7th.  Vitamin  A  was  then  restricted  to  15,000 
I.  U.  (burbot-liver  oil)  daily  by  mouth;  a  proper  diet 
was  advised  at  this  time.  The  corrected  vision  on  August 
6th  was  20/15  for  each  eye;  vision  at  night  had  notice- 
ably improved. 

Recovery  from  various  degrees  of  night  blindness  fol- 
lower intramuscular  administration  of  fortified  burbot- 
liver  oil  in  the  three  cases  in  which  the  light  threshold 
was  determined.  There  was  improvement  of  corneal  ul- 
ceration and  superficial  punctate  keratitis  in  two  cases.  In 
one  case  which  appeared  to  be  early  xerophthalmia,  vision 
improved  from  20/100  for  each  eye  to  20/20  O.  D.  and 
20/25  O.  S.  in  one  week. 

A  case  of  recurrent  corneal  desquamation  following  in- 
jury appeared  to  be  controlled  only  after  intramuscular 
administration  of  Vitamin  A. 

Corneal  vascularization  following  cataract  extraction,  in 
one  instance,  responded  favorably  to  the  combined  effects 
of  riboflavin  and  Vitamin  A. 

There  was  no  local  reaction  to  the  intramuscular  admin- 
istration  of   fortified  burbot-liver   oil. 


JOHN"  PHILLIPS  MEMORIAL  AWARD 
The  Board  of  Regents  of  the  American  College  of 
Physicians,  has  voted  the  John  Phillips  Medal  for  1941 
to  Dr.  William  Christopher  Stadie,  Associate  Professor 
of  Research  Medicine  at  the  University  of  Pennsylvania, 
for  his  great  contributions  to  the  knowledge  of  anoxia, 
cyanosis  and  the  physical  chemistry  of  hemoglobin,  and 
for  his  recent  studies  on  fat  metabolism  in  diabetes  mellitus. 


NEUROPSYCHIATRY  SOCIETY  OF  VIRGINIA 
Program  of  meeting  held  in  the  academy  of  medicine 
auditorium.  Richmond,  January  29th:  Yeast  Infection  of 
the  Nervous  System,  Dr.  J.  Asa  Shield,  Richmond,  Mental 
Deterioration  in  the  Psychoses,  Dr.  Ernest  H.  Alderman. 
Richmond.  The  Problem  of  the  Psychopathic  Personality 
in  the  Instituion  for  the  Feebleminded,  Dr.  G.  B.  Arnold, 
Colony,  Suicidal  Attempts  as  Seen  in  a  General  Hospital. 
Dr.    Patrick   H.    Drewry,   Jr..    Richmond. 


NORTH   CAROLINA   HAS  A  NEW  PHARMACY 
SERVICE 

Beginning  the  first  of  the  year  the  State  will  have  an 
Itinerant  Instructor  and  Consultant  in  Pharmacy,  in  the 
person  of  W.  Lee  Moose,  Ph.G..  successful  and  prominent 
pharmacist  of  Albemarle  and  Asheville.  This  position  was 
made  possible  under  the  George  Dean  Act  of  the  Federal 
Government  and  funds  provided  by  the  State;  and  spon- 
sored by  the  North  Carolina  Board  of  Pharmacy,  the  N.  C. 
P.  A.  and  the  School  of  Pharmacy  of  the  University.  The 
work  will  consist  of  holding  classes  at  convenient  locations 
throughout  the  States  as  well  as  consultations  in  the  indi- 
vidual stores. 


Richmond  Academy  Of  Medicine — Stated  Meeting, 
January  28:  Recent  Work  on  Human  Hypertension,  by 
Dr.  Eugene  M.  Landis,  Professor  of  Internal  Medicine 
in   the   University   of   Virginia   School   of   Medicine. 

On  February  4th,  the  Fourth  Lecture  in  the  Endocrine 
Symposium.  Endocrine  Therapy  of  Abnormal  Menstrua- 
tion and  the  Menopause,  by  Dr.  Willard  Allen  of  the 
Washington   University   School   of   Medicine. 


HOSPITAL  AT  RADFORD  OPENED  FEBRUARY  10th 
Radford's  new  community  hospital  opened  February 
10th,  with  Dr.  Edward  R.  Ambrose  as  resident  physician. 
On  the  staff  are  Drs.  J.  J.  Diesen,  T.  L.  Gemmell,  H.  L. 
Dean  and  H.  D.  Fitzpatrick  of  Radford  and  Drs.  A  .M. 
Sho waiter,  R.  M.  DeHart  and  R.  H.  Grubbs  of  Christian- 
burg. 


NEUROPSYCHIATRY    SOCIETY    OF    VIRGINIA 
At    the    meeting    on    January    29th.    in    Richmond,    the 

following   officers   for   the   next   year   were   elected: 

President.    Dr.    W.    Gayle    Crutchfield,    Vice-President. 

Dr.  Howard  R.  Masters,  Secretary-Treasurer,  Dr.  Edward 

H.  Williams, — all  three  of   Richmond. 


OBSTETRICIANS  AND  GYNECOLOGISTS 
NEW  OFFICERS 

Dr.  R.  A.  Bartholomew,  of  Atlanta,  was  elected  presi- 
dent of  the  South  Atlantic  Association  of  Obstetricians  and 
Gynecologists   February   8th. 

Delegates  voted  to  hold  their  1942  convention  in  Atlanta 
early   next  February. 

Dr.  Oren  Moore,  Charlotte,  was  named  president-elect. 
Dr.  Robert  A.  Ross,  Durham,  was  reelected  secretary- 
treasurer. 

State  committees,  who  are  to  select  their  own  chairman 
within   a   month   after   the   convention,   include: 

North  Carolina:  Dr.  W.  B.  Bradford,  Charlotte;  Dr. 
Bayard  F.  Carter,  Durham;  Dr.  T  L.  Lee.  Kinston,  and 
Dr.  Ivan  M.  Procter,  Raleigh. 


SIGMA  ZETA  LECTURE 
Doctor  E.  M.  Landis.  Professor  of  Medicine  at  the 
University  of  Virginia  Medical  School,  will  deliver  the 
annual  Sigma  Zeta  lecture  on  Wednesday,  March  12th, 
at  8:30  p.  m.  in  the  Baruch  Auditorium  of  the  Egyptian 
Building,  Medical  College  of  Virginia.     His  subject  will  be 


February    1941 


SOUTHERN  MEDICINE  &  SURGERY 


STRENGTH    TO    RESIST    THE    STORM 


The  storms  of  rough  wintry  weather  play 
havoc  with  the  health  and  well-being  of 
persons  whose  resistance  is  low.  Insofar  as 
diminished  resistance  may  be  due  to  vitamin 
deficiency  such  patients  may  be  adequately 
protected  by  supplementary  multivitamin 
medication  with  Vi-Penta  Perles  or  Vi-Penta 
Drops.  This  medication  is  suggested  espe- 
cially for  those  who  are  subject  to  recur- 
ring colds  and  other  respiratory  infections. 

Vi-Penta  Perles  are  tiny  gelatin  globules 
containing  exceptionally  high  potencies  of 


the  5  principal  vitamins  —  A,  B1(  B2  (G),  C, 
and  D;  Vi-Penta  Drops  are  a  concentrated 
palatable  solution  of  the  same  5  vitamins  to 
be  added  to  liquid  or  solid  foods.  The  Perles 
are  intended  for  adults  and  older  children, 
the  Drops  for  infants  and  others  who  cannot 
swallow  capsules. 

VI-PENTA  PERLES:  Cartons  of  25  and  100; 
bottles  of  250.  VI-PENTA  DROPS:  Vials  of 
15  and  60  cc  with  calibrated  droppers. 

HOFFMANN-LA    ROCHE   .    INC. 

ROCHE    PARK  •  NUTLEY  •  NEW    JERSEY 


VI-PENTA       PERLES 


VI-PENTA       DROPS 


SOUTHERN   MEDICINE   &■   SURGERY 


February   1941 


Aoal-Sed 

Analgesic,  Antipyretic  and  Sedative 

Each   fl.    oz.   contains: 

Aminopyrine    28  grains 

Caffeine    Hydrobromide    4  grains 

Potassium    Bromide    120  grains 

Adult  Dose 
One  teaspoonful  in  a  little  water. 

How   Supplied 

In  Pints,  Five  Pints  and  Gallons  to  Physicians  and 
Druggists. 


Burwell  &  Dunn  Company 


Manufacturing 
Established 


Pharmacists 
in   1887 


CHARLOTTE,  N.  C. 


Sample   sent   to 


ly    physician    in    the    U.   S.    on 
request 


Capillary   Physiology   and   Fluid   Balance.     The    public   is 
cordially  invited  to  attend. 


RICHMOND  ACADEMY  OF  MEDICINE 
The  following  officers  of  the  Section  on  the  History  of 
Medicine   were   elected  for   the   next  year   at   the   annual 
meeting  of  the  Section  on  February   11th: 
Chairman:    Dr  Marvin  Pierce  Rucker 
Vice-Chairman:   Dr.  William  Lowndes  Peple 
Secretary-Treasurer:   Dr.  Alexander  Stephens  Graham. 
The   Section   held   its   annual    banquet    and   meeting    on 
Tuesday.    February    11th.      Guests    of    honor    were    Drs. 
Andrew  D.   Hart,   Jr.,  Lecturer  on   the  History   of   Med- 
icine  at    the    University    of    Virginia,    and    Reginald   Fitz, 
Lecturer  on  the  History  of  Medicine  at  Harvard  Univer- 
sity. 


Dr.  A.  de  Talma  Valk,  of  Winston-Salem,  is  the  latest 
addition  to  the  Faculty  of  the  Bowman  Gray  School  of 
Medicine  of  Wake  Forest  College.  Dr.  Valk  will  be  Pro- 
fessor of   Chemical  Surgery. 


Dr.  W.  D.  Farmer,  of  Duke,  is  now  with  Dr.  G  .W. 
Banner,  of  Greensboro,  in  practice  in  diseases  of  eye, 
ear,   nose  and  throat. 

Dr.  Farmer  graduated  from  Duke  in  the  class  of  1934 
and  served  as  interne  at  Baltimore  City  hospital  in  1934 
and  1935.  He  was  interne  in  surgery  and  assistant  in 
the  Oto-laryngologic  clinic  at  Duke  1936-39  and  associate 
in  Oto-Iaryngology  since   1939. 


Dr.  Hamilton  W.  McKay,  of  Charlotte,  is  in  Florida 
convalescing  rapidly  from  an  illness  which  confined  him 
to    hospital   for   some   weeks. 


The  alumnae  of  the  Training  School  for  Nurses  of 
the  H.  F.  Long  Hospital,  of  Statesville,  presented  to  the 
hospital  on  December  3rd  a  painting  of  the  founder  of 
the    hospital — the   late    Dr.    Henry    F.    Long. 


Dr.  John  Qulncy  Myers,  of  Charlotte,  who  has  been 
indisposed  for  some  weeks,  is  conalescing  in  the  mountains 
of  the  State. 


Dr.  Monroe  T.  Gilmour  announces  the  opening  of 
offices  for  the  practice  of  internal  medicine  at,  117  West 
Seventh   Street.   Charlotte,  North   Carolina. 


Dr.  G.  W.  Klttscher,  Jr.,  of  Asheville,  underwent  a 
major  surgical  operation  on  February  11th.  Now  he  is 
reported  to  be  making   a  rapid  recovery. 


Dr.  Wlllum  K.  McDowell,  of  Scotland  Neck,  rceently 
elected  health  officer  of  Richmond  County,  has  resigned 
to  accept   the  same  position  in   Edgecombe   County. 


Dr.   L.    C.    Fergus   has    been   elected   health    officer    of 
Brunswick   County,   North   Carolina. 


Mary    Washington    Hospital,    at    Fredericksburg,    Va.. 
has  received  from  an  anonymous  donor  a  gift  of  $20,000. 


Dr.   Irvln   S.   Wright,   of   New   York,  was   guest-speaker 
at   the   meeting   of   the   Guilford   County  Medical   Society 


February    1941 


SOUTHERN  MEDICINE  &  SURGERY 


93 


in  Greensboro  on  the  night  of  January  6.  Dr.  Wright 
discussed  the:  Diagnosis  and  Treatment  of  Obliterative 
Arterial  Disease. 


MARRIED 


Dr.  Herman  Franklin  Eason  and  Miss  Kathryn  Amanda 
Scroggs,  of  Raleigh,  were  married  on  December  21st.  Dr. 
Eason  is  a  member  of  the  medical  staff  of  the  Sanatorium. 


Dr.  Fleming  Fuller,  of  Kinston,  and  Miss  Dorothy 
Barnes,  of  Brenham,  Texas,  were  married  on  December 
21st. 


Dr.  George  B.  F.  Traylor,  of  Lumberton,  North  Caro- 
lina, and  Miss  Leslie  Chappell  Bradshaw,  of  Richmond, 
were   married   on   December  21st. 


Dr.  Robert  Richardson  Eason.  of  Buena  Vista,  and 
Miss  Mabel  Xash,  of  Blackstone,  Yirgina,  were  married 
on    December    21st. 


Dr.  Arthur  George  Kussmann.  of  Ripon,  Wisconsin, 
and  Miss  Louise  Winfree  Scherer,  of  Chesterfield,  Virginia, 
were   married   on   December  21st. 


Dr.  Zachary  Fillmore  and  Miss  Virginia  Fay  Cox,  both 
of   Rockingham,   were   married    on    February    1st. 


Miss   Earline   Mann   and   Dr.    Fitzgerald   Cavedo,   both 
of   Richmond,  February   12th. 

DEATHS 


Dr.  Francis  Lee  Thurman,  Buena  Vista,  Rockbridge  Coun- 
ty, general  practitioner  and  for  years  assistant  surgeon  of 
the  Chesapeake  and  Ohio  Railway,  died  January  19th  at 
the   University   of  Virginia  Hospital. 

Dr.  Thurman  was  an  authority  on  old  families  and 
homes  in  Virginia  and  wrote  for  publication  on  these  sub- 
jects. He  was  an  ardent  sportsman  and  for  some  years 
was  secretary  and  treasurer  of  the  Keswick  Hunt  Club  and 
at  one  time  was  master  of  hounds.  He  was  chairman  of 
the  Buena  Vista  Board  of  Health,  a  charter  member  of 
the  Rockbridge  Historical  Society  and  had  been  president 
of  the  Rockbridge  Medical  Society  and  a  member  of  the 
Citv  Council. 


Dr.  Philemon  H.  Neal,  44,  ear,  nose  and  throat  special- 
ist of  New  York  City,  died  in  Doctor's  Hospital,  New 
York,   following  an   operation   several  weeks  ago. 

Dr.  Neal,  a  native  of  South  Boston,  Va.,  was  a  graduate 
of  Wake  Forest,  and  of  the  Medical  College  of  Virginia, 
Richmond.  He  did  interne  work  in  New  York  City,  later 
the  New  York  Eye  and   Ear  Infirmary. 

Dr.  J.   L.  Neal,  of   Danville,   Va.,  is  a  brother. 


Dr.  A.  B.  McCreary,  45,  State  Health  Officer  of  Florida, 
died  at  a  hospital  January  24th  of  a  heart  aliment.  Dr. 
McCreary  had  held  positions  as  epidemiologist  in  the 
Memphis,  Tenn.,  city  health  department,  assistant  in  public 
health  at  the  University  of  Tennessee,  director  of  the 
bureau  of  epidemiology  for  the  North  Carolina  State 
Board  of  Health,  and  health  officer  of  Northampton  Coun- 
ty, Va. 


Dr.  Charles  Wardell  Stiles,  74,  discoverer  of  hookworm 
as  a  parasite  of  humans,  and  a  recognized  authority  on 
medical  zoology,  died  at  Marine  Hospital,  Baltimore,  Jan. 


Before  solutions  are 
shipped,  their  sterility  and 

non-pyrogenic  qualities  must 
be  proved  by  21  rigid  inspections 
and  tests — chemical,  bacteri- 
ological, and  biological  (with 

laboratory  animals)  requir- 
ing 7  days  to  complete. 

BLOOD  TRANSFUSIONS 


Products  of  BAXTER  LABORATORIES 

Glenview,  111.;  College  Point,  NY.;  Glendale,  Cal.; 

Toronto,  Canada;  London,  England 

Produced  and  distributed  in  the 

Eleven  Western  States  by 

DON  BAXTER,  INC.,  Glendale,  Cal. 

Distributed  East  o/  the  Rockies  by 

AMERICAN  HOSFITAL  SUPPLY 

CHICAGO     CORPORATION     NEW  YORK 


94 


SOUTHERN   MEDICINE   &■   SURGERY 


February    1941 


24th.  For  a  number  of  years  Dr.  Stiles  was  stationed 
at  Wilmington,  and  from  there  cooperated  with  the  State 
Board  of  Health  in  a  campaign  against  hookworm  disease 
in    North    Carolina. 


Dr.  W.  E.  Jennings,  55,  died  unexpectedly  at  his  home 
at  Danville,  Ya.,  January  26th.  He  had  been  out  riding 
and  was  seated  in  a  chair  reading  a  newspaper  when 
overcome    with    a    heart    attack.  


Dr.  James  Marvin  Wells,  of  Middleburg,  N.  C,  died 
January  25th  in  Maria  Parham  hospital.  Henderson,  N.  C. 
Dr.  Wells  had  been  ill  six  weeks.  He  was  65  years  of 
age,   a   native   of   Shelby. 


Dr.  C.  E.  Moore,  86.  died  at  his  home  at  Wilson,  N.  C. 
February  13th.  Dr  K.  C.  Moore,  of  Newton  Grove,  is 
a   surviving  son. 

University   of   Virginia 

The  Phi  Lambda  Kappa  Medical  Fraternity  annual 
undergraduate  award,  a  gold  medal,  for  the  scientific  thesis 
judged  to  be  best  was  won  this  year  by  Leonard  J. 
Yamshon,  a  member  of  the  Third- Year  Class  in  the  De- 
partment of  Medicine.  The  thesis  was  based  on  the  re- 
search done  on  a  presomite  human  embryo  under  the 
direction  of  Dr.  James  E.  Kindred  of  the  School  of  Ana- 
tomy. 

On  January  16th,  Dr.  C.  C.  Speidel  addressed  the 
Harvey  Society  of  New  York  City  on  the  subject,  Adjust- 
ments of  Nerve  Endings. 

Dr.  I.  A.  Bigger,  Professor  of  Surgery  at  the  Medical 
College  of  Virginia,  gave  the  second  Alpha  Omega  Alpha 
Lecture  on  February  7th.  He  spoke  on  Ligation  of  Large 
Arteries. 


Now   EVERY  Doctor  Can 
Fit  a  Pessary 

with  the  use  of  Bach  Pessalator  and  Bach 
Soft  Rubber  Pessary 


Instruction   circular  on   request 


No  complicated  system  of  sizes. 

Easy,  accurate  placement  possible  by  use  of 
Pessalator.  Small  in  size — no  metal  spring  in 
rim  to  frighten  patient  or  to  cause  irritation. 

Pessalator  made  of  special  plastic,  pessary  of 
treated   rubber,   formed  on   precision   molds. 

Price:  Pessalator  and  Pessary  $1.50  each. 
Samples   (limited)    60%  discount. 

Distributed   by 

THE   SANITUBE  COMPANY 

NEWPORT,   R.   I. 


Academy  of  Medicine  on  February  11th,  Dr.  Andrew  D. 
Hart.  Jr.,  gave  one  of  the  Walter  Reed  Lectures.  He  dis- 
cussed Ignorance  and   Medicine. 

On  February  12th,  Dr.  Staige  D.  Blackford  presented 
a  paper  on  Swallowed  Air  before  the  Stuart  Circle  Hospital 
Clinical  Club  in   Richmond. 

On  February  7th.  Dr.  T.  J.  Williams  spoke  before  the 
South  Atlantic  Association  of  Obstetricians  and  Gyneco- 
logists, meeting  in  Jacksonville,  Florida.  His  subject  was 
Sterilization  in  the  Puerperium. 

On  February  11th,  Drs.  E.  P.  Lehman  and  Floyd  Boys 
spoke  before  the  Danville  Academy  of  Medicine  on  the 
subject,   Haparin   and   Peritoneal   Adhesions. 

At  the  meeting  of  the  Historical  Section  of  the  Richmond 


A  SURGEON  EXPLAINS  TO  THE  LAYMAN,  by  M. 
Benmosche,  M.  D.,  with  diagrams  by  Bhola  D.  Panth. 
Simon   &  Sinister,  New  York   C  ty.    1940.   $3.00. 

The  author  believes  that  people  generally  should 
be  told  more,  about  themselves  and  their  ills,  but 
that  they  should  not  be  mistold. 

We  are  informed  whv  the  book  was  written; 
then  about  the  tools  of  surgery,  about  the  removal 
of  the  appendix  and  near-by  organs,  about  tonsil 
and  adenoid  operations,  and  a  lot  of  the  other 
favorites. 

The  statement,  "Two  great  European  surgeons, 
Pare,  in  France,  and  Harvey,  in  England,  did  much 
to  advance  the  knowledge  and  status  of  the  man- 
midwife."  is  not  quite  clear.  The  only  two  Har- 
veys  of  England  of  which  this  reviewer  has  any 
knowledge  are  the  great  William  Harvey,  the  dis- 
coverer of  the  circulation  of  the  blood;  and  one 
Gideon  Harvey  (died  about  1700),  who  called  his 
contemporaries  "dung-doctors  who  drive  out  dis- 
eases through  the  anus."  Both  these  are  classed 
is  physicians  and  the  line  between  physicians  and 
ourgeons  is  sharply  drawn  in  England. 

Then,  Sir  James  Y.  Simpson  is  called  English, 
dthough  Scotland  gave  him  birth  and  he  became 
eminent  in  Edinburgh. 

It  is  said  that  until  1793  not  a  single  caesarean 
ection  had  been  performed  in  which  the  mother 
lived.  Evidently  the  author  places  no  credence  in 
the  oft-told  tale  that  the  Swiss  sow-gelder,  Jacob 
Xeufer,  about  the  year  1500,  so  delivered  his  own 
wife,  and  that  she  survived  to  bear  several  children 
and  died  at  the  age  of  77. 

The  Transactions  of  the  Medical  Association  of 
the  author's  own  State  for  the  year  1892  carry 
an  article  on  the  Achievements  of  American  Sur- 
gery from  which  it  may  be  seen  that  the  South's 
achievements   were   neither   few  nor   insignificant; 


Februarv    1941 


SOUTHERN  MEDICINE  &  SURGERY 


so  Sims  doing  his  great  work  in  Alabama  need 
occasion  no  wonder.  It  comes  to  mind  that  a  Pro- 
fessor of  Medicine  in  a  medical  school  in  New  York 
City  has  resigned  his  chair  in  order  to  accept  the 
same  chair  in  the  Medical  College  of  the  State  of 
South  Carolina — and  it  was  not  between  1860  and 
186S  either. 

Maybe  Julius  Caesar  was  "snatched  living  from 
his  mother's  womb."  The  reference  is  not  cited. 
It  is  generally  agreed  that  his  mother,  Aurelia, 
was  alive  when  her  famous  sen  was  campaigning 
in  Britain.  Certainly  Macduff  shakes  the  courage 
of  Macbeth  by  telling  him — 

"Macduff  was  from  his  mother's  womb 
Untimely  rip'd." 

This  banter  aside,  Dr.  Benmosche  has  written 
a  book  that  doctors  and  discriminating  laymen 
and  lay  women  would  do  well  to  read.  The  author 
has  been  about.  Innately  judgmatical,  his  acquisi- 
tions in  education  have  made  him  knowledgeable. 
From  his  rich  store  of  knowledge  he  has  chosen 
well,  and  all  is  expressed  in  a  pleasing  way. 

Finally,  brethren,  he  says  jinccology:  and  he 
does  not  mar  his  writings  with  ''after  all;"  when 
he  means  that  a  person  or  a  bit  of  work  is  dis- 
tinguished or  famous  he  does  not  say  he  or  it  is 
outstanding;  he  does  not  cystoscope  or  broncho- 
scope or  operate  a  patient. 


PHYSICIAN'S 

REQUIREMENTS 


HOPOUSIA,  or  The  Sexual  and  Economic  Foundations 
of  a  New  Society,  by  J.  D.  Unwdj,  M.  C,  Ph.  D., 
(Cantab),  Late  (1914)  Classical  Exhibitioner,  Oriel  Col- 
lege, Oxford  and  (1928-1931)  Fellow  Commoner.  Research 
Student,  Peterhouse,  Cambridge;  with  an  introduction  by 
Aldous  Huxley;  Preface  by  Y.  J.  Lubbock.  Oscar  Piest, 
250   West    57th    St.,    New   York    City.    1940.    $4.00. 

The  title  is  derived  from  the  Greek  word  mean- 
ing where.  Aldous  Huxley  regards  the  book  as 
valuable,  but  incomplete.  The  author  says  the 
reformer  merely  patches  the  social  system,  and 
eventually  the  patches  fall  apart.  The  author  re- 
gards society,  not  as  a  collection  of  individuals, 
but  as  a  network  of  human  groups.  He  says  that 
often  the  rationalist  is  not  the  scientist's  friend, 
that  the  illusion  of  progress  has  arisen  because, 
in  whatever  direction  a  society  travels,  it  thinks 
it  is  advancing.  After  careful  investigation  he  says 
that  expansive  energy  has  never  been  displayed  by 
a  society  that  inherited  a  modified  monogamy  or 
a  form  of  poylygamy.  Since  the  Norman  Con- 
quest the  period  in  which  any  clan  or  class  has 
dominated   has   been   five   generations,    150   years. 

Such  intensely  practical  matters  as  wants,  cur- 
rency, money,  and  commodity  exchange  are  in- 
quired into.  The  history  of  coinage  debasement 
is  recited,  and  the  evolution  of  banks  and  banking. 
The  Hypousians  will  not  have  a  commodity-cur- 


EYE.  EAR,  NOSE  and  throat  instruments.  Suction  and 
pressure  pumps.  Physicians'  equipment.  Cabinets.  Oper- 
ating tables.  Examining  chairs.  Sphygmomanometers. 
Trial  lenses.  New-Used.  HARRY  WREGG,  INC.  384 
Second  Ave.,  New  York  City. 

KARA'S  NEW  OTOSCOPE— Finest  in  quality.  Excep- 
t.onal  low  cost:  complete  with  3  specula  and  medium  bat- 
tery: handle  and  extra  lamp  in  modern  walnut  case.  Ask 
your  dealer  or  write  to  KARA  SURGICAL  SUPPLY  CO. 
5  E.  Gun  Hill  Rd„  New  York  City. 

USED  MEDICAL  HOSPITAL  AND  LABORATORY 
equipment  bought  and  sold;  estates  purchased:  sterilizers, 
microscopes,  lamps,  cystoscopes,  etc;.,  always  on  hand. 
Harry  Wells,  304  E.  S9th  St.  New  York  City. 

SULFOR-ALBA— A  strictly  ethical  product  for  the  con- 
trol of  acne,  acne  rosacea  and  similar  skin  affections.  1 
lb.  jar  for  $3.00  Professional  supply  for  clinical  test  sent 
on  request  to  physicians.  ALBOLAC  COMPANY,  Room 
1208  at  333  West  52nd  Street,  New  York  City. 

LUBRHGAINE— Anesthetic  Jelly  Water-Soluble,  Non- 
Toxic,  Non-Irritating.  A  valuable  aid  for  the  painless 
examination  of  mucous  membranes.  Marked  surface  an- 
esthesia develops  within  one  minute.  For  use  in  Rectum, 
Urethra,  Ear,  Nose,  Throat.  Sample  to  Physicians. 
AKATOS,  INC.,  55   Van  Dam  Street,  New  York  City. 

PLASTICO  MOULAGE  MATERIALS— Posmoulage  and 
p.ocess  accurately  reproduces  animate  and  inanimate  ob- 
jects. Simple  technic.  Moderate  cost.  Write  for  cata- 
logue PM  510.  WARREN-KNIGHT  CO.,  136  N.  12th 
Street,  Philadelphia,  Pa. 

SILICA  GEL  FILTER— Gives  a  good  smoke  plus  low 
cost  protection  against  nicotine  and  tar.  SMOKE  THE 
HEALTHY  WAY.  Sample  to  physicians,  no  obligation. 
CIGARETTE  Filter  Mfg.,  Co.,  Akron,  Ohio. 

COLLECT  YOUR  OWN  BILLS  —  An  up-to-date 
method  of  collecting  delinquent  bills.  Not  a  harsh  dun- 
ning method.  Debtor  remits  directly  to  you.  Sample 
book  on  request.  Total  cost  $1.00  only  if  you  decide  to 
keep  it.  Send  no  money.  Medical  Statistics  125  W.  40th 
Street,   New   York,   N.   Y. 

"GONOCOCCAL  INFECTION  IN  THE  MALE"  by 
A.  L.  Wolbarst,  M.  D.,  Fellow,  American  Urological  As- 
sociation; Second  edition,  completely  revised  and  enlarged. 
140  illustrations.  7  colored  plates.  Published  at  $5.50  by 
C.  V.  Mosby  Co.;  remainder  copies  at  $1.00  each  while 
they  last.  Send  no  money.  Pay  Postman  on  delivery. 
MEDICAL  BOOKS,  ROOM  1808,  at  1440  Broadway, 
New  York  City. 

ARE  YOU  VISITING  NEW  YORK  CITY?  If  so  stop 
at  the  Hotel  Park  Chambers.  Modern,  yet  retaining  the 
old  fashioned  hospitality  of  yesterday's  inns.  5  minutes 
from  Radio  City;  One  block  from  Central  Park.  Lux- 
uiious  rooms  from  $3.  single,  $4.  double,  suites  from  $7; 
Excellent  Food.  May  we  send  you  a  Guide-Map  of 
New  York  City?  A.  D'Arcy,  Manager.  HOTEL  PARK 
CHAMBERS.     68  West   58th   Street,  New  York  City. 


96 


SOUTHERN   MEDICINE   &■   SURGERY 


February   1941 


rencv.  nor  a  metal-currency.  Cheque  -  currency, 
with  tokens  for  very  small  transactions,  is  the 
currency  for  them. 

A  chapter  goes  into  details  as  to  four  methods 
of  commodity  exchange:  another  as  to  the  four 
follies:  another  subdivides  the  Hvpousian  struc- 
ture— provides  among  many  provisions  for  radical 
alterations  in  our  educational  plan,  and  for  alpha 
and  beta  marriages,  the  latter  a  sort  of  trial-and- 
error  arrangement. 

The  book  will  stimulate  thought.  Our  present 
system  is  not  so  good  that  we  can  close  our  minds 
to  radical  propositions   fcr  change. 


HYDROCEPHALUS:  Its  Symptomatology.  Pathology. 
Pathogenesis  and  Treatment,  by  Otto  Marburg,  M.  D  - 
Oskar  Piest,  250  West  57th  St.,  New  York  City.  1940. 
S3 .00. 

Few  of  us  would  have  thought  of  hydrocephalus 
as  a  disease  holding  the  key  position  in  the  solu- 
tion of  many  fundamental  problems  in  neurology. 
Yet  such  is  the  postulate,  and  a  fair  case  is  made 
out.  The  condition  is  said  to  be  more  prevalent 
now  than  formerly,  and  never  due  to  excessive 
secretion.  Trauma  is  given  as  an  important  cause. 
The  diagnosis  is  based  on  ventriculography  or  en- 
cephalography. 

Diuretics,  thyroid  extracts,  iodine  have  benefit- 
ted. Salt  and  sugar  solutions  hold  more  promise. 
X-ray  treatment  is  not  properly  appreciated.  Spinal 
puncture  is  of  value  in  h.  communicans  only. 

The  author  believes  that  hydrocephalus  is  pro- 
duced  by  a   disturbance  in   water  metabolism. 


CLINICAL  PELLAGRA,  by  Seale  Harris,  M.  D.. 
Professor  Emeritus  of  Medicine,  University  of  Alabama. 
Birmingham,  ass'sted  by  Seale  Harris,  Jr.,  M.  D..  For- 
merly Assistant  Professor  of  Medicine,  Yanderbilt  Univer- 
sity. Nashville:  with  a  foreword  by  E.  V.  McCollum, 
Ph.   D„   Sc.   D.  LL.   D..  Professor  of   Biochemistry.   School 


of  Hygiene  and  Public  Health,  The  Johns  Hopkins  Univer- 
sity, Baltimore.  Illustrated.  The  C.  V.  Mosby  Company, 
St.   Louis.    1941.   S7.00. 

Dr  Harris  has  been  a  close  student  of  pellagra 
for  the  duration  of  its  recognition  in  this  country. 
He  has  made  many  contributions  to  our  knowledge 
of  the  disease.  His  teachings  have  contributed 
largely  to  the  present  concept  of  the  condition  as 
one  of  protean  manifestations,  each  case  requiring 
individual  study  and  management.  His  book  should 
be  in  the  hands  and  eyes  of  every  medical  practi- 
tioner in  the  South,  and  it  would  enable  doctors 
all  over  the  Nation  to  recognize  a  lot  of  cases  they 
?re  misdiagnosing. 


A?  -EYILLE'S   BEGINNING   AS  A  HEALTH  RESORT 

(Reprint    from    Charlotte    Med.    Jour.,    1906) 
(G.    S.    Tranent,    Asheville,    in    Bui.    Bunc.    Co.    Med.   Soc,   Feb.) 

A  region  a  few  miles  beyond  the  present  compass  of 
the  county  was  known  as  a  health  resort  some  years 
before  its  settlement  by  the  whites.  The  Warm  Spring 
on  the  French  Broad  had  been  discovered  in  1778  by- 
Henry  Reynolds  and  Thomas  Morgan,  two  men  kept  out 
:n  advance  of  settlements  (in  Tennessee)  to  watch  the 
movements  of  the  Indians.  They  had  followed  some  stolen 
horses  to  the  point  opposite,  and  waded  the  river.  On 
the  southern  shore,  in  passing  through  a  little  branch 
hey  were  surprised  to  find  the  water  warm.  The  next 
year  the  Warm  Springs  were   resorted  to   by  invalids. 

The  first  consumptive  to  visit  Asheville,  so  far  as  we 
'.:now,  was  Dr.  Hardy,  who  came  in  1821.  He  was  cured, 
at   least   he  lived   here  in  good   health   for  61   years. 

About  1827  Judge  King,  of  Charleston,  and  Mister 
Charles  Baring,  of  the  well  known  firm  of  Baring  Brothers, 
then  living  in  Charleston,  came  to  Asheville  to  plant  a 
little  colony  of  summer  refugees,  driven  annually  by  the 
heat  and  fevers  from  the  south.  Meeting  with  opposition, 
they  bought  the  land  now  comprising  the  Flat  Rock  settle- 
ment. 

The  town,  however,  continued  to  be  visited  by  invalids, 
many  of  whom  were  consumptives,  off  and  on  till  1870 
when  the  publication  of  a  pamphlet  drew  wider  attention 
to  it.  This  pamphlet,  bore  the  following  title:  "Western 
North  Carolina,  its  Agricultural  resources.  Mineral  wealth. 


WAHL  AUTOMATIC  ELECTRIC  SHUT-OFF  TIMER 

For  AC  or  DC  operation — any  voltag: — Can   be  supplied   in   these   ranges: - 
1   to  60  seconds:    1  to  60  min;    1  to  5  hrs. 

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such  as  Violet  and  Sun  Ray  lamps.  Heating  pads. 
Diathermy  and  Physical  Therapy  machines  and 
other  Laboratory  apparatus. 

In  photography  for  controlling  Enlargers  In 
the  home  for  Oil  Burners.  Washing  machines,  Fans, 
Reading  lamps  etc. 

Simple   to   operate  —  Inexpensive 
Write  for  descriptive  circular. 

WAHL  ELECTRIC  COMPANY 


814  Broadway 


New  York,  N.  Y. 


February    1941 


SOUTHERN  MEDICINE  &  SURGERY 


CLINICAL  ABSTRACTS 

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CLINICAL    ABSTRACTS 

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Climate.  Salubriety  and  Scenery.  By  H.  P.  Gatchell, 
M.  D..  etc.  Published  by  E.  j.  Aston,  Esq.,  Asheville, 
Buncombe  County,  North  Carolina."  The  author  treats 
of  the  climatic  advantages  with  a  degree  of  moderation 
and  accuracy  that  could  have  been  copied  to  advantage 
by  many  succeeding  writers.  He  states  that  in  1S70  there 
were  many  people  living  in  Asheville  at  an  advanced  age 
who  had  "come  there  as  invalids  early  in  life  in  the  hope 
of   being  able  to   prolong   a  little   their  stay   on   earth." 

The  writer,  who  was  a  professor  in  Hahnneman  College, 
Chicago,  for  some  years,  conducted  at  Forest  Hill  the 
first    sanitarium    for    consumptives   ever    attempted   here. 

The    following   pamphlets   were   circulated    a   little   later: 

"Life  in  North  Carolina."  a  reprint  from  the  London 
Daily  News,  August   8,   1874. 

"Western  North  Carolina."  by  Beale  and  Martin,  Ashe- 
ville. 1875. 

"Western  North  Carolina  as  a  Health  Resort,"  by  Dr. 
J.  W.  Gleitsmann,  reprinted  from  Philadelphia  Medical 
and    Surgical    Reporter,    February,    1876. 

"Biennial  Report  of  the  Mountain  Sanitarium  for  Pul- 
monary   Disease,    1877." 

"The  American  Mountain  Sanitarium  at  Asheville,"  by 
Stanford  E.  Chaille.  New  Orleans  Medical  &■  Surgical 
Journal,   April.    1878. 

"The  Land  of  the  Sky.  Nature's  Trundle  Bed  of  Recup- 
eration," by  "Guy  Cyril,"  (Hinton  R.  Helper),  about 
1880. 

Several  of  these  to  the  number  of  64,000  were  circulated 
by    Dr.    Gleitsmann,   a    German   by   birth,    a   graduate    of 


the  University  of  Wurzburg,  who  came  here  from  Balti- 
more in  1875  after  hunting  through  the  Virginia  mountains 
for  a  suitable  location.  On  June  1st,  1875,  he  opened 
the  Mountain  Sanitarium  for  Pulmonary  Diseases  at  the 
old  Carolina  House  which  stood  opposite  to  the  Sluder 
p'ace  on  North  Main  Street.  Here  he  treated  on  an 
average  of  twenty  to  twenty-five  patients  daily  for  five 
years,  practically  all  of  them  coming  from  a  distance; 
in  the  winter  from  the  north  and  in  the  summer  from 
the  south.  Dr.  Gleitsmann  states  that  of  all  this  number 
there  were  not  more  than  a  dozen  lung  patients  from  the 
town  or  immediate  vicinity.  During  the  sixth  and  last 
year  of  his  stay  he  treated  his  patients  at  the  Eagle 
Hotel. 

He  gives  as  his  reason  for  throwing  up  the  work  and 
leaving  Asheville,  failure  to  obtain  a  suitable  house  wherein 
to  ca-ry  on  the  work.  It  may  be  presumed  that  had  more 
enterpri  ing  citizens  realized  the  immense  results  to  accrue 
from  Dr.  Gleitsmann's  advertising,  the  difficulty  would 
have  been  overcome,  and  the  Woodfin  House  which  the 
doctor  desired  for  a  sanitarium  would  have  been  obtained 
for  him.  Dr.  Gleitsmann  probably  did  more  than  anv 
other  man  to  bring  this  place  into  notoriety,  for  since 
his   time   the   stream   of   I  ravel   has  been   continuous. 


Female  patients  with  upper  right  abdominal  pain  sug- 
gestive of  sallbladder  diseases,  "colitis"  or  pleurisy  may  be 
suffering  from  gonorrheal  perihepatitis.  The  symptoms  may 
be  acute  or  chronic  with  formation  of  violin-string  adhe- 
sins. — A.  P.   Hudgins. 


PROFESSIONAL   CARDS 


February    1941 


GENERAL 


Nails  Clinic    Building 


THE  NALLE  CLINIC 

Telephone — 3-2141    (//  no  answer,  call  3-2621) 


412   North    Church    Street,   Charlotte 


General  Surgery 

BRODIE  C.  NALLE,  M.D. 
Gynecology  &  Obstetrics.. 
EDWARD    R.    HIPP,   M.D. 

Traumatic   Surgery 

PRESTON   NOWLIN,   M.D. 

Urology 


Consulting   Staff 

DRS.    LAFFERTY,   BAXTER   &   PARSONS 
Radiology 
BARRET   LABORATORY 
Pathology 


General   Medicine 


LUCIUS   G.   GAGE,   M.D. 

Diagnosis 


LUTHER   W.   KELLY,   M.D. 
Cardio-Resptratory   Diseases 


J.  R.  ADAMS,  M.D. 
Diseases  of  Infants  &  Children 


VV.  B.  MAYER,  M.  D. 
Dermatology  &  Syphilology 


C— H— M   MEDICAL   OFFICES 

DIA  GNOSIS— SURGER  Y 

WADE    CLINIC 

X-RAY— RADIUM 

Wade  Building 

Dr. 

G   Carlyle  Cooke — Abdominal  Surgery 
&  Gynecology 

Hot   Springs  National   Park,   Arkansas 

Dr. 

Geo.  W.  Holmes — Orthopedics 

H  King  Wade,  M.  D.                             Urology 

Dr. 

C.  H.  McCants — General  Surgery 

Charles  S.  Moss,  M.D.            General  Surgerv 

222 

226  Nissen  Bid.                    Winston-Salem 

Jack  Ellis,  M.D.                     General  Medicine 

Frank  M.  Adams,  M.D.         General  Medicine 

N.  B.  Burch,  M.D.  Eye,  Ear,  Nose  &  Throat 

Raymond  C  Turk,  D.D.S.       Denial  Surgery 

A.  W.  Scheer                           X-ray  Technician 

Etta  Wade                              Clinical  Pathology 

Marjorie  Wade                                 Bacteriology 

INTERNAL  MEDICINE 


ARCHIE   A.    BARRON,   M.  D.,   F.  A.  C.P. 
INTERNAL    MEDICINE— NEUROLOGY 

Professional   Bldg.  Charlotte 


JOHN  DONNELLY,  M.  D. 

DISEASES  OF  THE  LUNGS 

524'/-2  N.  Tryon  St.  Charlotte 


CLYDE    M.    GILMOixE,    A.  B.,    M.D. 
CARDIOLOGY— INTERNAL    MEDICINE 
Dixie  Building  Greensboro 


JAMES   M.  NORTHINGTON,  M.D. 
INTERNAL    MEDICINE— GERIATRICS 
Medical   Building  Charlotte 


ORTHOPEDICS 


HERBERT   F.   MUNT,   M.D. 

ACCIDENT  SURGERY  &  ORTHOPEDICS 

FRACTURES 

Nissen   Building  Winston-Salem, 


ALONZO    MYERS,    M.  D.,    F.A.C.S. 

ORTHOPEDIC  SURGERY  and 

FRACTURES 

Professional   Bldg.  Charlotte 


February   1941 


PROFESSIONAL   CARDS 


NEUROLOGY  and  PSYCHIATRY 


J.  FRED  MERRITT,  M.  D. 

NERVOUS  and  MILD  MENTAL 

DISEASES 

ALCOHOL  and  DRUG  ADDICTIONS 

Glenwood   Park   Sanitarium  Greensboro 


EYE,  EAR,  NOSE  AND  THROAT 


H.  C.  NEBLETT,  M.  D. 

OCULIST 

Phone  3-5852 

Professional  Bldg.  Charlotte 


AMZI  J.  ELLINGTON,  M.D. 

DISEASES  of  the 
EYE,  EAR,  NOSE  and  THROAT 

Phones:  Office  992— Residence  761 

Burlington  North   Carolina 


UROLOGY,   DERMATOLOGY   and   PROCTOLOGY 


THE  CROWELL   CLINIC   of   UROLOGY   and   UROLOGICAL   SURGERY 
Hours-Nine  to  Five  TeIephones-3-7101-3-7102 

STAFF 

Andrew  J.  Croweix,  M.D. 

(1911-1938) 

Angus  M.  McDonald,  M.  D.  Claude  B.  Squires   M  D 

Suite  700-711  Professional  Building  Charlotte 


Dr.  Hamilton  W.  McKay 


Dr.  Robert  W.  McKay 


DOCTORS  McKAY  and  McKAY 

Practice  Limited  to  UROLOGY  and  GENITO-URINARY  SURGERY 

Hours  by  Appointment 

Occupying  2nd  Flood  Medical  Arts  Bldg.  Charlotte 


Raymond  Thompson,  M.D.,  F.  A.  C.  S.  Walter  E-  Daniel?  A  B]  M  D 

THE  THOMPSON  -  DANIEL  CLINIC 
of 
UROLOGY  &  UROLOGICAL  SURGERY 
Fifth  Floor  Professional  Bldg. 


Charlotte 


C.  C.  MASSEY,  M.D. 

PRACTICE  LIMITED 
TO 

DISEASES   OF    THE   RECTUM 

Professional  Bldg.  Charlotte 


L.  D.  McPHAIL,  M.  D. 
RECTAL  DISEASES 


Professional   Bldg. 


Charlotte 


WYETT   F.   SIMPSON,   M.D. 

GENITO-URINARY    DISEASES 

Phone   1234 


Hot  Springs  National  Park 


Arkansas 


PROFESSIONAL   CARDS 


February    1941 


SURGERY 


R.   S.   ANDERSON,   M.  D. 

GENERAL  SURGERY 

144  Coast  Line  Street  Rocky  Mount 


W.   S.  CORNELL,  M.  D. 

GENERAL  SURGERY 

Phone   S876 

117    West    7th   St.  Charlotte 


R.    B.    DAVIS,    M.D.,    M.  M.  S.,    F.A.C.P. 
GENERAL  SURGERY 

AND 

RADIUM    THERAPY 

Hours  by  Appointment 

Piedmont-Memorial  Hosp.  Greensboro, 


WILLIAM    FRANCIS    MARTIN.    M.D. 
GENERAL  SURGERY 

Professional    Bldg.  Charlotte 


OBSTETRICS  &  GYNECOLOGY 


IVAN   M.  PROCTER,  M.  D. 

OBSTETRICS   &    GYNECOLOGY 

133   Fayetteville   Street  Raleigh 


SPECIAL   NOTICES 


THE  EDITING  OF  MEDICAL  PAPERS 

This  journal  has  arranged  to  meet  the  demand  for  the  service  of  editing  and  revis- 
ing papers  on  medicine,  surgery  and  related  subjects,  for  publication  or  preseniation 
to  societies.  This  service  is  rendered  on  terms  comparing  favorably  with  those  pre- 
vailing generally  in  other  Sections  of  the  Country. 

SOUTHERN  MEDICINE  &  SURGERY. 


REPRESENTATION  WANTED 
LEADING  MANUFACTURER  of  Physical   Therapy   Equipment  has  a   few 
territories  for  reliable  dealers.    Write  giving  full  details  to  '•Physical  Therapy"  c/o 
Southern  Medicine  &  Surgery,  Charlotte,  N.  C. 


THE  JOURNAL  OF 
SOUTHERN  MEDICINE  AND  SURGERY 

306  North  Tryon  Street,  Charlotte,  N.  C. 

The  Journal  assumes  no  responsibility  for  the  authenticity  of  opinion  or  statements  made  by  authors  or  in  communica- 
tions submitted  to   this  Journal  for  publication. 


JAMES   M.   NORTHLNGTON,   M.  D.,   Editor 


CHARLOTTE.  N.  C.  MARCH,   1941 


Some  Problems  and  Progress  in  Medicine 

Charles  J.  Andrews,  M.  D.,  Norfolk 


THE  Tri-State  Medical  Association  is  not 
now,  nor  has  it  ever  been,  a  society  of  spe- 
cialists. But  it  is  concerned  with  all  spe- 
cialties and  every  agency  which  has  prospect  of 
curing  or  preventing  illness  or  of  relieving  suffering 
from  human  ills.  At  various  times  the  programs 
of  this  Association,  discussions  and  papers  publish- 
ed in  its  Journal,  have  contributed  much  to  the 
accomplishment  of  these  objectives. 

It  is  my  purpose  at  this  time  to  call  attention  to 
some  of  the  problems  which  confront  the  medical 
profession  today  and  which  demand  a  solution.  In 
examining  the  list  of  previous  presidential  addresses 
before  the  Association,  I  find  many  interesting  and 
useful  subjects  such  as  cancer,  heart  disease,  the 
art  of  medicine  and  many  others,  but  no  word  of 
obstetrics.  I  offer  this  as  one  reason  if  I  give  spe- 
cial consideration  to  this  subject. 

A  study  of  statistics  is  always  discouraging,  par- 
ticularly so  when  we  find  that  the  Carolinas  and 
Virginia  are  in  a  high  obstetric  mortality  area, 
along  with  many  other  Southern  States.  This  is  no 
doubt  governed  to  some  extent  by  a  high  percent- 
age of  negroes  and  whites  in  a  very  low  income 
group.  It  is  interesting  to  note  that  one-half  the 
babies  born  in  the  United  States  are  born  of  fam- 
ilies on  relief  or  with  incomes  under  $1,000  annu- 
ally. We  are  repeatedly  asked  by  lay  organizations 
and  magazine  writers  why  the  obstetric  mortality 
rate  is  higher  in  this  country  than  in  most  other 

*To    the    Tri-State    Medical    Association    meeting    at    Greensboro, 


countries  for  which  we  have  records.  We  have 
found  a  way  of  answering  this  so  far  as  the  State 
of  Virginia  is  concerned. 

The  Maternal  Health  Committee  of  the  Medi- 
cal Society  of  Virginia  has  undertaken  to  study  the 
records  of  all  maternal  deaths  occurring  in  the 
State.  The  records  are  obtained  by  the  State 
Health  Department  by  a  painstaking  investigation 
of  every  case  including  the  hospital  records,  the 
physicians'  records,  if  any,  and  facts  as  furnished 
by  attending  physicians,  and  even  statements  of 
the  family  or  midwife.  In  some  cases  insufficient 
data  are  obtained  for  accurate  conclusion,  but  in 
many  it  is  only  too  obvious.  This  study  began 
with  deaths  occurring  after  December  1st,  1939. 
The  cases  studied  so  far  number  175,  and  the  list 
for  the  year  of  1940  is  not  complete. 

Poverty,  ignorance,  lack  of  cooperation  on  the 
part  of  the  victims  or  their  families  is  in  evidence. 
In  some  cases  no  medical  care  was  available.  Many 
of  these  cases  show  need  so  severe  that  it  exposes 
us  to  the  threat  of  state  medicine.  When  we  ap- 
proach the  medical  side  of  this,  we  recognize  our 
old  enemies — eclampsia,  sepsis,  hemorrhage  and 
obstetric  accidents.  Abortions  are  included  and 
contribute  liberally  to  deaths  from  hemorrhage  and 
sepsis.  The  percentages  from  each  of  the  main 
causes  are  approximately  the  same  as  have  been 
credited  to  them  before  by  other  studies,  except  for 
a  slightly  higher  proportion  from  toxemia.  Forty- 
February   24th-25th. 


PROBLEMS  &  PROGRESS — Andrews 


March   1941 


nine  in  this  group  died  of  toxemia,  and  90  per  cent 
of  these  had  no  prenatal  care. 

A  place  in  the  Hall  of  Fame  awaits  the  man 
who  discovers  the  cause  of  eclampsia;  but  enough 
is  now  known  to  practically  eliminate  it  if  this 
knowledge  can  be  made  available  in  every  case. 
Prenatal  care  is  the  most  important  single  factor. 
Ninety-three  Prenatal  Clinics  have  been  organized 
in  the  state  under  the  supervision  of  the  State 
Department  of  Health  and  these  are  beginning  to 
do  a  successful  work.  This  is  an  important  step; 
but  much  more  than  Prenatal  Clinics  is  needed. 
It  is  easy  to  criticize  after  the  case  has  ended 
fatally  but  more  difficult  to  accurately  evaluate 
the  factors. 

In  86  of  these  cases  there  is  reasonable  suspicion 
that  death  resulted  from  error  on  the  part  of  the 
attending  doctor,  and  in  most  of  these  the  error 
was  one  about  which  there  is  little  disagreement 
among  doctors.  All  these  errors  have  not  occurred 
in  the  homes  where  suitable  facilities  for  treatment 
were  not  available,  but  in  hospitals  where  these 
could  be  obtained.  Failure  to  studv  the  case  and 
to  plan  for  labor  and  the  type  of  delivery  led  to 
disaster;  failure  to  prepare  for  blood  transfusion 
in  the  treatment  of  placenta  praevia  and  hemor- 
rhage was  a  frequent  cause  of  death.  Cesarean 
section  in  some  cases  was  obviously  inadvisable. 
Pituitrin  in  the  second  stage  of  labor  continues  to 
claim  its  victims. 

Sulfanilamide  is  undoubtedly  saving  lives  in 
many  cases  of  infection:  but.  in  spite  of  its  use. 
49  of  the  175  deaths  were  due  to  sepsis.  Twenty- 
three  of  these  were  septic  abortions  mostly  self 
or  criminally  induced.  Occasionally  sepsis  followed 
normal  labor:  but  most  such  cases  had  been  pre- 
ceded by  difficult,  prolonged  labor,  particularly 
when  accompanied  bv  evcessive  hemorrhage.  Sul- 
fanilamide cannot  vet  be  substituted  for  good 
obstetrics  in  the  prevention  of  death  bv  sepsis. 

These  studies,  if  used  onlv  as  a  basis  for  adverse 
criticism,  would  not  be  helpful:  but  if  thev  cause 
us  to  recognize  our  mistakes  as  well  as  those  of 
others  they  should  prove  of  constructive  value. 
Someone  has  said  that  50  vears  nf  experience  may 
mean  making  the  same  mistakes  for  50  years.  The 
mistakes  have  to  be  recognized  as  such  before  thev 
can  be  corrected.  We  are  encouraged  bv  the  fact 
that  the  efforts  alreadv  made  are  reducing  the 
disasters  each  year.  The  mortality  rate  in  Vir- 
ginia has  been  reduced  from  7.2  per  1000  live 
births  in  1930  to  5.1  in  1039.  The  corresponding 
figures  in  the  whole  United  States  show  a  reduc- 
tion from  6.7  to  4.4  (1038).  The  states  of  North 
and  South  Carolina  are  doing  active  work  in  this 
direction   with   similar   results.      Further  progress 


will  depend  upon  funds  from  the  taxpayers'  money, 
wisely  and  efficiently  administered  by  public  offi- 
cials in  close  association  with  organized  medicine. 
It  will  also  depend  upon  education  and  reeducation 
of  ourselves  through  medical  association  activities 
and  other  means,  and  finally  the  individual  doc- 
tor's response  to  these  efforts. 

The  problem  of  contraception  is  closely  asso- 
ciated with  the  misfortunes  of  obstetrics.  The 
whole  movement  has  been  under  shadow.  Lay 
groups  attempted  to  teach  and  force  the  issue. 
They  have  recognized  the  error  of  their  way  and 
have  turned  to  the  medical  profession  for  leader- 
ship and  direction.  In  some  states,  such  as  North 
Carolina,  this  movement  is  now  under  the  wing 
of  the  State  Department  of  Health.  There  can  be 
no  doubt  that  conception  is  contraindicated  in  a 
considerable  number  of  cases,  some  temporarily 
and  some  permanently.  It  is  necessary  for  us  to 
face  the  facts.  Unfortunately,  those  who  need 
contraception  most — the  ignorant  and  the  careless 
and  the  subnormal — are  for  obvious  reasons  least 
successful  with  it.  Sterilization,  as  one  answer  to 
this  need,  is  on  the  increase.  In  the  criminal  and 
mentally  deficient,  this  may  be  done  by  process 
of  law,  but  in  other  suitable  cases  it  is  offered  and 
accepted  as  a  relief  from  disability  or  as  a  life- 
saving  measure.  Since  the  methods  have  been 
simplified  and  used  as  a  post-partum  procedure, 
it  is  made  more  practically  available.  Dr.  J.  R. 
McCord  expresses  the  belief  that  this  is  one  of  the 
principal  answers  to  the  obstetric  problem. 

Appendicitis  has  long  been  a  close  rival  of  child- 
birth as  a  cause  of  death,  with  approximately  the 
same  number  dving  each  vear  from  each  of  the  two 
causes.  The  consistent  rise  in  the  mortality  rates 
from  appendicitis  from  1900  to  1930  occasioned 
much  comment  and  concern.  During  this  period, 
the  deaths  from  appendicitis  nearly  doubled.  While 
there  were  certain  offsets  to  these  figures,  such  as 
a  more  correct  diagnosis  occasioned  by  more  gen- 
eral hospitalization,  still  the  situation  was  far  from 
satisfactory.  It  is  welcome  news  when  we  hear 
that  from  1930  to  1937  the  death  rate  from  ap- 
pendicitis shows  a  decrease  of  28  per  cent,  and 
there  is  evidence  that  this  decrease  continues  to 
ihe  present.  Most  of  these  deaths  are  preventable, 
vet  there  is  much  comfort  in  the  knowledge  that 
progress  is  being  made.  Here,  as  in  other  condi- 
tions, the  result  often  lies  in  the  hands  of  the 
people  themselves  or  the  doctor  who  sees  the 
patient  first.  The  continued  and  repeated  adver- 
tisement of  life-saving  facts  to  both  of  those  groups 
is  no  doubt  a  factor  in  the  improvement. 

Cancer  is  still  a  maior  problem.  There  were 
149,214  deaths  in  the  United  States  in  1938  from 


PROBLEMS   &  PROGRESS— Andrews 


this  cause.  Of  the  2.157  in  the  state  of  Virginia, 
360  were  cancer  of  the  pelvic  organs  and  206  were 
breast  cancers.  We  know  the  fact  is  that  early 
diagnosis  is  essential  to  cure.  A  considerable  pro- 
portion can  be  prevented  by  treating  socalled  pre- 
cancerous conditions.  If  treated  early,  a  high 
percentage  may  be  cured  by  means  now  available. 
The  recognition  of  wellknown  early  symptoms  is 
important,  but  it  is  necessary  to  do  more  than  this. 
Periodic  examinations  are  necessary  for  early  diag- 
nosis as  the  case  is  often  advanced  before  symp- 
toms appear.  This  has  been  stressed  repeatedly 
with  little  effect  by  the  American  Society  for 
Control  of  Cancer  and  many  other  organizations. 
Apparently  it  remained  for  women  to  do  this 
themselves.  The  Woman's  Field  Army  within 
five  years  has  been  organized  in  every  state  in 
the  Union  for  this  purpose,  and  they  appear  to 
be  making  a  good  job  of  it;  but  it  is  still  the 
problem  of  the  medical  profession,  as  individuals 
and  as  a  whole. 

Venereal  disease  control  is  a  colossal  undertak- 
ing of  Public  Health  organizations;  State,  City 
and  County  Medical  Societies;  Foundations  and 
philanthropic  individuals.  In  syphilis,  an  era  of 
real  progress  began  in  1935  with  Surgeon-General 
Thomas  Parran's  campaign  to  stamp  it  out.  He 
got  the  problem  presented  in  magazines  and  news- 
papers. Public  opinion  saw  for  the  first  time  that 
there  was  a  problem,  faced  it  squarely,  and  slowly 
started  to  work.  In  five  years,  there  developed 
active  and  effective  clinics  in  all  cities  and  many 
small  towns  and  villages.  Epidemiologists  in  syphi- 
lis, working  with  health  departments,  concentrated 
on  finding  the  early  cases  and  making  them  non- 
infectious. Industry  and  employers  generally  recog- 
nized the  importance  of  requiring  blood  tests.  This 
requirement  has  first  informed  many  victims  of 
their  need  for  treatment.  Approximately  half  of 
our  states  now  have  laws  requiring  examination 
before  marriage.  Such  development  of  clinics, 
requirements  of  industry  and  legislation  represent 
real  progress  in  our  never-ending  fight  for  health. 

The  fight  against  tuberculosis  has  been  most 
spectacularlv  successful.  It  has  been  moved  from 
first  place  as  a  cause  of  death  to  a  very  respectable 
distance.  These  improvements  have  resulted,  no 
doubt,  from  a  tremendous  and  sustained  advertis- 
ing campaign  and  a  widespread  realization  of  its 
terrible  devastations:  together  with  the  conviction 
among  both  the  people  and  the  profession  that 
something  could  be  done  about  it.  Tt  is  undoubt- 
ed^ nnc  of  the  most  expensive  conditions  to  treat 
that  is  known,  but  this  obstacle  is  being  overcome 
by  the  appeal  of  the  movement. 


These  are  only  a  few  of  the  many  problems 
confronting  the  medical  profession,  the  solution  of 
which  is  so  obviously  necessary  to  the  life,  health 
and  happiness  of  the  people  as  a  whole.  While 
progress  is  being  made  with  these,  we  have  at 
times  been  attacked  from  within  by  antagonistic 
legislative  efforts.  The  Wagner  Bill,  for  instance, 
while  it  had  some  good  intentions,  was  recognized 
as  an  instrument  which  would  be  a  serious  handi- 
cap to  the  accomplishment  of  these  objectives, 
This,  or  any  other  legislation  which  would  tend 
to  take  the  leadership  in  medical  matters  from 
the  medical  man  and  place  it  with  laymen  would 
be  destructive,  and  the  profession  will  continue 
to  oppose  it. 

At  the  present  time,  we,  along  with  the  rest 
of  mankind,  find  ourselves  faced  with  conditions 
which  are  unknown  and  unpredictable.  The  exi- 
gencies of  war  have  always  been  the  allies  of  dis- 
ease and  death.  It  is  not  difficult  to  foresee  that 
the  burdens  of  the  medical  profession  will  be  great 
and  progress  may  be  slow;  but,  as  in  all  times 
past,  the  doctor  will  continue  to  carry  on. 


LOCAL   REST  AS   A   THERAPEUTIC   AID 

(S.    S.    Povlin,    New   York    City,    in    Clin.    Med.) 

Galen  said  "pain  is  useless  to  the  pained."  Except  as 
a   warning  this  is  true. 

The  ointment  known  as  nupercainal  contains  1%  nu- 
percaine  base  and  gives  sustained  anesthesia  of  abrasions 
of  skin  or  mucous  membranes,  prompt  and  lasting  relief 
from  pain  and  itching. 

Nupercainal,  applied  to  relieve  the  pain,  allows  the  for- 
mation of  healthy  granulation  tissue  and  quick  healing. 
Rapid  healing  of  fissures  in  the  breasts  of  nursing  women 
has  been  obtained. 

In  cases  of  pruritus  ani  and  vulvae,  in  ulcers,  burns, 
and  the  like,  I  have  found  it  satisfactory  as  a  dressing 
following  the  suturing  of  wounds.  Its  prolonged  anes- 
thetic properties  render  it  ideal  in  this  type  of  work. 
It  would  appear  that  healing  is  accelerated  by  the  physi- 
ologic rest  thus  provided. 


MANAGEMENT  OF   CHRONIC   ASTHMA 

(R.    M.    Balyeat,    Oklahoma    City,    in   Southwestern   Med.,   Jan.) 

In  the  average  case  epinephrine  is  the  most  efficacious 
and  the  least  harmful  remery.  The  value  of  iodized  oil 
should  not  be  forgotten.  In  a  small  percentage  of  cases 
aspirin  is  of  value.  The  use  of  aminophyllin,  ether  in 
oil  per  rectum,  in  glucose  or  sucrose  intravenously,  or 
a  combination  of  all  three,  is  life-saving  in  some  cases. 
In  the  majority  of  cases  of  chronic  asthma  and  bron- 
chiectasis   morphine    is    contraindicated. 

In  the  treatment  of  the  chronic  asthmatic  desensitiz- 
ation  should  be  done. 

In  some  cases  of  chronic  asthma,  especially  those  com- 
plicated with  chronic  bronchitis,  or  bronchiectasis,  or 
chronic  sinusitis,  deep  x-ray  therapy  over  the  chest  and 
sinuses  is  worth   while. 

Most  chronic  asthmatics  have  a  dual  etiology;  sensi- 
tization and  mechanical  factors,  therefore,  in  outlining 
successful  treatment  both  factors  must  be  given  careful 
consideration. 


SOUTHERN  MEDICINE  &  SURGERY 


The  Organization  and  Service  of  Hospital  Unit  O  and 
Base  Hospital  No.  65 

Addison  G.  Brenizer,  M.  D.,  Charlotte,  North  Carolina 

IN    COLLABORATION    WITH 

Frederic  M.  Hanes,  M.  D.,  Durham,  North  Carolina 


THE  people  who  stayed  at  home  during  the 
World  War  No.  1  have  wondered  at  and 
given  expression  to  the  fact  that  the  men 
returning  from  war  had  so  little  to  say  about  it. 

While  it  is  true  that  ponderous  events  and  ex- 
periences immediately  affect  one  with  such  emotion 
that  he  does  not  care  to  repeat  them  even  i  n 
thought,  and  only  time  makes  a  recitation  of  the 
events  tolerable.  There  were  other  reasons  why 
the  men  had  so  little  to  say:  men,  who  were  active 
during  the  war,  were  so  concentrated  on  their  par- 
ticular task  that  they  neither  had  the  time  nor 
the  vision  to  look  around  and  see  the  war  maneu- 
vers in  other  parts  or  as  a  whole. 

This  was  so  true  during  the  very  active  period 
at  Base  6,  Talence,  France,  that  Major  Richard 
Cabot  saw  fit  to  inform  us,  and  we  were  all  well 
instructed  by  his  weekly  lectures,  and  charts,  show- 
ing us  what  was  going  on. 

The  casualties  arriving  at  Base  6  by  the  thous- 
and knew  very  little  about  the  war,  except  the 
very  small  area  over  which  they  passed,  before 
they  were  wounded.  In  fact,  in  the  excitement 
of  noise  and  activity  of  war,  a  great  many  did 
not  even  know  when  they  were  wounded. 

The  dough-boys  did  not  realize  that  thev  were 
the  only  soldiers  in  France  who  yelled  like  wild 
Indians — or  as  they  would  have  done  at  a  foot- 
ball game,  as  they  ran  forward  to  meet  the  enemy, 
nor  did  they  realize  that  in  their  excitement  of 
pushing  forward  that  they  would  throw  away  their 
pup-tents,  their  overcoats  and  even  their  rifles — 
their  rifles — their  only  excuse  for  being  there! 

The  first  recovered  casualties  did  see  something 
of  France,  but  later,  it  was  necessary  to  picket 
the  walls  of  the  hospital  grounds  night  and  day 
and  have  the  "shack-rousting  squad"  ever  vigilant 
to  prevent  an  overfilling  of  the  veneral  wards. 
There  were  wounded  men  who  reached  the  base 
hospital,  recovered,  and  returned  to  distribution 
centers,  without  having  seen  more  of  France  than 
their  immediate  surroundings. 

War  does  not  make  men  better,  it  makes  them 
worse.  The  extravagance  of  war,  the  recklessness  of 
it,  the  concentration  of  men  without  their  women, 
the  shifting,  temporary  residence  away  from  home, 
all  tend  to  favor  that  feeling  of  uncertain  restless- 
ness.    One   might   think,   before   he  analysed   the 


psvchology  of  this  situation,  that  a  man  who  had 
been  wounded  once  or  twice  and  was  again  about 
to  go  back  to  the  front  to  be  wounded  again  or 
be  killed,  would  begin  to  reconstruct  his  morals. 
Not  at  all.  His  bent  is  in  but  one  direction:  a 
fling  before  he  goes. 

Again,  we  have  just  learned  that  the  conscripted 
men  are  arriving  at  camp  in  various  stages  of  in- 
toxication, as  if  they  were  having  their  last  chance 
at  a  drink.  Unfortunately,  this  will  not  be  their 
last.  And  there  will  always  be  Bacchus  and  Venus 
to  serve  them. 

Phillip  Gibbs  wrote  a  book:  "Now  It  Can  Be 
Told."  He  didn't  tell  so  much — one  would  not 
dare  tell  it  all! 

I  am  npw  breaking  through  the  reticence  or 
modesty,  or  whatever  it  was,  that  has  bedumbed 
the  recounting  of  experiences  during  the  war  with 
a  brief  history  of  Hospital  Unit  O  and  Base  Hos- 
pital No.  65.  Their  stories  have  been  inadequately 
told. 

Those  of  us  who  took  part  in  World  War  No.  1, 
the  war  to  make  the  world  safe  for  democracy, 
thought  that  it  would,  at  least,  be  the  last  war. 
With  the  League  of  Nations  about  to  police  the 
world,  the  world  in  debt,  mostly  to  the  United 
States,  with  the  feeling  everywhere  by  everybody 
of  everything  lost  and  nothing  gained,  how  could 
we  think  that  any  one  who  had  sense  enough  to 
run  a  nation  could  allow  his  nation  to  go  to  war 
again?  How  could  we  think  that  there  could  be 
ten  other  little  wars  and  the  grand  finale  of  a 
second  World  War? 

We  had  felt  that  if  they  gave  another  war  and 
did  not  invite  us,  we  certainly  would  not  get  very 
mad  about  it! 

Perhaps  the  buck-private  in  the  army  of  occu- 
pation was  right,  when  asked  how  long  he  expected 
to  be  over:  "Until  the  end  of  the  peace,"  was  his 
reply. 

Those  of  us  who  have  seen  the  March  of  Time's: 
'The  Ramparts  We  Watch,"  find  it  stangely  remi- 
niscent of  1916  and  1917  and  decidedly  nostalgic 
of  those  days  just  before  we  entered  the  war.  Our 
feelings  were  aroused  to  a  white-heat  over  the  mere 
mention  of  the  cloven-foot  Hun,  the  Boche,  die 
Schwein-hunde  and  the  reported  German  atrocities. 
Our  feelings  must  have  been  somewhat  those  of 


March  1941 


HOSPITAL  UNIT  O  &  B.  B.  65—Brenizer  &  Hanes 


10S 


the  Crusaders  of  old;  certainly  the  feelings  of  the 
doctor  were  that  if  the  men  could  fight  it  out,  little 
else  could  we  do  than  look  after  their  health  and 
tend  their  wounds. 

Just  at  this  point  should  be  cited,  when  reduced 
to  simples  for  better  understanding,  the  greatest 
example  of  man's  insanity  in  allowing  to  take  place 
one  of  the  most  preposterous  situations  one  could 
possibly  imagine:  two  men  seeking  to  destroy  each 
other  by  bullet,  bayonet,  fire  or  gas,  and  back  of 
each  is  the  doctor,  ready  to  repair  the  damage  and 
restore  to  fighting  capacity  not  only  once  but  any 
number  of  times.  We  have  seen  the  same  men 
repaired  twice  and  sent  back  to  the  lines,  to  be 
finally  killed  outright.  And  for  those  who  are 
interested  in  the  cost:  during  the  last  war  it  cost 
S25.000  to  kill  a  man. 

What  can  be  wrong  with  the  mind  of  man  to 
allow  him  to  be  led  up  to  and  again  take  part  in 
such  a  catastrope!  And  this  is  man's  own  doings 
through  his  own  free  will,  wherin  he  is  showing 
himself,  again  and  again,  incapable  of  right  think- 
ing, or  an  equal-mindedness  and  control  of  his 
feelings  in  proper  relation  to  his  fellow  beings.  He 
cannot,  alone,  take  care  of  himself,  but  with  the 
very  products  of  his  genius  and  inventiveness  seeks 
to  destroy  himself  along  with  his  possessions. 

Is  there  an  answer;  is  there  a  solution?  Likely 
but  one:  the  application  of  true  Christianity.  Man 
must  have  Divine  guidance  and  a  Savior  of  him- 
self and  his  fellow-men.  But,  then,  that  would  be 
the  beginning  of  the  Kingdom  of  Heaven  on  earth 
— yes,  perhaps  it  would! 

At  this  time  of  the  year,  24  years  ago,  as  now, 
we  had  not  declared  war  on  Germany:  and  Presi- 
dent Wilson,  as  he  had  done  during  his  first  term, 
and  now  President  Roosevelt  during  his  third  termi 
was  going  to  keep  us  out  of  war. 

We  were  going  to  be  kept  out  of  war;  but  al- 
ready men  were  fighting  with  the  allied  troops,  doc- 
tors, the  Red  Cross,  ambulances  and  hospital  sec- 
tions were  already  being  sent  over,  as  now,  on  their 
missions  of  mercy. 

Questionnaires,  as  now  again,  had  been  filled  out 
■  doctors  all  over  our  country;  and  some  of  us 
had  already  received  letters  from  Colonel  Tefferson 
R-  Kean,  then  of  the  Red  Cross,  Drs.  Jno.  M.  T. 
Finney  and  Joseph  C.  Bloodgood.  who  were  pros- 
pecting and  inquiring,  only  tentatively:  "if  we 
should  so  to  war  (not  that  we  are  going,  but  only 
in  ca=e)  would  vou  be  available?" 
■When  I  speak  for  myself.  T  speak  for  most  of 
the  doctor,.  This  was  a  difficult  question  for  many 
of  us  to  answer.  I,  for  example,  was  running  a 
private  hospital,  where  I  had  staked  my  all  to  rent 
improve  and  purchase.    I  had  been  married  a  few 


years  and  a  son  had  been  born  to  us  only  a  year 
before.  Yet,  there  was  but  one  answer  to  the  in- 
quiry, and  that  was  a  positive  yes. 

HOSPITAL  UNIT  O 

There  was  a  latent  period  of  silence,  longer  than 
now,  then,  all  of  a  sudden,  after  a  chain  of  events 
with  which  most  of  you  here  are  familiar,  war  was 
declared  on  April  4th,  1917.  Three  weeks  after 
the  declaration  of  war,  the  following  telegram  was 
received  by  Dr.  Addison  G.  Brenizer  from  the  Sur- 
geon General's  office. 

"Assemble  and  enlist,  without  delay,  the  per- 
sonnel of  Hospital  Unit  0  to  embark  for  France  by 

June  12th,  1917 " 

I  visited  the  Surgeon  General's  office  to  find  out 
what  this  really  meant  and  was  told  that  Hospital 
Unit  O  and  two  other  such  units  were  to  be  mobil- 
ized to  substitute  for  French  military  hospital  units 
exhausted  of  personnel  and  supplies. 

The  news  was  startling,  since  I  had  thought  that 
my  acceptance  was  contingent  upon  our  entrance 
into  the  war  and  that  these  hospital  units  would 
move  with  our  troops.  Nevertheless,  we  were  com- 
mitted to  war  and  we  would  be  ready  when  called. 
"Both  the  French  and  British  missions,  under 
M.  Viviani  and  Mr.  Balfour,  respectively,  then  in 
our  country,  were  keen  to  have  American  recruits 
to  fill  up  the  ranks  of  their  armies"  (Pershing). 

"They  were  asking  for  one  division  to  stimulate 
French  morale 50,000  trained  men  for  rail- 
way service  and  to  work  in  shops  and  medical 
units"  (Pershing). 

General  Pershing  sailed  for  Europe  on  the  Baltic 
on  May  28th,  and  after  traversing  England,  landed 
at  Boulogne  June  13th. 

The  personnel  of  Hospital  Unit  0  was  fully  or- 
ganized by  June  12th. 

^  My  hospital  was  about  to  be  closed,  and  its  fur- 
nishings and  equipment  sold  at  one-fifth  of  their 
cost  and  the  structural  improvements  were  given 
to  the  owner  in  compensation  for  taking  the  build- 
ing off  my  hands. 

I  again  visited  the  Surgeon  General's  office  the 
last  of  June,  and  found  out  that  the  order  of  April 
27th  had  been  rescinded  on  the  advice  of  General 
Pershing,  then  in  France. 

As  already  stated,  three  weeks  after  war  was 
declared,  the  organization  of  Hospital  Unit  O  be- 
gan at  Charlotte,  on  the  appointment  by  Col.  Jef- 
ferson R.  Kean.  M.C..  U.S.A..  on  recommendations 
of  Drs.  Finney  and  Bloodo-ood.  of  Dr.  Addison  G. 
Brrni>er  as  commander  of  the  unit.  By  June  12th 
the  unit  was  fully  organized  and  recognized  by  the 
War  Department  as  Hospital  Unit  O. 

We  were  not  hurried  away  to  France. 


106 


HOSPITAL  UNIT  0  &  B.  H.  65— Brenizer  &  Hanes 


A  month  later  the  doctors  were  made  officers  of 
the  United  States  Army;  the  nurses  and  enlisted 
men  were  not  mentioned. 

Receiving  a  commission  is  a  grand  thing  in  it- 
self: receiving  a  commission  with  right  to  serve 
and  receive  pay,  that  is  with  all  appurtenances,  is  a 
quite  different  thing.  We  had  the  commissions  to 
be  sure,  as  attested  by  a  great  scroll  of  parchment 
which  said  as  much,  and  then.  too.  we  had  accepted 
it  for  what  it  was  worth.  Moreover,  as  evidence  of 
good  faith  on  our  part,  we  had  sworn  away  our 
young  lives  and  promised  to  stick  it  out  to  "the  end 
of  the  emergency"  or  to  a  time,  a  verv  indefinite 
time,  determined  by  the  "discretion  of  the  Presi- 
dent." 

We  knew  also  by  these  signs  that  we  had  rank: 
and  some  of  us  even  had  clothes  to  display  it:  but 
we  couldn't  wear  them. 

There  was  much  talk  and  a  unanimous  vote  of 
the  officers  of  this  organization  (we  had  onlv 
twelve  officers  among  an  even  dozen  allotted  to  the 
unit,  who  really  felt  their  respective  responsibility 
for  the  command)  was  that  I  go  to  Washington 
and  find  out  "where  we  stood"  and  if  the  War  De- 
partment still  recognized  our  existence.  This  was 
the  first  of  August. 

An  officer  in  the  S.  G.  O.  did  not  want  to  give 
out  anything  officially:  but  he  would  tell  me  un- 
officially that  if  he  were  I  he  would  close  his  hos- 
pital, and  call  on  his  gang,  because  the  first  three 
units  organized  were  to  be  sent  immediately  over- 
seas and  that  Unit  O  was  one  of  the  first  ready.  T 
thought  I  might  not  be  presuming  too  much  if  T 
took  this  suggestion  as  an  innuendo. 

Whereupon,  I  returned  home,  gave  out  the  news 
to  the  members  of  the  unit  and  consequentlv  to  the 
town  as  confidential,  but  real  stuff.  I  tried  on  my 
uniform  and  closed  mv  hospital. 

It  was  then,  during  July  and  August.  1917.  that 
we  actually  returned  to  nothingness.  We  were 
neither  doctors  nor  officers.  We  were  merely  "Unit 
O."  The  public  had  considered  us  as  gone,  and 
gone  we  felt:  but  we  had  no  place  to  go.  Our 
usually  indulgent  patients  didn't  want  us  and  the 
army  would  not  take  us  on  it  seemed. 

Once  more  our  officers  met  and  this  time  de- 
cided we  were  everything  implied  bv  three  blazen 
letters  S.  O.  L..  a  term  well  known  in  the  army, 
meaning  simply  "stranded  or  left."  with,  perhaps  a 
connotation  as  well  as  a  denotation.  We  decided, 
all  of  us,  that  I  again  go  to  Washington,  but  not 
alone  and  without  witnesses. 

One  of  the  officials  in  the  S.  G.  0.  didn't  know 
"when  in  the  hell"  wre  were  going,  but  assured  us 
if  we  were  rearing  for  service  he  could  send  the 
officers  to  camp.    He  also  suggested  that,  since  we 


were  in  the  army,  a  little  military  training  might 
not  be  inappropriate.  It  did  seem  reasonable.  He 
then  actuallv  gave  us  our  choice  and  left  it  with 
us  as  to  where  we  would  go.  We  decided,  most 
naturally,  that  we  would  all  like  to  go  together  to 
Oglethorpe. 

It  was  in  this  way  that,  on  September  15th,  one 
of  us  was  ordered  to  New  York,  another  to  Ver- 
mont, another  to  Georgia,  two  others  to  Pennsylva- 
nia and  the  rest  to  Tennessee.  Would  we  ever  come 
together  again? 

Left  behind  were  our  twenty-one  nurses  and 
fifty  enlisted  men,  restlessly  awaiting  instructions 
while  thev  tried  to  carry  on  their  usual  pursuits  as 
lawyers,  druggists,  bookkeepers,  stenographers, 
nurses,  etc.  The  stenographers  might  have  served 
me  well  in  answering  the  correspondence  from 
these  people  and  their  families. 

Then  came  a  series  of  significant  orders: 
The  first  order  was  received  October  15th,  while 
taking  a  course  in  the  Carrell-Dakin  method  of 
treating  wounds.  "Major  Addison  G.  Brenizer, 
M.R.C..  is  directed  upon  completion  of  his  course 
at  Rockefeller  Institute  for  Medical  Research, 
New  York  City,  to  report  in  person  to  Major 
Fred  H.  Albee,  Post  Graduate  Hospital,  New  York, 
for  a  course  of  instruction  in  orthopedic  work,  and 
upon  completion  of  this  duty  to  proceed  to  Fort 
Oglethorpe,  Georgia." 

Then.  November  8th:  "Major  Addison  G.  Bre- 
nizer. M.R.C..  is  relieved  from  his  present  duties 
at  Fort  Oglethorpe  and  will  proceed  to  Charlotte, 
for  the  purpose  of  mobilizing  Hospital  Unit  O." 

The  same  date  under  separate  orders  the  follow- 
ing officers  were  ordered  to  Fort  McPherson.  Ga.: 
Captains  James  P.  Matheson.  William  Allan, 
Robert  F.  Leinbach,  Hamilton  W.  McKay  and  W 
Myers  Hunter  from  Charlotte;  Captain  Robert  H. 
Crawford,  from  Rock  Hill,  S.  C:  Captain  Henry 
G.  Turner,  from  Raleigh:  Captain  Marion  H. 
Wyman,  from  Columbia,  S.  C;  1st.  Lieut.  Archie  A. 
Barron,  from  Charlotte:  1st  Lieuts.  Charles  I.  Al- 
len and  Jas.  M.  Davis,  from  Wadesboro. 

All  these  officers  were  promoted  to  a  higher 
grade  before  the  completion  of  their  duties  except 
Captain  Crawford,  who  voluntarily  left  the  army 
on  a  Red  Cross  commission  to  Macedonia,  with 
Captain  Paul  D.  White,  now  a  great  Boston  heart 
specialist. 

November  10th  under  War  Department  author- 
ity. November  3rd — "The  following  enlisted  per- 
sonnel of  Hospital  Unit  O.  Charlotte,  North  Caro- 1 
lina.  are  ordered  to  active  duty,  and  who  are  this 
date  transferred  to  the  Medical  Department,  Na- 
tional Army,  will,  upon  completion  of  mobilization, 
under   command   of   Major   Addison   G.    Brenizer, 


HOSPITAL  UNIT  0  &  B.  H.  65—Brenizer  &  Hanes 


M.R.C.,  proceed  without  delay  to  Fort  McPherson, 
Georgia,  for  the  purpose  of  training  and  equipping 
command  prior  to  duty  overseas." 

Then  followed  the  names: 

J.  W.  Sanford,  J.  B.  Pharr,  C.  B.  King,  Jr.,  John 
F.  Durham,  A.  P.  DuLong,  A.  Irvin  Henderson, 
Alfred  S.  Reilly,  E.  S.  Reid,  Jr.,  F.  H.  Medlock, 
Jr.,  B.  H.  Webster,  W.  J.  Brown,  E.  P.  Andrews, 
C.  F.  Brown,  R.  H.  Harding,  J.  E.  Corpening,  W. 
F.  Robertson,  J.  F.  Swing,  J.  L.  McAden,  W.  A. 
Davis,  J.  C.  Moose,  B.  H.  McGinnis— Charlotte ; 
D.H.Terrell,  Jacksonville:  T.J.Covington,  Wades- 
boro:  R.  M.  Miller,  Louisville:  D.  A.  Tompkins, 
Edgefield;  E.  D.  and  A.  B.  Taylor,  Winston;  C. 
Howell,  Cherryville;  J.  T.  McCrorey,  C.  L.  White- 
side. A.  L.  Young,  Paul  G.  Anderson,  Rock  Hill, 
S.  C;  Thomas  C.  Abernathy,  C.  B.  Crowell,  J. 
Frank  Love,  Lincolnton;  Fred  Johnson,  H.  S.  Cald- 
well, W.  M.  Gibson,  Davidson;  John  M.  Barringer, 
O.  M.  Marvin,  Statesville:  John  H.  Wilson,  Phil- 
adelphia; R.  T.  B.  Little,  Gibson,  X.  C;  Thomas 
L.  Taliaferro,  W.  M.  Osborne,  New  York;  W.  H. ' 
Branson.  Lexington,  Ky.;  J.  Foy  George,  Fort 
Worth,  Texas;  H.  L.  Everett,  Laurinburg;  Fred 
Field,  Mooresville;  Charles  Glasgow,  Lexington, 
Ya.;  Joseph  L.  McKnight,  Orrville,  Ala.;  Norman 
W.  Lynch,  Bessemer  City. 

'•Under  the  above  authority  the  following  named 
female  nurses  are  ordered  to  active  duty  and  upon 
completion  of  mobilization  will,  without  delay,  pro- 
ceed to  Ellis  Island,  N.  Y..  for  training  and  proper 
equipment." 

Then  followed  the  names: 

Mrs.  A.  W.  Allen  and  Misses  Margaret  White, 
Catherine  A.  Beard,  Julia  Colson,  Cora  L.  Dearmon, 
Josephine  Watts,  Katherine  Osborne,  Elma  Jones, 
Elizabeth  Lowe,  Elizabeth  Hill,  Edna  M.  Hill,  J. 
M.  Alderidge,  Lula  Lambeth,  Macie  Stanford,  Sue 
J.  Moore,  Blanch  Leonard,  Bess  Swearingan,  Rose 
A.  Downey,  Charlotte;  Sarah  M.  Harris,  Concord; 
Gertrude  Shepard,  Atlanta;  Harriett  L.  McCoy, 
Spartanburg,  S.  C. 

Five  of  our  men  were  lost  to  the  unit  at  Fort 
McPherson.  Dr.  C.  L.  Whiteside,  dentist  from 
Rock  Hill,  after  a  spell  in  the  hospital  with  fever 
and  heart  trouble,  was  allowed  to  go  home  on  a 
furlough  prior  to  his  discharge  and  there  he  died 
suddenly  of  endocarditis.  Caldwell  Howell,  of 
Cherryville,  was  left  behind  with  meningitis,  later 
recovered  almost  completely,  but  did  not  continue 
in  the  service.  Dr.  B.  H.  Webster,  dentist,  was 
transferred  to  the  dental  corps.  John  Wilson  and 
E.  S.  Reid,  Jr.,  were  transferred  to  the  aviation 
corps.  With  the  exception  of  attacks  of  pneumonia 
passed  through  by  Major  R.  F.  Leinbach,  Priva'e 
William    J.    Brown; and   Nurse   Sarah   M.   Harris' 


neck  being  cut  by  a  negro  patient  in  delirium,  there 
was  no  serious  sickness  nor  mishap  to  any  one  in 
the  unit  during  the  services  of  twenty-one  months 
in  this  country  and  in  France. 

'Cording  to  orders,  I  saw  the  nurses  off  from 
Charlotte  to  New  York  early  in  the  evening  of 
November  15th  and  escorted  the  men  over  a  night's 
ride  to  Atlanta,  over  beyond  which  city  lay  Fort 
McPherson.  With  fifty  men  dressed  in  civies,  we 
detrained  at  the  station  in  Atlanta,  made  our  way 
in  a  body  led  by  myself  to  the  first  street  car 
pointing  in  the  direction  of  the  Fort.  The  street 
urchins  were  very  annoying,  wanting  to  carry  pos- 
ters and  graft  free  tickets  to  the  minstrel  show. 
The  street  car  dumped  us  before  the  gate  of  Fort 
Mack,  as  the  conductor  pointed  it  out  to  us.  We 
entered  the  walls  of  that  ancient  fortification  to 
stand  a  siege  for  three  months.  Confined  to  camp, 
more  or  less,  we  spent  the  time  from  November, 
1917,  to  February,  1918,  with  many  false  alarms 
as  to  our  leaving  and  repeatedly  warned  to  be 
ready  to  depart  for  duty  overseas. 

On  February  4th  the  "confidential  order"  came, 
ordering  Units  B,  H,  0  and  R,  under  the  com- 
mand of  Major  Addison  G.  Brenizer,  to  Camp 
Merritt,  New  Jersey.  This  was  a  "secret  move- 
ment of  troops,"  known  to  all  our  friends  up  in 
North  Carolina,  who  met  us  at  the  stations  as  we 
passed  through  the  State. 

Just  at  this  point  of  our  chronology,  the  Char- 
lotte Chapter  of  the  Red  Cross  sent  a  fund  of 
$5,000  to  Unit  O.  This  fund  was  used  and  replaced 
frequently  when  the  Quartermaster  was  not  work- 
ing. The  large  part  of  it  was  regathered  from  the 
Quarter  Master  and  $4600  returned  to  Henry 
McAden,  then  Chairman  of  the  local  chapter  of  the 
Red  Cross.  It  was  the  sole  means  of  feeding  the  men 
from  supplies  gathered  from  the  French  on  the 
three  days'  passage  from  Le  Havre  to  Bordeaux. 

Our  stay  at  Camp  Merritt  was  short.  On  Feb- 
ruary 16th,  amid  clamor  and  confusion,  we  left  at 
6  a.  m.  for  Pier  56,  North  River,  New  York,  and 
arrived  there  about  8  o'clock.  One  of  our  officers 
was  left  sleeping  at  Camp  Merritt  and  only  arrived 
to  join  us  after  traversing  New  York  in  a  "flivver" 
and  arriving  at  the  pier  just  as  the  boat  was  raising 
its  gangway. 

Our  boat  was  the  Cunard  liner  Carmania,  which 
had  already  received  19  shots  when  she  sank  the 
German  El  Trafalgar,  a  pirate  ship,  near  Trinidad. 
We  were  sailing  at  a  bad  season  and  just  after  the 
sinking  of  the  Tuscania,  sister  ship  of  the  Carma- 
nia. It  was  very  cold.  At  Halifax  the  land  was 
covered  with  snow,  the  water  thick  with  blocks  of 
ice.  There  we  left  behind  Capt.  R.  F.  Leinbach, 
ill  of  pneumonia,  and  came  near  losing  Charles  S. 


HOSPITAL  UNIT  O  &  B.  B.  65—Brenizer  &  Banes 


March  1941 


Brown,  who,  returning  from  accompanying  Capt. 
Leinbach  to  shore,  was  barely  able  to  leap  from 
the  top  of  the  tug  on  to  our  ship,  as  she  was  mak- 
ing rapidly  out  to  sea. 

We  were  seventeen  days  on  the  water,  arriving 
at  Liverpool  March  4th.  Then  to  Southampton 
and  across  the  Channel  to  Le  Havre  and  on  to 
Talence,  near  Bordeaux,  arriving  March  16th. 

After  six  weeks  of  travel,  with  short  intermis- 
sions at  so-called  rest  camps,  and  ending  the  final 
lap  with  a  three-days-and-three-nights  trip  on  a 
troop  train,  we  were  delighted  to  come  to  a  halt. 

Capt.  Leinbach  joined  the  unit  several  months 
later.  At  Southampton,  where  the  streets  were  kept 
dark,  no  lights  were  allowed  on  automobiles  and 
the  rule  is  to  turn  to  the  left,  two  of  our  officers 
were  run  over  by  an  automobile  and  painfully 
injured.  Perhaps  our  most  exciting  adventure  was 
our  stopping  at  midnight  in  the  middle  of  the  Eng- 
lish Channel  following  an  explosion,  which  proved 
to  be  the  engines  out  of  order;  and  here  we  waited 
for  two  hours  under  such  encouraging  admonitions 
from  the  encircling  torpedo  boat  as,  "If  you  loiter 
around  here  much  longer  you'll  get  a  torpedo 
through  you!" 

We  shall  never  forget  the  day:  Immediately 
after  the  arrival  at  Base  6  that  wonderful  lunch  of 
beef,  pommes  frites,  white  bread,  fromage,  con- 
fiture and  chocolade,  the  first  bath  and  clean-up 
followed  by  a  dance  that  night.  North  Carolina's 
reception  at  the  hands  of  Boston  was  all  we  could 
wish,  and  before  our  final  parting,  after  the  war, 
many  warm  friendships  had  been  developed  be- 
tween us. 

Unit  O  was  merged  with  the  Massachusetts  Gen- 
eral Hospital  Unit  and,  with  the  addition  of  casual 
officers,  nurses  and  orderlies,  formed  the  largest 
single  Base  Hospital  in  France — No.  6  located  near 
Bordeaux  on  the  line  between  the  18  miles  of 
American  docks  and  the  whole  Southern  Sector 
and  formed  a  hospital  of  5,000  beds — 3,800  surgi- 
cal and  1,200  medical. 

The  personnel  of  Unit  O  was  distributed  over 
the  surgical  and  medical  services  of  the  hospital. 
Major  Richard  Cabot  of  Boston  was  placed  in 
charge  of  the  medical,  Major  Addison  G.  Brenizer 
in  charge  of  the  surgical,  service. 

Base  6  (Mass.  General  Hospital  and  Hospital 
Unit  O)  sent  several  teams  to  the  front;  particu- 
larly active  at  the  front  were  Major  R.  F.  Lein- 
bach and  Capt.  Robert  H.  Crawford.  Capt.  Craw- 
ford had  already  been  over  with  a  Red  Cross  hos- 
pital before  we  entered  the  war,  and  after  the 
armistice  went  with  Dr.  Paul  D.  White  to  Greece. 

Base  6  also  staffed  preoperative  trains  to  aid  by 
blood    transfusion,    operations   when   necessary   en 


route  to  bring  the  wounded  in  better  condition  to 
Base  6. 

At  one  time  before  July  18th,  1918,  the  whole 
personnel  of  Hospital  Unit  O  was  about  to  be 
placed  in  charge  of  one  of  the  four  mobile  hospi- 
tals at  the  extreme  front.  This  transfer  had  been 
arranged  with  Lieut.  Col.  Geo.  W.  Brewer.  Drs. 
Flint,  St.  John  and  Crile  were  directing  the  other 
three  mobile  Units,  and  it  was  arranged  between 
Drs.  Brewer  and  Brenizer  for  Dr.  Brenizer  to  re- 
place Dr.  Brewer.  This  arrangement  was  inter- 
rupted by  Major  Gen.  Shaw,  who  retained  Dr. 
Brenizer  and  Hospital  Unit  O  at  Base  6. 

BASE  HOSPITAL  No.  65 
The  original  officer  personnel  of  Base  Hospital 
No.  65  was  as  follows: 

Lieut.  Col.  John  W.  Long  and  Lieuts.  Edward 

C.  Ashby,  Louis  G.  Beall  and  Capt.  H.  H.  Ogburn 
from  Greensboro;  Major  Frederic  M.  Hanes  and 
1st  Lieut.  S.  W.  Hurdle  from  Winston-Salem;  Ma- 
jor Marshall  H.  Fletcher,  Capt.  A.  T.  Pritchard 
and  1st  Lieut.  Lewie  M.  Griffith  from  Asheville; 
Capt.  James  B.  Bullitt  from  Chapel  Hill;  Capt. 
Sidney  D.  Foster  from  Toledo;  Capt.  John  C.  Mc- 
Nair  from  Mississippi;  Capt.  (D.  C.)  Henry  O. 
Lineberger  from  Raleigh;  Capt.  Harry  S.  Noble 
from  St.  Marys,  Ohio;  Capt.  James  M.  Northing- 
ton  from  Minneapolis,  Univ.  of  Minn.;  Capt.  (D. 
C.)  George  K.  Patterson,  1st  Lieut.  John  E.  Wine 
and  1st  Lieut.  James  T.  Robertson  from  Wilming- 
ton; Capt.  Jacob  H.  Shuford  from  Hickory;  Capt. 
Alfred  R.  Warner  from  New  York;   1st  Lieut.  Don 

D.  Brooks  from  Connelsville,  Pa.;  1st  Lieuts. 
Hugh  E.  Clark  and  Alvin  C.  McCall  from  Rocky 
Mount;  1st  Lieut.  Milton  T.  Edgerton,  Jr.,  from 
Greenville;  1st  Lieut.  Amzi  J.  Ellington  from  Ral- 
eigh; 1st  Lieut.  Edward  J.  Engberg  from  St.  Paul, 
Univ.  of  Minn.;  1st  Lieut.  Henry  J.  Gallagher  from 
Boston;  1st  Lieut.  (S.  C.)  Harold  H.  Hultgren 
from  Minneapolis;  1st  Lieut.  Mose  M.  Hyman 
from  Detroit;  1st  Lieut.  Herbert  F.  Hunt  from 
Boardman;  1st  Lieuts.  Thomas  M.  Stanton  and 
Frederick  R.  Taylor  from  High  Point;  1st  Lieut. 
Samuel  B.  Sturgis  from  Lenoir,  and  2nd  Lieut. 
(Q.M.C.)   Charles  A.  Johnson  from  Florida. 

Most  of  the  enlisted  personnel  of  Base  Hospital 
No.  65  was  ordered  mobilized  at  Fort  McPherson 
in  March,  1918,  and  Major  F.  M.  Hanes  was  or- 
dered there  and  assumed  command  of  the  organi- 
zation. For  the  first  two  weeks  at  Fort  McPherson 
the  enlisted  personnel  was  attached  to  Army  Gen- 
eral Hospital  No.  6,  and  the  experience  in  ward 
and  kitchen  aided  greatly  in  preparing  the  newly 
enlisted  men  for  the  organization  of  their  own  Hos- 
pital Unit.   The  entire  authorized  quota  of  enlisted 


HOSPITAL  UNIT  0  &  B.  H.  65—Brenizer  &  Hanes 


men  was  not  filled  until  May,  1918,  and  this 
proved  a  blessing,  for  recruits  were  added  grad- 
ually to  the  detachment  and  easily  assimilated. 

The  training  of  the  Unit  was  handicapped  by 
the  lack  of  officers,  since  Major  F.  M.  Hanes  and 
Lieut.  F.  R.  Taylor  were  the  only  officers  of  Base 
Hospital  No.  65  ordered  to  duty  at  Fort  McPher- 
son.  The  officers  of  the  Unit  were  in  the  various 
training  camps  and  hospitals  and  did  not  join  the 
Unit  until  June,  1918 — three  months  after  the  Unit 
was  mobilized.  Capt.  Northington,  who  had  enter- 
ed from  the  University  of  Minnesota,  and  was  on 
active  duty  examining  recruits  to  the  M.R.C.  at 
Minneapolis  within  a  month  of  the  United  States' 
declaration  of  war,  then  being  transferred  to  Base 
Hospital,  Camp  Dodge,  Iowa,  was  invited  to  join 
this  North  Carolina  group  because  of  his  previous 
practice  in  this  State.  In  the  meantime,  officers 
of  Base  Hospitals  No.  26  and  No.  13,  then  in  train- 
ing at  Fort  McPherson,  volunteered  to  assist  in 
training  enlisted  men  of  Base  Hospital  No.  65,  and 
their  efficient  help  was  invaluable. 

The  men  made  rapid  progress  in  their  training, 
and  every  department  of  a  Base  Hospital  was  or- 
ganized. Fortunately,  the  enlisted  men  were  of  an 
unusually  high  type  and  no  great  difficulty  was 
encountered  in  filling  the  clerical  positions  with 
well-trained  men.  Of  course  the  work  was  entirely 
new  and  army  paper-work  unfamiliar  to  all,  but 
the  various  demands  were  met  and  gradually  a 
well-trained  group  of  office  men  were  developed. 
In  this  phase  of  the  work  advantage  was  taken  of 
the  opportunity  offered  by  Col.  Thomas  S.  Brat- 
ton,  Commanding  Officer  of  Army  General  Hos- 
pital No.  6,  of  sending  men  to  the  various  offices 
of  his  hospital  for  training. 

By  dint  of  the  constant  and  enthusiastic  efforts 
of  all  the  organization  had  assumed  a  roughly  per- 
fected form  by  June  1st,  1918.  At  this  time  the 
remaining  officers  were  ordered  to  join  the  Unit, 
and  during  the  next  two  months  intensive  training 
of  men  and  officers  proceeded. 

Major  Frederic  M.  Hanes  was  in  command  of 
Base  Hospital  No.  65  until  July  24th,  1918,  when 
Major  C.  S.  Lawrence,  M.C.,  was  ordered  to  the 
command  of  the  Unit.  He  was  succeeded  on  July 
27th  by  Major  W.  E.  Butler,  M.C.,  from  Brook- 
lyn. 

On  August  9th,  Base  Hospital  No.  65  was  or- 
dered to  Camp  Upton,  N.  Y.,  and  the  months  of 
hard  but  pleasant  training  were  over.  The  organi- 
zation had  been  treated  with  unfailing  kindness 
and  helpful  consideration  by  all  in  authority  at 
Fort  McPherson,  and  the  months  spent  there  re- 
main a  happy  memory. 

Excellent  travel  accommodations  were  provided 


for  the  trip  to  Camp  Upton,  and  this  was  reached 
without  mishap  of  any  kind  on  August  10th. 

On  August  29th,  at  4  a.  m.  Base  Hospital  No. 
65  left  Camp  Upton  for  Hoboken,  and  by  noon 
the  organization  was  safely  stored  bag  and  bag- 
gage on  the  S.  S.  Kroonland. 

One  of  the  officers  of  Base  Hospital  65  says  the 
old  Kroonland  was  not  much  to  look  at  but  a 
honey  of  a  sailor.  She  was  a  Dutchman — good  sea 
language  if  poor  English — as  you  would  gather 
from  her  name,  and  she  rode  very  low  in  the  water. 
A  rumor  had  gone  around  that  our  C.  O.  of  that 
date,  the  Brooklyn  one,  had  said  he,  having  special 
influence,  had  got  extra  good  accommodations  for 
our  going  across.  When  one  of  our  waggish  corps 
men  got  his  first  look  at  the  Kroonland  he  an- 
nounced: "It's  a  good  thing  Col.  Butler  had  a 
drag,  or  all  we'd  have  got  would  have  been  rafts 
and  paddles."  But  the  Kroonland  was  taking  the 
rough  weather  like  a  duck  in  a  mill  pond,  when 
two  larger  ships  of  our  convoy  were  pitching  so 
that  not  a  stomach  on  board  either  could  have 
kept  anything  in  it  but  its  lining  membrane. 

The  trip  across  was  devoid  of  incident,  and  land- 
ing was  made  at  Brest  the  afternoon  of  September 
13th.  From  this  date  until  September  16th,  the 
organization  was  in  camp  at  Camp  Pontanezen, 
just  outside  the  walls  of  barracks  built  by  the  first 
Napoleon  a  few  miles  from  Brest.  Orders  then 
came  that  the  Unit  would  proceed  to  Kerhuon 
Hospital,  four  miles  on  the  other  side  of  Brest, 
and  prepare  it  for  the  reception  of  patients. 

Soon  after  arrival  in  France  Lieut.  Col.  Hanes 
was  detached  for  special  duty  in  subduing  an  epi- 
demic of  influenza  and  meningitis  at  Pontanezen. 
Then  he  returned  to  Hospital  Center  Kerhuon  as 
Commanding  Officer,  Lieut.  Col.  John  W.  Long 
having  been  ordered  to  special  duty  at  Paris. 

The  history  of  Base  Hospital  No.  65  from  Sep- 
tember 16th,  1918,  to  the  present  (March  20th, 
1919)  is  the  history  of  Hospital  Center  Kerhuon; 
for  Base  Hospital  No.  65  is  the  only  Base  Hos- 
pital that  functioned  as  such  at  this  Center. 

Under  the  organization  as  a  Hospital  Center 
Major  Northington  was  Director  of  Professional 
Services,  these  being  three— Medical,  Surgical  and 
Psychiatric.  Major  Northington  was  succeeded  by 
Capt.  S.  W.  Hurdle  as  Chief  of  Medical  Service; 
Major  J.  H.  Shuford,  and  later  Major  H.  H.  Og- 
burn,  became  Chief  of  Surgical  Service;  while  Ma- 
jor L.  G.  Beall  became  Chief  of  Psychiatric  Serv- 
ice. 

The  following  named  nurses  were  attached  to 
Base  Hospital  No.  65: 

Bree  Kelly,  Chief  Nurse,  June  E.  Abernathy, 
Anna  M.  Alexander,  Rose  Allison,  Mary  M.  Am- 


HOSPITAL  UNIT  0  &  B.  H.  65—Brenizer  Sr  Hanes 


March   1941 


bier,  Lela  E.  Anderson,  Evelyn  Armstrong,  Edith 
L.  Bailey,  Annie  J.  Bell,  Mae  F.  Benge,  Blanch 
Bischoff,  Jean  P.  Blue,  Bess  B.  Bodenheimer,  Lola 
J.  Boyd,  Mary  lone  Branch,  Irene  Brewster,  Kath- 
erine  Burt,  Hartley  Butt,  Lillian  P.  Britt,  Dena 
Marie  Boyce,  Wilhelmina  Collender,  Alice  B.  Ca- 
sey, Odessa  Chambers,  Helen  M.  Cleary,  Clara  M. 
Compton,  Florence  M.  DeSautel,  Gladys  M.  De- 
Venney,  Rosalie  A.  Ferguson,  Ella  Fly,  Ruby  Fra- 
ley,  Clara  R.  Fredere,  Minnie  R.  Fritz,  Sadie  C. 
Gallagher,  Anna  K.  Gaertner,  May  Greenfield,  Ada 
Estelle   Harris,   Myatt    Herndon,    Bessie   Hooten, 
Ethel   Hughes,    Marjorie    Ide,    Caroline   Johnson, 
Gaye  Johnson,  Pearl  A.  Johnson,  Helen  A.  John- 
son, Betty  Johnson,  Lucy  Jones,  Daisy  E.  Kins- 
land,  Mable  A.  King,  Rose  E.  Kliment,  Hildur  A. 
Laconius,  Louise  G.  Livingston,  Rachel  G.  Loman, 
Betty  E.  Manley,  Bess  A.  Manley,  Margaret  E. 
MacLellan,  Sue  M.  McNeill,  Florence  MacKenzie, 
Emily  Morton,  Mabel  Niblock,  Bert  C.  Nichols, 
Anna  H.  Osback,  Esther  E.  Oswood,  Ada  F.  Paige, 
Letitia    Payne,    Sarah    Pennington,    Pearl    Phifer, 
Maude  E.  Pierce,  Harriet  J.  Poole,  Mabel  Potts, 
Bessie  D.  Powell,  Allie  Reavis,  Elizabeth  K.  Rich- 
ards, Harriett  E.  Roddey,  Pauline  Robinson,  Nova 
R.  Rogers,  Bertha  L.  Rose,  Effie  N.  Sassar,  Sara 
L.  Satterfield,  Gwendolyn  J.  Scriven,  Elizabeth  M. 
Sears,  Clara  Belle  Smith,  Frankie  Smith,  Minnie 
Staley,  Bertha  Steele,  Grace  F.  Stevens,  Alexandra 
T.   Stewart,  Haldis  Sundre,  Caroline  Tillinghast, 
Mamie  L.  Timberlake,  Myrtle  Truell,  Loma   C. 
Trull,  Pauline  D.  Troch,  Mamie  Ulrich,  Elizabeth 
Water,  Lillie  Ruth  Wicker,  Isabel  Williams,  Jessie 
K.    Willson,    Annie    Yow,    Gertrude    Falkenhagen 
(Dietitian),  Hilda  Larson. 

The  version  of  the  nurses  attached  to  Base 
Hospital  No.  65  of  their  activities  was  as  follows: 
"We  were  mobilized  at  one  of  the  nurses'  bases 
in  New  York  City,  and  from  there  went  in  a  body 
to  France  and  united  with  hospital  forces  at  Brest. 
Twenty -two  hundred  desperately  ill  patients 
were  brought  in  before  the  barracks  were  ready. 
There  were  no  electric  lights,  only  oil  hand  lan- 
terns and  flashlights  were  available.  The  nurses 
wore  hip  boots  and  waded  in  slush  from  building 
to  building.  One  hundred  and  two  nurses  took 
care  of  this  large  number  of  sick  and  dying  sol- 
diers. Many  types  of  diseases  as  well  as  wounds 
were  treated,  among  which  were  influenza,  pneu- 
monia, pleurisy,  cerebrospinal  meningitis  and  in- 
sanity. In  October,  1918,  the  Chief  Surgeon  of 
the  American  Expeditionary  Forces  called  upon 
Base  Hospital  No.  65  for  two  operating  teams  to 
be  sent  to  the  front.  This  was  a  hazardous  duty 
and  called  for  highly  trained  women.  Dr.  Long 
selected  two  North  Carolina  nurses  to  do  this  work, 


and  they  spent  many  weeks  of  active  service  on  the 
firing  line  and  within  sound  of  the  big  guns. 
The  work  done  by  this  unit  has  gone  down  in  the 
history  of  the  War  Department  as  one  of  unex- 
celled value." 

Here  are  interpolated  extracts  from  Sergeant 
Wallace  Hoffman's  sketch  of  B.  H.  65: 

The  2>-l/2  mile  hike  leisurely  done  brought  us 
to  Napoleon's  old  barracks  at  Pontenezan  just  out- 
side of  which  we  found  the  tents  we  were  to  occupy 
as  our  alleged  rest-camp.  Sleeping  on  duck-boards 
to  keep  out  of  the  mud,  and  being  able  to  take  off 
shoes  and  leggings  and  breeches  to  go  to  bed  seem- 
ed a  great  luxury. 

Most  of  the  men  would  say  we  spent  a  long  time 
at  the  rest  camp;  but  it  was  only  three  nights,  as 
on  the  afternoon  of  September  16th,  having  been 
under  pack  and  waiting  for  transportation  since 
early  morning,  the  trucks  arrived  and  took  us  from 
Pontenezan  to  our  brand  new  hospital  at  Kerhuon. 
Here  were  many  new  and  half-finished  and  just- 
begun  barracks  and  we  carried  beds  and  were 
were  issued  lots  of  blankets  to  put  on  the  springs, 
and  for  the  first  time  since  leaving  Upton  those 
who  did  not  have  to  be  up  with  patients  could  sleep 
in  comfort. 

The  work  of  equipping  the  wards  with  all  the 
material  available  from  the  supply  station — carry- 
ing beds,  mattresses,  blankets,  tables  etc. — went 
forward  rapidly.  The  nurses  were  with  us  for  the 
first  time,  and  soon  we  had  2800  beds  available 
for  patients.  Eighty-one  men  were  sent  down  to 
Pontenezan  on  detached  service  to  help  in  the 
emergency  with  influenza  and  meningitis,  and  re- 
ceived their  first  real  experience  in  the  work  they 
were  to  do.  Soon  recalled  to  Kerhuon  as  patients 
began  to  arrive  with  rapidity  and  we  were  soon 
full  to  limit. 

At  first  the  work  was  almost  entirely  with  sick 
arriving  from  U.  S.  As  Brest  was  entrance  har- 
bor for  many  convoys,  our  death  record  showed 
the  coming  of  ships.  During  October  at  the  height 
of  the  influenza  epidemic,  with  the  rush  to  get  men 
over  we  had  greatest  mortality,  66  in  one  day,  and 
for  the  month  585. 

Nurses,  officers  and  men  were  added  and  the 
Hospital  expanded  until  it  had  an  enlisted  person- 
nel of  1200  and  4200  beds  for  patients;  and  many 
officers  from  other  groups  served  with  us.  Col. 
Clyde  S.  Ford,  of  the  regular  Army,  now  came  to 
us  as  commanding  officer. 

With  November  we  were  covered  up  with  work, 
and  then  came  the  Armistice,  with  its  great  rejoic- 
ing, and  the  knowledge  that  in  the  changed  condi- 
tions we  would  not  have  to  salvage  the  men  wasted 
(To  Page  122) 


SOUTHERN  MEDICINE  &  SURGERY 

Antithetical  Views  on  Twinning  Found  in  the 
Bible  and  Shakespeare 

Groesbeck  Walsh,  A.  B.,  M.  D.,  F.  A.  C.  P. 
Chief  of  the  Medical  Clinic,  Employees  Hospital  of  Fairfield 

AND 

Robert  M.  Pool,  A.  B.,  M.  D.,  F.  A.  C.  S. 

Assistant  Chief  Surgeon,  Employees  Hospital  of  Fairfield 

Fairfield,  Alabama 


PART    I 

THE  EDITOR  of  the  Lancet1,  in  comment- 
ing on  a  previous  paper2  of  the  authors, 
makes  an  estimate  of  the  Bard  of  Avon 
which  is  couched  in  such  inimitable  English  that  we 
cannot  forbear  quoting  from  it. 

"Shakespeare"  says  he,  "was  such  an  admirable 
observer  that  he  tempts  us  into  believing  him 
omniscient,  but  he  was  first  and  foremost  a  drama- 
tist with  an  eye  for  a  situation  and  he  knew  what 
he  was  about.  He  used  his  knowledge  as  a  cook 
uses  thickening  in  gravy,  but  the  structure  of  his 
plays  was  dramatic,  not  scientific."  We  will  admit 
that  we  have  yielded  to  the  temptation  alluded  to 
not  only  in  this  study  but  even  more  frequently 
'in  a  work  on  Shakespeare's  knowledge  of  Later- 
ality Dominance  something  on  which  we  are  pres- 
ently engaged3. 

Shakespeare  wrote  at  a  time  when  the  instru- 
mentality of  science  was  at  a  bare  minimum.  We 
might  retort  to  the  distinguished  editor  from  whose 
words  we  have  quoted,  that  the  dramatist's  re- 
flections upon,  and  observations  of,  human  ills, 
weaknesses  and  efforts  both  spiritual  and  mental 
could  be  molded  by  the  proper  hands  into  a  treatise 
which  would  far  excell  any  abstract  scientific  thesis 
of  its  time.  What  may  have  added  to  our  confu- 
sion in  the  matter  is  the  projection  of  the  dramatic 
in  these  matchless  plays  into  the  foreground  while 
the  uncanny  qualities  of  his  more  human  analyses 
lurk  in  the  background. 

Many  of  Shakespeare's  plays  portray  characters 
living  in  a  Christian  world.  They  are  shown 
attempting  with  various  degrees  of  success  to  ad- 
here to  the  Christian  way  of  life.  Their  lives  are 
rewarded  or  punished  according  to  the  dictates  of 
an  authority  which  stems  from  the  Scriptures.  The 
playwright  expresses  a  philosophy  which  is  essen- 
tially orthodox.  This  makes  it  all  the  more  sur- 
prising when  we  have  occasion  to  note  the  manner 
in  which  he  views  the  broad  subject  of  twinning. 
Here  he  is  at  variance  with  the  Hebrew  philosophers. 
The  products  of  twin  conceptions  in  his  plays  are 
always  people  of  the  highest  type.     The  Jews  sur- 


round such  rare  events,  rare  in  the  sense  that  they 
are  infrequently  described,  with  an  unmistakable 
aura  of  tragedy.  To  them  misfortune  is  shown  as 
following  the  footsteps  of  such  human  beings;  to 
such  an  extent  as  to  foster  the  belief  that  such 
descriptions  are  brought  into  the  narrative  with 
deliberate  intention. 

Twin  births  are  told  of  twice  in  the  Old  Testa- 
ment while  the  New  Testament  contains  only  refer- 
ences to  these  past  events.  These  references  brief  in 
extent  only  serve  to  accentuate  the  bleak  regard 
with  which  such  happenings  were  viewed.  In  the 
several  allusions  to  the  earlier  events  brought  forth 
in  the  New  Testament  there  is  nothing  to  suggest 
that  the  Christian  writers  had  in  any  manner 
changed  their  point  of  view.  Indeed  the  impres- 
sion received  from  the  entirety  of  such  a  study  is 
that  twin  births  were  surrounded  with  tragic  hap- 
penings which  wrecked  the  lives  of  many  of  those 
who  participated  in  the  scene.  They  are  only 
mentioned  to  remind  us  that  misfortune  followed 
them.  The  repetition  of  such  advices  in  the  New 
Testament  make  this  impression  all  the  more  con- 
vincing. 

In  the  long  lists  of  children  born  under  the  old 
regime,  lists  which  sometimes  run  without  inter- 
ruption in  the  text  through  many  chapters  of  the 
earlier  books  in  the  Bible,  there  is  not  to  be  found 
a  single  reference  which  would  lead  us  to  a  con- 
trary belief.  No  instance  of  twinning  is  brought 
forth  in  which  such  happenings  were  followed  by 
peace  and  the  drawing  closer  of  natural  family 
ties. 

As  will  be  described  later  in  one  instance  at  least, 
Jacob,  the  second  born  in  a  twin  pregnancy  dis- 
rupted the  blessing  of  his  elder  grandson  in  favor 
of  the  younger  grandson.  He  did  this  deliberately 
despite  the  spoken  objections  of  the  child's  father, 
Joseph.  In  doing  so  one  judges  from  the  text  that 
he  was  perpetuating  an  injustice  which  was  against 
all  Hebrew  precedent  at  that  time  and  was  ob- 
iectionable  to  those  adults  who  took  part  in  the 
ceremony.  This  proceeding,  which  is  surely  one 
of  the  most  moving  in  the  Old  Testament  can,  we 


TWINNING— Walsh    <S-   Pool 


feel,  be  read  only  in  the  light  that  Jacob  or  Israel 
as  he  was  then  called,  was  bent  on  repeating  a 
formula  which,  with  the  connivance  of  his  mother, 
Rebekah,  he  had  perfected  in  his  youth  against 
his  twin  brother,  Esau.  We  might  assume  also  that 
the  selection  of  the  younger  son  Joseph,  as  the  head 
of  the  family  on  the  death  of  Jacob,  which  led  to 
the  displacement  of  his  older  brothers,  Reuben  and 
Benjamin  among  them,  was  a  deed  of  the  same 
caliber. 

The  tragic  story  of  the  strife  between  Jacob  and 
Esau  is  ushered  in  almost  immediately  after  their 
mother.  Rebekah  discovered  she  was  with  child. 
Rebekah,  who  was  the  sister  of  Laban,  the  Syrian, 
a  point  which  was  of  moment  in  the  later  life  of 
her  favorite  son.  Jacob,  married  Isaac  when  the 
latter  was  forty  years  of  age.  At  first  she  was 
barren.  The  narrative  describes  how  she  became 
pregnant  due  to  the  intercessions  of  her  husband 
with  the  Lord.  The  struggle  which  was  to  continue 
later  between  the  two  youths  began  within  her 
womb. 

Genesis  25:   22  and  23 

"And  the  children  struggled  together 
within  her,  and  she  said,  If  it  be  so 
why  am  I  thus? 

And  she  went  to  inquire  of  the  Lord." 

"And  the  Lord  said  unto  her,  Two  nations 
are  in  thy  womb,  two  manner  of  people 

"shall  be  separated  from  thy  bowels,  and 
the  one  people  shall  be  stronger  than 

"the  other  people  and  the  elder  shall  serve 
the  younger." 
This  manner  of  advice  may  have  determined 
all  her  latter  actions  in  the  tragedy  which  shortly 
disrupted  her  family.  Whether  that  was  the  de- 
termining power  of  her  decision  or  whether  she  was 
repelled  by  Esau's  appearance  we  do  not  know  but 
from  the  moment  of  her  twins'  birth  she  became 
the  active  partisan  of  the  younger  one,  Jacob.  At 
the  time  of  parturition  Jacob  was  found  holding 
to  the  heel  of  Esua.  The  implication,  the  reason 
why  this  particular  is  mentioned,  we  believe  to  have 
been  founded  on  the  belief  that  Jacob  was  attempt- 
ing to  prevent  his  brother's  appearance  in  the  outer 
world.  At  once  the  family  became  divided.  Isaac 
loved  Esau  but  the  mother  adhered  to  the  younger 
son.  While  they  were  still  youths  Esau,  in  a  sudden 
fit  of  hunger  and  weakness,  sold  his  birthright  to 
the  other  boy.  This,  obviously  however,  was  a 
contract  without  merit;  only  a  preparatory  scene 
to  the  more  tragic  one  which  followed.  The  father 
must  first  be  deceived  before  the  agreement  became 
valid.  Meanwhile  the  inheritance  became  a  great 
one,  so  great  indeed  that  Isaac  was  ordered  to 
leave  by  Abimelech,  in  whose  country  and  under 


whose  protection  he  was  then  living,  with  the  words, 
"Go  from  us  for  thou  are  much  mightier  than  we.'' 

When  Isaac  had  grown  old  and  his  eyes  could 
not  see,  the  mother  and  the  younger  son  decided 
that  the  time  for  the  deception  had  come.  The 
manner  in  which  the  old  man  was  imposed  upon 
has  been  told  many  times.  In  this  deception  the 
mother  and  the  younger  son  played  equal  parts. 
"The  voice  is  Jacob's  voice,  but  the  hands  ars  the 
hands  of  Esau."  The  consummation  of  this  deceit 
brought  about  a  decision  on  the  part  of  Esau  to 
kill  Jacob.  His  mother  learned  of  this  and  sent 
her  favorite  out  of  the  country  to  her  brother, 
Laban,  the  Syrian.  Here  he  lived  for  many  years 
with  the  threat  of  murder  hanging  over  his  head. 
Later  in  life  when  a  meeting  with  his  brother  Esau 
became  inevitable  Jacob  had  many  misgivings  as 
to  the  outcome.  He  seemed  under  the  impression 
that  Esau  would  kill  him  on  sight  and  prepared 
his  belongings  in  such  a  way  that  much  would 
go  to  his  brother  as  a  gift  of  appeasement.  As  he 
himself  stated  the  case,  "I  will  appease  him  with 
the  present  that  goeth  before  me,  and  afterward 
I  will  see  his  face,  peradventure  he  will  accept  of 
me." 

The  thirty-second  and  thirty-third  chapters  of 
Genesis  are  taken  up  with  the  description  of  the 
wrestlings  of  Jacob  with  his  conscience  and  his 
fears  at  the  prospect  of  the  coming  meeting.  Not 
the  least  impressive  portion  of  the  narrative  is  that 
which  describes  his  emotional  storm  when,  to  his 
evident  surprise  he  found  his  brother,  Esau,  in  the 
spirit  of  forgiveness.  Jacob  expected  death  and  he 
met  with  generosity.  The  crime  which  he  had 
committed  against  his  twin  brother  was  the  factor 
which  divided  the  family  of  Isaac  and  Rebekah. 
The  fraternal  strife  which  resulted  led  to  the  flight 
of  the  younger  son  under  a  threat  of  murder.  A 
crime  which  would  have  been  consummated  but 
for  the  vigilance  of  the  mother,  Rebekah.  The 
resulting  series  of  events,  tragic  in  character,  em- 
braced the  flight  of  Jacob  into  strange  lands  where 
he  spent  his  life  among  strangers,  the  estrangement 
of  Esau  from  his  father  and  mother  when  he  wed 
against  their  wishes.  Jacob  seems  to  have  spent 
most  of  his  early  days  under  the  constant  fear  of 
murder,  a  crime  which  we  judge  from  the  context 
would  have  been  justified  in  his  own  eyes.  That 
his  brother  was,  in  the  end,  willing  to  forgive  and 
forget  aroused  an  emotional  storm  in  his  own  soul 
which  gives  us  an  indication  of  how  great  his  own 
injustice  appeared   in  his  own  eyes. 

Later  in  the  Old  Testament  (Hosea,  12:  2)  it  is 
recorded  that  "the  Lord  will  punish  Jacob  accord- 
ing to  his  ways.  He  took  his  brother  by  the  heel 
in  the  womb  and  by  his  strength  he  had  power 


March   1941 


TWINNING— Walsh   &   Pool 


with  God." 

Nor  does  Esau  seem  to  have  been  regarded  as 
blameless  in  the  controversy.  (Obadiah  1:  10) 
"For  thy  violence  against  thy  brother,  Jacob, 
shame  shall  cover  thee  and  thou  shalt  be  cut  off 
forever." 

The  same  strain  of  thought  is  continued  in  an- 
other of  the  elder  prophets. 

Malachi  1:2;  "Was  not  Esau  Jacob's  brother 
saith  the  Lord.  Yet  I  loved  Jacob  and  I  hated 
Esau  and  laid  his  mountains  and  heritage  waste 
for  the  dragons  of  the  wilderness."  Nor  is  there 
any  softening  of  the  regard  in  the  New  Testament 
as  we  find  in  Hebrews  12:   16  and  17. 

"Lest  there  be  any  fornicator  or  profane  person 
as  Esau,  who  for  one  morsel  of  meat  sold  his 
birthright.  For  ye  know  how  that  afterward  when 
he  would  have  inherited  the  blessing  he  was  re- 
jected, for  he  found  no  place  of  repentance  though 
he  sought  it  carefully  with  tears."  The  air  of 
tragedy  still  persists  in  another  quotation  from 
the  New  Testament,  Romans  IX:  10  and  to  follow. 

"And  not  only  this  but  when  Rebecca  also  had 
conceived  by  one,  even  by  our  father  Isaac.  (For 
the  children  being  not  yet  born,  neither  having 
done  any  good  or  evil,  that  the  purpose  of  God 
according  to  election  might  stand  not  of  works 
but  of  him  that  calleth).  And  it  was  said  unto 
her  the  elder  shall  serve  the  younger."  "As  it  is 
written  Jacob  have  I  loved  but  Esau  have  I  hated." 

The  tragedy  of  the  twin  birth  of  Jacob  and  Esau 
seems  capable  of  arousing  hatred  not  only  in  all 
who  took  part  in  it  but  in  all  commentators  as 
well.  Both  in  the  Old  Testament  and  the  New 
the  story  serves  to  call  forth  expressions  of  re- 
proach. More  than  once  as  we  have  seen  it  has 
served  as  a  text  to  put  upon  display  something 
which  merits  nothing  but  disapprobation.  The  one 
twin  or  the  other  seems  to  have  been  held  respon- 
sible for  all  that  afterward  befell.  The  only  re- 
deeming feature  in  the  entire  narrative,  the  whole- 
hearted forgiveness  by  the  wronged  Esau  of  his 
younger  brother,  alone  seems  to  have  been  neglected. 
We  cannot  help  but  feel  that  this  series  of  allusi- 
ons and  implications  informs  us  that  to  the  ancient 
Jews,  the  act  of  twinning,  whether  or  not  it  was 
bound  up  in  the  inheritance  of  property  was  some- 
thing which  they  could  very  well  do  without. 

The  only  other  story  of  twinning  contained  in 
the  scriptures  occupies  in  its  entirety  the  38th 
chapter  of  Genesis.  It  concerns  itself  with  the 
tragic  intercourse  which  took  place  between  Judah 
and  his  daughter  in  law,  Tamar.  It  is  of  interest 
to  note  that  Judah,  who  played  the  leading  part 
in  the  drama  and  the  father  of  the  illegitimate  off- 
spring of  this  union  was  himself  the  son  of  a  twin, 


Jacob.  His  mother,  Leah  was  introduced  into  the 
bed  of  Jacob  at  the  wedding  feast  which  was 
supposed  to  celebrate  the  marriage  of  Jacob  and 
Rachel.  After  this  act  of  deception  by  Laban 
Jacob  agreed  to  labor  seven  years  more  for  Rachel. 

The  descriptions  of  these  two  tragic  series  of 
events  fall  into  each  other  aptly.  Each  one  is  a. 
story  all  its  own  yet  bound  together  within  two 
generations  of  a  family  which  has  the  distinction, 
if  we  can  call  it  such,  of  bearing  the  only  two 
sets  of  twins  mentioned  in  the  scriptures.  The 
inference  may  be  that  the  narrators  had  this  in 
mind  and  used  each  separate  chapter  to  make  more 
manifest  their  idea,  racial  in  character,  that  twins 
and  their  bearing  denoted  something  which  was 
reprehensible. 

Judah  who  was  the  fourth  son  of  Leah  and 
Jacob,  married  a  Canaanite  woman  named  Shuah, 
who  bore  him  three  sons.  The  father  selected 
a  wife  named  Tamar  for  his  first  born  son,  Er. 
The  first  husband  was  slain  by  the  Lord.  Judah 
promptly  commanded  his  second  born,  Onan  to 
wed  Tamar.  Onan,  whose  name  has  been  made  a 
word  in  our  own  language,  rather  than  impregnate 
his  brother's  widow  spilled  his  seed  upon  the 
ground.  He  met  the  fate  of  his  brother,  Er.  Tamar, 
at  the  suggestion  of  her  father  in  law,  withdrew 
to  her  father's  house  until  the  third  son,  Shelah, 
should  become  nubile.  "Lest"  in  the  words  of 
Judah,  "peradventure  he  die  also  as  his  brethren 
did."  Tamar  became  aware  that  Judah  did  not 
intend  to  complete  his  bargain  and  dressing  as  a 
harlot  waylaid  him  as  he  went  to  Timnath  to  shear 
his  sheep.  She  covered  her  face  after  the  habit 
of  her  class  and  sat  in  an  open  place.  All  un- 
knowing that  he  was  approaching  his  daughter  in 
law  Judah  made  overtures  to  her.  She  consented 
but  took  first  from  him  his  pledges  his  signet,  his 
bracelets  and  his  staff. 

After  this  incestuous  union  was  consummated 
Tamar  returned  to  her  father's  house  bearing  with 
her  the  precious  pledges.  Three  months  later  Judah 
was  informed  that  his  daughter  in  law  had  played 
the  harlot  and  was  pregnant.  Judah  commanded 
that  according  to  the  law  she  should  be  brought 
forth  and  burned  to  death.  Before  the  sentence 
could  be  carried  out  she  sent  a  message  to  her 
father  in  law  with  the  pledges  she  had  exacted 
before  the  intercourse  had  taken  place.  This  was 
the  message. 

"By  the  man  whose  these  are  am  I  with  child. 
Discern  I  pray  thee  whose  are  these,  the  signet, 
the  bracelets  and  the  staff."  Judah  acknowledged 
the  justice  of  her  claim  with  the  words  "She  hath 
been  more  righteous  than  I,  because  that  I  gave 
her  not  to  Shelah,  my  son."    When  the  children 


TWINNING— Walsh   &   Pool 


March   1941 


were  born,  the  hand  of  one  appearing,  the  mid- 
wife attached  to  one  of  the  fingers  a  scarlet  thread, 
saying,  "This  came  out  first."  But  in  the  struggle 
to  appear  in  the  world  the  other  child  won  and 
was  born  first  bringing  from  the  midwife  the  out- 
burst "How  has  thou  broken  forth,  this  breach 
be  upon  thee."  The  latter  incident  reminds  us  of 
the  events  which  took  place  when  Jacob  and  Esau 
were  born;  the  manner  in  which  Jacob  clung  to 
Esau's  heel. 

The  whole  narrative  reeks  with  violence;  the 
sudden  deaths  of  Er  and  Onan,  the  deception 
practiced  upon  Tamar  by  her  father  in  law,  Judah; 
the  manner  in  which  Tamar,  to  obtain  revenge, 
played  the  part  of  a  prostitute;  the  incestuous 
union  which  followed;  the  threat  of  a  shameful 
death  and  what  must  have  amounted  to  the  dis- 
grace of  a  prince  of  Israel.  With  twinning  the 
scriptures  do  not  further  concern  themselves.  We 
think  enough  has  been  said  to  foster  the  belief 
that  these  stories  were  told  with  a  purpose  and 
that  there  is  a  bond  which  holds  these  two  narra- 
tives together.  In  any  event,  so  far  as  the  Old 
Testament  is  concerned,  the  only  impression  one 
can  obtain  is  that  tragedy  hovers  over  such  events 
and  that  such  bringings  forth  are  surrounded  with 
forces  which  disrupt  family  life  and  threaten  the 
well  being  of  all  who  take  part  in  them.  No  word 
could  be  found  to  ameliorate  these  impressions  in 
any  other  part  of  the  Bible.  The  implications  we 
beiieve  to  be  unmistakable. 

We  have  difficulty  in  even  hazarding  a  guess  as 
to  upon  what  the  evident  distaste  of  the  ancient 
Jews  toward  twinning  was  founded.  We  may  take 
it  for  granted  we  think  that  the  belief  that  one 
twin  acts  against  the  well  being  of  the  other  is 
almost  as  old  as  humanity.  That  this  antagonism 
shows  itself  by  an  attack  on  the  sexual  potency 
of  one  of  the  partners  by  the  other  seems  to  be 
widely  held  by  the  people  at  large.  When  Newman 
and  his  associates  at  the  University  of  Chicago 
were  preparing  their  book  on  Twins  &  Twinning 
a  large  correspondence  was  entailed  with  the  peo- 
ple of  the  Middle  West. 

This  was  made  necessary  by  the  attempts  of 
the  authors  to  persuade  numerous  pairs  of  twins 
to  come  to  Chicago  for  the  purpose,  among  others, 
of  determining  the  value  of  the  factors  of  nurture 
and  nature'.  Many  of  the  letters  addressed  to 
Newman  took  the  form  of  queries  and  he  records 
the  fact  that  the  one  relating  to  the  impairment 
of  the  sexual  potency  of  one  twin  by  his  birth 
partner  was  the  form  of  question  which  most  fre- 
quently became  apparent.  To  the  Jews,  a  noma- 
dic and  warlike  tribe,  the  matter  of  sexual  potency 
among  its  people  was  a  very  important  one.    The 


bearing  of  many  children  by  a  couple  were  events 
eagerly  sought  for.  Barrenness  was  viewed  as  a 
curse  or  something  even  more  unfortunate.  It  is 
quite  possible  that  the  Jews  held  views  in  these 
matters  similar  to  those  that  we  find  so  frequently 
today,  that  one  twin  is  apt  to  be  impotent  or 
sterile,  and  this  may  have  been  one  of  their  rea- 
sons for  their  evident  antagonism  toward  the  phe- 
nomenon of  twinning.  There  is  nothing  in  the 
scriptures  to  indicate  a  belief  in  the  occurrence 
of  free-martinry  among  human  beings.  Unless  it 
is  by  implication. 

In  the  two  sets  of  twins  which  we  have  described 
the  sex  was  similar  in  both  pairs  of  infants;  Jacob 
and  Esau  being  boys,  as  were  Pharez  and  Zarah, 
the  sons  of  Judah  and  Tamar.  The  impairment 
of  the  sexual  growth  of  a  female  infant  born  twin 
to  a  male  by  the  suppression  of  her  sexual  hor- 
mones due  to  their  comparative  later  develop- 
ment does  not  enter  into  the  question.  This  state- 
ment is  made  with  knowledge  of  the  fact  that  the 
question  of  human  free-martinry  has  never  been 
adequately  affirmed  or  denied". 

This  point  of  view  is  similar  to  that  which  we 
hear  expressed  by  the  present  generation.  Among 
the  laity  free-martinry  is  a  term  which  is  unheard 
of.  The  question  of  sexual  encroachment  is  found- 
ed upon  a  conception  which  embraces  twinning  as 
a  whole  regardless  of  the  sex  of  the  children. 
Indeed  the  fact  that  the  children  are  of  the  same 
sex  seems  to  be  considered  as  an  ideal  situation 
to  make  this  theory  active.  This  is  true  whether 
either  boys  or  girls  are  involved.  The  means  by 
which  such  fanciful  events  transpire  are  not  even 
hinted  at  but  that  the  idea  is  widely  held  is  self 
evident. 

A  woman  has  recently  informed  us  of  events 
which  took  place  in  the  family  of  her  husband 
which  makes  the  point  clear.  Her  mother  in  law 
was  one  of  twins.  From  what  we  have  been  able 
to  unearth  one  of  identical  twins.  She  bore  seven 
children.  Her  twin  sister  went  through  a  long 
married  life  with  an  active  life  partner  without 
ever  becoming  pregnant.  No  attempts  were  made 
so  far  as  is  known  to  avoid  such  happenings  as 
the  wife  was  eager  to  bear  children.  Our  informant 
remembers  hearing  the  matter  discussed  in  the 
family  circle  and  the  conclusion  reached  that  as 
one  twin  became  more  fruitful  the  chances  of  her 
sister  to  become  a  mother  became  increasingly  more 
remote.  It  was,  she  told  us,  accepted  as  a  matter 
of  course,  what  might  be  expected;  as  one  unit 
of  the  twinship  had  absorbed  all  the  reproductive 
powers  of  the  twain.  The  barren  wife,  who  was 
well  aware  of  these  conversations  must  have  at 
length  resigned  herself  to  her  fate.    Whether  any 


TWINNING— Walsh   &   Pool 


sense  of  injury  was  ever  felt  is  unknown  as  tb.: 
two  women  remained  devoted  to  the  end  of  their 
days.  It  seems  to  be  a  fact  that  many  people  hav  ■ 
been  made  aware  of  this  solitary  facet  of  tradition 
regarding  twinning  to  the  exclusion  of  all  others 
We  have  not  been  able  to  find  any  statistical  fig- 
ures regarding  the  child  bearing  performances  of 
twins  of  the  same  sex.  At  the  present  time  when 
so  much  time  and  effort  have  been  expended  . 
curtail  offspring  any  such  information  would  be  of 
doubtful  value.  This  is  particularly  true  when  we 
consider  that  such  a  search  would  have  to  be  made 
among  the  better  educated  of  the  community  where 
the  practices  of  contraception  have  made  their 
greatest  strides. 

Xowhere  in  either  the  New  or  the  Old  Testa- 
ment can  be  discovered  any  instance  which  would 
guide  us  to  discern  just  what  the  knowledge  of  the 
ancient  Jews  may  have  been  regarding  the  acci- 
dents which  we  now  believe  accompany  the  events 
of  multiple  pregnancies.  We  may  rest  assured  we 
think  that  a  race  so  avid  of  sexual  knowledge  and 
so  eager  to  increase  the  number  of  the  tribe  may 
have  become  aware  of  some  of  these  happenings. 

Thev  were  realists,  able  to  weigh  against  each 
other  the  advantages  or  disadvantages  of  such  af- 
fairs. Shakespeare  looked  upon  the  problem  of 
twinning  with  an  indulgent  eye.  The  spectacle  of 
two  human  beings  bound  together  in  a  mutual 
love  and  understanding  which  trancended,  was 
deeper,  than  any  other  form  of  mortal  relation- 
ship, fascinated  him.  As  we  judge  from  the  read- 
ing of  The  Comedy  of  Errors  and  Twelfth  Night 
he  was  anxious  to  translate  his  viewpoint  to  the 
world.  Not  so  the  Ancient  Jews.  Just  why  is 
purest  speculation  but  we  may  presume  that  know- 
ledge under  the  following  heads  may  have  been 
disclosed  to  them  through  some  primitive  form  o* 
examination  and  analysis. 

1.  Twin  pregnancies  were  not  only  more  apt  to 
result  in  abortions  fatal  to  either  or  both  the 
embryos,  but  the  intrauterine  struggle  for  such 
existance  resulted  in  the  weakening  of  one  child 
and  its  frequent  mutilation. 

2.  Twin  pregnancies,  if  carried  to  term,  were  a 
greater  hazard  to  the  life  of  the  mother  and 
created  obstetrical  complications  which  took 
their  toll. 

3.  The  sexual  potency  of  one  partner  might  be 
seriously  impaired.  A  vital  factor  in  a  tribe 
which  carried  on  almost  incessant  warfare. 

4.  Twin  pregnancies  led  to  deformities  in  one  or 
the  other  of  the  children;  six  fingers,  six  toes, 
and  so  on. 

5.  The  occurrence  of  twins  was  an  unnatural  hap- 
pening per  se. 


6.  The  occurrence  of  twins  led  to  the  increase  of 
left  handed  people.  This  in  itself  was  a  great 
disadvantage  in  war  like  tribes  where  universal 
military  service  was  a  matter  of  course.  That 
the  Jews,  supposed  by  many  to  be  a  left  handed 
people  nevertheless  held  this  condition  to  be  a 
curse,  is  the  only  conclusion  which  can  be  ob- 
tained by  reading  the  scriptures.  The  state- 
ments making  this  plain  occur  over  and  over 
again. 

The  undesirability  of  twinning  with  its  resultant 
production  of  mancinism  must  have  early  become 
apparent  to  the  Jews  who  engaged  in  constant 
warfare  not  only  for  conquest  but  for  their  self 
preservation.  It  would  be  only  with  great  diffi- 
culty that  a  left  handed  recruit  could  be  taught 
to  use  his  sword  or  spear  with  his  right  hand. 
At  the  best  such  soldiers  could  have  presented  but 
vulnerable  targets  for  their  more  skillful  adversa- 
ries. That  this  state  of  affairs  was  recognized  by 
the  ancient  Hebrews  and  was  made  use  of  with 
great  intelligence  is  made  apparent  to  us  from  the 
passage  Judges  20:  15  and  16,  which  has  been 
frequently  quoted. 

"And  the  children  of  Benjamin  were  numbered 
at  that  time  out  of  the  cities  twenty  and  six  thous- 
and men  that  drew  sword  besides  the  inhabitants 
of  Gibeah  which  were  numbered  seven  hundred 
men. 

Among  all  this  people  there  were  seven  hundred 
chosen  men  left  handed;  everyone  could  sling 
stones  at  an  hair  breadth  and  not  miss." 

The  militant  Jews  we  would  understand  from 
this  passage  were  able  to  take  advantage  of  an 
apparent  weakness  and  turn  it  into  a  military 
asset.  The  proportion  of  left  handedness  occur- 
ring among  twins,  being  nearly  half  of  those  in- 
volved, might  have  induced  the  Hebrews  to  look 
upon  its  occurrence  with  disfavor  if  only  from  the 
viewpoint  of  the  martial  world.  Be  that  as  it  may 
the  glorification  of  the  right  side  of  the  body  and 
the  corresponding  condemnation  of  the  left  side 
might  almost  be  considered  one  of  the  religious 
beliefs  of  the  writers  of  the  scriptures  so  frequently 
and  with  such  thudding  force  is  it  applied. 

All  this  despite  the  fact  noted  by  Newman7  that 
one  of  the  Apostles,  St.  Thomas,  was  referred  to 
as  "Thomas  which  is  called  Didymus,"  the  latter 
word  being  the  Greek  word  for  twin. 

We  have  been  unable  to  find  any  evidence  which 
would  point  either  to  the  right  handedness  or  left 
handedness  of  St.  Thomas,  to  whom  we  have  re- 
ferred. From  a  survey  of  the  scriptures  which  the 
authors  have  just  completed,  however,  we  can  state 
that  both  the  Gospels  of  St.  John  and  St.  Luke 
bear  reasonable  proof  of  the  left  handedness  of 


TWINNING— Walsh   &   Tool 


March   1941 


Simon  Peter.  From  a  study  of  the  Koran6  with 
reference  to  laterality  dominance  we  have  con- 
cluded that  there  is  very  definite  indication  that 
Moses  suffered  from  at  least  one  of  the  defects 
frequently  associated  with  mancinism. 

Newman',  in  reviewing  the  objections  to  twin- 
ning entertained  by  some  of  the  primitive  peoples 
brings  out  a  point  of  even  more  importance.  They 
are  objected  to  by  such  congregations,  it  would 
appear,  because  they  are  looked  down  upon  as 
reversion  to  the  animal  or  litter  type  of  bearing 
young.  This  robs  the  parturition  of  something 
which  is  obtained  in  the  case  of  singletons;  a  pride 
in  its  essential  humanity.  An  event  which  was 
believed  to  be  inherent  in  the  annals  of  man  alone. 
Whether  this  viewpoint  influenced  the  ancient 
Hebrews  is  a  matter  of  pure  conjecture  but  it  may 
have  played  its  part. 

That  Shakespeare  was  well  acquainted  with  the 
scriptures  both  old  an  new  and  with  the  book  of 
Common  Prayer  of  The  Church  of  England  has 
been  known  for  centuries.  The  dramatist's  know- 
ledge in  this  respect  has  been  the  subject  of  many 
searching  analyses.  The  common  verdict  has  been 
that  not  only  was  his  acquaintance  with  the  Bible 
intimate  and  extensive  but  that  it  was  applied  with 
great  distinction  and  accuracy.  So  much  so  that 
his  plays  were  made  richer  or  of  deeper  import  to 
those  whose  knowledge  of  the  scriptures  equalled 
that  of  the  author  himself. 

It  has  only  been  of  recent  years  that  it  has  been 
discovered  just  how  frequently  he  makes  use  of 
biblical  allusions.  This  is  so  as  Richmond  Nobles 
points  out  because  only  too  often  the  incidents  for 
a  comparison  are  mentioned  but  the  biblical  per- 
sonality itself  receives  no  further  indentification. 
It  is  as  if  Shakespeare  had  presented  something 
which  might  be  enjoyed,  nit  depending  upon 
the  cultural  level  of  the  reader.  Where  and  when 
Shakespeare  gained  this  type  of  knowledge  is  not 
know.  It  is  most  unlikely  that  it  was  obtained  in 
his  childhood.  Noble  remarks  that  whatever  minor 
mistakes  Shakespeare  made  in  his  biblical  allusions 
and  paraphrases  became  increasingly  less  frequent 
as  he  grew  older.  From  this  it  is  deduced  that 
his  store  of  scriptural  knowledge  was  gained  after 
he  had  reached  maturity  and  went  pari  passu  with 
his  dramatic  skill,  which  showed  marked  improve- 
ment as  time  went  by.  To  refer  to  Nobel  again, 
it  is  believed  that  Shakespeare  made  in  his  plays 
identifiable  quotations  from  or  allusions  to  forty 
two  books  of  the  Bible.  Of  these  Books  eighteen 
each  came  from  the  Old  and  New  Testament  and 
six  from  the  Apocrypha. 


PART  II 

IT  HAS  BEEN  SAID  of  Shakespeare  that  his 
point  of  view  is  artistic  and  not  scientific. 
This  is  brought  out  in  his  attitude  toward 
twinning.  He  is  interested  in  the  finished  product. 
He  sees  in  this  everything  that  is  admirable. 
Sharply  contrasted  with  the  biblical  view  he  dis- 
regards the  obstetrical  tragedies  which  so  often 
complicate  the  lives  of  twins  and  their  mothers. 
He  feels  that  these  are  matters  which  do  not  con- 
cern the  playwright.  The  latter  deals  only  with 
those  comparatively  rare  instances  of  multiple 
pregnancies  which  have  emerged  unscathed  from 
their  terrible  ordeal.  The  idea  that  they  should 
reflect  either  in  body  or  soul  the  desperate  struggle 
for  existence  which  surrounded  them  in  their  time 
of  intra-uterine  life  is  abhorrent  to  him.  To  him 
they  are  superior  beings  and  must  not  ever  show 
by  act  or  by  appearance  the  scars  of  fraternal 
strife. 

It  is  most  likely  that  Shakespeare  knew  little  of 
the  hazards  which  surround  the  early  life  of  twins. 
Certainly  he  never  indicates  by  a  single  word  that 
such  human  beings  would  be  likely  to  display  de- 
formities which  might  make  them  repulsive  to  be- 
holders. All  that  he  sees  is  a  pair  of  human  beings, 
either  of  the  same  sex  as  in  The  Comedy  of  Errors 
or  of  different  sexes  as  in  Twelfth  Night  going  on 
their  several  days  united,  bound  together  by  that 
rarest  form  of  human  affection  which  places  the 
well  being  of  another  above  one's  own.  Viola  and 
Sebastian.  Antipholus  of  Ephesus  and  Antipholus 
of  Syracuse  have  one  great  gift  in  common;  they 
love  their  twins  with  an  almost  unearthly  love. 
Throughout  the  tragic  and  comic  scenes  which 
make  up  these  two  plavs,  the  love  of  these  four 
people  for  each  other  shines  like  a  lode  star.  In- 
deed the  dramas  themselves  seem  to  be  a  back- 
ground which  displays  in  varying  forms  the  supe- 
riority which  twins  have  over  singletons  in  this  life 
we  all  know,  and  the  depths  of  the  emotions  which 
mutually  endear  the  one  to  the  other.  Other  char- 
acters of  Shakespeare's  may  be  derelict  in  their 
duties,  may  shirk  and  disappoint  us:  but  his  twins 
never.  To  the  fiml  dropping  of  the  curtain  they 
remain,  as  from  the  first,  happy  in  the  dedication 
of  their  lives  to  their  birth  companions. 

It  is  a  fact  of  interest  that  in  both  Shakespeare 
and  the  Bible  we  find  the  matter  of  twinning  treat- 
ed twice  over  on  a  grand  scale.  It  would  appear 
that  on  each  occasion,  the  matter  was  brought  up 
with  the  intention  of  pushing  home  a  point.  In  the 
Old  Testament.  Jacob  and  Esau  are  held  up  to  the 
public  consciousness  and  all  that  surrounds  their 


TWINNING— Walsh   &   Pool 


lives  is  brought  forth  in  pitiless  detail.  As  if  the 
narrators  felt  that  the  story  could  not  be  fully  told 
in  one  sitting.  Judah  and  Tamar  and  their  derelic- 
tions are  brought  forward  again  as  a  final  and  ter- 
rible chapter  on  the  subject  of  twinning.  Thence- 
forth in  the  Old  Testament  the  matter  is  brought 
forward  no  more.  Twinning  is  never  mentioned 
again. 

Shakespeare  tells  the  tale  of  the  devotion  of  the 
Antipholi  to  each  other  in  The  Comedy  of  Errors. 
In  Twelfth  Night  he  again  plays  on  his  theme. 
This  time,  however,  in  the  manner  to  let  us  know 
that  not  only  are  twins  of  the  same  sex  superior 
and  devoted  beings,  but  when  we  find  them  of  dif- 
ferent sexes  the  emotions  which  provoke  our  ad- 
miration are  even  more  fulsomelv  displayed.  What- 
ever the  reason  may  be  the  people  of  our  day  have 
gone  along  with  the  Immortal  Bard.  They  too  look 
upon  twins  with  unmixed  affection.  Though  the 
knowledge  of  what  such  mutliple  pregnancies  may 
mean  for  both  the  embryos  and  the  mothers  is  be- 
coming more  widespread  it  has  not  affected  the 
popular  idea  so  far  as  we  can  ascertain  regarding 
the  twins  themselves.  Such  matters  are  quickly  for- 
gotten. 

Even  the  suspicion  that  one  twin  may  make 
havoc  with  the  sexual  development  of  his  fellow 
seems  to  be  lightly  regarded,  even  by  the  ones 
most  intimatelv  engaged  in  the  matter.  Just  why 
we  have  turned  awav  from  the  warnings  of  the 
ancient  Hebrews  and  have  followed  the  philosophy 
of  an  Englishman  of  the  Seventeenth  Century  we 
do  not  know.  That  the  writings  of  the  plavwright 
have  influenced  us  to  some  degree  is  probably  true. 
He  has  affected  so  manv  of  our  viewpoints  that  we 
presume  here  also  his  word  has  been  potent  even 
though  it  may  be  difficult  to  to  define  it,  as  to 
degree. 

In  addition  to  the  two  plavs.  Twelfth  Nieht  and 
The  Comedv  of  Errors,  Shakespeare  touches  on 
the  subject  of  twinning  in  several  of  his  other  com- 
positions. In  this  he  differs  from  the  Scriptures, 
with  which  his  works  have  been  so  often  compared! 
In  each  instance  a  careful  reading  convinces  us  that 
his  attitude  is  invariably  the  same.  Whether  the 
mutual  affection  of  twins  is  stated  directly  or  by 
comparison  with  animals  occupying  other  develop- 
ment levels,  or  bv  the  analogv  of  comparison  with 
inanimate  objects  as  is  done  in  Henry  the  Eighth 
the  inference  follows  the  same  pattern.  Twins  to 
Shakespeare  occupv  a  place  in  his  regard,  high 
and  without  rivals,  to  use  a  word  of  which  he  was 
SO  fond  and  which  he  frequently  employs,  they  are 
something  to  conjure  with. 
|  _  The  minor  references  to  twinning  vary  greatly 
in  significance  and  value,  several  of  them  embody 


merely  the  use  of  the  word  twin.  In  Henry  the 
Fifth,  Act  Four,  Scene  One,  Line  251  occurs  an 
instance  of  this  sort.  In  Anthony  &  Cleopatra, 
Act  Three,  Scene  One,  Line  12  another.  And  a 
third  appears  in  The  Merry  Wives  of  Windsor, 
Act  Two,  Scene  One,  Line  74.  There  are  however, 
several  employments  of  the  picture  we  have  under 
description  which  makes  plain  we  believe  the  un- 
changing admiration  which  buttresses  the  author's 
viewpoint.  One  of  these  latter  appears  in  the 
tragedy  of  Coriolanus.  As  the  story  progresses  to 
its  inevitable  conclusion  Coriolanus  is  driven  from 
Rome  by  an  edict  of  exile.  In  his  bitterness  of 
spirit  he  seeks  an  alliance  with  his  ancient  ememy, 
Tullus  Aufidius,  General  of  the  Volscians.  Him  he 
finds  in  Antium  about  to  feast  his  nobles.  Corio- 
lanus, who  is  in  disguise  seeks  direction  from  one 
of  the  natives  and  pauses  to  soliloquize  before  he 
enters  the  house  of  Aufidus. 

Coriolanus 
Act  Four 
Scene  Four 
Line  XIII 

O   world,   thy  slippery  turns; 

Friends  now  fast  sworn 
Wnose  double  bosoms  seem  to 

wear  one  heart 
Whose  hours,  whose  bed,  whose 

meal  and  exercise 
Are  still  together,  who  twin,  as 

'twere,  in  love 
Unseparable,  shall  within  this  hour 
On  a  dissension  of  a  doit,  break  out 
To  bitterest  enmity;   so,  fellest  foes 
Whose  passions  and  whose  plots 

have  broke  their  sleep 
To  take  the  one  the  other,  by 

some  chance 
Some  trick  not  worth  an  egg, 

shall  grow  dear  friends 
And  interjoin  their  issues. 

So  with  me: 
My  birthplace  hate  I,  and  my 

love's  upon 
This  enemy  town.    I'll  enter; 

if  he  slay  me 
He  does  fair  justice;  if  he  give 

me  way, 
I'll  do  his  country  service. 
These  lines  are  worthy  of  note  for  several  rea- 
sons. First,  the  prime  purpose  of  their  repetition 
is  to  call  attention  to  the  manner  in  which  the 
closest  form  of  human  intimacy  is  described  to 
justify  the  use  of  the  word  twin.  This  is  in  keep- 
ing with  all  other  similar  references.  Another  point 
of  note,  the  manner  in  which  the  word  is  used  as 


TWINNING— Walsh   &   Pool 


March   1941 


a  verb.  Needless  to  say  this  has  long  since  gone 
out  of  vogue.  Shakespeare  frequently  so  employed 
it.     Most  noteworthy  of  all  is  the  line 

"Whose  double  bosoms  seem  to  wear  one  heart." 
Wittingly  or  otherwise  Shakespeare  here  defines 
with  exactness  a  condition  all  to  common  in  mul- 
tiple pregnancies  wherein  there  is  but  one  heart 
to  two  bosoms,  the  heart  of  one  of  the  twins  having 
ceased  to  exist  (acardiacus.)  We  must  absolve 
the  author  of  any  such  knowledge  of  the  pathology 
of  twin  conceptions.  Such  a  state  of  affairs  would 
have  been  highly  unlikely  in  that  day  and  time. 
We  submit,  however,  that  the  expression,  particu- 
larly in  connection  with  the  background  of  twin- 
ning is  a  most  remarkable  one  of  which  to  make 
use.  It  would  seem  most  improbable  that  Shake- 
speare could  have  known  what  an  acardiacus  was. 
There  is  a  brief  recurrence  of  twinning  analogy 
Othello,  Act  Two,  Scene  Three,  Line  200— Othello 
retiring  for  the  night  with  Desdemona  in  the  castle 
in  Cyprus  is  much  concerned  over  the  setting  of 
the  watch.  He  pauses  for  a  moment  to  remind 
Cassio  of  the  importance  of  the  matter.  Cassio 
informs  him  that  though  Iago  has  charge  of  the 
watch,  he,  Cassio,  will  look  to  it  with  his  "personal 
eye." 

Later  in  the  evening  Iago,  having  succeeded  in 
making  Cassio  drunk  to  further  his  own  ends, 
makes  such  a  disturbance  that  the  castle  bell  is 
set  ringing  and  in  the  middle  of  the  riot  of  sound 
and  fighting  Othello  makes  his  appearance.  He 
has  difficulty  in  discovering  just  what  is  underway, 
but  he  makes  his  intentions  evident  in  the  following 

Othello 

Now  by  heaven 
My  blood  begins  my  safer  guides  to  rule 
And  passion,  having  my  best  judgement 

collied , 
Assays  to  lead  the  way;  if  I  once  stir, 
Or  do  but  lift  this  arm,  the  best  of  you 
Shall  sink  in  my  rebuke.  Give  me  to  know 
How  this  foul  rout  began,  who  set  it  on 
And  he  that  is  approved  in  this  offence 
Though  he  had  twinned  with  me, 

both  at  a  birth 
Shall  lose  me.   What  in  a  town  of  war, 
Yet  wild,  the  people's  hearts  brimful 

of  fear, 
To  manage  private  and  domestic  quarrel, 
In  night,  and  on  the  court  and  guard 

of  safety; 
'Tis  monstrous.  Iago,  who  began  it? 
Iago  has  incited  a  fight  between  Cassio  on  one 
side  and  Roderigo  and  Montano  on  the  other.  Iago 
instructs  Roderigo  to  go  outside  and  cry  a  mutiny. 
After  the  bell  starts  ringing  Othello  enters  on  the 
scene.    Even   when   inanimate   objects   merit   the 


highest  praise  Shakespeare  adds  a  touch  of  some- 
thing  precious  to  them  by  comparing  them  to 
human   twins. 

The  following  passage  is  taken  from  Henry  the 
Eight,  Scene  Two,  Act  Four,  Line  45 — Griffith  is 
extolling  the  virtues  of  Cardinal  Wolsey  to  Kath- 
arine. He  informs  her  that  for  once  the  merits 
of  a  man,  fashioned  in  this  instance  into  two  twin 
seats  of  learning  will  perpetuate  the  memory  of 
the  Cardinal. 

Griffith 

Noble  madam 
Men's  evil  manners  live  in  brass; 

their  virtues 
We  write  in  water.    May  it  please 

your  highness 
To  hear  me  speak  his  good  now? 


Katharine 


Griffith 


Yes  good  Griffith; 
I  were  malicious  else. 

This  Cardinal 
Though  from  an  humble  stock 

undoubtedly 
Was  fashioned  to  much  honor  from 

his  cradle. 
He  was  a  scholar,  and  a  ripe  and  good  one 
Exceeding  wise,  fair  spoken  and 

persuading; 
Lofty  and  sour  to  them  that  loved 

him  not 
But  to  those  men  that  sought  him 

sweet  as  summer. 
And  though  he  was  unsatisfied 

in  getting, 
Which  was  a  sin,  yet  in  bestowing 

madam 
He  was  a  scholar,  and  a  ripe  and  good  one; 

for  him 
Those  twins  oj  learning  that  he 

raised  in  you 
Ipswich  and  Oxford;  one  o)  which 

jell  with  him 
Unwilling  to  outlive  the  good  that  did  it; 
The  other  though  unfinished,  yet  so 

famous 
So  excellent  in  art  and  still  so  rising 
That  Christendom  shall  ever  speak 

his  virtue, 
His  overthrow  heap'd  happiness  upon  him 
For  then,  and  not  till  then,  he 

felt  himself 
And  found  the  blessedness  of  being  little 
And,  to  add  greater  honours  to  his  age 
Than  man  could  give  him,  he  died 

fearing  God. 


March   1941 


TWINNING— Walsh    &    Pool 


Christ  Church  College  Oxford  founded  by  Wolsey 
under  the  name  of  Cardinal's  College  has  well 
borne  out  Griffith's  prediction.  It  has  interested 
us  greatly  to  discover  that  this  discourse  of 
Griffith's  which  appears  to  have  been  paraphrased 
from  Holinshed's  Chronicles  of  England,  Scotland 
and  Ireland  differs  from  its  precursor  in  one  im- 
portant particular.  Holinshed  speaks  of  "His  two 
Colleges  at  Ipswich  and  Oxenford."  The  inter- 
pellation of  the  word  twin  with  its  implication 
seems  to  have  come  from  Shakespeare's  pen. 

The  other  minor  reference  to  twinning  comes  to 
us  in  The  Winter's  Tale,  Act  One,  Scene  Two 
Line  60.  Polixenes,  King  of  Bohemia  is  describing 
to  Hermione,  Queen  to  Leontes,  the  life  which  he 
and  her  husband  lived  when  they  were  boys  to- 
gether. It  trips  the  same  measure.  The  old  man 
uses  the  analogy  of  a  twinned  existence  to  recreate 
the  days  of  his  youth,  when  life  was  happiness 
unimpaired. 

Polixenes 

Your  guest,   then,  madam; 
To  be  your  prisoner  would  import 

offending ; 
Which  is  for  me  less  easy  to  commit 
Than  to  punish. 
Hermione 

Not  your  gaoler,  then 
But  your  kind  hostess.    Come  I'll 

question  vou 
Of  my  lord's  tricks  and  yours  when 

you  were  boys; 
You  were  pretty  lordlings  then? 
Polixenes 

We  were  fair  queen, 
Two  lads  that  thought  there  was  no 

more  behind, 
But  such  a  day  tomorrow  as  today, 
And  to  be  boy  eternal. 
Hermione 

Was  not  my  lord 
The  verier  wag  o'  the  two? 
Polixenes 

We  were  as  twinned  lambs  that  did 

frisk  i  the  sun 
And  bleat  the  one  at  the  other; 

what  we  changed 
Was  innocence  for  innocence; 

we  knew  not 
The  doctrine  of  illdoing,  nor  dreamed 
That  any  did.    Had  we  pursued  that  life. 
And  our  weak  spirits  ne'er  been 

higher  rear'd 
With  stronger  blood,  we  should  have 
answered  Heaven 


Boldly,  "not  guilty;"  the  imposition 

cleared 
Hereditary  ours. 
Hermione 

By  this  we  gather 
You  have  tripp'd  since. 

The  two  plays,  The  Comedy  of  Errors  and 
Twelfth  Night,  differ  in  some  particulars.  Their 
differences  however  only  serve  to  bring  out  the 
great  similarity  which  is  apparent  in  the  under- 
lying structure  of  each  creation.  The  activating 
motive  of  each  drama  is  the  desire  on  the  part  of 
twin  human  beings  to  be  united  the  one  with  the 
other.  Though  the  locus  may  vary  from  Illyria 
to  Ephesus,  the  period  of  separation  change  from 
years  in  The  Comedy  of  Errors  to  a  matter  of 
days  in  Twelfth  Night,  the  underlying  humanity 
with  its  uncontrollable  urges  toward  a  reunion  of 
body  and  soul  with  a  twin  mate  remains  always 
the  same. 

Indeed  without  this  passionate  devotion  to  an 
ideal  it  is  evident  that  neither  of  the  two  plays 
would  have  been  written.  All  that  we  see  on  the 
stage  is  the  story  of  this  attempt  to  be  reunited. 
The  things  that  happen  in  this  search  are  presented 
act  by  act  in  an  ordered  dramatic  structure  which 
moves  quickly  toward  its  ends.  These  latter  mani- 
festly are  the  bringing  together  of  these  so  like 
human  beings,  the  two  men  in  The  Comedy  of 
Errors  and  the  youth  and  the  maiden  in  Twelfth 
Night.  The  play  ends  in  each  instance  as  if  it 
were  by  common  consent  when  this  finality  is  con- 
summated. The  very  love  stories  which  add  pas- 
sion and  reality  to  the  lives  of  the  actresses  and 
actors  under  observation  are  blurred  with  some- 
thing comical  in  their  immediate  surroundings. 
While  they  appear  important  enough  to  those 
taking  part  therein  they  have  a  sense  of  diminished 
import  to  the  audience  who  have  been  admitted 
behind  the  scenes. 

The  audience  has  been  permitted  by  prearrange- 
ment  to  pierce  the  disguise  of  Viola.  It  is  only  at 
the  very  end  in  Twelfth  Night  when  the  cards 
have  been  finally  laid  on  the  table  and  Viola  and 
Sebastian  produced  simultaneously  in  the  flesh  that 
the  lives  of  the  remaining  players  are  thought  of 
as  having  been  set  for  all  time  in  a  fixed  pattern. 
How  could  we  consider  Olivia  as  having  been 
comfortably  settled  in  life  when  we,  though  not 
she,  were  aware  this  hour  or  more  that  she  had 
been  wedded  to  the  wrong  human  being?  We  must 
feel  in  the  same  case  in  regard  to  the  Duke  who 
has  amazed  us  by  not  being  able  to  discover  that 
his  sprightly  page,  Cesario,  was  in  truth  a  maiden 
already  deeply  attached  to  him. 


TWINNING— Walsh   &■   Pool 


The  declaration  of  the  twins  in  their  true  light 
makes  an  end  to  all  uncertainty.  We  feel  that 
interesting  as  much  of  the  drama  has  been  in  re- 
gard to  the  minor  characters  it  has  been  but  a  by 
play  after  all.  The  devotion  of  the  twins,  the  over- 
whelming importance  of  their  reunion  toward  which 
they  were  obviously  directing  every  tithe  of  their 
energies  was  what  mattered  most.  As  we  have 
said  without  Viola  and  Sebastian,  without  the 
tragedy  of  their  separation,  without  their  headlong 
love  for  one  another  there  would  have  been  no 
Toby  Belch,  or  Sir  Andrew,  or  any  other  of  the 
amusing  and  compassionate  ones  who  walked  the 
boards. 

The  hope  of  meeting  was  what  held  both 
young  people,  strangers  and  aliens  in  Illyria.  Had 
not  Viola  received  the  encouraging  news  from  the 
sailor  in  the  first  act  as  to  the  possibility  of  Sebas- 
tian having  been  saved  she  must  have  been  on  her 
long  journey  home  before  the  drama  began.  It 
was  no  small  evidence  of  devotion  that  she  was 
willing  to  change  her  sex,  undergo  all  manner  of 
wild  experiences,  threats  upon  her  life,  unrequited 
love  from  another  and  misguided  woman  all  for 
the  purpose  of  remaining  in  Illyria  on  the  chance 
that  her  beloved  Sebastian  might  still  be  in  the 
land  of  the  living.  All  that  we  have  said  of  Viola 
can  be  said  in  part  at  least  of  Sebastian.  That 
Shakespeare  created  his  twins  in  attractive  guise 
is  easily  seen  from  the  course  of  the  play.  Viola 
is  pictured  as  having  a  dual  form  of  allure.  She 
could  create  a  great  passion  in  the  breast  of  Olivia, 
to  whom  she  appeared  as  a  vouth  and  at  the  same 
time  awaken  in  the  Duke  a  love  which  smoldered 
against  all  form  and  precedent  until  her  appearance 
in  her  true  body  made  everything  clear  and  de- 
fensible. Commentators  upon  Shakespeare's  char- 
acters have  gone  to  great  extremes  in  extolling 
Viola's  many  qualifications.  Winter  in  his  Shadows 
of  The  Stage  describes  her  thus: 

"Viola  is  Shakespeare's  ideal  of  the  patient  idol- 
atry and  devoted  silent  self  sacrifice  of  perfect 
love." 

She  was  possessed  not  only  of  rare  beauty  but 
of  a  discerning  soul  as  well.  We  have  been  in- 
trigued by  the  observation  that  Olivia,  who  fell 
in  love  with  Viola  on  sisht,  but  for  reasons  plain 
to  us  but  beyond  her  comprehension  was  repulsed, 
nevertheless  was  enabled  to  create  in  the  mind  of 
Sebastian  a  feeling  toward  her  similar  to  her  own. 

In  a  word  there  was  some  strong  tide  of  emotion 
which  bound  these  three  together  in  a  topsv  turvv 
pattern.  The  psychologist  might  note  also  that  the 
position  of  the  two  women  was  the  same  in  this 
respect.  They  were  both  "oins  through  the  ago- 
nies of  a  separation  bv  death  from  beloved  brothers, 


They  were,  unknown  to  themselves,  perhaps  search- 
ing for  the  great  consolation.  As  for  Sebastian, 
that  he  was  handsome  goes  without  saying.  He 
was  a  masculine  image  of  his  sister.  That  he  was 
unusually  attractive  in  all  ways  the  actions  of 
Olivia,  a  lady  of  high  degree,  make  us  fully  aware. 
He  was  possessed  of  more  than  beauty,  he  was 
filled  with  determination,  with  purpose,  what  he 
wanted  he  reached  for  and  took.  To  quote  Ulrici, 
"taking  with  one  snatch  that  which  the  Duke  has 
in  vain  endeavored  to  obtain  bv  entreaties,  lamen- 
tations and  sighs."  That  he  could  make  friendships, 
the  devotion  of  Antonio  testifies.  He  must  have 
been  capable  of  uncommon  deeds  of  strength  and 
endurance  when  he  was  able  to  rescue  himself  from 
the  shipwreck.  That  he  was  a  veritable  man  among 
men  in  an  age  choleric  and  given  to  violence  is 
shown  bv  the  mauling  he  gave  to  Sir  Tobv  Belch 
and  Sir  Andrew.  He  was,  we  found  out,  an  evil 
man  to  arouse  and  one  fully  capable  of  taking 
care  of  himself  in  any  emergencv.  No  better  com- 
mendation of  the  characters  of  the  twins  Viola  and 
Sebastian  can  be  made  than  to  attest  that  they 
have  been  objects  of  admiration  on  account  of 
their  many  virtues,  not  alone  of  their  little  group 
of  companions  but  of  thousands  of  strangers  for 
well  nigh  four  centuries. 

The  nobility  of  all  the  family  related  to  the 
brothers  Antipholus  is  bravely  stated  in  the  very 
first  exchanges  of  the  play  entitled  The  Comedy 
of  Errors.  This  note  is  sounded  in  the  "prologue 
like"  speech  of  Aegeon  in  the  first  act.  From  this 
statement  we  find  that  the  merchant  has  risked 
not  only  his  fortune  but  his  very  life  itself  by 
venturing  to  the  city  of  Ephesus.  This  adventure 
had  been  brought  about  by  his  desire  to  reunite 
members  of  his  family  who  years  before,  much 
as  in  Twelfth  Night,  had  been  separated  during 
the  course  of  a  ship  wreck.  He  came  to  Ephesus 
in  this  search  knowing  well  that  he  risked  his  life 
thereby.  Not  his  eagerness  alone  brought  about 
the  dangerous  journey. 

As  we  listen  to  his  words  we  discover  that 
the  twin  who  had  remained  with  him  after  the 
separation  at  sea  had  joined  his  supplication  to 
his  father's.  So  that  in  the  end  father,  separate 
son,  seeking  reunion  with  his  brother,  and  finally 
the  twin  servant  Dromio  all  set  out  together  on 
a  common  purpose.  When  the  father  was  con- 
demned in  Ephesus  thev  had  been  years  upon 
their  journev.  With  what  faithfulness  and  at  what 
a  cost  the  search  had  been  carried  on  we  may  dis- 
cern from  one  of  the  paragraphs  of  Aegeon 's  speech 
to  Solinus.  The  expenses  of  this  faring  must  have 
embarassed  the  fortunes  of  one  far  richer  than 
Aegeon.     One  reaction  to  the  description  of  these 


TWINNING— Walsh   &   Pool 


events  must  be  in  the  main  to  the  unselfish  natures 
which  for  the  satisfaction  of  a  family  love  were  led 
to  such  dangerous  adventuring.    Act  One,  Scene 
One,  Line  133 — 
Aegeon 

Five  summers  have  I  spent  in  _ 

farthest  Greece, 
Roaming  clean  through  the  bounds 

of  Asia, 
And  coasting  homeward,  came  to 

Ephesus; 
Hopeless  to  find  yet  loath  to  leave 

unsought 
Or  that  or  any  place  that  harbors  men 
But  here  must  end  the  story  of  my  life; 
And  happy  were  I  in  my  timely  death, 
Could  all  my  travels  warrant  me 
they  live. 
These  expressions  of  a  resigned  heroism  are  what 
we  might  expect  from  Shakespeare  in  his  wish  to 
describe  the  father  of  identical  twins.    And  best  of 
all  for  the  purposes  of  our  story  it  was  a  heroism 
that  was  shared  by  father,  by  son  and  by  twin 
servant.     We  could  have  no  better  introduction  to 
the  characters  of  the  Brothers  Antipholus,  no  fitter 
authentication  of  the  real  fineness  of  their  natures 
than  in  this  opening  address  of  their  father's.  While 
the  father  is  led  away  to  await  his  untimely  end 
Ant.  S.  decides  to  continue  his  search  for  his  broth- 
er though  he  distrusts  the  town   in  which   he  is 
living  and  feels  that  his  time  spent  there  is  full 
of  danger.    Act  One,  Scene  Two,  Line  96 — 
Ant.  S. 

They  say  this  town  is  full  of  cozenage ; 
As,  nimble  jugglers  that  deceive  the  eye, 
Dark  working  sorcerers  that  change 

the  mind. 
Soul  killing  witches  that  deform 

the  body, 
Disguised  cheaters,  prating  mountebanks 
And  many  such  like  liberties  of  sin. 
That  Ant.   S.  was  able   to  evoke   the   deepest 
emotions   in   women   is  made  plain   at   once  from 
the  passionate   diatribe   which   Adriana   addresses 
to  him  when  she  thinks  her  husband  has  turned 
against  her.     Act  Two,  Scene  Two,"  Line  Three— 
Adriana 

Ay,  ay,  Antipholus,  look  strange 

and  frown 
Some  other  mistress  hath  thy 

sweet  aspects; 
I  am  not  Adriana,  nor  thy  wife. 
How  dearly  would  it  touch  thee 
to  the  quick 


Should  thou  but  hear  I  was  licentious 
And  that  this  body  consecrate  to  thee 
By  ruffian  lust  should  be  contaminate: 
I  am  possess'd  with  an  adulterate  blot 
My  blood  is  mingled  with  the  crime 

of  lust 
For  if  we  two  be  one  and  thou 

play  false; 
I  do  digest  the  poison  of  thy  flesh 
Being  strumpeted  by  thy  contagion. 
All  this  bespeaks  an  attachment  which  has  been 
founded  upon  a  rock.     The  woman's  devotion  to 
her  husband  is  all  embracing,  the  suggestion  that 
he  is  playing  her  false  well  nigh  sets  her  mad.   As 
further  proof  of  the  attraction  of  the  two  brothers 
witness  the  scene  between  Antipholus  S.  and  his 
sister  in  law,  Luciana.    Act  Three,  Scene  Two,  Line 
One. 

Here  occur  some  of  the  most  heart  searching 
lines,  in  the  play.  All  through  this  intimate  ex- 
change it  is  evident  that  the  lady  while  loyal  to  her 
sister's  cause  is  maintaining  her  position  with  some 
difficulty.  Through  her  lines  shows  the  undoubted 
affinity  which  she  is  already  feeling  for  Ant.  S. 
even  though  she  still  considers  him  in  truth  her 
sister's  husband.  The  exchanges  between  the  two 
have  been  often  commented  upon  and  admired. 
For  our  purpose  they  serve  as  additional  proof  of 
the  powers  of  attraction  which  reinforced  the  per- 
sonalities of  the  Brothers  Antipholus.  Far  from 
being  a  proof  of  personality  defect  the  irritability 
displayed  at  times  bv  Ant.  E.  throughout  the  scenes 
we  think  may  be  considered  but  a  deeper  insight 
and  appreciation  of  the  incompleteness  which  the 
separate  partner  of  a  twin  presents.  It  must  be 
remembered  that  Ant.  E.  is  the  one  who  has  lived 
most  alone. 

Durinsr  his  adolescence  he  did  not  have  the  sup- 
porting influences  of  either  his  father  or  his  brother. 
That  he  was  peevish,  somewhat  inclined  to  vio- 
lence, what  today  we  would  call  temperamental 
to  nur  minds  was  all  intentioned  on  the  part  of 
his  creator.  The  latter  we  think  was  showing  us 
what  incompleteness  might  produce  in  a  solitary 
twin  bereft  of  his  alter  ego.  If  we  might  hazard 
a  guess,  we  mieht  suggest  that  he  was  the  left 
handed  one  of  the  combination. 

That  he  was  well  regarded  in  the  community 
we  feel  sure  from  the  experiences  described  by 
Ant.  S.  as  he  wanders  around  the  city  and  is  mis- 
taken for  his  brother.  Shakespeare  would  allow 
no  depreciation  of  one  of  his  twins  by  his  neigh- 
bors. Nor  did  as  we  will  quickly  see.  Act  Four, 
Scene  Three,  Line  One — 


122 


TWINNING— Walsh    &   Pool 


March   1941 


Ant.  S. 

There's  not  a  man  I  meet  but 

doth  salute  me 
As  if  I  were  their  well-acquainted 

friend ; 
And  every  one  doth  call  me  by  my  name, 
Some  tender  money  to  me;  some 

invite  me; 
Some  other  give  me  thanks  for 

kindnesses ; 
Some  offer  me  commodities  to  buy 
Even  now  a  tailor  called  me  in  his  shop 
And  showed  me  silks  that  he  had 

bought  for  me 
And  therewithal  took  measure  of 

my  body 
Sure  these  are  but  imaginary  wiles, 
And  Lapland  sorcerers  inhabit  here. 
The  character  which  Ant.  E.  bears  in  his  own 
city  is  aptly  brought  out  by  the  exchanges  which 
take  place  between  Angelo,  the  goldsmith  and  the 
Second  Merchant  when  they  discuss  the  mystery 
of  the  gold  chain  which  has  been  delivered  to  the 
wrong  twin.    Act  Five,  Scene  One,  Line  One — 
Angelo 

I  am  sorry,  sir,  that  I  have  hindered  you; 
But  I  protest  he  had  the  chain  of  me, 
Though  most  dishonestly  he  doth  deny  it. 
Second 
Merchant 

How  is  the  man  esteemed  here 
in  the  city? 
Angelo 

Of  very  reverent  reputation,  sir 
Of  credit  infinite,  highly  beloved, 
Second  to  none  that  lives  here  in  the  city 
His  word  might  bear  my  wealth 
at  any  time. 
Shakespeare  has  established  the  worthy  charac- 
ters of  his  twins  many  times  throughout  the  lines 
of  the  play.     They  set  the  measure  of  the  piece. 
When  their  perplexities  come  to  an  end  the  play 
does  also  and  the  minds  of  all  the  characters  are 
set  at  rest. 

To  think  of  the  events  surrounding  twinning  in 
the  Bible  is  to  review  a  scene  of  violence  and  de- 
ceit. Misfortune  is  the  reward  of  those  who  figure 
in  such  happenings.  These  misfortunes  vary  from 
flight  to  prevent  one's  destruction  as  in  the  case 
of  Jacob,  to  the  conviction  of  incest,  and  the  sub- 
sequent disgrace  as  befell  Judah.  The  scriptures 
bring  forward  no  ameliorating  circumstances.  The 
stories  of  the  two  twinnings  are  tales  of  stark 
tragedy.  Human  nature  is  shown  at  its  worst, 
treacherous,  grasping,  bloody  minded. 

The  immortal  bard  ends  one  of  his  stories  of 


twinning  with  the  haunting  melody  of  the  Clown's 
song, 

''With  hey,  ho  the  wind  and  the  rain." 

All  is  well  with  the  principals  of  the  drama. 
Twin  brother  and  sister  have  found  mutual  happi- 
ness. Their  harrowing  adventures,  separation  by 
ship  WTeck  serve  only  as  a  background  to  light 
their  present  happiness.  Their  wandering  days 
have  come  to  an  end.  They  have  received  a  reward 
for  their  many  virtues.  So  too  in  The  Comedy  of 
Errors.  All  the  uncertainities  that  arose  due  to 
the  mistakes  in  identity  have  been  settled  to  the 
satisfaction  and  amusement  of  all.  We  see  the 
final  scene  of  a  well  rounded  comedy.  It  is  a 
significant  thing  that  Shakespeare  elected  to  treat 
twinning  in  this  lighter  vein.  What  he  might  have 
done  with  it  had  he  so  desired  a  reading  of  such 
a  play  as  King  Lear  informs  us.  He  could  not  see 
the  strange  happening  in  that  light.  To  him  it 
was  something  to  be  extolled,  something  out  of 
which  an  amusing  story  with  a  happy  ending  might 
be  suitably  devised. 

The  curtain  is  about  to  fall  on  The  Comedy  of 
Errors.  The  Abbess  has  invited  all  and  sundry 
into  her  home  to  celebrate  what  has  happened  and 
what  is  to  come.  Solinus  the  Duke  of  Ephesus 
voices  the  sentiments  of  many  in  his  final  unctuous 
line. 

"With  all  my  heart,  I'll  gossip  at  this  feast." 

References 

1.  The  Lancet,  Editorial,  Volume  I,  No.  XXVI,  1940. 
June  29,   1940. 

2.  Groesbeck  Walsh  and  R.  M.  Pool,  Twins  and  Twin- 
ning, Southern  Medicine  and  Surgery,  Vol.  102,  No.  4, 
April,   1940. 

3.  Groesbeck  Walsh  and  R.  M.  Pool,  Shakespeare's 
Knowledge  of  Laterality  Dominance.  (Awaiting  Pub- 
lication) . 

4.  Horatio  H.  Newman,  Frank  N.  Freeman  and  Karl 
J.  HoLzrNGER,  Twins  A  Study  of  Heredity  and  En- 
vironment.  The   University   of  Chicago   Press,   1937 

5.  Horatio  H.  Newman,  The  Physiology  of  Twinning, 
The   University   of   Chicago   Press,   1923. 

6.  The  Meaning  of  the  Glorious  Koran,  An  Explanatory 
Translation,  By  Marmaduke  Pichthall,  Published  by 
Alfred  A.  Knopf,  New  York,  1930. 

7.  Horatio  H.  Newman,  Multiple  Human  Births,  Pub- 
lished by   Doubleday  Doran  and  Company,   1940. 

S.  Shakespeare's  Biblical  Knowledge  and  Use  of  The  Book 
of  Common  Prayer  as  exemplified  in  The  Plays  of  The 
First  Portfolio,  By  Richmond  Noble,  Published  by 
The  Society  For  Promoting  Christian  Knowledge,  Lon- 
don. England,  1935. 


O  &  65— From  Page  110 
in  the  rush  of  getting  overseas.  Hospital  work 
got  lighter  and  one  could  take  time  to  get  acquaint- 
ed with  the  surrounding  country.  And  Thanks- 
giving had  a  new  meaning  because  of  the  Armis- 
tice 


March   1941 


HOSPITAL  UNIT  0  &■  B.  H.  65—Brenizer  &  Hones 


123 


The  work  of  Hospital  Centre  Kerhuon  now  was 
to  get  the  men  started  back  home.  We  had  many 
returning  from  the  front  to  be  put  in  the  best  con- 
dition possible,  nursed,  equipped  and  sent  to  the 
returning  ships.  The  tendency  was  not  to  send 
us  the  more  serious  cases,  but  convalescent  wound- 
ed, and  later  our  work  was  that  of  an  equipping 
and  evacuating  point. 

There  was  a  certain  feeling  in  belonging  to  the 
"Original  65"  and  a  Carolina  Club  was  organized 
which  gave  several  delightful  dances,  during  the 
period  that  restrictions  were  lifted.  A  Masonic 
Club  was  formed  at  Casemates  Fautras  and  served 
to  bring  together  men  from  all  over  the  U  .S. 

May  30th,  Memorial  Day  in  a  foreign  country 
and  with  many  of  our  dead  near  us,  gave  oppor- 
tunity for  observation  and  thought  that  many  will 
never  forget.  Many  received  three-day  leave  in 
Paris  and  enlarged  their  views  of  France. 

July  14th  we  had  our  farewell  dance,  and  watch- 
ed the  fireworks  in  the  harbor,  the  French  celebrat- 
ing, and  all  search-lights  from  our  ships  playing. 

Sergeant  Hoffman  tells  us  that  "Casuals  who 
had  been  all  over  France  said  we  fed  better  than 
any  other  post." 

The  following  list  includes  the  names  and  aa- 
dresses  a  few  years  after  the  war  of  the  corps  men 
of  Base  Hospital  65: 

C.  R.  Albea,  G.  M.  Apperson,  G.  H.  Allman, 
A.  E.  Bennett,  J.  R.  Binkley,  L.  W.  Binkley,  G. 
W.  Boger,  S.  L.  Byerly,  A.  T.  Cobb,  C.  V.  Connell, 

F.  S.  Dalton,  Z.  A.  Davis,  T.  E.  Dodson,  H.  D. 
Doyle,  S.  VV.  Evans,  H.  E.  Frazier,  R.  C.  Gilbert, 
S.  J.  Goforth,  R.  D.  Hancock,  J.  D.  Hankin,  Jake 
Hege,  Ollie  Hege,  W.  E.  Helsabeck,  Hazel  Hitch- 
cock, M.  W.  Ingle,  G.  L.  Johnston,  W.  D.  Joyce, 
Wm.  A.  Julian,  J.  E.  King,  T.  R.  Lehman,  H.  T. 
Lilly,  W.  G.  Marler,  S.  W.  Minter,  J.  F.  Morton, 
M.  W.  Morton,  R.  J.  McCollum,  E.  E.  Norman, 
J.  L.  Palmer,  R.  J.  Patterson,  R.  D.  Peeler,  W.  B. 
Pierce,  J.  L.  Poindexter,  Wm.  R.  Poindexter,  J.  C. 
Pulliam,  J.  R.  Sharpe,  J.  H.  Smitherman,  J.  F. 
Southern,  Clarence  Warner,  G.  F.  Webb,  W.  B. 
Williams,  H.  S.  Wimbish,  O.  E.  Wright  and  Wm. 
Wright,  Winston-Salem;  L.  G.  Albright,  E.  L.  Al- 
ston, Jack  Anthony,  J.  W.  Andrews,  P.  H.  Beeson, 

G.  A.  Burns,  H.  H.  Bristow,  J.  F.  Case,  G.  C.' 
Clark,  R.  W.  Clemmons,  George  Creson,  R.  C. 
East,  J.  T.  Heath,  A.  B.  Holt,  E.  B.  Huffines,  J. 

F.  Job,  W.  C.  Kerr,  E.  W.  Knight,  G.  P.  Mead- 
ows, R.  C.  Milliken,  C.  A.  Pope,  M.  L.  Ralls,  Max 
Reeves,  J.  P.  Reeves,  0.  W.  Thomas,  M.  S.  Turner, 

G.  A.  York,  G.  W.  Tyson  and  J.  S.  Ridge,  Greens- 
boro; W.  P.  Bain,  Lexington;  E.  T.  Beddingfield, 
Clayton;  Wm.  I.  Berryhill,  J.  H.  Collins,  G.  R.' 
Hamilton   and   A.   E.   Presnell,   Charlotte;    J.   C. 


Bolton,  J.  R.  Garrison,  Jesse  Harris,  A.  E.  Holmes, 
J.  J.  Pittman,  H.  A.  West  and  H.  A.  White,  Fay- 
etteville;  J.  C.  Burgess,  Glenwood;  F.  E.  Brown, 
Cycle;  J.  W.  Bryan,  Jr.,  Greenville;  Shorty  Boyd, 
Kinston;  Charles  Craig,  J.  W.  Cunningham,  E.  J. 
Jones,  F.  W.  Morris  and  George  B.  Prather,  Gas- 
tonia;  Ben  Cabel,  J.  M.  Watson  and  G.  E.  Way- 
nick,  Elon  College;  J.  D.  Chavey,  Hollman;  S. 
W.  Daniels.  Oxford;  A.  L.  Cobb,  C.  W.  Coving- 
ton, M.  B.  Fels,  M.  H.  McMichael,  J.  L.  Pinnix 
and  C.  G.  Strader,  Reidsville;  L.  H.  Fogleman, 
Snow  Camp;  A.  L.  Freeze,  H.  G.  Hedrick,  G.  W.' 
Lowe,  R.  B.  Pegram,  H.  E.  Samuels,  David  Stan- 
ton, L.  R.  Sykes,  C.  W.  Thompson,  E.  L.  Winfrey 
and  J.  U.  Wright,  High  Point;  A.  P.  Fulk,  J.  M. 
Hiatt,  J.  E.  Needham  and  R.  R.  Redmon,  Pilot 
Mountain;  F.  M.  Fuller,  J.  B.  King  and  W.  B. 
Tucker,  Louisburg;  C.  H.  Gibson,  Madison;  Z.  V. 
Harris,  Trinity;  J.  E.  Harris,  Henderson;  J.  C. 
Hanes,  Mocksville;  L.  V.  Hart,  Tarboro;  P.  B. 
Henley,  J.  F.  Lewallen,  W.  C.  Page  and  C.  T. 
Richardson,  Asheboro;  A.  L.  Hood,  Lenoir;  R.  E. 
Hollingsworth,  Mount  Airy;  P.  R.  Home,  Wades- 
boro;  S.  W.  Hoffman,  M.  R.  Long,  J.  G.  Mor- 
rison, E.  L.  Nash  and  L.  B.  Shaver,  Statesville; 
M.  G.  Jenkins,  Rosemary;  P.  M.  Jordan,  Gibson- 
ville;  R.  A.  Joyce,  Danbury;  G.  L.  Lawrence, 
Elkin;  L.  A.  Lefort,  Denim;  W.  S.  Linville,  Jr., 
Kernersville;  J.  T.  Matthews,  East  Bend;  H.  A.' 
Mitchel,  Archdale;  J.  M.  Morgan,  Dunn;  B.  A. 
Mahaffey,  Hiddenite;  D.  M.  McMillan  and  R. 
A.  McQueen,  Red  Springs;  D.  L.  Nance,  Oak 
Ridge;  M.  B.  Neal,  Walnut  Cove;  F.  L.  O'Neal 
and  W.  D.  Perkins,  Selma;  P.  L.  Pearson  and 
T.  G.  Williams,  Raleigh;  M.  W.  Page,  Elm  City; 
M.  D.  Privett  ,  Lovelace;  C.  J.  Roberts,  Went- 
worth;  M.  C.  Ross,  Bonnerton;  D.  D.  Sherrill, 
Catawba;  A.  L.  Smith,  Concord;  J.  D.  Snow[ 
Rusk;  Tonie  Stott,  Bailey;  Clyde  Thomas,  Stone- 
vdle;  R.  S.  Toxey,  Elizabeth  City;  0.  P.  White, 
Salemburg;  P.  W.  Whitlock,  Salisbury;  R.  L.  Wil- 
moth,  State  Road;  R.  C.  Wilkerson,  Kenly;  J.  W. 
Thomasson,  Buck  Shoals;  W.  D.  Alford,  Hanni- 
bal, Mo.;  Gordon  Bowers,  Sevierville,  Temr  M 
A.  Byerly,  P.  A.  Dixon  and  C.  M.  Sherrill,  Roa- 
noke, Va.;  Dwight  Brantly,  Omaha,  Neb.;  D.  R 
Cox,  Pulaski,  Va.;  A.  M.  Clement,  and  G.  C  Bur- 
chett,  Louisville,  Ky.;  C.  R.  Franks  and  J.  C. 
Twiggs,  Hiawassee,  Ga.;  J.  B.  Gill,  Miami,  Fla.; 
D.  S.  Hollenga,  Petersburg,  Va.;  T.  A.  Hooper 
Cleveland,  Ga.;  P.  C.  Hunter,  Chicago-  O  H 
Johnson,  Fargo,  N.  D.;  D.  W.  Mitchell,' Dalton,' 
Ga.;  W.  L.  Morris,  Wytheville,  Virginia;  D.  j! 
Robertson,  (address  unknown);  J.  S.  Rogers,  Han- 
over, Ind.;  Wm.  F.  Rodgers,  East  Cambridge, 
Mass;  Roy  Thomasson,  Detroit;  C.  H.  Wicks,  Jr., 


HOSPITAL  UNIT  0  &  B.  H.  65—Breriizer  &  Banes 


Syracuse,  N.  Y.;  S.  M.  Wrenn,  Richmond;  M. 
F.  Wright,  Providence;  W.  D.  Wylie,  Buffalo; 
E.  J.  Adsit  (unknown);  O.  J.  Allison,  Columbia, 
S.  C;  R.  A.  Dean,  Durham;  W.  H.  Creech,  Selma; 
E.   B.   Page,   Wilmington,   Va. 

The  following  is  a  consolidated  report  of  Base 
Hospital  No.  65  (B.  H.  No.  92  &  105)  included. 
H.  C.  Kerhuon,  A.  P.  O.  Amer.  E.  F. 

Transferred  Transferred 

To     Discharged    To 
United        To        Other 
Date     Admissions     States     Duty     Hospitals     Deaths 
September 

1918  80S  0  31  0  3 

October 

1918  3491  74  1062  436  584 

November 

1918  8298  6164  268  734  27 

December 

1918  3631  5447  170  0  20 
January 

1919  4179  2736  149  0  4 
February 

1919  7538  7184  284  0  7 

March 

1919  9191  7405  381  0  13 

Grand 
Total  37133         29010  2345  1170  658 

Comparing  the  services  of  Hospital  Unit  O 
merged  immediately  on  arrival  at  Talence  near 
Bordeaux  with  the  Base  Hospital  from  the  Massa- 
chusetts General  Hospital  of  Boston  to  form  Base 
Hospital  No.6,  with  the  services  of  Base  Hospital 
No.  65  there  was  a  distinct  advantage  to 
the  entire  personnel  of  Hospital  Unit  O  in  that 
the  Mass.  General  Hospital  unit  had  already  been 
located  for  several  months  in  a  boys'  school,  which 
they  had  almost  entirely  reconstructed  and  t  o 
which  they  had  added  both  brick  and  wooden 
barracks,  connected  by  covered  and  steam  heated 
corridors  and  board  and  brick  walks.  The  steam 
heated  barracks,  reception  rooms  and  operating 
rooms  made  it  possible  to  divide  the  surgical  pati- 
ents into  three  classes:  (1)  The  recently  operated 
on  or  acutely  ill;  (2)  the  convalescent  and  (3) 
the  ambulatory.  In  addition,  Base  Hospital  No. 
6  was  backed  by  various  hospitals  at  Bacheville 
and  DeSouge,  as  well  as  Colonel  Bergonie's  farm 
and  the  hospitals  in  the  extreme  rear.  When  Beau 
Desert  was  first  used,  and  it  was  never  used  much 
beyond  this  initiation,  it  was  lent  nearly  2,000  beds 
and  equipment  from  the  supplies  of  Base  Hospital 
No.  6.  The  construction  of  Base  6  and  the  pro- 
viding of  supplies  was  due  almost  entirely  to  the 
foresight  and  management  of  Colonel  Washburn, 
former  superintendent  of  the  Mass.  General  Hos- 
pital, Boston.  He  was  a  superb  officer  and  hospital 
manager,  very  strict  but  fair  in  the  extreme.    We 


regretted  that  he  was  removed  to  England  and  that 
a  weaker  command  was  left  with  Colonel  Babcock 
in  spite  of  all  the  plans  Colonel  Washburn  had 
laid  down. 

While  the  service  of  Base  Hospital  No.  65  was 
largely  medical  and  done  under  conditions  near 
and  after  the  armistice,  and  met  under  conditions 
of  extreme  disorganization  at  Brest,  the  service  of 
Hospital  Unit  O  and  the  Mass.  General  Hospital 
Unit  was  largely  surgical,  first  to  the  French  and 
English  and  to  German  prisoners,  and  then  to  our 
men,  from  July  18th,  1918  on  to  the  completion 
of  our  activities  in  France.  The  surgical  cases 
listed  in  the  operating  room  book,  which  I  still 
possess,  were  17,466  from  March  19th,  1918  to 
February  14th,  1919,  when  we  were  replaced  by 
other  units  and  set  sail  for  home. 

The  greatest  "renown  gained  and  maintained  by 
any  of  the  doctors  of  these  two  hospital  units  has 
been  that  of  Lieut.  Col.  Frederic  Hanes  as  Pro- 
fessor of  Medicine  at  Duke  University  and  of 
Major  Wm.  Allan  with  his  work  in  Heredity.  Major 
Jas.  M.  Northington  has  contributed  greatly  to 
medical  publication,  to  the  literary  style  of  the 
medicine  of  this  section,  and  its  better  organiza- 
tion, and  he  has  been  the  stout  champion  of  the 
general  practitioner.  However,  I  suspect  that  al- 
though these  doctors  and  officers  gave  their  ser- 
vices Unstintingly  and  efficiently  to  the  cause  of 
war,  the  war,  in  fact,  was  wasted  time  for  them, 
and  that  their  successes  lie  further  back  in  train- 
ing and  within  themselves,  than  anything  the  war 
period  had  to  offer  them. 

I  think  it  will  be  seen  again,  now,  how  the  doc- 
tors all  over  our  country  will  respond  to  the  call, 
and  will  give  themselves  over  entirely  to  the  cause, 
if  we  go  again  to  war. 


AN  ABORTIVE  FOR  THE  COMMON  COLD 
(M.  Kovnat,  State  Island,  in  Med.  Rec,  Mar.  5th) 
Fresh  TJ.  S.  P.  tincture  of  iodine,  8  minims  every  few 
hours  for  several  days  has  been  used  in  a  routine  general 
practice  during  the  past  four  years.  It  is  our  belief  that 
it  has  been  successful  in  aborting  the  common  cold  in  the 
great  majorti  yof  cases.  Except  for  slight  diuresis  no  un- 
toward effects  have  been  noted.  There  has  been  no  case 
of  iodism. 


EXFOLIATIVE  DERMATITIS  AND  DEATH  DUE  TO 

PHENOBARBITAL 

(D.  L.  Sexton,  et  al.,  St.  Louis,  in  //.  A.  M.  A.,  Feb.  22nd) 

Phenobaibital   is   advisable,  to   administer  first  in   small 

doses,   increasing   gradually    until    tolerance   is   established. 

Withdrawal  of  the  drug  at  the  first  appearance  of  the  rash 

is  the  safest  procedure.    Even  then  a  severe  constitutional 

'eaction  may  occur,  but  for  the  most  part  a  fatal  outcome 

will  be  averted,    he  tolerance  of  phenobarbita.1  depends  on 

individual   susceptibility.    A   case   is   reported   emphasizing 

these  points. 


SOUTHERN  MEDICINE  &■  SURGERY 


125 


Spontaneous  Hypoglycemia:  Report  of  Cases* 

F.  Raymond  Keating,  Jr.,  M.  D., 
Fellow  in  Internal  Medicine,  Mayo  Foundation 

AND 

Russell  M.  Wilder,  M.  D., 

Division  of  Medicine,  Mayo   Clinic 

Rochester,  Minnesota 


HYPOGLYCEMIA  may  or  may  not  be 
accompanied  by  symptoms.  In  either  case 
it  depends  on  abnormality  of  the  mecha- 
nisms which  regulate  the  level  of  blood  sugar.  Ir- 
regularity develops  in  pathologic  conditions  of  the 
liver,  in  the  presence  of  insufficient  function  of  the 
anterior  lobe  of  the  pituitary  gland,  the  cortex  of 
the  adrenal  gland  or  thyroid  gland,  and  in  organic 
or  functional  disorders  of  the  nervous  system  as 
well  as  in  disorders  of  the  pancreas. 

The  symptoms  of  hypoglycemia,  whatever  the 
cause,  result  from  the  hypoglycemia  itself,  and 
never  from  insulin  unless  hypoglycemia  is  pro- 
duced by  an  excess  of  insulin.  Particularly  im- 
pressive symptoms  of  hypoglycemia  are  hunger, 
weakness,  disorientation  and  a  strikingly  prompt 
relief  of  symptoms  after  taking  sugar. 

A  number  of  writers  have  suggested  that  the 
so-called  nervous  hypoglycemia,  that  is,  the  hypo- 
glycemia of  patients  who  have  unstable  nervous 
systems,  or  recognizable  functional  nervous  dis- 
orders, represents  functional  hyperinsulinism.  The 
suggestion  is  unsupported  by  evidence  and,  in  our 
opinion,  isolated  attacks  of  spontaneous  hypoglyce- 
mia are  never  in  themselves  sufficient  evidence  to 
justify  the  diagnosis  of  a  primary  disorder  of  the 
pancreas  or  other  organs  in  the  blood  sugar  regu- 
lating system. 

On  the  other  hand,  hyperinsulinism  should  be 
recognized  as  a  disease.  Its  diagnosis  has  been 
established  with  complete  reliability  only  in  cases 
in  which  operation  or  necropsy  has  revealed  an 
adenoma  or  carcinoma  originating  in  the  islands 
of  Langerhans.  The  number  of  such  cases  has 
been  small.  Frantz,  who  recently  reviewed  the 
world  literature,  found  only  ninety-six  cases  in 
which  the  diagnosis  had  been  proved  at  operation 
or  necropsy.  We  can  add  to  his  compilation  six 
earlier  cases  from  the  Mayo  Clinic  which  he  failed 
to  include  and  four  cases  heretofore  unreported. 
This  gives  a  total  of  106  cases. 

Eighteen  cases  of  hyperinsulinism  have  been 
identified  at  the  clinic  in  fourteen  years.  Sixteen 
were  found  at  operation  and  two  at  necropsy.    In 

'^eu^.tSfA'3SS.formed  ,he  b"i'  for  •  kctu™  *- 


the  same  period  hyperinsulinism  was  suspected 
and  operation  was  performed  in  eighteen  additional 
cases  without  finding  tumors  of  the  islet  cells.  In 
five  of  these  cases  evidence  of  hepatic  disease  could 
account  for  hypoglycemia.  In  the  remaining  thir- 
teen, nothing  abnormal  was  revealed  at  operation. 
Hyperinsulinism  also  has  been  diagnosed  in  nine 
cases  in  which  operation  was  not  performed.  In 
summary,  hyperinsulinism  has  been  diagnosed  or 
suspected  in  forty-five  cases  at  the  clinic;  opera- 
tion or  necropsy  confirmed  the  diagnosis  in  only 
eighteen. 

The  group  of  thirteen  cases  in  which  operation 
revealed  neither  tumor  of  the  pancreas  nor  disease 
of  the  liver  provides  material  for  special  attention. 
In  an  undetermined  number  of  cases  a  tumor  of 
the  pancreas  may  have  been  overlooked.  In  some, 
we  possibly  had  to  deal  with  primary  overactivity 
of  nontumorous  insular  tissue,  analogous  to  the 
hyperthyroidism  of  exophthalmic  goiter.  In  the 
latter,  diffuse  cellular  hypertrophy  and  hyperplasia 
of  thyroid  tissue  can  be  identified  microscopically. 
In  analogous  cases  of  suspected  hyperinsulinism 
in  the  absence  of  tumor,  microscopic  examination 
of  tissue  from  the  pancreas  occasionally  reveals 
changes  that  suggest  hypertrophy  or  hyperplasia 
of  islet  tissue.  However,  estimation  of  the  relative 
amount  of  insular  tissue  is  attended  with  great 
difficulties.  In  a  few  cases  of  this  type,  subtotal 
resection  of  the  pancreas  or  a  comparable  pro- 
cedure has  been  corrective.  David,  in  a  recent 
review,  stated  that  of  seventeen  patients  so  treated, 
eleven  were  apparently  cured  and  another  im- 
proved. Thus,  the  evidence  for  hyperinsulinism 
in  such  cases  is  by  no  means  complete. 

The  foregoing  explains  why  a  degree  of  uncer- 
tainty attends  the  diagnosis  of  hyperinsulinism  in 
many  cases.  Before  the  pancreas  is  explored,  a 
diagnosis  at  best  can  be  only  a  presumptive  deci- 
sion as  to  probabilities.  Nevertheless,  in  all  cases 
of  abnormal  depression  of  the  blood  sugar,  such 
a  decision  must  be  made,  because  if  the  evidence 
for  primary  overactivity  of  the  pancreas  is  inade- 
quate operation  is  uncalled  for;  if  it  is  adequate, 
operation  should  be  performed.    Insular  adenomas 

N.    C,   November  4th,    1940.      by   Dr.    Wilder  at  a  symposium  at 


SPONTANEOUS   HYPOGLYCEMIA— Keating  &  Wilder 


March  1941 


are  likely  to  become  malignant  and  for  this  reason 
alone  should  be  excised.  In  his  review,  Frantz  found 
that  in  five  of  ninety-six  cases  of  islet  tumor  the 
tumors  were  malignant  and  had  metastasized,  in 
twenty-one  they  presented  the  histologic  picture  of 
malignant  growths  but  had  not  metastasized  and 
in  seventy  were  relatively  benign  according  to 
microscopic  examinations.  Removal  of  the  tumor 
provides  lasting  relief  in  cases  in  which  hypoglyce- 
mia depends  on  insulin  exported  from  tumors.  If 
a  tumor  cannot  be  found  in  a  case  that  satisfies 
the  clinical  criteria  demanded  for  a  diagnosis  of 
hyperinsulinism,  surgical  methods  for  reducing  the 
total  export  of  insulin  from  the  pancreas  are  avail- 
able and  deserve  trial. 

Of  the  eighteen  cases  of  islet-cell  tumor  which 
have  been  encountered  at  the  Mayo  Clinic  in  the 
last  fourteen  years,  twelve  were  reported  in  detail 
by  one  of  us  (Wilder")  and  two  were  mentioned 
in  the  tabular  material  in  the  same  work.  In  this 
review  we  shall  report  briefly  five  cases  of  islet 
cell  tumor  with  hyperinsulinism,  one  of  which  was 
included  in  the  tabular  material  elsewhere  but  was 
not  described,  and  four  of  which  were  encountered 
recently. 

In  addition  we  shall  present  nine  cases  of  severe 
spontaneous  hypoglycemia  in  which  islet  cell  tu- 
mors apparently  were  not  the  cause.  Four  of  the 
nine  have  been  reported  elsewhere  in  greater  de- 
tail*. 

Hyperinsulinism  with  Tumor  of  Islands  of 
Langerhans 

In  the  following  cases  the  diagnosis  of  hyper- 
insulinism was  established  by  discovery  of  tumors 
of  insular  origin  at  operation  or  necropsy. 

Case  1. — A  housewife,  aged  fifty-six  years,  registered  at 
the  clinic  on  June  11th,  1940.  For  two  years  she  had 
had  attacks  of  unconsciousness,  occasionally  with  convul- 
sions, mental  lapses  and  confusion.  These  attacks  had 
been  precipitated  by  fasting  or  exercise.  She  also  had  had 
minor  episodes  of  weakness  and  sweating.  Relief  had 
been   obtained   by   taking   food. 

Examination  disclosed  nothing  abnormal.  In  the  course 
of  examination  the  patient  had  hysterical  attacks  of  laugh- 
ing, crying,  weakness  and  trembling.  The  morning  value 
for  blood  sugar  was  0.038  gm.  per  100  c.c.  of  whole  blood. 
A  six-hour  fast  produced  convulsions  and  coma,  but  relief 
was  obtained  after  intravenous  administration  of  a  solu- 
tion of  dextrose.  On  June  17th,  1940  a  small  encapsu- 
lated adenoma  was  removed  from  the  tail  of  the  pancreas. 
Transient  postoperative  diabetes  developed  but  disappeared 
by  the  third  postoperative  day.  A  pancreatic  retention 
cyst  was  drained  surgically.  The  patient  was  seen  again 
three  months  later;   symptoms  had  not  recurred. 

Case  2. — A  woman,  aged  fifty-five  years,  registered 
April  16th,  1940,  and  related  that  attacks  of  convulsions 
and  unconsciousness  had  begun  two  and  a  half  years  prior 
to  registration  and  had  occurred  when  she  was  hungry, 
usually  in  the  morning.  She  also  had  had  minor  attacks 
of  sweating,  weakness,  diplopia  and  drunken  behavior. 

Results  of  examination  were  negative.  The  morning  value 


for  blood  sugar  was  0.038  gm.  per  100  c.c.  After  fasting 
for  sixteen  hours  the  value  was  0.033  gm.  The  patient 
had  convulsions,  but  obtained  instant  relief  from  intra- 
venous administration  of  solution  of  dextrose.  A  diet 
high  in  protein  which  included  sufficient  calories  to  meet 
the  basal  requirement  was  given,  and  60  per  cent  more. 
Six  feedings  per  day  were  prescribed.  The  symptoms  were 
relieved  completly  for  six  days  while  the  patient  was  in 
bed.  Walking  about  before  a  meal  on  the  sixth  day  pre- 
cipitated  a  severe   reaction. 

At  operation  a  small  encapsulated  adenoma  was  removed 
from  the  head  of  the  pancreas.  Transient  postoperative 
diabetes  developed  but  disappeared  after  forty-eight  hours. 
A  pulmonary  embolism  occurred  on  the  sixth  day,  with 
recovery  of  the  patient.  Former  symptoms  had  not  re- 
turned when  she  was  dismissed  three  months  later. 

Case  3. — A  farmer,  aged  thirty-three  years,  registered 
August  19th,  1940,  and  related  that  recurrent  attacks  of 
weakness,  paresthesia,  loss  of  consciousness  and  convul- 
sions, as  well  as  minor  episodes  of  weakness  and  sweating, 
had  increased  in  severity  for  eighteen  months.  Relief  had 
been  obtained  after  eating.  Results  of  examination  were 
negative.  An  electro-encephalogram  revealed  nothing  ab- 
normal. After  fasting  for  seventeen  hours  the  value  for 
blood  sugar  was  0.067  gm.  per  100  c.c.  A  diagnosis  of 
epilepsy  was  made.  The  patient  was  dismissed  and  dilan- 
tin  sodium  (sodium  5.5-diphenyI-hydantoinate)  was  pre- 
scribed. 

The  patient  returned  one  month  later  because  of  pro- 
longed coma  and  convulsions.  He  was  observed  in  his 
second  such  attack  the  night  of  his  arrival  and  the  condi- 
tion was  recognized  as  typical  hypoglycemia;  the  value 
for  blood  sugar  was  0.032  gm.  per  100  c.c.  Prompt  relief 
was  obtained  after  intravenous  administration  of  solution 
of  dextrose.  At  operation  a  small,  well-encapsulated  ade- 
noma was  removed  from  the  middle  portion  of  the  pan- 
creas. The  postoperative  course  was  uneventful  and  the 
patient  was  dismissed  on  the  eleventh  day.  Symptoms 
have  not  recurred. 

Case  4. — A  woman,  aged  fifty-four  years,  registered  on 
January  2nd,  1940.  She  gave  a  history  of  typical  hypogly- 
cemia of  fifteen  years  duration.  Weakness  and  sweating 
had  been  precipitated  by  exercise  or  hunger  and  relieved 
by  food.  Onset  of  attacks  of  unconsciousness  had  begun 
four  years  prior  to  registration.  These  had  become  in- 
creasingly prolonged  and  had  been  associated  with  con- 
vulsions. The  patient  had  learned  to  control  these  attacks 
by  means  of  frequent  feedings. 

Results  of  examination  were  negative.  The  value  for 
fasting  blood  sugar  was  0.040  gm.  per  100  c.c.  A  spon- 
taneous attack  occurred  in  the  hospital  four  hours  after 
a  meal;  the  value  for  blood  sugar  at  this  time  was  0.02S 
gm.  Prompt  relief  was  obtained  after  food  had  been 
taken. 

At  operation  a  well-encapsulated  adenoma  was  removed 
from  the  body  of  the  pancreas.  The  postoperative  course 
was  stormy  and  severe  postoperative  diabetes  developed. 
The  value  for  the  blood  sugar  was  0.400  gm.  per  100  c.c. 
Urinalysis  disclosed  glycosuria  grade  4,  acetone  and  diacet- 
tic  acid.  The  hyperglycemia  disappeared  and  the  urine 
became  normal  by  the  fifth  day.  Drainage  from  the  pan- 
creatic fistula  continued  for  many  weeks.  A  pleural  ef- 
fusion on  the  left  side  was  also  drained.  Secondary  anemia 
developed,  for  which  many  blood  transfusions  were  given. 
When  the  patient  was  dismissed  five  months  after  operation 
she  was  free  of  symptoms. 

Case  5. — A  farmer,  aged  thirty-five  years,  registered  at 
the  clinic  on  March  29th,  1936.  He  stated  that  he  had 
had  a  momentary   lapse   of   consciousness  one   year   prior 


March  1941 


SPONTANEOUS   HYPOGLYCEMIA— Keating  &  Wilder 


127 


to  registration.  Six  months  later  attacks  of  sweating,  men- 
tal confusion  and  dizziness  had  begun.  A  few  days  later 
he  had  become  comatose  and  transient  hemiplegia  had 
developed,  which  had  lasted  for  several  days.  He  had 
been  hospitalized  elsewhere  and  a  diagnosis  of  brain  tumor 
had  been  made.  He  had  recovered  and  had  been  free  of 
symptoms  for  five  months.  Twenty-four  hours  before 
admission  to  the  clinic  he  had  suddenly  become  comatose. 

The  patient  was  comatose  on  arrival  at  the  clinic. 
Results  of  examination  were  negative,  except  for  bilateral 
Babinski  reflexes.  The  spinal  fluid  was  normal;  blood  sugar 
determinations  were  not  recorded.  A  ventriculogram  dis- 
closed an  obstructing  lesion  which  was  thought  to  be 
located  below  the  third  ventricle.  A  presumptive  diagnosis 
of  brain  tumor  was  made. 

Three  days  after  admission  the  patient  regained  con- 
sciousness momentarily  after  intravenous  administration  of 
solution  of  dextrose,  but  he  again  became  comatose  and 
seven  days  later  he  died  of  pneumonia.  At  necropsy  an 
adenoma  of  the  islands  of  Langerhans  was  found;  de- 
generative cerebral  changes  probably  secondary  to  the 
adenoma,  were  present,  as  well  as  evidences  of  broncho- 
pneumonia and  abscesses  of  the  lungs. 

In  four  of  these  five  cases,  hyperfunctioning  ade- 
nomas of  the  islands  of  Langerhans  were  removed 
at  operation,  at  the  clinic  or  elsewhere,  with  ap- 
parent cure.  In  the  fifth  case,  a  similar  tumor, 
entirely  unsuspected,  was  found  at  necropsy.  In 
similar  cases,  assay  of  tissue  from  the  tumor  has 
revealed  a  content  of  insulin  far  in  excess  of  nor- 
mal'. These  cases,  therefore,  can  safely  be  regarded 
as  cases  of  proved  hyperinsulinism.  Certain  fea- 
tures of  the  clinical  data  attract  attention: 

In  each  instance  the  course  of  the  disease  was 
characterized  by  progression  in  the  severity,  fre- 
quency and  duration  of  attacks  of  hypoglycemia. 
In  each  instance,  in  which  a  determination  of  the 
blood  sugar  was  made  in  the  course  of  a  spontane- 
ous attack,  the  level  was  found  to  be  extremely 
low.  In  each  instance  in  which  it  was  determined 
the  morning  value  for  blood  sugar  was  low. 

In  three  instances  in  which  a  fast  test  of  thirty- 
six  hours  was  undertaken,  typical  hypoglycemic 
crises  were  induced,  often  long  before  expiration 
of  the  fast.  Levels  of  blood  sugar  during  such 
attacks  were  always  extremely  low,  varying  from 
0.033  to  0.044  gm.  One  patient  (case  3)  had 
withstood  seventeen  hours  of  fasting  without  symp- 
toms when  food  was  given.  The  value  for  blood 
sugar  at  that  time  was  0.067  gm.  The  diagnosis 
was  established  later  when  he  was  seen  in  a  typi- 
cal spontaneous  attack. 

In  spontaneous  attacks  dextrose  given  intrave- 
nously or  sugar  by  mouth  produced  almost  instan- 
taneous relief  of  symptoms. 

Results  of  dextrose  tolerance  tests  were  not 
helpful.  Marked  variations  occurred  in  the  form 
and  magnitude  of  the  curve  of  blood  sugar.  The 
effect  of  epinephrine  on  levels  of  the  blood  sugar 
was  not  consistent. 


Severe   Spontaneous   Hypoglycemia 

In  the  following  cases  hyperinsulinism  was  sus- 
pected but  no  abnormality  of  the  pancreas  was 
found  at  operation. 

Case  6  (previously  reported  in  detail  by  Judd,  Kepler 
and  Rynearson) . — The  patient,  a  woman  forty-three  years 
of  age,  registered  in  July,  1929.  Her  history  revealed 
that  in  1926  diabetes  mellitus,  with  the  typical  triad,  had 
developed  and  had  increased  in  severity.  When  first  seen 
at  the  clinic,  the  diabetes  was  adequately  controlled  by 
a  diet  low  in  carbohydrate  and  by  administration  of  70 
units   of   insulin  per   day. 

In  1930,  periods  of  intractable  glycosuria,  which  did  not 
respond  to  insulin,  although  some  doses  were  as  large  as 
600  units  per  day,  began  to  alternate  with  periods  of 
severe  and  prolonged  reactions  to  as  small  a  dose  as  10 
units  of  insulin.  In  1931  administration  of  insulin  was 
discontinued.  In  1932,  spontaneous  hypoglycemia  occurred 
every  few  days.  Frequent  feedings  of  a  diet  high  in  car- 
bohydrate were  prescribed.  In  1933  hypoglycemic  coma 
developed  which  lasted  for  two  weeks.  Intravenous  ad- 
ministrations of  solution  of  dextrose  were  ineffective.  This 
attack  was  followed  by  marked  personality  changes  and 
peripheral  neuritis.  The  patient  became  addicted  to  bar- 
biturates. 

At  exploratory  laparotomy  performed  in  1933  the  pan- 
creas was  found  to  be  normal;  biopsy  of  the  liver  disclosed 
the  presence  of  fatty  metamorphosis  and  mild  cirrhosis. 
In  1934  periodic  attacks  of  hypoglycemia  occurred.  Gly- 
cosuria was  present  continuously.  In  1937  the  episodes 
of  hypoglycemia  became  more  frequent.  The  value  for 
blood  sugar  at  this  time  ranged  from  0.S00  to  0.600  gm. 
per  100  c.c. ;  250  gm.  of  sugar  was  excreted  in  the  urine 
in  twenty-four  hours.  In  1938  abdominal  pain,  weakness 
and  anorexia  developed,  followed  by  loss  of  weight.  In 
1939  ascites  developed  and  multiple  paracenteses  were  per- 
formed but  death  occurred.  At  necropsy  atrophic  cirrhosis 
and  fibrosis  of  the  pancreas  were  found. 

Case  7  (previously  reported  by  Judd,  Kepler  and  Ryn- 
earson) . — A  woman,  aged  thirty-six  years,  registered  at 
the  clinic.  Attacks  of  unconsciousness,  convulsions,  somno- 
lence, weakness,  disorientation  and  drunken  behavior  had 
occurred  for  two  years.  Relief  had  been  obtained  by 
eating  or  from  intravenous  administrations  of  solution  of 
dextrose.  Some  improvement  of  symptoms  had  been  noted 
by  frequent  feedings  of  a  diet  high  in  carbohydrate.  The 
patient  was  disoriented  and  behaved  drunkenly  on  arrival. 
The  value  for  blood  sugar  was  0.036  gm.  per  100  c.c. 
unless  she  ate  frequently;  she  did  not  respond  promptly 
to  solution  of  dextrose  given  intravenously.  At  operation 
the  pancreas  was  normal.  Biopsy  of  the  liver  revealed 
fatty  metamorphosis  and  portal  cirrhosis. 

Convalescence  was  uneventful.  The  attacks  continued 
but  remained  mild  if  frequent  feedings  of  a  diet  high  in 
carbohydrate  were  maintained.  The  patient  was  too  weak 
and  mentally  confused  to  work  and  she  died  six  years 
later.  Details  of  the  immediate  cause  of  death  and  findings 
at  necropsy  were  not  obtainable. 

Case  8. — The  patient,  a  farmer  aged  thirty-seven  years, 
registered  on  January  9th,  1940.  The  previous  year  he 
had  had  attacks  of  weakness,  sweating,  diplopia,  disorien- 
tation, drunken  behavior,  convulsions  and  occasional  losses 
of  consciousness.  These  attacks  had  been  precipitated  by 
hard  work.  Results  of  examination  were  negative.  Sweat- 
i*  g.  diplopia  and  tremors  of  the  extremities  occurred  after 
twenty-four  hours  of  fasting.  The  value  for  the  blood 
sugar  at  this  time  was  0.048  gm.  per  100  c.c.  At  the  end 
of  thirty  hours  the  value  was  0.037  gm. 


128 


SPONTANEOUS    HYPOGLYCEMIA— Keating   &■   Wilder 


March   1941 


At  operation  the  pancreas  disclosed  nothing  abnormal, 
but  it  was  ligated.  Hepatitis,  cirrhosis  and  fibrosis  of  the 
liver  were  present;   no  tissue  was  removed. 

Convalescence  was  uneventful  except  for  development  of 
a  temporary  pancreatic  fistula.  Symptoms  have  not  re- 
turned at  the  time  of  this  writing. 

Case  9. — A  woman,  aged  sixty-four  years,  registered  on 
September  17th,  1940.  A  year  prior  to  registration  she 
had  had  an  attack  of  aphasia,  mental  confusion  and  hemi- 
plegia, which  had  cleared  in  three  days.  Two  months 
before  registration  she  had  had  attacks  of  dizziness,  weak- 
ness, sweating,  coldness  and  crying  spells;  her  gait  had 
become  unsteady  and  she  had  become  mentally  confused. 
Eating  had  relieved  the  attacks. 

Examination  revealed  generalized  arteriosclerosis,  mental 
confusion  and  marked  slowness.  The  value  for  morning 
blood  sugar  was  0.048  gm.  per  100  c.c.  After  fasting  for 
thirty-eight  hours  the  value  was  0.042  gm.  Fasting  in- 
creased the  confusion,  talkativeness  and  instability.  Intra- 
venous administration  of  solution  of  dextrose  produced  no 
immediate  improvement.  At  exploratory  operation  the 
liver  and  pancreas  and  other  viscera  appeared  entirely 
normal  The  postoperative  course  was  uneventful.  The 
patient  has  had  no  further  attacks,  but  the  mental  status 
has  not  improved. 

Case  10. — A  girl,  aged  seventeen  years,  registered  on 
November  Sth,  1939.  She  had  diabetes  of  seven  years' 
duration  which  had  been  difficult  to  control  because  of 
the  frequent  reactions  to  insulin.  Two  years  prior  to 
registration  epileptiform  convulsions  had  occurred,  accom- 
panied by  coma  and  sweating ;  at  times  the  value  for  the 
blood  sugar  had  been  low  and  at  other  times  normal  or 
high.  These  attacks  had  increased  in  severity  and  the 
requirement   for   insulin   had  varied. 

Results  of  examination  were  essentially  negative.  The 
patient's  personality  was  peculiar.  Results  of  the  fast  test 
were  negative;  the  value  for  blood  sugar  after  twenty- 
fours  of  fasting  was  0.28S  gm.  per  100  c.c.  There  was 
no  evidence  of  liver  dysfunction.  An  electro-encephalogram 
disclosed  decreased  alpha  waves  and  delta  activity  on  the 
left,  which  suggested  multiple  scattered  lesions.  Operation 
was  not  considered  indicated.  Soon  after  leaving  the  clinic, 
the  patient  had  a  severe  attack  of  hypoglycemia  despite 
large  amounts  of  solution  of  dextrose  given  intravenously , 
the  blood  sugar  three  hours  later  was  so  low  it  could  not 
be  determined.  Consciousness  returned  three  days  later. 
Exploratory  laparotomy  performed  elsewhere  shortly  there- 
after was  negative  and  the  patient  died  postoperatively. 
At  necropsy,  a  tumor  of  the  pancreas  apparently  was  not 
demonstrated.  The  hepatic  cells  were  filled  with  glycogen. 
Analysis  revealed  a  6  per  cent  content  of  glycogen,  which 
autolyzed  slowly.  This  was  interpreted  as  glycogenosis 
(von  Gierke's  disease). 

Case  11. — A  woman,  aged  twenty-eight  years,  registered 
January  Sth,  1940.  Four  years  prior  to  registration  she 
had  been  placed  on  a  reduction  diet  and  had  taken  thy- 
roid substance  for  control  of  obesity.  Too-rapid  loss  of 
weight  had  led  to  discovery  of  diabetes.  Doses  of  insulin 
had  been  increased  to  72  units  in  six  months,  then  three 
months  later,  its  administration  had  been  discontinued. 
Thereafter  the  urine  was  sugar-free  without  insulin  and 
she  gained  30  pounds  (14  kg).  Two  years  before  registra- 
tion attacks  of  unconsciousness  had  begun  which  had 
lasted  for  six  hours,  and  she  had  had  many  attacks  of 
weakness  and  sweating.  Exploratory  laparotomy  performed 
elsewhere  revealed  no  abnormalities.  Just  prior  to  regis- 
tration she  had  had  severe  hypoglycemic  reactions  with 
convulsions. 

Results  of  examination  at  the  clinic  were  negative,  except 


for  mental  confusion  and  facetiousness.  After  fasting  for 
thirteen  hours  the  value  for  blood  sugar  was  0.037  gm. 
per  100  c.c.  A  mild  reaction  occurred.  The  fasting  value 
for  blood  sugar  the  next  morning  was  0.222  gm.  The 
patient  had  several  severe  reactions,  one  after  fasting  and 
three  during  intravenous  administration  of  a  10  per  cent 
solution  of  dextrose.  During  one  attack  the  value  for 
sugar  was  0.022  gm.  in  blood  removed  from  one  arm 
while  a  solution  of  dextrose  was  running  into  a  vein  in 
the  other  arm.  Exploratory  operation  on  January  19th, 
1940,  revealed  nothing  abnormal.  The  pancreas  was  ligat- 
ed. The  postoperative  period  was  stormy.  A  fistula  and 
pleural  effusion  developed  and  the  hypoglycemic  attacks 
continued.  The  patient  returned  in  November,  1940,  and 
a  third  exploratory  laparotomy  was  performed.  The  pan- 
creas, with  the  exception  of  the  head,  was  atrophied. 
Tissue  was   not  removed. 

Case  12  (previously  reported  by  Rushton,  Cragg  and 
Stalker). — A  woman,  aged  thirty-nine  years,  was  admitted 
to  the  Rochester  State  Hospital  on  February  7th,  1939. 
For  seven  years  prior  to  this  she  had  had  paranoid 
ideas  and  periodic  attacks  of  excitement,  irritability  and 
violence;  these  attacks  were  not  related  to  fasting  and 
were  not  relieved  by  food.  Results  of  physical  examina- 
tion were  negative.  A  psychiatric  diagnosis  of  paranoid 
dementia  praecox  was  made.  The  patient  was  negativis- 
tic  and  asocial.  Shortly  after  admission,  she  had  three 
attacks  of  unconsciousness  after  refusing  to  eat.  These 
attacks  consisted  of  weakness,  confusion,  sweating  and 
pallor,  followed  by  coma.  The  value  for  blood  sugar  in 
one  attack  was  0.040  gm.  per  100  c.c.  Prompt  relief  was 
obtained  after  sugar  in  some  form  was  given  orally  or 
intravenously.  A  similar  attack  was  induced  by  fasting 
for  forty  hours;  at  the  end  of  this  time  the  value  for 
blood  sugar  was  0.031  gm.  Prompt  relief  was  obtained 
after  dextrose  was  given.  Other  studies  were  uninforma- 
tive.  Exploratory  operation  revealed  nothing  abnormal. 
The  pancreas  was  ligated  and  the  patient  died  suddenly 
twenty-four  hours  after  operation.  At  necropsy  the  adre- 
nal glands  were  extremely  atrophic  and  the  liver  was  found 
to  be  lacking  in  glycogen. 

In  these  seven  cases,  exploration  of  the  pancreas 
was  undertaken,  either  at  the  clinic  or  elsewhere, 
because  it  was  felt  that  the  tendency  to  downward 
displacement  of  the  level  of  the  blood  sugar  was 
persistent  and  the  symptoms  presented  were  in- 
distinguishable from  those  in  the  cases  in  which 
tumors  could  be  demonstrated.  Analysis  of  the 
clinical  and  laboratory  data  does  not  reveal  any 
consistent  differences  in  the  two  groups  of  cases. 
However,  as  a  group,  these  cases  do  not  present 
the  clear-cut  picture  seen  in  the  cases  in  which 
tumors  were  present.  In  some  of  the  cases,  there 
was  at  times  a  surprising  lack  of  correlation  be- 
tween symptoms  of  hypoglycemia  and  the  level  of 
blood  sugar.  In  some,  the  response  to  dextrose 
administered  during  attacks  was  delayed  or  was 
absent.  In  some,  the  patient  manifested  some 
degree  of  personality  change  between  attacks  of 
hypoglycemia.  In  some,  a  history  of  antecedent 
diabetes  mellitus  was  obtained.  In  one  instance 
(case  6)  diabetes  existed  side-by-side  with  attacks 
of  severe  hypoglycemia. 

Cases    6    and    7    apparently    represent    primary 


SPONTANEOUS   HYPOGLYCEMIA— Keating  &  Wilder 


hepatic  disease  with  selective  or  specialized  de- 
rangement of  the  carbohydrate  function  of  the 
liver.  Both  of  these  patients  died  several  years 
after  exploration.  In  case  6,  necropsy,  which  was 
performed  elsewhere,  was  reported  as  disclosing 
marked  atrophic  cirrhosis  of  the  liver.  It  is  prob- 
ably safe  to  assume,  in  view  of  the  similar  circum- 
stances, that  death  in  case  7  was  due  to  a  similar 
cause. 

In  case  8  cirrhosis  and  fibrosis  of  the  liver  were 
reported  by  the  surgeon,  but  this  was  not  con- 
firmed as  biopsy  was  not  performed.  The  patients 
in  this  case  and  in  case  9  were  relieved  of  further 
symptoms,  at  least  until  the  time  of  dismissal. 
One  cannot,  however,  fairly  assume  on  such  evi- 
dence that  pancreatic  ligation,  which  was  carried 
out  in  these  two  cases,  was  curative. 

Exploration  in  case  9  revealed  nothing  to  ac- 
count for  the  symptoms.  The  patient  in  case  10 
died  after  completely  negative  exploration  per- 
formed elsewhere.  At  necropsy  a  disturbance  of 
glycogenolysis  similar  to  that  found  in  cases  of 
glycogenosis  was  found. 

Both  cases  9  and  10  raise  the  interesting  possi- 
bility that  lesions  of  the  central  nervous  system  in 
the  region  of  the  hypothalamus  may  be  the  cause 
of  the  attacks  of  hypoglycemia.  The  patient  in 
case  9  was  a  woman  who  had  evidence  of  severe 
generalized  and  cerebral  arteriosclerosis;  she  had 
had  a  stroke  a  year  previous  to  the  appearance  of 
the  symptoms  of  hypoglycemia  and  may  have  suf- 
fered from  a  vascular  lesion  which  affected  the 
hypothalamus.  In  case  10  "brittle"  diabetes  was 
present;  this  fact  suggests  the  possibility  that  scat- 
tered lesions  of  the  hypothalamus  attributable  to 
earlier  induced  attacks  of  hypoglycemia  might 
underlie  the  later  tendency  to  spontaneous  attacks 
of  hypoglycemia. 

Meakins  reported  three  cases  of  postencephalitic 
Parkinson's  disease  in  which  attacks  of  convulsions 
were  associated  with  low  values  of  blood  sugar. 
He  urged  further  search  for  other  cases  in  which  a 
connection  between  a  hypothalamic  lesion  and 
hypoglycemia  was  suggested.  Adlersberg  and 
Friedman,  who  reported  on  disturbances  of  carbo- 
hydrate metabolism  in  twenty-one  cases  of  posten- 
cephalitic Parkinson's  disease,  observed  pathologi- 
cally low  levels  of  blood  sugar  in  only  three  cases 
and  these  levels  were  observed  after  administration 
of  SO  gm.  of  glucose.  Hypoglycemia  was  reported 
by  Rathery,  Derot  and  Sterne  in  two  cases  of  sub- 
dural hemorrhage  and  by  Birnbaum  and  Wood  in 
cases  of  general  paralysis. 

Such  a  cause  for  hypoglycemia  is  offered  merely 
as  a  suggestion.  To  answer  the  many  questions 
involved  will  require  much  more  experimental  and 


controlled  clinical  study  than  the  subject  has  re- 
ceived. 

Case  11  is  a  fair  example  of  the  most  puzzling 
group  of  all.  The  severe  disabling  hypoglycemia 
was  unrelieved  by  ligation  of  the  greater  portion 
of  the  pancreas  and  there  was  no  demonstrable 
disease  of  the  liver  or  any  other  organ  to  account 
for  the  persistence  of  the  disability.  In  our  present 
state  of  knowledge,  we  can  neither  explain  such 
cases  nor  offer  any  really  effectual  or  permanent 
relief.  Diet  apparently  can  ameliorate  the  severity 
of  attacks,  but  affects  their  frequency  or  duration 
only  a  little. 

Case  12  represents  a  very  unusual  and  perhaps 
overemphasized  cause  of  severe  spontaneous  hypo- 
glycemia. In  view  of  the  findings  at  necropsy,  this 
case  must  be  regarded  as  one  of  insufficiency  of 
the  adrenal  cortex  attributable  to  adrenal  atrophy 
or  Addison's  disease  without  pigmentation. 
Unusual  Types  of  Hypoglycemia 

The  following  two  cases  represent  unusual  types 
of  severe  hypoglycemia,  which  were  recognized  as 
such  by  the  clinician  and  in  which  surgical  explora- 
tion of  the  pancreas  was  not  advised. 

Case  13. — A  farmer,  aged  sixty-four  years,  registered  at 
the  clinic  September  2nd,  1940.  For  eighteen  months  prior 
to  registration  he  had  had  severe  attacks  of  pain  in  the 
upper  portion  of  the  abdomen  and  progressive  enlargement 
of  the  abdomen.  Temporary  improvement  followed  roent- 
gen therapy.  He  had  been  weak,  constipated  and  had  lost 
38  pounds  (17  kg.)  in  the  two  months  before  registration. 
On  the  way  to  the  clinic  he  had  an  attack  of  weakness, 
dizziness  and  confusion,  which  was  relieved  by  eating. 

On  examination  the  patient  was  cachectic  and  sick.  The 
chief  finding  was  an  enormous,  hard  and  nodular  mass  in 
the  upper  portion  of  the  abdomen,  which  was  apparently 
the  liver.  Roentgenograms  of  the  thorax  disclosed  bilateral 
nodular  metastatic  lesions.  Other  findings  were  not  signifi- 
cant. The  patient  omitted  supper  and  breakfast  in  prep- 
aration for  abdominal  roentgenographic  examination. 
Twenty-one  hours  after  eating  he  became  weak,  confused 
and  ataxic.  He  was  sent  to  the  hospital  and  on  admission 
was  comatose;  the  value  for  the  blood  sugar  was  0.036 
gm.  per  100  c.c.  Intravenous  administration  of  ISO  c.c.  of 
a  10  per  cent  solution  of  dextrose  produced  prompt  recov- 
ery. Two  days  later  a  similar  attack  began  when  break- 
fast was  delayed;  this  was  aborted  by  administration  of 
sugar.  Because  of  the  hopeless  prognosis  further  study  was 
not  carried  out. 

Case  14  (previously  reported  by  Foley,  Snell  and 
Craig) . — A  man,  aged  twenty-eight  years,  registered  on 
December  28th,  1934,  and  told  of  abdominal  pain  and 
weakness  of  a  year's  duration.  Anorexia  had  developed 
and  had  progressed  to  complete  aversion  to  food.  The 
patient  had  lost  38  pounds  (17  kg.)  in  four  months.  At  no 
time  had  he  had  symptoms  of  hypoglycemia. 

Examination  disclosed  a  dull,  lethargic,  cachectic  man 
with  poor  muscle  tone,  eunuchoid  habitus,  scanty  hair  with 
feminine  distribution,  dry  skin  and  acidotic  breath.  Gen- 
eral examination  otherwise  disclosed  nothing  abnormal. 
The  value  for  blood  sugar  on  arrival  (one  hour  after  a 
meal)  was  0.043  gm.  per  100  c.c.  Subsequent  values  varied 
from  0.033  to  0.078  gm.     At  no  time  were  symptoms  ob- 


SPONTANEOUS    HYPOGLYCEMIA— Keating   &   Wilder 


March  1941 


served  which  were  attributable  to  the  low  levels  of  blood 
sugar.  A  gastric  roentgenogram  revealed  the  presence  of  a 
duodenal  ulcer;  a  roentgenogram  of  the  skull  revealed  a 
large  tumor  of  the  pituitary  gland;  examination  of  the 
visual  fields  disclosed  bitemporal  hemianopsia. 

Transfrontal  craniotomy  was  performed  and  a  large  cyst 
of  the  pituitary  gland  was  aspirated  and  partially  removed. 
The  pathologists  made  a  diagnosis  of  chromophobe  ade- 
noma. Convalescence  was  uneventful.  The  patient  was 
dismissed  to  the  care  of  his  physician  in  his  home  locaUty 
on  January  25th,  1935.  He  died  two  months  later.  Details 
of  the  terminal  illness  or  findings  at  necropsy  were  not 
obtained. 

Although  the  data  are  incomplete,  case  13  ade- 
quately illustrates  the  fact  that  occasionally  the 
function  of  the  liver  may  be  sufficiently  disarrang- 
ed by  carcinoma  to  permit  development  of  the  hy- 
poglycemic syndrome.  The  history  and  physical 
findings  in  this  case  adequately  rule  out  any  possi- 
bility that  the  malignant  process  was  primary  in 
the  islands  of  Langerhans. 

Case  14  is  typical  of  the  abnormal  carbohydrate 
metabolism  sometimes  associated  with  disease  of 
the  pituitary  gland.  Despite  persistently  low  levels 
of  blood  sugar,  which  were  often  well  within  the 
range  found  in  cases  of  islet  cell  tumors  associated 
with  hyperinsulinism,  this  patient  had  never  expe- 
rienced symptoms  attributable  to  hypoglycemia. 
Nervous  Hypoglycemia 

Nervous  hypoglycemia  is  a  designation  applied 
here  to  hypoglycemia  associated  with  functional 
neurosis  or  a  hyperirritable  autonomic  nervous 
system.  The  patient  as  a  rule  is  emotionally  un- 
stable. He  complains  of  hunger  and  weakness  be- 
fore meals  and  may  faint  on  occasion.  If  he  faints, 
consciousness  is  regained  in  a  few'  minutes,  without 
treatment  being  necessary.  He  often  complains  of 
high  or  low  pulse  rates,  irregular  respiration  and 
immoderate  perspiration,  but  these  symptoms  are 
usually  not  worse  during  his  episodes  of  hunger 
and  weakness  than  at  other  times.  He  may  be 
hungry  and  weak  at  meal  time,  but  if  the  meal  is 
not  taken  his  hunger  and  weakness  disappear  in  an 
hour  or  two.  Especially  notable  is  an  absence  of 
symptoms  at  night;  the  values  for  blood  sugar 
after  a  night's  fast  are  not  abnormally  low.  In  this 
type  of  hypoglycemia,  the  symptoms  and  low  levels 
of  blood  sugar  are  related  more  to  the  taking  than 
the  withdrawal  of  food:  the  hypoglycemic  phase 
of  the  blood  sugar  time  curve  of  the  dextrose  toler- 
ance test  is  abnormally  low. 

The  failure  of  levels  of  blood  sugar  to  remain 
at  pathologically  low  levels  during  fasting  is  evi- 
dence that  the  pancreas  does  not  secrete  insulin 
continuously  in  such  cases.  Experiments  with  pro- 
tamine-zinc  insulin  have  revealed  that  a  small  and 
continuous  supply  of  insulin  is  sufficient  to  cause 
abnormal  levels  of  blood  sugar  among  fasting  sub- 


jects. Evidence  is  completely  lacking  that  the  pan- 
creas in  cases  of  this  type  is  intermittently  pro- 
voked to  excessive  activity  by  nervous  stimulation. 
It  is  more  probable  that  when  true  hypoglycemia 
is  encountered  in  such  cases,  it  is  a  result  of  direct 
action  of  the  nerves  on  the  glycogen  mechanism  of 
the  liver. 

While  considering  hypoglycemic  symptoms  of 
patients  without  organic  disease,  it  is  perhaps  de- 
sirable to  consider  the  normal  range  of  blood  su- 
gar. 

Matthews  determined  the  postabsorptive  blood 
sugar  of  117  normal  persons  and  found  that  it 
ranged  from  0.06  to  0.11  gm.  per  100  c.c;  the 
values  of  70  per  cent  fell  between  0.07  and  0.08 
gm.  Hart  and  Lisa  analyzed  all  determinations  of 
blood  sugar  made  over  a  six-year  period  at  City 
Hospital,  New  York  City.  This  included  routine 
determinations  in  21,000  cases.  In  about  11  per 
cent  the  concentration  of  blood  sugar  was  less  than 
0.08  gm.;  in  7  per  cent,  between  0.070  and  0.079 
gm.;  in  2.3  per  cent,  between  0.060  and  0.069  gm.; 
in  0.8  per  cent,  between  0.050  and  0.0S9  gm.  and 
in  0.4  per  cent  less  than  0.050  gm.  Symptoms  were 
not  noted  in  the  entire  group  with  the  exception  of 
one  case  in  which  the  level  of  blood  sugar  was  0.030 
gm. 

Sufficiently  strenuous  exercise  may  produce  se- 
vere hypoglycemia  even  among  trained  and  healthy 
athletes."  1B  Patients  who  are  nervous  or  high- 
strung  seem  less  able  than  others  to  withstand 
effectively  the  strain  placed  on  the  homeostasis  of 
the  blood  sugar  by  exercise.  Michael  performed 
several  determinations  of  the  blood  sugar  on  each 
of  thirty  golfers  in  the  course  of  eighteen  holes  of 
golf  after  they  had  eaten  their  usual  luncheon.  The 
values  dropped  to  hypoglycemic  levels  (the  aver- 
age value  was  0.054  gm.  per  100  c.c.)  between  the 
ninth  and  fifteenth  holes,  or  about  two  hours  after 
the  meal.  The  hypoglycemic  period  corresponded 
to  a  period  of  fatigue,  mild  symptoms  of  hypogly- 
cemia and  lessened  efficiency,  as  reflected  bv  poorer 
scores.  Both  the  hypoglycemia  and  severity  of 
symptoms  were  exaggerated  among  the  poorer 
golfers,  apparently  because  of  tension,  anxiety,  and 
greater  output  of  energy,  and  were  far  less  marked 
than  average  among  the  expert  golfers,  who  were 
usually  well  poised  and  relaxed.  A  second  obser- 
vation was  made  on  the  same  group  after  they  had 
eaten  food  which  contained  more  fat  and  less  car- 
bohydrate; consumption  of  sugar  or  candy  at  the 
seventh  and  eighth  holes  resulted  in  elimination 
of  both  hypoglycemia  and  its  symptoms,  as  well  as 
much  better  scores. 

It  may  be  pertinent  to  suggest  that  many  of 
these  persons  who  have  sporadic  attacks  of  hunger, 


SPONTANEOUS   HYPOGLYCEMIA— Keating  &  Wilder 


weakness  and  so  forth  who  are  relieved  by  eating 
sugar,  and  are  therefore  presumed  to  represent 
hypoglycemia,  the  disturbance  lies  not  in  any  ab- 
normality of  carbohydrate  metabolism  itself  but 
rather  in  an  abnormal  sensitivity  of  the  individual 
to  physiologic  excursions  of  the  blood  sugar  level. 
As  has  been  said,  moderate  activity  of  healthy 
persons  may  cause  depression  of  the  blood  sugar 
to  low  normal  or  even  to  hypoglycemic  levels,  with 
or  without  mild  symptoms  of  hypoglycemia.  Also, 
both  the  depression  of  the  level  of  blood  sugar  and 
the  symptoms  appear  to  be  exaggerated  by  tension 
or  anxiety.  As  this  is  true,  it  seems  reasonable  to 
assume  that  just  as  the  nervous  person  overreacts 
to  pain  and  other  stimuli,  he  also  overreacts,  as 
compared  to  a  normal  person,  to  the  level  of  sugar 
in  the  blood. 

Summary  and  Conclusions 

Five  cases  of  hyperinsulinism  caused  by  hyper- 
functioning tumors  of  the  islands  of  Langerhans 
are  reported.  In  three  cases  typical  hypoglycemic 
symptoms  were  induced  by  fasting.  The  symptoms 
were  accompanied  by  low  levels  of  the  blood  sugar, 
and  were  relieved  by  administration  of  dextrose. 
The  fourth  patient  withstood  a  fast  of  seventeen 
hours  but  later  was  observed  in  a  severe  spontane- 
ous hypoglycemic  crisis.  In  the  fifth  case  the  con- 
dition was  not  recognized  until  necropsy.  In  retro- 
spect the  response  of  the  coma  to  administration 
of  dextrose  seems  to  point  to  the  diagnosis. 

Nine  cases  of  severe  spontaneous  hypoglycemia 
not  associated  with  tumor  of  the  islands  of  Langer- 
hans are  presented;  four  of  them  have  been  re- 
ported previously.  In  seven  of  the  nine,  explora- 
tory operations  performed  at  the  clinic  or  else- 
where did  not  reveal  a  tumor  of  the  pancreas.  In 
the  other  two,  abdominal  exploration  was  not  per- 
formed. In  three,  and  perhaps  in  four  of  the  nine 
cases,  the  symptoms  of  hypoglycemia  were  attrib- 
utable to  disease  of  the  liver.  In  one,  the  cause 
was  found  to  be  atrophy  of  the  adrenal  glands.  In 
one,  which  differed  from  the  others  in  the  complete 
absence  of  symptoms  of  hypoglycemia,  a  tumor  of 
the  pituitary  gland  was  found.  In  three,  the  cause 
for  the  hypoglycemia  could  not  be  ascertained.  In 
some  cases  in  which  no  other  cause  can  be  deter- 
mined, the  spontaneous  hypoglycemia  may  be  due 
to  organic  lesions  in  the  diencephalon. 

The  use  of  the  term  "hyperinsulinism"  is  re- 
stricted to  those  cases  of  severe  spontaneous  hypo- 
glycemia in  which  disease  of  the  pancreas  can  be 
demonstrated  and  in  which  operation  on  the  pan- 
creas may  be  expected  to  afford  lasting  relief. 

The  conception  of  functional  hyperinsulinism  is 
unsupported  by  evidence.  The  condition  designat- 
ed as  "nervous  hypoglycemia"  does  not  require  the 


assumption  that  the  pancreas  is  provoked  intermit- 
tently to  excessive  secretion  of  insulin  by  nervous 
stimulation.  Alternative  explanations  of  nervous 
hypoglycemia  are  (1)  abnormal  depression  of  the 
level  of  blood  sugar  owing  to  stimulation  of  nerves 
to  the  liver;  (2)  exaggeration  of  ordinary  physiolo- 
gic fluctuations  of  the  concentration  of  sugar  in 
the  blood  owing  to  tension  and  anxiety,  and  (3) 
hypersensitivity  to  physiologic  fluctuations  of  the 
level  of  the  blood  sugar  analogous  to  hypersensi- 
tivity to  other  stimuli,  notably  that  of  pain. 

References 
1.  Frantz,  V.  K.:  Tumors  of  islet  cells  with  hyperinsulin- 
ism; benign,  malignant  and  questionable.  Ann  Surg., 
112:161-176  (Aug.)  1940. 
2.  David,  V.  C:  The  indications  and  results  of  pancrea- 
tectomy for  hypoglycemia.  Surgery,  8:212-224  (Aug.) 
1940. 

3.  Wilder,  R.  M.:  Clinical  diabetes  mellitus  and  hyper- 
insulinism. Philadelphia,  W.  B.  Saunders  Company, 
1940,  459  pp. 

4.  Wilder,  R.  M.,  Allan,  F.  N.,  Power,  M.  H.,  and 
Robertson,  H.  E.:  Carcinoma  of  the  islands  of  the 
pancreas;  hyperinsulinism  and  hypoglycemia.  /.  A.  M. 
A.,  «>:348-355   (July  30)    1927. 

5.  Judd,  E.  S.,  Kepler,  E.  J.,  and  Rynearson,  E.  H.: 
Spontaneous  hypoglycemia;  report  of  two  cases  asso- 
ciated with  fatty  metamorphosis  of  the  liver.  Am.  J. 
Surg.,  24:345-363   (May)    1934. 

6.  Rushton,  J.  G.,  Cragg,  R.  W.,  and  Stalker,  L.  K.: 
Spontaneous  hypoglycemia  due  to  atrophy  of  the  ad- 
renal glands;  report  of  a  case.  Arch.  Int.  Med.,  66: 
531-540   (Sept.)    1940. 

7.  Meaktns,  J.  C:  Hypoglycemia  following  encephalitis. 
Ann.  Int.  Med.,  13: 1830-1836  (Apr.)   1940. 

8.  Adlersoerg,  D.,  and  Friedman,  R.:  Quoted  by  Meak- 
ins,  J.  C.7 

9.  Rathery,  F.,  Derot,  M.,  and  Sterne,  J.:  Hypoglycemic 
dans  deux  cas  d'hemorragic  meningee  sous-aracbnoid- 
ienne.  Bull.  et.  mint.  Soc.  mid.  d.  hop.  de  Paris,  47: 
1578-1582    (Nov.  2)    1931. 

10.  Btrnbaum,  Leo,  and  Wood,  J.  A.:  Hypoglycemia  as  a 
cause  of  seizures  in  general  paralysis.  M.  Bull.  Vet. 
Admin.,  74:236-240  (Jan.)   1938. 

11.  Foley,  M.  P.,  Snell,  A.  M.,  and  Craig,  W.  M.:  An- 
terior pituitary  tumor  associated  with  cachexia,  hypo- 
glycemia, and  duodenal  ulcer.  Am.  J.  M.  5c,  198:1-8 
(July)    1939. 

12.  Matthews,  M.  W.:  A  study  of  the  one  dose  three 
hour  (standard)  and  the  two  dose  one  hour  (Exton- 
Rose)  glucose  tolerance  tests.  Thesis,  University  of 
Minnesota,  1939. 

13.  Hart,  J.  F.,  and  Lisa,  J.  R.:  Rate  of  occurrence  of 
hypoglycemia;  study  of  21,000  routine  fasting  blood 
sugars.    Endocrinology,  27:19-22    (July)    1940. 

14.  Levine.  S.  A.,  Gordon,  Burgess,  and  Derick,  C.  L.: 
Some  changes  in  the  chemical  constituents  of  the  blood 
following  a  marathon  race.  /.  A.  M.  A.,  82: 1778-1779 
(May  31)    1924. 

15.  Jokl,  Ernst:  Sportarzliche  Kasuistik.  Klin.  Wchnschr., 
72:913-914  (June  10)   1933. 

16.  Michael,  Paul:  Blood  sugar  studies  on  golfers.  /.  A. 
M.  A.,  775:286-287  (July  27)   1940. 


SOUTHERN  MEDICINE  &  SURGERY 


March   1941 


On  Some  of  the  General  Problems  of  Old  Age* 

Levvellys  F.  Barker,  M.  D.,  Baltimore 


IT  IS  VERY  gratifying  to  note  the  marked 
increase  in  attention  paid  during  the  past  two 
or  three  years  to  the  problems  of  old  age.  Not 
only  the  medical  profession  but  the  general  public 
now  exhibit  a  deep  interest  in  the  fact  that  the 
relative  number  of  old  persons  is  rapidly  on  the 
increase  in  the  United  States,  a  situation  that  is 
givmg  rise  to  problems  of  far-reaching  scientific, 
social,  and  political  significance.  When  we  realize 
that  in  1930  there  were  12  million  children  under 
five  years  of  age  in  this  country  and  6^>  million 
persons  over  65  years  of  age  and  that  reliable 
calculations  indicate  that  in  1975  there  will  not  be 
more  than  6T/2  million  children  under  five  years 
of  age  though  there  will  then  be  some  30  million 
persons  over  60  and  about  22  millions  over  65 
years  of  age,  the  importance  of  the  changing  situa- 
tion becomes  obvious.  Many  have  asked  why  there 
should  be  this  increase  in  the  relative  number  of 
old  people;  several  factors  seem  to  be  concerned, 
including  (1)  restriction  of  immigration,  (2)  rapid 
decline  of  the  birth  rate,  and  (3)  a  great  increase 
in  life-expectancy  due  to  advances  in  preventive 
and  curative  medicine.  The  increased  life  expec- 
tancy has  been  chiefly  for  the  younger;  the  gain 
for  persons  over  50  has  been  only  slight  in  the 
past  century  and  life-expectancy  after  the  age  of 
60  has  recently  been  diminishing.  Only  a  few 
people  live  to  be  over  100  years  old  and  I  think 
it  improbable  that  further  advances  in  medical 
knowledge  will  very  greatly  increase  the  number 
of  persons  who  live  beyond  the  century  mark. 
Greater  length  of  life  is  scarcely  to  be  desired, 
for  the  major  involution  that  occurs  in  all  human 
beings  is  necessary  for  the  good  of  the  human 
race.  As  Goethe  once  said  "Death  is  Nature's 
device  for  securing  abundant  life."  The  surest  way 
to  live  long  is  to  select  for  one's  self  long-lived 
ancestors;  for  longevity  is  exquisitely  hereditary. 
To  a  large  extent  the  duration  of  life  is  prede- 
termined by  the  constitution  of  the  germ  plasm 
at  the  moment  the  human  ovum  is  fertilized  by 
the  sperm  cell.  As  my  friend  Dr.  James  S.  Mc- 
Lester  of  Birmingham  put  it:  "The  arc  of  the 
bullet  is  determined  bv  the  charge  it  receives  be- 
fore it  leaves  the  muzzle."  Though  life  can  of 
course  be  ended  prematurelv  bv  disease,  by  bad 
habits,  or  by  violence,  aside  from  these  it  pursues 

•Address    delivered    by    invitation    to    the    meeting    of    the    Tri-S 
it   Greensboro,    N.    C,    Feb.    24th. 


the  path  that  is  determined  for  it  by  the  inherent 
qualities  of  the  genes  from  which  it  starts. 
Physiological  and  Pathological  Old  Age 
The  human  body,  no  matter  how  good  its  in- 
heritance or  how  fortunate  it  has  been  in  avoiding 
infections,  into-  ications  and  traumata,  is  destined 
inevitably  to  decline  in  functional  capacity  as  it 
grows  older  and,  finally,  it  must  die.  Body  cells 
undergo  atrophy  in  later  life;  the  interstitial  tissue 
of  the  organs  increases  during  senescence.  In 
physiological  (or  natural)  old  age  this  process  is 
very  gradual,  physical  and  mental  deteriorative 
changes  developing  only  slowly.  On  the  physical 
side,  we  often  see  failure  of  accommodation  in  the 
eyes  (presbyopia),  graying  of  the  hair,  loss  of 
teeth,  diminution  of  sex  desire  and  potency,  in- 
creased fatiguability.  stooping  of  the  posture,  de- 
crease of  weight,  stiffening  of  joints,  flabbiness  of 
muscles,  wrinkling  of  skin  with  development  of 
senile  keratoses,  arcus  senilis,  some  thickening  and 
calcification  of  the  arteries,  shortness  of  breath  on 
exertion,  slowing  of  digestion  with  tendency  to 
constipation  and  hemorrhoids,  enlargement  of  the 
prostate  with  difficulty  in  starting  the  flow  of  urine, 
diminution  of  the  endocrine  functions,  and  some 
changes  in  muscular  coordination.  Even  in  physio- 
logical old  age  some  mental  disturbances  are  likely 
to  become  manifest.  The  older  man  begins  to  for- 
get names,  to  be  less  receptive  to  new  ideas,  to 
show  an  increasing  tendency  to  conservatism,  to 
manifest  some  loss  of  memory  for  recent  events, 
and  to  find  sustained  attention  and  concentration 
more  difficult;  often  there  is  increased  tendency 
to  egocentricitv,  a  greater  stubbornness,  a  tendency 
to  suspicion  and  sometimes  pathological  irritability 
and  emotionalism.  Despite  these  physical  and 
mental  infirmities  that  may  be  experienced  in 
physiological  old  acre,  the  old  man  or  woman  may 
still  enjoy  life.  Normal  persons  desire  to  live  long 
provided  their  bodily  and  mental  health  be  not 
too  greatly  disturbed.  You  may  recall  the  witty 
but  somewhat  paradoxical  statement  of  Talley- 
rand— "Everybody  wants  to  live  long,  but  nobody 
wants  to  be  old."  Fortunately,  in  many  persons 
who  attain  to  physiological  old  age.  the  intellectual, 
artistic  and  spiritual  faculties  are  long  retained; 
I  need  only  remind  vou  of  Sophocles  who  wrote 
his   "Oedipus"   when    he  was   90,   of  Titian   who 

tate    Medical    Association    of    the    CaroKnas    and    Virginia,    held 


OLD    AGE— Barker 


produced  his  masterpiece  at  the  age  of  85  and 
lived  to  be  99,  and  of  Benjamin  Franklin  who  was 
fruitfully  active  until  the  age  of  82;  many  other 
interesting  examples  could  be  cited.  Shakespeare's 
Adam,  in  As  You  Like  It,  is  a  good  example  of 
physiological  old  age;  he  looked  old  but  was  still 
strong  and  lusty  and  Shakespeare  assumed  that 
this  was  due  to  the  fact  that  in  youth  he  had 
lived  hygienically,  never  wooing  "the  means  of 
weakness  and  debility." 

Desirable  as  physiological  old  age  may  be,  every- 
one would  hope  to  escape  pathological  old  age  for 
no  one  wishes  to  be  a  serious  burden  either  to 
himself  or  to  others  in  later  life.  Severe  bodily 
diseases  (cardiovascular,  renal,  neurological  or  can- 
cerous) may  make  later  life  almost  intolerable. 
Even  worse  than  the  phvsical  disorders  of  patho- 
logical old  age  are  the  presenile  and  senile  psy- 
choses that  may  develop  with  catastrophic  effects 
upon  the  personalities  of  those  who  suffer  from 
them.  I  need  only  mention  simple  senile  demen- 
tia, presbyophrenia.  Alzheimer's  disease,  Pick's 
disease,  arteriosclerotic  dementia,  and  Stern's  dis- 
ease (bilateral  symmetrical  degeneration  of  the 
optic  thalamus),  to  illustrate  what  I  mean. 

Shakespeare,  in  his  King  Lear,  gave  us  a  mar- 
vellous picture  of  second  childhood,  of  pathologi- 
cal old  age  in  the  form  of  senile  dementia.  You 
will  recall  that  Lear  knew  that  he  had  become  a 
foolish,  fond  old  man,  fourscore  and  upward,  feared 
that  he  was  not  in  his  right  mind,  was  ignorant 
of  where  he  was,  did  not  know  where  he  had  lodged 
the  night  before,  nor  whence  the  very  garments 
that  he  wore  had  come: — the  old  fool  had  become 
a  babe  again! 

Educational,  Social  and  Political  Relationships 
Of  The   Old   Age  Problem 

Because  of  the  marked  relative  increase  in  the 
number  of  older  people  in  our  population  there 
can  be  no  doubt  that  serious  economic  problems 
will  have  to  be  faced.  Manual  workers  as  they 
grow  older  often  find  themselves  in  a  bad  plight. 
Many  men  of  40  or  SO  are  laid  off  because  they 
cannot  maintain  the  pace  of  modern  speed-up  pro- 
cesses: many  of  these  are  forced  to  remain  in  the 
ranks  of  the  unemployed  for  they  find  it  difficult 
or  impossible  to  obtain  other  jobs,  being  forced 
to  give  place  in  all  occupations  to  younger  and 
more  vigorous  men.  During  the  past  ten  years 
the  prolonged  depression  has  also  made  it  difficult 
for  youth  to  find  work  and  the  social  problems 
that  have  resulted  have  become  verv  serious.  For- 
tunately, at  the  moment,  the  number  of  jobs  avail- 
able has  undergone  increase  because  of  the  magni- 
tude of  our  defense  problem. 

Compulsory  retirement  from   many  occupations 


at  a  certain  arbitrary  age  irrespective  of  individual 
variations  of  capacity  in  later  life  may  cause  great 
depression  and  discouragement.  When  an  older 
person  feels  that  he  has  been  laid  on  the  shelf 
he  is  all  too  likely  to  grow  old  rapidly  and  dan- 
gerously. One  of  our  main  problems  is  to  find 
out  how  to  make  use  of  the  skills  older  people  still 
possess,  for  their  own  good  and  for  the  good  of  so- 
ciety in  general.  To  impair  the  morale  of  our  older 
people  is  unwise  from  a  social  standpoint.  Feeble 
attempts  to  overcome  the  difficulty  have  been  made 
in  the  form  of  old-age  pensions  and  old-age  security 
laws;  but  you  cannot  satisfy  the  old  by  giving  them 
a  little  money  when  they  are  no  longer  gainfully 
employed.  We  have  to  find  out  how  to  make  them 
feel  that  they  are  still  needed,  and  that  their  skills, 
their  knowledge  and  their  wisdom  are  of  real  value 
to  society;  for  in  no  other  way  can  we  expect  them 
to  be  happy.  Unless  we  devise  national  measures 
for  the  solution  of  these  old-age  problems  we  may 
see  very  serious  political  repercussions,  for  elderly 
voters  are  becoming  so  numerous  that  they  will  be 
able  to  put  enormous  pressure  upon  State  legis- 
latures and  upon  Congress.  Notable  examples  of 
such  pressure  were  seen  recently  in  California  and 
in  Ohio:  if  the  legislatures  of  those  States  had  been 
unwise  enough  to  vield  to  such  pressures  they 
would  have  been  forced  into  bankruptcy. 
Comments  upon  the  Care  or  the  Aged 
Some  of  vou  will  have  heard  the  excellent  paper 
read  bv  vour  secretary,  Dr.  Northington,  at  the 
meeting  of  the  Mecklenburg  County  Medical  Socie- 
ty in  March  of  the  past  year,  in  which  he  advocated 
conservatism  in  the  medical  care  of  the  old  and 
warned  against  unnecessarily  extensive  diagnostic 
studies  and  against  abrupt  changes  in  dietetic  and 
other  habits. 

As  life  advances,  the  perfection  of  action  of  the 
inherent  regulatory  functions  gradually  diminishes: 
people  become  more  susceptible  to  heat  and  cold, 
their  capacity  to  work  and  to  sleep  at  high  alti- 
tudes becomes  less,  the  capacity  of  the  circulatory 
system  to  adapt  itself  grows  less  adequate,  the 
febrile  reactions  during  infections  are  less  than  in 
youth,  and  the  mortality  rate  from  certain  diseases 
increases  rapidly.  The  knowledge  we  have  gained 
of  the  slow  decline  of  the  bodily  functions  makes 
it  clear  to  medicnl  men  who  care  for  the  old  that 
thev  should  see  to  it  that  activities  in  their  entirety 
should  be  verv  gradually  adapted  to  this  decline, 
for  abrupt  and  profound  changes  in  the  mode  of 
life  of  a  man  are.  as  Dr.  Northington  emphasized, 
likelv  to  be  harmful  At  middle  age  all  sensible 
people  should  be  fnu-hi  to  think  of  what  later 
life  mav  have  in  store  for  them,  and  should  begin 
to  make  the  adaptations  that  are  desirable  rather 


OLD    AGE— Barker 


March   1941 


than  postpone  these  to  a  period  when  the  changes 
will  have  to  be  made  rapidly  rather  than  by  de- 
grees. The  phenomena  of  physiological  old  age 
are  inevitable,  though  they  vary  somewhat  as  the 
germ-plasm  varies,  and  also  as  the  environment 
varies. 

Old  people  who  are  relatively  well  should  when- 
ever possible  live  in  their  own  homes  for,  as  a 
rule,  they  will  be  happier  there  than  living  with 
relatives  or  in  homes  for  the  aged.  An  elderly 
woman  wants  to  have  her  own  Lares  and  Penates 
about  her. 

Old  people  who  are  well-to-do  often  decide  to 
spend  their  winters  in  the  South  and  their  sum- 
mers in  the  North.  When  compelled  to  live  in 
one  climate  the  year  round  care  should  be  taken 
to  protect  them  adequately  from  extreme  cold,  on 
the  one  hand,  and  from  excessive  heat  on  the 
other. 

When  old  persons  become  chronically  ill  or 
markedly  enfeebled  they  can  be  greatly  helped 
and  comforted  by  proper  nursing.  Such  persons 
do  best  to  sleep  in  a  bed  about  two  feet  high  from 
the  floor  with  a  comfortable  mattress  protected  in 
the  middle  by  a  piece  of  rubber  sheeting  or  oil- 
cloth. Daily  care  of  the  skin  and  of  the  mouth 
and  teeth  is  important.  Bedsores  should  be  pre- 
vented by  change  of  position  in  bed,  by  avoiding 
prolonged  pressure  upon  any  part,  and  by  keeping 
the  lower  bedding  free  from  wrinkles  and  from 
crumbs  of  food.  Old  patients  who  are  ill  and  have 
to  be  kept  in  bed  should  not  remain  too  long  in 
the  strictly  recumbent  position'  because  of  the  dan- 
ger of  hypostatic  pneumonia;  if  able  they  should 
be  allowed  to  sit  in  an  easy  chair  occasionally  or 
at  any  rate  the  use  of  a  back-rest  in  bed  can  be 
helpful.  Rest  in  bed  is,  however,  often  necessary 
for  old  patients  who  are  really  ill  or  greatly  fa- 
tigued. The  nurse  will  see  to  it  that  the  bowels 
are  evacuated  regularly  and  that  the  bladder  is 
emptied  routinely.  When  insomnia  is  marked  it 
is  best  to  avoid  hypnotics  like  bromides  and  bar- 
biturates wherever  possible  as  older  people  do  not 
tolerate  them  well;  some  find  that  a  little  whisky 
and  water  at  bed-time  acts  as  a  sedative,  or  that 
a  glass  of  hot  milk  at  10  p.  m.  promotes  sleep. 
An  electric  lamp  should  be  at  the  patient's  bedside 
and  a  bell  should  be  accessible  by  means  of  which 
a  nurse  or  some  member  of  the  family  can  be 
summoned. 

The  old  should  be  cautioned  against  accidents; 
only  too  often  we  meet  with  fracture  of  the  neck 
of  the  femur  from  a  slip  in  the  tub  or  on  the  bath- 
room floor.  Fortunately,  newer  surgical  measures 
have  greatly  improved  treatment  of  this  fracture. 

Occupation   for  older  patients  should  be  care- 


fully selected.  Men  may  enjoy  reading  or  listening 
to  the  radio;  women  may  wish  to  knit,  crochet 
or  embroider.  An  electric  sewing  machine  may 
be  a  godsend  to  a  grandmother. 

Nurses  and  others  in  attendance  upon  the  old 
should  be  cheerful  and  encouraging,  and  should  try 
to  gratify  even  the  trivial  desires  of  the  patient. 
The  patient's  interest  in  personal  appearance 
should  be  kept  up.  Men  should  shave  regularly, 
keep  their  hair  tidy,  and,  if  up  and  about  should 
have  their  clothing  frequently  cleaned  and  pressed. 
Women  should  be  regularly  manicured,  have  a 
hair  wave  occasionally,  and  be  encouraged  to  keep 
themselves  well-groomed  by  telling  them  how  well 
they  look. 

The  diet  should  undergo  some  change  as  life 
advances.  Most  older  people  tend  to  lose  weight 
for  old  age  is  proverbially  the  time  of  "the  lean 
and  slippered  pantaloon;"  but  undue  emaciation 
should  be  guarded  against  as  well  as  obesity.  It 
is  better  to  be  a  little  under-  than  over-weight  when 
old.  The  diet  should  contain  adquate  amounts 
of  protein,  carbohydrate,  animal  fats,  mineral  salts, 
vitamins  and  water.  Many  persons,  however,  be- 
come faddists  about  foods,  because  of  the  extrava- 
gant claims  of  charlatans  or  because  of  the  advice 
of  well-meaning  but  over-apprehensive  relatives 
who  insist  upon  special  diets.  If  an  all-round  diet 
of  meat,  chicken,  fish,  milk,  potatoes,  brown  bread 
and  butter,  green  vegetables,  fruit,  simple  desserts 
and  water  be  regularly  taken  there  will  be  no  food 
deficiencies,  provided  the  processes  of  digestion  and 
absorption  are  not  too  much  impaired.  Such  a 
diet  contains  all  necessary  vitamins  and  mineral 
salts.  The  public  has  been  almost  too  greatly 
"vitamin-conscious"  in  recent  years;  the  family 
physician,  by  studying  the  diets  of  his  older  pati- 
ents, can  make  sure  that  they  lack  none  of  the 
essential  food  elements. 

Endocrine  deficiencies  do  sometimes  occur  in  old 
age  but  marked  lack  of  hormones  is  less  common 
than  the  literature  would  lead  one  to  believe. 
Diabetes  and  hypothyroidism  should  of  course  not 
be  overlooked.  Attempts  to  benefit  old  people  by 
the  administration  of  sex  hormones  are  frequently 
made,  but  the  help  derived  from  them  has  been 
less  striking  than  had  been  hoped   for. 

Surgery  in  the  old  is  to  be  avoided,  of  course, 
wherever  possible;  but  it  is  amazing  to  find  how 
well  aged  patients  tolerate  even  major  surgery,  if 
they  are  properly  prepared  before  operation  and 
are  given  good  care  afterwards.  Removal  of  the 
prostate,  transurethral  prostatic  resection,  resection 
of  the  stomach,  hysterectomy,  and  operations  for 
removal  of  cancer  and  for  strangulated  hernia,  all 

(Continued  on  Page   154) 


SOUTHERN  MEDICINE  &  SURGERY 


135 


CLINIC 


Conducted  By 

Frederick   R.   Taylor,    B.S.,   M.D.,   F.A.C.P. 

High   Point,   North   Carolina 


On  January  12th,  1917,  a  20-year-old  school 
teacher  complained  of  pain  in  the  back  of  her  neck 
and  a  general  eruption.  She  stated  that  3  days 
previously  4  lumps  appeared  in  the  back  of  her 
neck.  A  5th  one  appeared  the  evening  before  she 
consulted  me.  Her  neck  had  been  stiff  and  sore 
from  the  beginning  of  this  trouble,  her  appetite 
and  sleep  poor.  She  had  a  slight  sore  throat  of  a 
few  hours'  duration.  There  was  slight  photopho- 
bia. There  were  no  gastrointestinal,  cardiorespira- 
tory or  urinary  symptoms,  and  no  nervous  symp- 
toms other  than  the  pain  in  her  neck.  She  had  no 
ear  trouble.  She  had  had  a  very  severe  attack  of 
measles  the  previous  spring,  in  which  I  had  attend- 
ed her.  Her  past  history  was  otherwise  unimpor- 
tant, her  habits  good.  Her  father  had  arterioscler- 
osis and  her  mother  amebic  dysentery.  She  was  an 
only  child. 

The  patient  appeared  very  comfortable.  There 
was  slight  lacrimation  and  congestion  of  her  eyes, 
but  her  eyes  are  especially  susceptible  to  all  influ- 
ences. Her  nose,  ears,  tongue  and  throat  were  neg- 
ative. There  were  no  Koplik's  spots.  She  had  a 
pale,  rose-pink,  rather  morbilliform  general  erup- 
tion. There  was  very  marked  enlargement  of  the 
posterior  cervical  lymph  nodes,  which  did  not 
fluctuate  on  palpation.  She  had  a  normal  tempera- 
ture. Her  pulse  rate  was  94,  her  respiratory  rate 
20.  A  diagnosis  of  German  measles  was  made,  and 
it  was  learned  that  she  had  been  exposed  to  at  least 
5  persons  who  had  just  recovered  from  German 
measles.  As  she  was  comfortable,  no  treatment  was 
given,  and  she  made  an  uneventful  recovery. 

A  24-year-oi.d  school  teacher  consulted  me  Oct. 
24th,  1927,  complaining  of  sudden  transitory  dim- 
ness of  vision.  A  week  before  she  had  had  her  first 
attack,  when  she  got  dizzy  and  couldn't  see  much, 
though  she  had  light  perception.  This  was  follow- 
ed at  once  by  nausea  but  no  vomiting.  She  had 
not  fainted  or  lost  consciousness  in  any  of  her  at- 
tacks. The  first  attack  lasted  10  or  15  minutes. 
She  had  a  slight  attack  the  next  day  lasting  two 
minutes  or  so.  Two  days  before  I  saw  her,  while 
she  was  in  a  stand  watching  a  football  game,  fac- 
ing the  sun,  she  had  two  short  attacks  in  rapid  suc- 
cession. She  goes  through  these  attacks  sitting  up, 
and  never  falls  or  has  to  lie  down.  She  ate  a  honey- 
dew  melon  before  her  first  attack,  but  nothing  un- 
usual before  the  last  two  attacks.  In  1924  she  had 
a  tonsillectomy  and  a  refraction  at  this  time  by  a 
good  ophthalmologist,  who  told  her  she  was  near- 


sighted, but  didn't  need  glasses.  She  had  recently- 
had  a  little  unusual  eyestrain  grading  a  lot  of 
poorly  written  4th  grade  papers.  Her  sister  stated 
she  had  noticed  that  patient's  eyes  were  puffy  two 
days  previously.  Reading  a  long  time  would  cause 
headache.  There  were  no  other  symptoms  of  im- 
portance. Her  personal  and  family  history  threw 
no  light  on  her  condition. 

Her  physical  examination  was  essentially  nega- 
tive, including  examination  of  her  eyegrounds.  T. 
98.6,  p.  76,  r.  15,  b.  p.  116/64.  A  chamber  spec- 
imen of  urine  (just  at  the  end  of  a  menstrual  pe- 
riod) showed  many  pus  cells  and  a  trace  of  albu- 
min, but  was  otherwise  negative.  No  diagnosis 
was  made  at  this  time,  but  she  was  referred  to  Dr. 
0.  B.  Bonner  for  ophthalmologic  examination.  He 
reported  a  slight  increase  of  intraocular  tension  in 
her  left  eye,  though  there  was  no  cupping  of  the 
optic  disc.  His  diagnosis  was  a  mild  acute  glau- 
coma. He  kept  her  out  of  school  a  week  and  used 
pilocarpine.  She  was  treated  successfully  by  him. 
Another  specimen  of  urine  a  few  days  later  was 
negative. 

Comment:  Acute  glaucoma  may  be  a  very  se- 
rious emergency.  This  case  was  not  of  great  sever- 
ity, but  it  is  conceivable  that  it  might  have  become 
so  and  even  been  destructive  to  her  sight,  had  she 
not  had  a  fairly  early  diagnosis  and  treatment. 
The  lesson  here  seems  to  be  that  one  should  always 
refer  a  patient  promptly  to  a  specialist  when  un- 
able to  make  a  diagnosis.  Perhaps  there  is  another 
lesson,  too,  that  is  less  often  recognized  by  physi- 
cians. It  is  a  very  simple  matter  to  test  the  intra- 
ocular tension  by  palpation  of  the  closed  eyes. 
However,  slight  differences  in  tension  are  not  likely 
to  be  recognized  unless  the  physician  palpates  the 
eyes  of  many  normal  patients,  just  as  slight 
changes  in  breath  sounds  are  unrecognized  unless 
one  listens  to  many  normal  chests.  How  many  of 
us,  in  a  general  physical  examination,  employ  this 
simple  procedure?  For  mere  visual  disturbances 
without  knowing  the  underlying  pathology,  we  are 
apt  to  tell  the  patient  to  see  an  ophthalmologist  at 
his  convenience.  If,  however,  we  recognize  glau- 
coma, we  should  refer  for  e  animation  and  care 
after  the  manner  of  an  old  teacher  of  mine  who 
used  to  say  when  I  had  failed  to  finish  some  al- 
lotted mathematical  problems — "You  will  complete 
this  work.  Sir,  at  your  earliest  inconvenience!"  If 
no  ophthalmologist  is  promptly  available,  the  phy- 
sician should  instil  a  miotic  when  a  frank  glaucoma 
is  recognized,  as  this  will  give  the  patient  time  to 
get  to  an  ophthalmologist  at  a  distance  with  less 
risk  of  impairment  of  sight.  However,  the  differen- 
tial diagnosis,  in  such  a  case,  must  be  kept  in  mind, 
between    glaucoma    and    iritis,    as    the   emergency 


SOUTHERN  MEDICINE  &  SURGERY 


treatment  of  the  two  conditions  is  precisely  oppo- 
site— miotics  being  indicated  in  glaucoma,  mydri- 
atics in  iritis. 

In  mild  cases,  such  as  the  one  cited,  many  of  the 
diagnostic  criteria  present  in  severe  glaucoma  will 
be  absent.  In  these  cases,  however,  there  is  less 
urgent  need  of  drugs  affecting  the  pupil.  In  the 
presence  of  a  dilated,  oval,  fixed  pupil  when  no 
mydriatic  has  been  used,  coupled  with  obvious 
increase  in  intraocular  tension,  a  shallow  anterior 
chamber,  perhaps  a  turbid  aqueous  and  a  steamy 
insensitive  cornea,  the  physician  should  not  hesi- 
tate to  instil  a  miotic  if  a  competent  ophthalmolo- 
gist is  not  at  hand.  For  those  of  us  in  the  larger 
towns,  however,  the  safest  plan  is  to  get  the  pa- 
tient promptly  to  a  good  ophthalmologist  and  to 
have  him  take  responsibility  for  the  diagnosis  and 
treatment  of  the  case. 


SURGICAL  OBSERVATIONS 


DAVIS   HOSPITAL  STAFF 
Stataville 


EVOLUTION   OF   THE   TREATMENT   FOR 
ABSENT  VAGINA 

(R.  T.  Frank,  New  York  City,  in  Jl  Mt.  Sinai  Hasp.,  Jan.-Feb.) 
Absence  of  the  vagina  is  fairly  common.  The  vulva 
appears  normal.  A  dimple  or  small  blind  pouch  is  round 
in  the  region  of  the  hymen.  In  almost  every  instance  the 
uterus  is  represented  by  a  small,  solid,  muscular  rod.  The 
tubes  may  or  may  not  be  canalized.  The  ovaries  are 
usually   normal. 

Dupuytren  burrowed  into  the  urethrorectal  septum  and 
inserted  plugs.  The  result  was  disappointing.  Heppner, 
in  1872,  introduced  skin  flaps,  the  canal  later  contracting. 
Attempts  to  line  a  preformed  canal  with  skin  grafts  like- 
wise failed.  Gersuny,  in  1897,  transplanted  the  anterior 
wall  of  the  rectum  with   passable   result. 

Baldwin,  in  1907,  isolating  a  loop  of  the  ileum,  reestab- 
lishing the  continuity  of  the  bowel,  then  fastening  the 
double  loop  of  the  intestine  between  urethra  and  rectum, 
and  later  made  the  canal  single  by  applying  a  crushing 
clamp.  The  mortality  was  17JA%  and  several  fatalities 
were    never    reported 

Popoff,  Schubert,  and  others  devised  a  difficult  but 
less  dangerous  procedure.  The  lower  rectum  was  liberated 
and  transplanted  into  the  urethrorectal  septum ;  the  lower 
sigmoid  was  liberated  from  below  and  united  with  the 
remaining  anal  portion  of  the  rectum — 3  deaths  in  53 
cases.  Rectovagnal  fistulae,  incontinence  and  other  dis- 
agreeable sequelae  resulted.  Others  devised  less  dangerous 
but  also  less  effective  methods  which  utilizing  pedicle  flaps 
obtained  from  the  hymen,  fourchette,  and  vulvar  skin. 

In  1925  several  cases  of  absence  of  vagina  presented 
themselves.  Geist  and  I  made  tubular  flaps  from  the 
inner  regions  of  the  thighs  to  fashion  a  complete  skin 
covering  for  the  newly  formed  canal.  While  this  operation 
proved  satisfactory,  it  entailed  a  3-stage  operation  with 
at  least  8  weeks  of  hospitalization. 

The  time  for  any  intervention  is  preferably  between 
18   and   20  years. 

I  have  always  been  impressed  by  the  ease  with  which 
it  was  possible  to  separate  rectum  from  urethra  after 
incision  of  the  hymen  and  superficial  fascia.  In  1935  a 
case  presented  itself  in  which  there  was  a  deep  dimple, 
apparently  the  result  of  vigorous  attempts  at  coitus;  such 
attempts  usually  end  in  dilatation  of  the  urethra,  coitus 
taking  place  through  this  canal,  sometimes  resulting  in 
(To   Page   138) 


THE  POST-HOSPITAL  TREATMENT  OF 

PATIENTS  WHO  HAVE  HAD  A 

TRANSURETHRAL  PROSTATIC 

RESECTION 

It  is  unfortunate  that  a  general  impression 
seems  to  prevail  among  the  laity  and  some  mem- 
bers of  the  medical  profession  that  a  transurethral 
resection  is  a  minor  operation,  that  the  results  are 
quick,  sure  and  certain,  and  that  relief  is  imme- 
diate and  permanent.  Such,  of  course,  is  not  the 
case. 

It  is  true  that  in  patients  who  are  in  good  gen- 
eral condition  and  whose  kidnev  and  bladder  func- 
tion is  not  impaired  and  who  do  not  have  cancer, 
a  transurethral  resection  usually  gives  fine  results. 
Naturally,  the  success  of  this  method  of  treatment 
is  not  so  satisfactory  in  patients  who  have  waited 
a  long  time  before  having  anything  done,  whose 
kidneys  are  greatly  impaired  and  who  have  hyper- 
trophy of  the  wall  of  the  bladder  with  a  cystitis 
which  has  become  chronic.  Often  too  there  is  a 
dilatation  of  the  ureters,  great  impairment  of  kid- 
ney function  and  sometimes  kidney  involvement 
that  makes  a  good  result  almost  impossible.  Asso- 
ciated with  conditions  of  this  kind  are  sometimes 
cardiac  disability  and  a  general  impairment  of  the 
body  function,  especially  a  generalized  arterioscler- 
osis and  often  other  complications  which  add  to  the 
hazard  and  make  the  outlook  doubtful. 

The  care  after  prostatic  resection  is  not  always  a 
simple  thing.  Every  possible  therapeutic  aid  to 
build  up  the  patient's  general  health  and  strength 
should  be  used  both  before  and  after  operation 
and  continued  after  the  patient  returns  home,  and 
certain  special  instructions  are  to  be  given  the  pa- 
tient and  those  with  whom  the  patient  lives  in 
order  to  get  all  possible  help  for  best  results  for 
the  patient. 

To  expect  the  patient  and  members  of  the  fam- 
ily to  remember  the  details  of  verbal  instructions 
is  unreasonable  and,  for  this  reason,  we  have 
worked  out  a  letter  of  instructions  which  is  given 
to  each  patient  on  leaving  the  hospital.  It  is  not 
intended  to  take  the  place  of  medical  attention 
but  to  bridge  the  gap  between  what  the  patient 
should  do  for  himself  and  the  treatment  that  is 
given  by  his  home  doctor. 

We  have  found  that  these  detailed  instructions, 
when  carefully  followed  by  the  patient,  will  do 
much  toward  obtaining  a  good  result  and  will  en- 
able him  to  avoid  many  complications  which  might 


SOUTHERN   MEDICINE   &   SURGERY 


137 


otherwise  develop. 

The  following  instructions  are  given  to  patients 
who  have  had  this  operation: 

Principles  to  be  observed: 

( 1 )  It  is  important  that  you  take  proper  care 
of  yourself  for  a  long  time  after  you  return  home. 

(2)  Patients  sometimes  return  home  with  the 
idea  that  thev  can  do  as  they  please,  eat  every- 
thing they  wish,  go  about  freely  and  take  long  au- 
tomobile rides,  all  of  which  is  erroneous.  You 
should  plan  for  several  weeks  to  several  months  of 
quiet,  peaceful  living,  depending  upon  the  advice 
given  you  by  the  doctor.  Some  patients  will  re- 
quire more  prolonged  rest  than  others,  depending 
upon  the  condition  found  at  operation. 

(3)  For  the  first  six  weeks,  it  is  especially  im- 
portant that  you  take  extremely  good  care  of 
yourself,  and  even  after  that  you  should  be  careful. 
During  this  time,  internal  healing  is  taking  place, 
and  the  bladder  irritation  usually  becomes  less, 
and  the  frequency  of  urination  decreases.  To  get 
the  best  result  from  rest,  you  must  undress  and 
get  in  bed  and  rest  for  a  while  morning  and  after- 
noon— at  first  for  an  hour  or  more  in  the  forenoon 
and  at  least  two  hours  in  the  afternoon  in  bed.  You 
should  sleep  in  a  room  that  is  comfortable— not  too 
warm,  not  too  cold — and  in  a  good,  comfortable 
bed. 

(4)  Moderation  in  everything  should  be  vour 
guide,  especially  as  to  exercise,  straining  or  lifting. 
An  unusual  strain  might  tend  to  cause  bleeding 
into  the  bladder. 

Specific  directions: 

1.  Drink  plenty  of  water  all  through  the  day. 
This  keeps  the  kidneys  and  bladder  flushed  out  and 
aids  in  the  healing  process. 

2.  Xever  use  any  drink  containing  alcohol— no 
beer,  no  wine,  no  liquor.  Instead,  drink  pure  wa- 
ter, orange  juice,  lemonade,  buttermilk  and  the 
various  fruit  juices  that  agree  with  you.  While  it 
is  permissible  to  drink  a  little  tea  or  coffee,  it  is 
better  to  leave  these  off.  Take  no  fountain  drink 
except  orange  juice  and  the  other  fruit  juices  that 
are  permissible. 

3.  Keep  the  bowels  regular.  This  is  important. 
Should  it  be  necessary  for  you  to  strain  at  stool, 
there  is  danger  of  this  causing  bleeding  into  the 
bladder.  It  is  sometimes  necessary  for  a  patient,  in 
addition  to  taking  laxatives,  to  use  enemas  to  re- 
move the  fecal  matter  from  the  lower  bowel.  In 
the  rectum,  the  impacted  fecal  material  may  press 
against  the  prostatic  area  and  cause  pain,  retention 
of  urine  and  distress  generally,  if  it  is  not  removed. 
You  can  avoid  this  trouble  by  keeping  the  bowels 
regular.  .Mineral  oil  is  helpful  and  may  be  taken 
twice  daily;  but  remember  this  is  not  a  purgative, 


not  even  a  laxative,  merely  a  lubricant,  and  it  may 
be  necessary  for  you  to  take  some  laxative  in  addi- 
tion to  this.  Ask  your  doctor. 

4.  Do  not  overeat.  Take  a  moderate  amount  of 
plain,  wholesome  food,  but  greasy  and  highly  sea- 
soned foods  are  to  be  taken  sparingly  if  at  all. 
Eat  foods  which  you  have  found  to  agree  with  you. 
Vegetables,  cereals,  milk,  especially  butteijmilk, 
eggs  and  whole-wheat  bread  are  all  right.  "En- 
riched flour"  contains  certain  vitamines  which  have 
been  added,  and  bread  made  from  this  flour  is  pref- 
erable. Liver  may  be  eaten  twice  weekly  for  its 
blood-building  effect.  Fish  and  chicken  are  seldom 
found  to  disagree. 

5.  Avoid  straining  or  overexertion.  Do  not  take 
long  automobile  rides.  Never  ride  horseback.  Don't 
lift  heavy  things.  Lead  a  very  quiet  existence  for 
at  least  six  weeks  after  operation. 

6.  Avoid  getting  chilled  or  overheated. 

7.  Sometimes  there  will  be  a  little  blood  in  the 
urine.  When  this  occurs,  you  should  go  to  bed 
immediately  and  be  at  as  nearly  absolute  rest  as 
is  possible.  Call  your  doctor.  Go  on  a  liquid  diet, 
assure  bowel  movements  without  straining.  A  little 
bleeding  is  not  unusual  and  should  not  alarm  or 
frighten  you.  If  bleeding  is  severe  you  should  re- 
turn to  the  hospital  for  local  treatment. 

You  will  often  notice  shreds  in  the  urine,  possi- 
bly for  as  long  as  several  months  you  may  have 
occasional  flakes  of  blood  or  possibly  little  spots 
of  blood  in  the  urine.  This  does  not  mean  there  is 
anything  very  wrong.  Your  home  doctor  will  ad- 
vise you  what  if  anything  to  do  about  this. 

Remember  that  the  success  of  the  operation  de- 
pends, to  a  great  extent,  on  the  care  you  take  of 
yourself  after  you  return  home. 

Once  in  a  long  while  the  bladder  will  fill  up  and 
give  considerable  pain.  Call  your  home  doctor 
immediately.  Catheterization  usually  will  give 
prompt  relief  and  seldom  will  it  have  to  be  re- 
peated. 

There  may  be  certain  treatments  that  you  should 
take  on  returning  home.  Be  sure  that  you  under- 
stand what  you  are  to  do  and  what  medicine  you 
are  to  take. 

The  impression  has  gone  out  that  this  operation 
is  :i  minor  operation.  While  it  is  possible  to  get  out 
of  bed  in  a  short  while,  it  is  safer  for  many  patients 
to  remain  in  bed  eight  to  ten'  days  or  longer  on 
returning  home. 

There  will  often  be  a  burning  sensation  in  the 
bladder  region  on  voiding.  Sometimes  there  is 
pain  just  after  emptying  the  bladder.  This  is  not 
unusual,  and  it  will  gradually  subside  after  a  while. 

At  first  you  may  void  frequently  during  the  day 
and  several  times  during  the  night.   As  the  internal 


SOUTHERN  MEDICINE  6-  SURGERY 


March   1941 


healing  progresses,  this  becomes  less  frequent. 
Don't  be  alarmed  about  this.  Just  keep  up  the 
general  treatment  as  advised  and  you  will  improve. 

Watch  your  weight.  If  you  gain  or  lose  too 
much,  see  your  doctor  at  once.  

Avoid  coffee  and  tea;  at  any  rate,  be  moderate 
in  the  use  of  these. 

It  is  better  not  to  use  tobacco  in  any  form. 

In  some  cases  a  special  diet  mav  be  necessary, 
especially  for  patients  who  have  diabetes.  In  these 
cases  it  is  important  to  follow  the  diet  given  you, 
and  follow  it  strictly  every  day. 

You  should  return  to  the  hospital  at  regular  in- 
tervals for  an  examination.  Some  patients  should 
come  more  often  than  others.  Before  you  leave  the 
hospital,  ask  your  doctor  how  often  you  should 
return  for  recheck  or  for  any  treatment  that  might 
be  advisable. 

If  there  is  anything  about  which  you  are  in 
doubt,  be  sure  to  ask  the  doctor  before  you  leave 
the  hospital.  If  you  have  any  trouble  of  any  kind 
after  you  return  home,  get  in  touch  with  your  home 
doctor  and  he  will  advise  you,  or  return  to  the  hos- 
pital immediately  if  your  home  doctor  is  not  avail- 
able. 

You  should  read  this  over  and  over  again  until 
you  are  thoroughly  familiar  with  the  instructions. 


CARCINOMA  OF  THE  PROSTATE  GLAND 

It  seems  that  carcinoma  of  the  prostate  gland 
is  increasing  in  frequency.  At  least  we  are  finding 
more  cases  than  ever  before. 

Recently  a  man,  37  years  rjf  age,  appeared  with 
a  trouble  in  the  region  of  the  lower  end  of  the  left 
ulna,  evidenced  by  some  swelling  and  some  pain 
and  tenderness  in  this  area.  X-ray  examination 
revealed  what  appeared  to  be  a  malignant  growth 
of  an  area  1 J/2  inches  long  an  inch  above  the  lower 
end  of  the  left  ulna. 

Tissue  was  taken  for  biopsy,  and  this  proved  to 
be  cancer.  The  pathologist  suggested  this  might 
be  secondary  to  a  primary  tumor  in  the  prostate 
gland.   This  is  evidently  correct. 

In  the  clinic  we  have  found  a  number  of  cases  of 
carcinoma  of  the  prostate  gland  which  were  in- 
curable from  the  standpoint  of  offering  an  opera- 
tion that  might  give  permanent  relief.  In  all  these 
cases  there  was  complete  obstruction  to  the  out- 
flow of  urine,  catherization  being  necessary. 

In  all  these  cases  it  has  been  possible,  so  far,  to 
relieve  the  obstruction  by  a  transurethral  resection, 
which  enables  the  patients  to  return  home  in  a  few 
days  and  to  be  up  and  about,  almost  as  usual.  The 
general  physical  and  mental  improvement  after 
these  operations  is  remarkable  in  many  instances, 
and  makes  patients  feel  that  life  is  again  worth 
living  and,  these  old  men  are  enabled  to  enjoy  the 


remaining  months  of  living  in  comparative  comfort 
and  ease. 

Occasionally  a  second  resection  is  necessary  in 
these  incurable  cases  of  cancer  of  the  prostate 
gland,  but  the  patients  are  able  to  go  through  this 
without  much  distress  and  again  return  home  in  a 
few  days  with  the  obstruction  removed  and  passing 
the  urine  freely  and  painlessly. 

Transurethral  resection  for  relief  of  complete  ob- 
struction of  the  urine  in  inoperable  carcinoma  of 
the  prostate  is  far  preferable  to  continuous  catheter 
drainage  through  the  urethra  or  continuous  drain- 
age from  a  suprapubic  opening. 

This  again  reminds  us  that  every  patient  with 
suspected  prostatic  trouble  deserves  and  should 
have  a  thorough  and  careful  examination. 


(ABSENT  VAGINA— From  P.  136) 
permanent  incontinence  of  urine.  In  this  instance  the 
efforts  had  resulted  more  successfully.  The  septum  between 
urethra  and  rectum  in  absence  of  the  vagina  can  be  sepa- 
rated by  the  introduction  of  two  fingers  after  the  hy- 
meneal membrane  has  been  incised,  and  the  resilience  and 
softness  of  these  tissues  had  repeatedly  struck  me  as  en- 
couraging. I  had  the  patient  introduce  heavy  glass  tubes, 
first  of  small  diameter,  later  increasingly  larger,  to  enlarge 
the  opening  made  by  coitus  and  to  my  surprise  and 
gratification,  within  a  few  weeks  a  canal,  7%  cm.  in  length, 
was  developed.  Since  then  8  further  cases  have  been  com- 
pleted by  this  simple,  non-operative,  ambulatory  method 
of  treatment.  Canals  fully  established  remain  lined  with 
soft,  yet  resistant  mucosa,  which  has  only  a  moderate, 
non-irritating  secretion.  These  canals  retain  their  full 
length  and  show  no  tendency  to  obliteration  or  stenosis. 
This  simple  procedure  has  proved  uniformly  successful 
in  establishing  potentia  coeundi  and  in  restoring  the  self- 
respect  and  happiness  of  the  afflicted  individuals. 


SUGAR  AS  A  PAIN-RELIEVER 
(Jose  Barbosa  in  Brasil-Medico,  July) 
After  intravenous  injection  of  50%  solution  of  glucose 
prompt  cessation  of  the  pains  was  obtained  in  all  cases 
of  angina  pectoris  or  gastroduodenal  ulcer.  Without  any 
exception  it  acts  superior  to  any  anesthetic,  even  morphine, 
by  the  promptness  with  which  it  controls  the  painful 
attack. 


Aminophylline  intravenously  in  acute  coronary  throm- 
bosis may  relieve  pain  more  effectively  than  a  narcotic. 
Its  value  may  be  enhanced  by  the  simultaneous  intravenous 
administration  of  hypertonic  solutions  of  glucose.  It  should 
be  given  at  the  time  of  the  attack  in  a  dose  of  0.48 
gm.  and  continued  b.  i.  d.  in  the  same  dose  until  the 
acute  symptoms  subside,  then  intravenously  once  daily 
for  one  to  two  weeks,  or  orally  in  daily  doses  of  9  to 
IS  grains  over  a  prolonged  period  of  time. — McMahon 
&  Nussbaum,  St.   Louis. 


Dislocation  (Forward)  of  4th.  Cervical  Vertebra  by 
Catatonic  Posture. — A  case  is  reported  difficult  of  diag- 
nosis by  x-ray  examination,  reduced  by  application  of 
Crutchfield's  tongs  to  skull  and  attaching  a  40-pound 
weight.    N.    J.    Giannestros,    in/our.    of   Med.,    Jan. 


Frequently   overlooked,  as  a  cause  of  precordial  dis- 
tress, is  arthritis  of  the  dorsal  spine. 

D.    W.   Ingham,   in   Med.   Rec. 


SOUTHERN   MEDICINE  &   SURGERY 


DEPARTMENTS 


HUMAN  BEHAVIOUR 

James   K.   Hall,  M.  D.,  Editor,   Richmond,   Va. 


A  CIVIC  TRAGEDY 
From  the  hands  and  from  the  pen  of  Dr.  Hubert 
A.  Royster  of  Raleigh,  I  have  just  received  a  copy 
of  the  booklet  in  which  he  sets  forth  an  account  of 
the  birth,  the  development,  the  life,  and  of  the 
assassination  of  an  institution. 

The  institution  was  a  school.  It  was  the  Med- 
ical Department  at  Raleigh  of  the  University  of 
Xorth  Carolina.  The  school  was  opened  for  the 
matriculation  of  students  in  September,  1902.  Its 
doors  were  closed  after  graduation  of  the  class  in 
June,  1910.  The  school  was  brought  into  being  by 
the  Trustees  and  by  the  President  of  the  Univer- 
sity of  Xorth  Carolina.  It  was  assassinated,  for 
want  of  protectors,  by  organized  alien  might.  The 
destructive  power  was  a  so-called  philanthropic 
organization — the  Carnegie  Foundation — and  the 
power  was  conjointly  wielded  through  the  Amer- 
ican Medical  Association  and  the  Carnegie  Foun- 
dation. Dr.  Colwell,  Secretary  of  the  Council  on 
Education  of  the  American  Medical  Association, 
and  Dr.  Abraham  Flexner,  of  the  Carnegie  Foun- 
dation, made  a  brief  visit  to  the  office  of  Dr. 
Royster,  Dean  of  the  Raleigh  School,  spoke  their 
words  of  disapproval  of  the  school,  and  departed 
for  the  region  out  of  which  they  had  come.  They 
did  not  inspect  the  school;  they  did  not  visit  Ral- 
eigh for  that  purpose.  They  called  upon  the 
school's  Dean  merely  to  inform  him  that  his  school 
was  proscribed.  The  school  did  not  die  of  a  dis- 
ease; it  was  assassinated  by  the  might  of  alien 
money.  Though  it  was  only  an  infant,  and  alto- 
gether worthy  of  a  protector,  no  one  came  to 
shield  it  and  to  sustain  it.  The  school  died  for 
want  of  civic  sustenance  and  protection  against 
the  hands  of  alien  killers. 

What  has  become  of  the  Carnegie  Foundation? 
Has  it  ceased  to  attempt  to  ingratiate  itself  and 
to  bring  deification  to  its  creator  by  pensioning  a 
few  college  and  university  senescent  professors? 

A  campaign  of  destruction  was  organized  and 
released  against  many  of  the  Nation's  too-many 
medical  schools  early  in  the  present  century.  Lack 
of  a  certain  size  seemed  to  damn  and  to  doom  a 
medical  school  to  death.  Smallness  seemed  to  im- 
ply lack  of  virtue  and  mere  bigness  to  carry  with 
it  didactic  efficiency.  And  the  insistence  upon 
quantum  carried  with  it  the  demand  for  an  endow- 
ment in  terms  of  millions  and  clusters  of  buildings 


and  of  colonnades.  I  do  not  recall  that  much 
thought  was  given  to  an  effort  to  find  out  if  those 
who  were  engaged  in  teaching  were  fitted  to  teach. 
If  the  Foundations  and  the  Malefactors  of  Munifi- 
cence could  gain  control  of  the  schools  they  would 
have  both  the  opportunity  and  the  time  in  which 
to  deal  with  the  teachers. 

Now  in  a  Federal  Court  Room  in  Washington, 
some  of  the  officials  of  the  American  Medical  As- 
sociation are  feeling  the  impingement  of  the  might 
of  power— that  of  the  United  States  Government. 
I  wonder  if  those  officials  are  reflecting  occasion- 
ally upon  the  experiences  of  many  medical  colleges 
and  the  teachers  in  them  within  the  first  decade  or 
so  of  the  present  century?  Long  ago  the  Preacher 
observed  the  cycloidal  tendency  of  things,  and  he 
recorded,  with  fatalistic-sounding  finality,  his  own 
opinion:  that  which  hath  been,  it  is  that  which 
shall  be;  and  that  which  is  done  is  that  which  shall 
be  done;  and  there  is  no  new  thing  under  the  sun. 
There  have  been  for  several  years  those  who 
have  feared  that  medicine  was  being  brought  under 
the  control  of  certain  organized  groups;  there  are 
today  many  who  realize  that  the  present  Federal 
Administration  has  determined  to  exercise  domin- 
ion over  all  the  phases  of  medical  activities.  Man 
may  be  instinctively  urged  to  tyrannize  over  his 
fellow-mortals.  What  a  pity  that  medical  school 
in  Raleigh  was  not  sustained  by  the  state  and  by 
the  University! 

I  am  not  going  to  write  the  name  of  a  single 
matriculate  or  of  a  single  graduate  of  that  school. 
The  first  student  to  register,  on  September  9th, 
1902,  became  a  graduate  of  the  school  in  1903.  He 
has  been  for  several  years  one  of  the  best  known 
physicians  in  the  English-speaking  world.  He  is 
one  of  the  best  teachers  medicine  has  ever  known. 
Had  the  school,  during  the  seven  years  of  its  exist- 
ence, educated  only  that  single  "matriculate,  the 
life  of  the  school  would  have  been  justified  and  the 
school  would  have  been  made  immortal.  A  number 
of  the  school's  graduates  have  become  distinguish- 
ed. Many  of  them  developed  into  skillful  practi- 
tioners. Almost  without  exception  they  have  all 
done  well. 

During  the  brief  life  of  the  school  it  had  eighty- 
seven  matriculates.  Seventy-six  of  them  were 
graduated.  At  the  first  commencement,  in  1903, 
four  were  graduated;  the  next  year,  four;  in  1905, 
nine  were  graduated;  the  number  steadily  increas- 
ed until  1910,  the  last  year,  when  the  number  of 
graduates  reached  fourteen.  What  a  pity  the  school 
was  not  sustained  and  continued!  The  death  of 
it— the  slaughter  of  it— constitutes  one  of  the  civic 
tragedies  of  North  Carolina. 

Dr.    Royster,    mere    youngster    though    he   was 


SOUTHERN  MEDICINE  &■  SURGERY 


March   1941 


served  as  Dean  of  the  school  and  also  as  a  member 
of  the  teaching  staff,  during  its  life.  The  other 
members  of  the  faculty  were  the  leading  physicians 
of  Raleigh.  Most  of  them  had  sound  academic  and 
medical  educations  and  most  of  them  were  experi- 
enced in  teaching.  All  of  them  gave  their  services 
to  the  school.  None  of  them  was  remunerated. 
Why  was  the  school  not  sustained  and  continued? 
Since  that  school  was  launched  in  Raleigh  the 
educational  life  of  North  Carolina  has  experienced 
a  rebirth.  Large,  state-supported  schools  have 
come  into  being  since  the  Medical  School  in  Ral- 
eigh was  closed.  And  most  of  the  state-supported 
schools,  from  the  University  down  to  the  smallest 
public  school,  have  been  built  again.  Why  was 
the  Medical  School  in  Raleigh  allowed  to  perish 
or  to  be  killed?  That  was  a  shameful  experience 
in  the  state's  life. 

And  whoever  you  be,  whether  physician,  official 
of  North  Carolina,  educator,  or  plain  citizen,  lay 
your  hands,  I  beg  you,  upon  a  copy  of  the  pam- 
phlet. I  know  you  will  read  each  of  the  seventy- 
two  pages  of  it.  Dr.  Royster's  address  at  Chapel 
Hill  in  February,  1940,  to  the  Alumni  of  the 
School,  will  tell  you  of  its  brief,  brave  and  produc- 
tive life.  Dr.  Royster,  gifted  in  many  ways,  is  as 
skillful  with  his  pen  as  with  his  surgical  instru- 
ments. His  own  account  of  anything  would  be  in- 
formative and  interesting.  He  tells  all  about  the 
school.  And  his  historic  address  is  followed  by  a 
biographic  sketch  of  sixty  of  the  seventy-six  grad- 
uates of  the  school.  I  should  be  happy  to  know  by 
the  use  of  what  psychological  trick  Dr.  Royster 
induced  sixty  doctors  to  comply  with  his  request 
for  a  sketch  of  themselves.  But  thev  wrote  about 
themselves,  generally  briefly,  and  without  jarring 
the  walls  of  Jericho.  Every  medical  organization, 
small  and  large,  should  keep  a  biographic  sketch 
of  each  of  its  members. 

I  do  not  think  of  North  Carolina  as  an  aggres- 
sively progressive  state.  Many  citizens  of  the 
state  are  progressive,  a  few  of  them  even  outside 
the  domain  of  matter.  But  the  state's  exhibition 
of  apparent  progressive  activity  has  been  mainly 
in  the  field  of  matter.  The  progressive  spirit — and 
progress  is  a  matter  of  spirit  and  of  intellect — has 
its  motivations  in  the  intellectual  domain.  In  spirit 
and  in  thinking  North  Carolina  as  a  civic  organi- 
zation is  profoundly  conservative.  She  merely 
boasts  of  her  liberalism;  she  puts  little  of  it  into 
practice.  Had  the  state  been  far-seeing  she  would 
have  known  that  soon  there  would  be  somewhere 
within  the  state  a  degree-granting  medical  school. 
The  state  would  have  and  should  have  protected 
and  sustained  and  improved  the  University's  Med- 
ical School  at  Raleigh.   But  the  people  were  with- 


out that  vital  vision,  and — the  school — and  a  por- 
tion of  the  state — perished.  What  a  tragedy! 


GENERAL  PRACTICE 

James    L.    Hamner,    M.  D.,    Editor,    Mannboro,    Va. 


THE  COMMON  COLD. 

The  drinking  of  a  level  teaspoonful  of  table 
salt  in  a  glass  of  cold  water  at  the  onset  of  a 
cold,  repeated  several  times  the  first  day,  will  do 
more  good  than  any  of  the  alkaline  drinks. 

Two  tablespoonfuls  of  strained  honey  with  the 
juice  of  one-half  of  a  lemon  in  a  glass  of  hot  water, 
sipped  at  bedtime,  is  an  ideal  drink  in  the  treat- 
ment of  colds. 

Cathartics  decrease  the  body  fluids,  deplete  the 
patient,  and  prolong  a  cold. 

Coughs  lasting  more  than  two  weeks,  unless 
proved  otherwise,  can  be  considered  due  to  a 
sinus  infection,  antra  most  frequently.  With  each 
antrum  infection  there  is  some  ethmoid  infection, 
but  once  the  antrum  infection  is  over  with  the 
ethmoid  cells  usually  clear. 

I  inject  the  antra  with  27%  iodine  in  oil  every 
10  to  14  days  in  the  subacute  or  chronic  cases, 
and  watch  the  progress  by  roentgenograms.  If  the 
infection  persists,  a  large  permanent  opening  is 
made  into  the  antrum  under  the  inferior  turbinate 
— in  children  under  two  or  three  of  age  in  the 
middle  meatus.  Antra  have  a  tendency  to  become 
water-logged  by  too  frequent  irrigations.  Very 
often  a  patient  who  has  had  frequent  or  daily 
irrigations  will  improve  bv  merely  stopping  treat- 
ment for  10  days  and  permitting  the  cavity  to 
dry  out. 

If  bronchiectasis  is  suspected,  after  cocainizing 
the  nose  and  trachea,  the  tongue  is  pulled  forward, 
and  the  oil  injected  into  the  nose  and  allowed  to 
flow  into  the  bronchial  tree,  this  followed  immedi- 
ately by  roentgenograms. 

Many  children  have  frequent  colds  and  hyper- 
trophy of  the  lympoid  tissue  on  the  posterior 
pharyngeal  wall.  This  finding  usually  is  an  indi- 
cation for  small  doses  of  iodine;  if  the  membranes 
are  particularly  pale  and  swollen,  one-fourth  to 
one-half  grain  of  thyroid  with  one  or  two  grains 
of  iodine  per  day.  For  sweets  and  soft  drinks 
honey  makes  an  excellent  substitute,  which  does 
not  ferment  in  the  intestinal  tract. 

Vaccines  give  no  assurance  of  immunity  to  colds. 
Vitamins  are  important  to  the  general  health  and 
in  the  prevention  of  frequent  colds. 

Breakfast   is   the   most   important   meal    of   the 


1.    H.    M.    Goodyear,    Cincinnati,    in    Ohio   Statt   Med.    //.,    Feb.| 


March   1941 


SOUTHERN  MEDICINE  5-  SURGERY 


day.  Many  people  have  nothing  more  than  a 
portion  of  carbohydrate  and  coffee.  Eating  a  good 
breakfast  should  be  cultivated  from  childhood. 


SURGERY 

Gio.  H.  Buxch,   M.  D„   Editor,  Columbia,  S.  C. 


THE  AMERICAN  BOARD  OF  SURGERY 

When  a  graduate  in  medicine  is  certified  by 
any  State  Board  of  Medical  Examiners,  whether 
by  reciprocity  or  by  examination,  he  becomes  en- 
titled to  obtain  a  license  to  practice  medicine  and 
surgery  in  that  state.  This  is  granted  although  it 
is  well  known  that  no  medical  school  can  possibly 
give  adequate  surgical  training  to  undergraduate 
students  in  the  four-year  course.  When  the  physi- 
cian without  special  surgical  training  attempts  to 
do  major  surgery  the  results  to  the  patient  are 
bound  to  be  disastrous. 

Composed  of  eminent  surgeons,  the  American 
Board  of  Surgery  has  been  organized  by  the  lead- 
ing surgical  associations  of  America  to  examine 
applicants  and  to  issue  certificates  to  those  who 
are  found  qualified  to  do  general  surgery  accept- 
ably. The  Board  has  no  legal  status  and  appear- 
ance before  it  is  not  compulsory.  However,  as 
time  passes  its  influence  must  increase,  for  soon  it 
may  be  necessary  for  a  surgeon  to  be  certified  by 
the  Board  before  he  can  serve  on  the  staff  of  any 
standardized   hospital. 

Justification  for  the  American  Board  of  Surgery 
must  ultimately  depend  upon  its  accomplishments. 
Thorough  investigation  of  the  general  training  and 
the  moral  character  of  the  applicant,  examination 
both  clinical  and  didactic  of  his  surgical  qualifica- 
tions, personal  observation  of  his  judgment,  diag- 
nostic ability  and  operative  technique  should  en- 
able the  board,  through  its  agents,  to  fairly  well 
determine  the  fitness  of  the  applicant. 

Although  it  has  existed  only  about  four  years 
an  unexpected  benefit  from  the  activities  of  the 
Board  has  already  resulted.  It  has  been  found  that 
many  applicants  are  sadly  lacking  in  basic  knowl- 
edge of  surgical  pathology.  The  ability  to  recog- 
nize and  to  identify  gross  disease  in  tissues  at 
operation  is  fundamental,  if  the  surgeon  is  to  act 
with  intelligence,  for  proper  operative  procedure 
must  be  dependent  upon  diagnosis  and  understand- 
ing. Perfection  in  maintaining  aseptic  technique 
may  make  an  operator;  alone,  it  can  never  make  a 
surgeon.  vmm 

Since  the  matter  has  been  called  to  the  attention 
of  teachers  of  surgery  in  the  medical  schools,  surgi- 
cal  pathology   will   no   doubt   now   be  sufficiently 


stressed  so  that  this  apparent  lack  of  basic  surgical 
training  will  soon  be  overcome. 

We  believe  that  the  National  Board  of  Surgery 
is  doing  good  work.  Ultimately  every  one  intend- 
ing to  do  major  surgery,  to  be  eligible  for  staff  ap- 
pointment in  an  accredited  hospital,  will  have  to 
be  certified  by  the  Board.  Indeed,  certification  is 
going  to  be  demanded  by  the  accredited  hospital 
of  every  surgeon  seeking  its  facilities  for  operating 
even  upon  his  private  patients.  When  this  condi- 
tion prevails  it  will  make  a  new  and  a  better  era, 
for  it  will  do  much  to  protect  the  patient  against 
incompetency.  Is  it  asking  too  much  of  the  sur- 
geon for  him  to  prove  that  he  is  qualified? 
Reference 

Graham,  E.  A.:  Report  of  the  American  Board  of  Sur- 
gery, Annals  of  Surgery,  Dec,  1939. 

PUBLIC  HEALTH 

N.  Thomas  Ennett,  M.  D.,  Health   Officer  Pitt   County, 
Greenville,  N.  C,  Editor 


THE  PRE-SCHOOL  EXAMINATION  AND 
DIPHTHERIA  VACCINATION 

The  regular  spring  pre-school  examinations  in 
North  Carolina  will  soon  be  under  way.  For  chil- 
dren who  have  not  been  previously  vaccinated,  the 
pre-school  clinic  is  convenient  for  this  purpose. 

In  spite  of  the  North  Carolina  law  passed  in 
1939  requiring  that  all  children  "between  6  months 
and  12  months"  be  immunized  against  diphtheria, 
and  that  all  children  "between  the  ages  of  12 
months  and  5  years"  be  immunized  against  diph- 
theria unless  previously  immunized,  thousands 
upon  thousands  of  children  in  the  State  are  un- 
immunized.  Many  factors  are  responsible  for  this 
lack  of  compliance.  Probably  the  chief  factor  is 
lack  of  information.  Expense  should  no  longer  be 
a  factor,  for  we  understand  that  the  State  Board 
of  Health  furnishes  free  diphtheria  toxoid  to  all 
physicians  and  to  all  health  departments  through- 
out the  State. 

If  insufficient  information  of  the  situation  is 
responsible  for  the  high  morbidity  and  the  high 
mortality  from  diphtheria  in  North  Carolina 
(about  7%  of  all  diphtheria  reported  in  the  United 
States  in  1939  occurred  in  North  Carolina),  then 
our  first  objective  must  be  supplying  this  informa- 
tion. 

Our  local  health  departments  and  local  physi- 
cians are  in  a  strategic  position  to  carry  on  this 
program.  The  local  health  departments  are  paid 
out  of  public  tax  money  to  carry  on  a  preventive 
medicine  educational  program  in  season  and  out 
of  season. 


SOUTHERN  MEDICINE  &  SURGERY 


As  a  local  Health  Officer,  we  are  ready  to  admit 
that  our  skirts  are  not  entirely  clean  as  regards 
such  a  program;  though  we  have — through  the 
daily  press,  through  the  schools,  through  the  local 
medical  society  and  through  the  health  department 
nurses  in  their  daily  rounds — urged  diphtheria  vac- 
cinations. We  understand  that  another  agency  has 
recently  become  very  active  in  the  matter  of  diph- 
theria vaccination,  and  this  agency  is  the  North 
Carolina  State  Parent-Teacher  Association.  We 
also  understand  that  this  Association  is  urging  each 
one  of  its  local  associations  to  inaugurate  a  special 
diphtheria  clinic  in  addition  to  the  pre-school 
clinic,  a  clinic  primarily  for  infants  and  babies,  the 
age  at  which  vaccination  counts  for  most. 

When  we  have  been  asked  by  the  president  of  a 
local  Parent-Teacher  Association  to  hold  such  a 
clinic,  we  have  agreed  to  do  so  provided  the  Parent- 
Teacher  Association  obtained  the  approval  of  the 
local  physicians. 

In  a  very  timely  paper  entitled,  "The  Diphthe- 
ria Situation  in  North  Carolina,"  by  Dr.  Aldert 
S.  Root,  a  pediatrician  of  Raleigh,  read  at  the 
Post-Graduate  course  in  Obstetrics  and  Pediatrics 
given  at  Wrightsville  Beach,  last  June,  Dr.  Root, 
after  making  a  number  of  explanations  as  to  the 
family  phvsician's  difficulties  in  vaccinating  all  the 
babies  under  his  care,  said:  "But  he  (family  phy- 
sician) has  failed  to  impress  upon  these  people  the 
importance  of  having  their  children  taken  to  a 
health  center  where  they  can  have  toxoid  given 
free  of  charge,  if  necessary." 

We  believe  that  most  family  physicians  when 
their  attention  is  called  to  it,  are  thoroughly  willing 
to  cooperate  in  this  respect. 

The  chief  purpose  of  this  article  is  to  request 
the  physicians  throughout  the  State  to  give  their 
full  support  to  the  special  infant  and  baby  diph- 
theria vaccination  clinics  now  being  sponsored  by 
the  Parent-Teacher  groups.  In  sponsoring  these 
diphtheria  immunization  clinics,  the  private  physi- 
cian will  be  deprived  of  a  certain  number  of  vac- 
cination fees;  but,  even  here,  if  he  will  urge 
prompt  vaccination  of  the  baby  at  6  or  8  months 
of  age,  there  will  be  few  pay  patients  left  for  the 
periodic  health  department  clinic.  At  any  rate,  it 
has  been  our  experience  that  the  average  physi- 
cian is  always  ready  to  make  a  personal  sacrifice 
for  the  welfare  of  his  community. 


THERAPEUTICS 

J.  F.  Nash,  M.  D.,  Editor,  Saint  Pauls,  N.  C. 


Encephalography  probably  should  be  considered  the 
fifth  most  important  diagnostic  procedure  available  to  the 
neuropsychiatrist,  the  first  four  being  history  taking,  ob- 
servation of  the  patient,  neurologic  examination  and  spinal 
puncture. — D.  H.  Echols. 


PREGNANCY 
THE  PREVENTION  OF  TOXEMIA  IN 
Most  of  those  who  deplore  and  condemn  the 
"unnecessary"  loss  of  life  attendant  on  the  bearing 
of  children  offer  nothing  more  helpful  than  that 
woman  should  be  under  the  care  of  specialists  in 
obstetrics  throughout  pregnancy,  and  delivered  in 
a  lying  in  hospital. 

This  Department  Editor  has  just  run  across  an 
article  written  in  an  entirely  different  spirit,  by 
a  doctor  having  the  saving  grace  of  common  sense, 
which  causes  him  to  realize  that  what  may  (or  may 
not)  be  desirable  must  be  balanced  against  what 
is  attainable.  Read  what  he  has  to  say.  Although 
he  has  the  temerity  to  say  that  simple  measures  are 
often  better  than  complicated,  to  speak  and  practice 
against  putting  "the  expectant  family"  to  unnec- 
essary expense  and  to  go  in  many  ways  against 
the  orthodox — even  to  saying  there's  no  need  for 
a  pregnant  woman  to  drink  milk  unless  she  wants 
to — apparently  his  results  are  just  as  good  as  those 
of  the  specialists  who  practice  under  what  they 
regard  as  "ideal,"  and  what  are  certainly  very  ex- 
pensive, conditions. 

Here's  the  gist  of  what  hei  has  to  say: 
Over  a  period  of  ten  years,  out  of  8,307  deliver- 
ies we  have  had  only  eight  cases  of  eclampsia. 
Three  of  these  cases  had  never  been  seen  previous 
to  their  entrance  into  the  hospital  and  all  eight  of 
them  recovered.  The  most  accepted  opinion  is  that 
eclampsia  is  due  to  some  poison  maternal  or  fetal 
in  origin,  or  both. 

We  know  of  no  other  animal  that  starts  vomiting 
when  it  is  pregnant,  but  we  see  eclampsia  near  term 
and  postpartum  among  our  domestic  animals. 

Today  too  many  of  our  women  are  well  versed 
in  contraception  and  too  few  have  knowledge  of 
reproduction  sufficient  to  cooperate  well  with  their 
obstetrician.  A  girl's  school  teaches  our  girls  the 
same  subjects  taught  our  boys.  The  young  man 
comes  to  his  responsibilities  well  prepared  but  some 
of  our  coeds  come  to  theirs  so  frightened  they  can 
do  little  or  nothing  but  vomit.  On  the  other  hand, 
their  knowledge  of  contraception  is  complete  at  a 
rather  early  age.  The  birth  rate  in  this  country 
decreased  33  per  cent  between  1915  and  1936. 
Primiparae  comprise  30  per  cent  of  all  labor  cases,| 
but  toxemia  is  nine  times  as  frequent  in  primiparae 
as  in  multiparae. 

.1   C.    E.    Galloway,    Evanston,    111.,    in   lour.    Kansas   Med.   Soli 


SOUTHERN  MEDICINE  &  SURGERY 


In  order  to  obtain  cooperation  one  should  quote 
a  flat  fee  for  entire  care  instead  of  separate  fees 
for  each  visit.  One  does  not  need  a  large  scientific 
laboratory  to  practice  good  obstetrics.  Blood  chem- 
istry studies  are  of  very  little  practical  value.  To 
outline  the  care  of  the  pregnant  woman  and  name 
the  five  instruments  of  attack  which  we  have  at  our 
command  and  should  use: 

1.  A  general   physical  examination   and  an  at- 
tempt to  cure  all  physical  disease. 

2.  A  scale. 

3.  A  blood  pressure  apparatus. 

4.  A  test-tube  and  burner. 

5.  A  knowledge  of  food. 

Infected  tonsils  and  teeth  should  be  removed 
early  in  pregnancy.  I  require  x-ray  examination  of 
all  the  patient's  teeth  shortly  after  her  first  visit; 
15  per  cent  of  my  patients  have  abscessed  teeth 
in  spite  of  good  dental  care.  An  increased  b.  m.  r. 
to  plus  20  may  be  looked  upon  as  normal;  but  if, 
as  pregnancy  advances,  the  rate  remains  low,  the 
patient  should  be  given  thyroid  extract  sufficient 
to  correct.  Epsom  salts  should  be  used  as  often  as 
every  two  or  three  days  in  some  cases  but  not  for 
long.  In  order  to  increase  the  urinary  output  daily 
doses  of  ammonium  nitrate  may  be  used — six  to 
10  grains.  As  a  rule,  the  intake  of  fluids  should  be 
less  than  output  if  edema  is  present,  considering 
from  10  to  30  per  cent  of  ingested  fluids  lost  by 
way  of  the  lungs  and  skin,  depending  on  temper- 
ature and  humidity.  Every  toxic  patient  should 
be  at  rest,  depending  upon  severity,  from  12  to  24 
hours  a  day.  Sedatives  should  be  used  freely  day 
and  night.  Mild  toxemia  may  furnish  us  with  a 
premature  separation  of  the  placenta  or  uterine 
apoplexy. 

Most  of  the  cases  of  toxemia  are  in  women  who 
gain  too  rapidly  and  too  much.  The  individual 
should  not  weigh  more  than  20  pounds  over  her 
normal  weight  at  delivery  which  means  an  average 
gain  of  one-half  pound  a  week  if  she  is  normal  to 
start  with,  or  it  may  mean  that  she  must  lose 
weight  throughout  her  pregnancy.  This  loss  of 
weight  will  not  affect  the  baby  providing  diet  is 
balanced  and  contains  the  necessary  vitamins  and 
minerals.  One  having  marked  increase  in  weight 
should  be  given  1200  calories  a  day  and  epsom 
salts  twice  a  week  and  little  sodium  chloride.  Ex- 
cess weight  without  edema  may  not  be  dangerous 
but  sudden  edema  warns  of  convulsions,  pulmonary 
edema,  cyanosis  and  heart  failure. 

If  the  b.  p.  rises  above  130  and  increases  each 
visit  the  patient  must  be  regarded  as  developing 
toxemia  and  must  be  examined  more  frequently. 
On  the  other  hand  if  she  maintains  a  b.  p.  above 
normal  and  it  does  not  increase  and  there  are  no 


other  signs  of  toxemia  she  may  be  treated  as  essen- 
tial hypertension  and  not  toxic.  One  woman  twice 
delivered  by  the  author  had  systolic  pressure  pres- 
sure, every  reading  between  170  and  180.  Toxemia 
causes  a  rise  in  b.  p.  before  it  causes  albumin  to 
pass  into  the  urine.  If  the  b.  p.  rises  to  170  the 
patient  is  in  grave  danger  and  if  it  is  allowed  to 
remain  at  that  level  for  any  length  of  time  she  is 
apt  to  develop  chronic  nephritis  regardless  of  con- 
vulsions. 

There  is  no  need  to  do  elaborate  tests  on  urine 
and  blood.  The  heat  and  acetic  acid  test  for  albu- 
min is  all  right,  and  single  specimens  of  urine  will 
furnish  the  evidence  one  wants.  Microscopic  ex- 
amination of  urine  should  be  done;  in  severe  cases 
always  look  for  acetone  and  diacetic  acid.  One 
may  be  inclined  to  become  careless  after  testing 
many  hundreds  of  specimens  for  sugar,  because 
very  few  diabetic  women  conceive.  However,  one 
should  test  for  sugar,  because  if  at  about  the  fifth 
or  sixth  month  one  finds  a  positive  test  for  sugar, 
that  individual  may  be  the  one  who  will  later  fur- 
nish a  case  of  pre-eclamptic  toxemia. 

Blood  chemistry  is  of  very  little  value  in  helping 
us  to  decide  to  keep  or  terminate  the  pregnancy. 
One  can  make  as  good  a  decision  without  it  as 
with  it  and  in  some  cases  a  better  decision  is  based 
alone  on  physical  findings,  blood  pressure  and  urine 
analysis.  The  only  reliable  blood  chemistry  is  the 
uric  acid  determination  and  we  should  not  burden 
the  patient  with  unnecessary  expense  nor  should 
we  burden  the  laboratory  with  unnecessary  proce- 
dures. 

Most  pregnant  women  eat  too  much.  Only  a  few 
must  eat  more  than  they  are  accustomed  to.  Most 
of  my  patients  get  along  very  well  on  1500  calories 
a  day,  a  few  on  1200.  They  are  asked  to  allow 
themselves  only  one-half  pound  gain  a  week.  If 
they  were  overweight  they  must 'lose  or  stay  the 
same  until  their  weight  is  what  may  be  called  nor- 
mal for  that  period  of  gestation.  The  patient 
should  weigh  herself  at  least  every  other  day.  The 
ingestion  of  salt  should  be  kept  at  a  minimum.  If 
she  shows  signs  of  toxemia  she  should  use  no  salt 
at  all.  Sodium  bromide  and  bicarbonate  should  be 
left  off.  If  salt  is  restricted  for  any  length  of 
time  give  iy2  grams  of  potassium  chloride  a  day 
in  order  to  maintain  a  proper  chloride  balance. 
Excretion  of  sodium  cloride  is  impaired  during 
pregnancy  but  here  again  one  can  determine  the 
NaCl  in  the  urine  in  one's  office  laboratory.  It 
should  run  two  to  three  grams  per  day  or  less. 

If  toxemia  develops  administer  glucose— just 
as  effective  at  home  as  in  the  hospital.  Glucose  by 
mouth  is  more  effective  in  most  cases  than  by  vein 
or  subcutaneous  injection  because  it  goes  directly 


SOUTHERN  MEDICINE  &  SURGERY 


o 


Major  Cro«a. 


o 


Minor  Croee. 


HATCHING 
of  Blood. 


OI'MIJ 

Blood. 

OBTAINING  A  JO  eo.   luer  can  ba  avbatltutot 

•  Blood.  for  the  flaak. 


This  simple  equipme.it  is  all  that  is  needed  for  transfusion 


to  the  liver  through  the  portal  circulation.  Long 
before  severe  symptoms  develop  the  patient  is  told 
to  buy  Dextrose  or  Dyno  and  to  measure  out  eight 
level  tablespoons  each  morning  and  to  see  to  it  that 
that  amount  is  consumed  by  night.  She  may  use 
it  in  place  of  sugar  or  eat  it  as  such. 

As  for  protein,  advise  its  reduction  only  in  cases 
where  liver  involvement  predominates  and  not 
where  there  is  marked  edema  and  albuminuria. 
Quantitative  albumin  tests  are  easily  done  in  one's 
office.  If  the  patient  shows  as  much  as  ten  grams 
of  albumin  she  should  be  given  as  much  as  150 
grams  of  protein  a  day. 

The  average  pregnant  woman  requires  a  general 
diet  of  about  70  grams  of  protein,  18  grams  of  fat 
and  350  grams  of  carbohydrate — 1800  calories; 
but  she  may  need  much  less  if  she  is  overweight  or 
signs  of  toxemia  have  developed.  The  general  diet 
should  be  maintained  including  proteins  until  some 
definite  indication  for  a  decrease  in  protein  is 
shown — hypertension,  little  or  not  albumin,  reduc- 
tion in  urine,  no  edema,  with  headache  and  epigas- 
tric pain.  Many  patients  with  edema,  albumi- 
nuria and  moderate  hypertension  have  been  made 
worse  by  "no  meat  or  other  proteins."  Some  pa- 
tients should  have  their  proteins  reduced  in  the 
last  six  weeks  of  pregnancy  if  there  is  retention  of 
nitrogen,  but  it  should  not  be  denied  entirely. 

The  average  pregnant  woman  does  not  need  to 
drink  any  milk  unless  she  likes  it  and  can  digest  it 
easily.  About  20  per  cent  of  all  adults  should  not 
drink  milk.  About  125  foods  were  recently  tested  in 
a  leading  clinic  as  to  distress  after  eating;  500 
patients  were  questioned  and  the  three  foods  rank- 
ing highest  as  the  cause  of  gastric  distress  were 


onions,  cabbage  and  milk.  A  well-balanced  diet 
with  sufficient  variety  will  meet  all  needs.  If  after 
careful  study  it  seems  advisable  to  furnish  the  pa- 
tient with  additional  calcium,  iron  or  vitamins  they 
may  be  administered  in  whatever  form  seems  best. 
The  routine  use  of  these  additional  dietary  ele- 
ments is  not  good  medical  practice  and  may  consti- 
tute a  considerable  increase  in  the  financial  burden 
placed  upon  the  expectant  family. 

Just  when  a  pregnancy  should  be  terminated  in 
order  to  avoid  risking  the  mother's  life  or  to  avoid 
some  permanent  impairment  to  her  health,  sue  has 
chronic  nephritis,  requires  long  experience  and 
good  judgment.  Consultation  with  someone  equal 
or  superior  to  the  physician  in  charge  should  always 
be  sought  before  attempting  to  empty  the  uterus  if 
the  toxemia  becomes  severe.  Certainly  we  have  no 
right  to  risk  the  mother's  life  unless  she,  with  full 
knowledge  of  her  condition,  insists  upon  it.  She 
may  and  does  in  many  cases  carry  her  next  baby 
to  term  without  becoming  toxic. 


THE  BENZYL  BENZOATE  TREATMENT  OF 

SCABIES 

(R.   E.  King,  British  Med.  Jl„  Nov.  9th,  1940) 

The  writer  recommends  the  benzyl  benzoate  method  as 
safe,  reliable  and  rapid. 

The  lotion  consists  of  equal  parts  of  benzyl  benzoate, 
industrial  spirit,  and  soft  soap;  amount  for  complete  treat- 
ment of  one  case  is  l'A  ounces. 

Anoint  the  body  with  soft  soap,  rubbing  it  with  special 
areas.  Allow  the  lotion,  and  the  lather  produced,  to  dry 
axillae,  wrists,  and  between  the  fingers.  Soak  for  10  min- 
utes in  a  bath  at  100°.  the  patient  rubbing  the  affected 
areas  thoroughly  during  this  time.  WhiJe  the  body  is  still 
wet  apply  the  lotion  for  five  minutes  by  means  of  a  pig- 
bristle  shaving  brush,  very  thoroughly,  and  all  parts  must 
receive  attention,  particular  care  being  paid  to  the  infected 


March   1941 


SOUTHERN  MEDICINE  &  SURGERY 


areas.  Allow  the  lotion,  and  the  lather  produced,  to  dry 
on  the  skin,  and  again  apply  the  lotion  vigorously  for  a 
further  five  minutes,  then  dry  the  body  with  a  towel. 

Resume  clothes  worn  before  treatment ;  24  hours  later  a 
bath  is  taken  and  clean  clothes  put  on.  The  discarded 
underclothing  and  the  bedclothes  used  by  the  patient  are 
sterilized  by  boiling.  Close  contacts  of  the  patient  should 
be  treated  on  the  same  day.  even  though  they  show  no 
sign  of  the  disease. 

Those  portions  of  the  skin  showing  severe  pyogenic  in- 
fection must  be  treated  as  energetically  as  the  unabraded 
areas. 

The  patient  is  ambulant  throughout,  and  is  subjected  to 
a  minimum  of  inconvenience  and  discomfort,  no  matter 
how  severe  the  infection.  The  sarcopticidal  action  of  ben- 
zyl benzoate  is  immediate  and  reliable  ,and  no  post-thera- 
peutic irritation  of  the  skin  results.  Pyodermatitis  due 
to  infected  scabies  can  be  thoroughly  treated  and  rapidly 
cured.  The  whole  treatment  is  completed  in  30  minutes, 
at    small   cost. 


TUBERCULOSIS 

J.   Donnelly,  M.  D.,  Editor,   Charlotte,  N.   C. 


CASE-FINDING  IN  TUBERCULOSIS 

Case-finding  in  tuberculosis  is  well  recognized 
as  the  basic  principle  in  tuberculosis  control.  Since 
the  discovery  of  the  tubercle  bacillus  by  Robert 
Koch  the  disease  has  been  known  as  an  infectious 
and  transmissible  disease,  but  in  spite  of  the  con- 
tinuous efforts  to  stimulate  earlier  diagnosis  of  the 
disease  at  least  75  per  cent  of  the  cases  now  enter- 
ing sanatoria  over  the  country  are  in  an  advanced 
stage.  Furthermore,  statistics  indicate  that  20  per 
cent  of  sanatorium  discharges  are  by  death  and 
that  at  least  SO  per  cent  of  those  discharged  alive 
do  not  survive  as  long  as  five  years  without  a  re- 
activation of  their  disease.  In  fact,  the  greater 
proportion  of  deaths  among  discharged  sanatorium 
patients  occurs  in  the  first  three  years  following 
discharge,  and  the  most  of  those  who  maintain 
their  disease  in  an  arrested  or  quiescent  state  for 
periods  longer  than  three  years  are  handicapped 
in  earning  a  reasonably  adequate  livelihood. 

Such  facts  indicate  that,  although  the  facilities 
for  treatment  and  the  methods  of  treatment  have 
been  greatly  extended  and  improved  in  the  past 
few  years,  the  sanatorium  death  rate  remains  ap- 
proximately what  it  has  been  for  a  good  many 
years.  It  is  also  true  that  the  institutional  and 
treatment  phases  of  the  disease  have  required  the 
expenditure  of  the  larger  part  of  the  funds  pro- 
vided for  the  fight  against  tuberculosis,  some  part 
of  which  funds  might  have  been  used  to  finance 
more  thorough  methods  of  case-finding.  The  loca- 
tion and  proper  care  of  the  infectious  tuberculosis 
case  is  still  the  basis  of  a  control  program.  Whether 
or  not  the  modern  methods  of  treatment,  notably 


collapse  therapy,  have  reduced  the  ultimate  death 
rate  of  institutional  cases,  such  procedures  have 
been  of  inestimable  value  in  rendering  many  pa- 
tients non-infectious  and  therefore  not  a  danger  to 
their  contacts.  Hence  the  number  of  possible  fu- 
ture active  cases  of  the  disease  is  thereby  appre- 
ciably reduced. 

The  greatest  handicap  to  the  general  practition- 
er of  medicine  in  the  recognition  of  early  cases  of 
tuberculous  disease  is  the  fact  that  primary  infec- 
tions by  the  tubercle  bacillus  are,  as  a  rule,  symp- 
tomless. Such  patients  are  not  sick,  and  therefore 
do  not  seek  medical  advice  until  their  disease 
process  is  fairly  well  advanced.  Hence,  if  the  dis- 
ease is  to  be  discovered  in  its  early  stage  in  any 
number  of  instances,  examinations  must  be  made 
of  the  apparently  healthy  population  of  the  com- 
munity. The  routine  tuberculin  skin-testing  of 
school  children,  which  has  been  carried  on  rather 
generally  for  several  years,  has  been  a  step  in  this 
direction,  although  this  does  not  comprise  a  com- 
plete program.  Pulmonary  tuberculosis  of  the  in- 
fectious type  is  rare  in  children  between  the  ages 
of  five  and  IS  years,  but  positive  reactions  in 
children  of  these  ages  indicate  the  presence  of 
sources  of  infection  with  which  such  children  are, 
or  have  been,  in  contact.  The  percentage  of  posi- 
tive reactors  among  Negro  school  children  is  from 
two  to  five  times  as  high  as  among  whites,  the 
rate  of  incidence  depending  apparently  on  varying 
economic  and  environmental  conditions.  Tubercu- 
losis and  poverty  go  hand  in  hand  and  general  im- 
provement in  living  conditions  in  any  section  has 
its  effect  in  the  reduction  of  tuberculous  infection. 
Because  of  more  congested  living  conditions  and 
possibly  lower  physical  resistance  to  infection,  ad- 
vanced pulmonary  disease  is  likely  to  be  found 
more  frequently  among  early  teen-age  Negro  chil- 
dren than  among  whites  of  similar  age  periods. 

A  program  of  mass  examination  of  the  appar- 
ently healthy  adults  in  any  community  is  a  rather 
large  and  expensive  order,  but  it  has  been  at- 
temped  in  sections  of  the  larger  cities  with  ex- 
tremely encouraging  results.  In  figures  from  sur- 
veys noted  by  H.  R.  Edwards  of  New  York  City 
in  a  recent  article  in  Diseases  of  the  Chest  the 
highest  percentage  of  active  disease  was  found 
among  inmates  of  lodging  houses  (5.3%)  and 
Riker's  Island  Penitentiary  (4.5%).  In  this  re- 
port it  is  noted  that  in  16,810  examinations  among 
students  in  the  colleges  operated  by  the  City  of 
New  York  only  34  cases  of  active  disease  (0.2%) 
were  found.  This  low  incidence  of  disease  is  ex- 
plained by  the  fact  that  85  per  cent  of  the  en- 
rollment were  Jews,  a  race  which  has  a  well  known 
resistance    to    tuberculous    infection.      Among   en- 


SOUTHERN  MEDICINE  &  SURGERY 


rollees  of  the  National  Youth  Administration  8708 
examinations  were  done,  resulting  in  the  recog- 
nition of  79  cases  of  tuberculosis,  a  percentage 
0.8.  Department  of  Health  employees  of  the 
city  showed   1.1  per  cent. 

A  considerable  amount  of  valuable  work  in 
case-finding  has  been  accomplished  in  industrial 
plants  and  industrial  construction  work  by  medical 
supervision  of  the  workers  and  preemployment 
examinations  of  prospective  employees.  This  has 
been  particularly  noteworthy  in  the  dusty  trades, 
statistics  indicating  that  the  principal  causes  of 
death  amoung  silicotics  is  tuberculosis.  Although 
lower  among  the  better-paid  industrial  workers 
than  it  is  among  the  low-wage  unskilled  labor- 
ers,or  the  relief  workers,  there  will  be  found  a 
sufficient  number  of  cases  of  active  disease  among 
them  to  justify  the  effort  required  to  find  them. 
Among  these  groups  of  workers,  as  a  matter  of 
economy,  the  tuberculin  skin-test  should  be  used 
as  a  screening  process  whereby  the  negative  re- 
actors may  be  eliminated  from  further  examination. 
The  positive  skin-reaction  in  an  adult  is  of  very 
little  value  as  an  indication  of  active  disease,  but 
it  does  show  that  there  has  been  at  some  time  an 
infection  bv  tubercle  bacilli.  The  x-ray  film  is 
the  most  important  method  of  diagnosing  early 
tuberculosis  and  every  positive  skin-reactor  should 
have  the  benefit  of  this  diagnostic  procedure  if 
possible.  Fluoroscopic  examination  is  of  consider- 
able value  in  such  cases  if  lack  of  funds  is  an 
item  and  fluoroscopic  facilities  are  available. 
Much  work  is  being  done  in  the  effort  to  originate 
a  less  expensive  method  of  producing  satisfactory 
x-ray  films  of  the  lungs. 

Lack  of  the  necessary  hospital  beds  to  care  for 
infectious  patients  when  found  has  been  used  as 
an  argument  against  more  intensive  case-finding 
efforts,  but  such  arguments  are  without  point. 
The  earlier  the  diagnosis  is  made  the  more  easily 
and  successfully  can  the  disease  be  cared  for  in 
the  home.  Many  early  cases  will  recover  without 
institutional  treatment  if  the  proper  regimen  is 
instituted  immediately,  and  the  patient  is  carefullv 
checked  at  frequent  intervals  to  avoid  the  possible 
dangers  of  an  acute  spread  of  the  disease  process. 
Although  no  institutional  patient  should  be  dis- 
charged until  the  sputum  remains  negative  for  a 
reasonable  length  of  time,  available  hospital  beds 
can  take  care  of  many  more  patients  if  patients 
under  collapse  therapy  having  a  continuously  neg- 
ative sputum  are  permitted  to  leave  the  institution, 
their  refills  to  be  furnished  by  clinics  or  capable 
medical  men.  As  a  matter  of  fact,  the  effort  to 
return  the  person  with  moderately  advanced  tuber- 
culosis to  lucrative  employment  is  merely  inciden- 


tal in  the  eventual  control  of  the  disease.  The  pre- 
vention of  the  infection  of  possible  contacts,  and 
thereby  the  reduction  of  future  cases  of  the  dis- 
ease, is  the  most  important  consideration. 


OPHTHALMOLOGY 

Herbert  C.  Neblett,  M.  D.,  Editor,  Charlotte,  N.  C. 


INTERSTITIAL  KERATITIS  IN  YOUNG 
CHILDREN 

This  type  of  keratitis  is  exceptionally  rare  be- 
fore the  6th  and  after  the  20th  year  of  life.  The 
commonest  cause  is  syphilis,  especially  hereditary 
syphilis;  about  10  per  cent  of  the  cases  are  due  to 
tuberculosis.  Both  causative  agents  may  coexist  in 
the  same  subject.  The  disease,  though  rarely  so,  is 
observed  in  acquired  syphilis  and  may  be  so  con- 
tracted, namely,  from  a  nurse  maid. 

It  has  been  supposed  that  the  disease  is  never 
the  first  symptom  of  hereditary  syphilis,  but  posi- 
tive observations  now  contradict  this  view  (Fuchs) 

A  report  of  three  cases  seen  within  the  year  is 
here  appended.  Two  of  them  come  within  the  ear- 
liest age  limit  and  one  is  the  youngest  such  patient 
I  am  able  to  find  record  of.  Only  one  of  these  chil- 
dren presented  other  symptoms  of  hereditary  syph- 
ilis prior  to  the  development  of  keratitis.  All  were 
well  developed  and  well  nourished  for  age. 

Case  1 — White  boy  baby,  aged  6  months,  resid- 
ing in  nearby  rural  district,  first  and  only  child  of 
young  parents  both  of  whom  had  syphilis.  At  4 
months  of  age  developed  inflammation  of  the  left 
eyeball,  followed  a  month  later  by  similar  involve- 
ment of  the  right.  The  left  cornea  presented  a 
severe  and  advanced  parenchymatous  inflamma- 
tion, the  left  likewise  inflamed  but  less  severely. 
The  blood  Wassermann  and  Kahn  were  four-plus. 
There  was  no  other  evidence  of  hereditary  syph- 
ilis. 

Case  2 — Ginger-cake  boy,  aged  7,  residing  in 
this  city,  first  and  only  child  of  a  mulatto  father 
and  Negro  mother.  Both  under  treatment  for 
syphilis  at  time  of  marriage.  Had  been  treated  for 
one  month  for  "rheumatism,"  and  for  soreness  of 
eyes  which  had  developed  one  week  prior  to  being 
seen  by  the  writer.  Due  to  involvement  of  both 
knee  joints  the  child  was  unable  to  walk.  There 
was  no  evidence  of  other  symptoms  of  inherited 
syphilis.  Both  eyes  presented  an  advanced  paren- 
chymatous keratitis,  worse  in  the  right.  The  blood 
Wassermann  and  Kahn  were  four-plus. 

Case  3 — White  girl,  aged  9,  residing  in  a  nearby 
town,  oldest  of  two  children,  the  other  a  boy  aged 
5.    The  father  and  mother  of  this  patient  denied 


SOUTHERN  MEDICINE  &  SURGERY 


147 


syphilis  and  showed  no  evidence  of  it.  Two  Was- 
sermann  tests  on  the  father  at  the  State  Labora- 
tory and  one  here  were  negative,  two  on  the  moth- 
er and  one  on  the  boy  at  the  State  Laboratory  were 
negative.  Three  years  ago  a  Negro  cook  was  em- 
ployed in  the  home  who  was  found  to  have  syph- 
ilis after  having  been  in  the  home  for  a  year.  Two 
weeks  prior  to  be  seen  by  the  writer  this  child  had 
been  treated  for  sore  eyes  which  was  at  first 
thought  to  be  in  some  way  connected  with  the  re- 
cent flu  epidemic  although  the  child  had  not  had 
the  disease.  When  first  seen  a  well  advanced 
parenchymatous  keratitis  was  present  in  each  eye, 
worse  in  the  left.  There  was  no  other  evidence  of 
syphilis.  The  blood  Wassermann  and  Kahn  tests 
were  four-plus. 

Summary:  These  cases  present  several  instruc- 
tive features:  (a)  one  subject  is  near  the  lower 
age  limit  for  the  development  of  keratitis  of  heredi- 
tary lues;  (2)  one  developed  keratitis  from  a  like 
cause  in  the  first  few  months  of  infancy  and  is  the 
youngest  such  patient  I  am  able  to  find  record  of; 
fc)  one  developed  interstitial  keratitis  from  ac- 
quired syphilis  which  is  a  rare  finding  for  age;  (d) 
in  only  one  case  was  there  any  evidence  of  syphilis 
antedating  the  eye  involvement;  (e)  a  greater 
awareness  of  the  probability  of  the  presence  of 
specific  disease  in  household  employees  and  a  more 
frequent  medical  check-up  to  detect  it  is  indicated 
especially  among  housemaids,  nurses  and  cooks 
who  come  in  more  or  less  intimate  contact  with 
the  children  of  the  home. 


HOSPITALS 

R.  B.  Davis,  M.  D.,  Editor,  Greensboro.  N.  C. 


IT  IS  THEIR  FAULT 

It  has  often  been  said  that  ignorance  of  the  law 
is  no  excuse  but  it  is  equally  as  disastrous  to  be 
ignorant  of  one's  opportunity.  Affliction  with  just 
such  ignorance  is  very  common.  It  is  human  na- 
ture to  put  the  blame  on  somebody  else  when 
things  go  wrong,  but  that  has  very  little  to  do  with 
remedying  the  cause  or  preventing  the  disaster. 
The  only  aid  worth  seeking  is  knowledge. 

The  medical  profession  in  all  of  its  various  ram- 
ifications and  connections  is  sick  and  tired  of 
hearing  criticism  about  the  charges  made  by  hos- 
pitals. If  an  individual  spends  one  night  in  the 
hospital  he  is  prone  to  use  the  experience  as  an 
excuse  for  neglecting  all  of  his  bills  for  the  next 
twelve  months.  This  is  particularly  true  if  the 
second  bill  happens  to  be  a  doctor's,  dentist's  or 
nurse's  bill.  I  know  of  no  condition  in  life  where 
the  old  saying,  "prepare  for  a  rainy  day,"  is  more 


neglected  than  it  is  in  the  matter  of  preparing  for 
sickness,  although  we  all  know  that  there  comes 
to  nearly  every  individual  the  rainy  day  of  sick- 
ness. 

Because  people  have  been  so  negligent  in  pre- 
paring for  sickness  a  small  group  of  individuals, 
known  as  hospital  folks,  have  prepared  a  new  rem- 
edy. This  remedy  is  in  the  form  of  a  cooperative 
hospital  insurance  and  in  some  cases  the  insurance 
has  already  extended  into  the  medical  service. 
Therefore  there  is  no  reason  why  any  person 
should  be  financially  embarrassed  because  of  a 
hospital  bill  except  in  the  very  rare  instances  where 
there  is  prolonged  hospitalization.  If  people  persist 
in  neglecting  to  take  out  hospital  insurance  then 
it  is  their  own  fault  if  they  find  themselves  unable 
to  pay  for  needed  hospital  services.  But  placing 
the  blame  does  not  remedy  the  situation.  What 
will  remedy  the  situation  is  for  one  to  make  up 
his  mind  that  he  will  profit  by  experience,  for  if 
he  does  not  all  of  his  dependents  or  employees 
may  find  themselves  in  an  unfortunate  condition. 
Therefore  the  hospital  operators  and  superintend- 
ents as  well  as  the  employees  can  help  prevent  the 
lay  public  from  neglecting  hospital  insurance. 

How  can  this  aid  best  be  put  into  practice?  If 
all  of  the  employees  of  the  hospitals  in  North  Car- 
olina would  both  preach  and  practice  hospital  in- 
surance, within  twelve  months  the  citizenship  of 
our  State  would  no  doubt  respond  tremendously. 
It  goes  without  saying  that  any  form  of  insurance 
the  day  it  is  needed  is  a  god-send  and  no  one  will 
complain  of  the  cost.  Fortunate  indeed  it  is  that 
hospital  insurance  is  so  inexpensive  that  no  one 
has  any  excuse  to  complain  when  he  is  paying  the 
premiums.  It  may  be  obtained  at  a  rate  of  from 
60c  to  $1.00  a  month  and  this  is  within  the  finan- 
cial grasp  of  everyone.  In  conclusion,  therefore,  it 
would  be  well  for  both  patient  and  doctor  to  con- 
sider this  opportunity  for  their  mutual  benefit. 


DENTISTRY 

J.    H.    Guion,   D.  D.  S.,   Editor,   Charlotte.   N.    C. 


FORENSIC  ASPECTS  OF  THE  TEETH  AND 
JAWS 

For  persons  dead  and  mutilated  beyond  recogni- 
tion by  ordinary  means  to  be  identified  by  dental 
restoration  is  not  an   uncommon  happening. 

The  head  of  a  British  Dental  Board  writesi  on 
forensic  dentistry  from  a  different  angle. 

Certain  diseases  may  accelerate  or  delay  the 
eruption  of  teeth.  Very  rarely  one  or  more  decidu- 
ous teeth  may  be  erupted  at  birth.    Hypoplasia  of 

1.  Evelyn   Sprawson,   in  Proc.  Royal  Soc.  of  Med.,  Lond.,   1940. 


SOUTHERN  MEDICINE  &■  SURGERY 


March    1941 


the  decidous  teeth  is  usually  evidence  of  deficien- 
cies in  the  maternal  diet,  and  the  evidence  dis- 
appears with  the  deciduous  teeth.  In  the  perma- 
nent teeth  there  is  evidence  which  may  persist 
throughout  life.  The  transverse  linear  hypoplasia 
mostly  seen  on  the  incisor  teeth  is  evidence  of  an 
acute  short  illness  at  the  time  the  parts  of  the 
teeth  affected  were  forming,  but  its  absence  is  no 
evidence  to  the  contrary. 

The  efforts  put  forth  in  suckling  tend  to  widen 
the  jaws  and  so  make  room  for  regular  alignment 
of  the  teeth.  There  are  some  who  do  not  alto- 
gether agree  with  this.  I  look  on  the  hand-feeding 
of  children  as  providing  a  large  proportion  of  the 
orthodontist's  work. 

The  special  form  of  attrition  shown  on  the  max- 
illary incisor  teeth  of  boot-lasters  is  well  known, 
so  also  is  that  form  of  abrasion  shown  bv  the  clay 
pipe  smoker;  I  have  several  times  been  assured  bv 
patients  showing  a  well-marked  pipe  notch  that 
they  have  only  smoked  pipes  having  vulcanite 
stems,  but  I  am  not  convinced  that  vulcanite  can 
cause  this  notch.  Small  jagged  notches  occasion- 
ally seen  on  the  maxillary  incisor  teeth  of  women 
are  caused  by  biting  ends  of  cotton. 

"Erosion"  cavities  tell  us  that  the  patient  takes 
some  care  of  the  teeth,  that  they  scrub  too  hard 
or  use  too  stiff  a  brush  or  too  abrasive  a  dentifrice, 
that  they  use  their  toothbrush  in  the  wrong  man- 
ner; and  they  may  also  indicate  whether  the  indi- 
vidual is  right-  or  lefthanded. 

The  form  of  anterior  open  bite  shown  by  the 
thumb  or  finger  sucker  is  good  evidence,  especially 
in  childhood. 

The  rampant  caries  of  the  baker  or  confectioner 
is  also  of  value.  I  once  saw  a  professional  choco- 
late taster  who  had  cervical  caries  on  every  tooth 
in  an  otherwise  almost  complete  dentition.  Exten- 
sive cervical  caries  has  also  been  noted  in  young 
employees  at  chemical  factories  who  had  to  do 
with  the  manufacture  of  sulphuric  and  tartaric 
acids.  A  patient  in  the  habit  of  sucking  lemons 
had  dissolved  most  of  the  enamel  off  the  labial 
aspects  of  the  teeth. 

The  smoker  will  have  such  salivary  calculus  as 
is  on  his  teeth  stained  dark  brown,  notablv  lingual 
to  the  mandibular  incisor  teeth,  and  the  drinker  of 
strong  tea  will  often  have  it,  or  his  dentures,  stain- 
ed black. 

The  gingival  blue  line  of  chronic  lead  poisoning 
is  not  present  when  there  are  no  teeth  and  is  de- 
pendent on  some  degree  of  gingival  infection.  A 
bismuth  deposit,  as  when  this  drug  is  used  in  anti- 
syphilitis  treatment,  is  usuallv  browner  than  that 
caused  by  lead. 

People  who  use  soot  as  a  dentifrice  also  show  it 


in  their  gums,  sometimes  as  a  line  following  the 
gingival  contour  and  sometimes  as  a  deposit  tat- 
tooed into  the  actual  gum  tissue  bv  the  toothbrush 
bristles. 

Tribal  marks  are  made  in  some  primitive  races 
by  the  filing  away  of  portions  usually  of  the  max- 
illary incisor  teeth  and  occasionally  the  removal 
of  one  or  more  anterior  teeth;  though  in  the  Aus- 
tralian aboriginal  the  removal  of  one  or  two  max- 
illary incisor  teeth,  when  practiced,  is  not  of  this 
nature  but  apparently  part  of  the  initatory  cere- 
monies at  puberty. 

In  other  countries  the  stained  teeth  of  the  betel 
chewer  may  also  be  evidence  of  value. 

The  degree  of  attrition  seen  on  the  permanent 
teeth  gives  some  indication  of  the  habits,  especial- 
ly masticatorv  habits,  of  the  individual.  It  is  the 
duty  of  the  Esouimaux  women  to  soften  the  seal 
skins  used  for  clothing  and  this  they  do  by  masti- 
cating them. 

Absence  of  d°ntal  caries  in  childhood  or  young 
adult  life  mav  indicate  some  degree  of  dietetic 
perfection  rather  than  conservative  care. 

Chronic  anterior  gingivitis,  especially  in  the 
young,  is  almost  pathognomonic  of  mouth-breath- 
ing occasioned  bv  nasal  obstruction. 

The  character  and  type  of  conservative  work, 
if  present,  will  indicate  many  things,  including  at 
present,  social  status  and  even  perhaps  nationality. 
The  dentistrv  of  necessity  and  the  dentistry  of  lux- 
ury are  of  different  types. 


DENTAL  CARIES  IN  HIGH  SCHOOL 
CHILDREN 

No  longer  do  we  tell  parents  that  a  clean  tooth 
will  not  decav.  Proper  attention  to  tooth  clear- 
ness will  and  does  lessen  the  incidence  of  decay, 
how  much  we  would  not  undertake   to  estimate. 

In  the  vast  majority  of  cases  tooth  repair  and 
restoration  are  required. 

A  recent  study1  brings  out  facts  worthy  of  atten- 
tion. 

The  data  given  are  derived  from  dental  examin- 
ations of  1,841  children  attending  the  high  schools 
of  Hagerstown.  Md.,  and  of  nearby  communities 
by  a  dental  officer  of  the  United  States  Public 
Health  Service.  The  analysis  was  designed  to  pro- 
vide information  on  the  prevalence  of  caries,  dental 
care  in  the  form  of  fillings,  carious  defects  without 
evidence  of  fillings,  and  dental  defects  which  had 
terminated  in  complete  tooth  destruction. 

Analysis  of  the  data  indicates  that: 

1.  The  incidence  of  new  cavities  is  0.6  affected 
permanent  teeth  and  2.0  affected  permanent  tooth 
surfaces  per  high  school  child  per  year. 


1     H    Klein     D.    D.    S.,   and   C.    E.    Palmer,    M.    D.,    Bethesda, 
Md.,    in    U.    S.    P.   H.    Reports,   July, 


SOUTHERN  MEDICINE  &  SURGERY 


2.  The  incidence  of  dental  care  in  the  form  of 
fillings  is  0.4  permanent  tooth  surfaces  per  high 
school  child  per  year. 

3.  The  average  disparity,  over  the  high  school 
interval,  between  the  rates  of  incidence  of  caries 
and  provision  of  care  by  fillings  is  shown  to  account 
for  an  average  of  1  l-3rd  permanent  teeth  extracted 
or  with  remaining  roots  per  high  school  child. 

4.  The  average  disparity  between  the  annual  rate 
of  development  of  caries  and  the  annual  rate  of 
placement  of  fillings  may  measure  the  adequacy 
of  dental  care  received  by  population  groups. 

Each  year  brings  a  new  increment  of  untreated 
cavities.  The  average  person  on  reaching  adult 
age  presents  a  reparative  problem  complex.  Small 
initial  lesions  may  be  cared  for  by  simple  fillings, 
if  left  untreated  the  destructive  process  continues, 
and  more  dental  work  is  required  to  stop  the  pro- 
cess and  restore  complete  usefulness.  As  the  de- 
struction goes  on  there  is  more  and  more  chance 
that  economic  obstacles  may  become  serious. 

It  is  well  to  emphasize  that  most  of  the  injurious 
effects  of  dental  caries  may  be  prevented  by  filling 
carious  lesions  early. 


CARDIOLOGY 

Clyde  M.   Gllmore,  M.  D.,  Editor,  Greensboro,  N.   C. 


THE   COMBINED    USE    OF    OUABAIN   AND 

DIGITALIS  IN  THE  TREATMENT  OF 

CONGESTIVE  HEART  FAILURE 

All  of  us  chafe  under  the  slow  action  of  digi- 
talis in  those  cases  in  which  it  seems  that  life 
depends  on  prompt  relief.  Very  welcome  is  the 
suggestion1  that  ouabain  be  given  to  hasten  digi- 
talis effect. 

Digitalis  requires  2  to  5  hours  before  any  effect 
and  must  be  repeated  in  smaller  doses  under  care- 
ful supervision  in  order  to  produce  complete  and 
safe  digitalization. 

Ouabain  intravenously  exerts  an  "initial  effect 
in  from  5  to  20  minutes,  and  a  maximum  effect 
in  from  IS  to  50  minutes."  It  is  eliminated  quickly. 

Patients  were  selected  whose  heart  disease  could 
be  classified,  who  had  congestive  heart  failure,  and 
no  recent  myocardial  infarction  and  no  digitalis 
within  the  previous  two  weeks,  who  were  cooper- 
ative and  capable  of  taking  medication  by  mouth. 

The  maximum  effect  of  treatment  other  than 
digitalis  was  ascertained  whenever  possible.  Then 
0.5  mg.  (5  cat  units)  of  ouabain  was  given  intra- 
venously simultaneously  with  6  or  8  cat  units  of 
digitalis  leaf  orally;   the  amount  of  the  latter  de- 

1     R.    C.   Batterman,   et   u\;  Naw  York   in   Amcr.   Heart  Jl„  Oct. 


pended  on  the  estimated  edema-free  weight  of  the 
patient.  No  other  digitalis  was  given  for  24  hours. 
At  the  end  of  this  time  the  patient  was  placed  on 
a  daily  maintenance  dose  of  one  to  two  cat  units 
of  reliable  digitalis  leaf  by  mouth.  Ouabain  in 
solution  undergoes  deterioration.  All  patients  were 
observed  carefully  for  digitalis  toxicity,  changes  in 
weight,  blood  pressure,  and  ventricular  and  pulse 
rates. 

Digitalization  was  produced  60  times  in  59  cases. 
Improvement  was  noted  within  15  minutes  in  30% 
of  the  60  trials,  within  one  hour  in  60%  and  within 
two  hours  in  80%.  Improvement  occurred  very 
rapidly  in  the  majority  of  the  cases.  As  a  rule, 
this  improvement,  once  established,  was  progres- 
sive, maximum  effect  at  24  hours. 

Almost  all  of  the  rheumatic  patients  showed  im- 
provement within  one  hour.  All  patients  with 
hypertension,  uncomplicated  by  arteriosclerosis, 
were  improved  within  two  hours;  with  arterio- 
sclerosis in  only  10y2  within  the  first  2  hours. 
Eighty-three  per  cent  of  the  patients  with  auricu- 
lar fibrillation  were  improved  within  one  hour, 
whereas  only  58%  of  those  with  normal  sinus 
rhythm  showed  improvement   in   this  period. 

Eighteen  per  cent  showed  mild  toxicity  at  the 
end  of  24  hours 

Dose  of  digitalis  for  patients  who  weigh  less 
than  125  pounds,  4  cat  units  (0.4  gm.);  for  those 
125  to  175,  6  cat  units;  over  175  pounds,  8  cat 
units. 

The  use  of  ouabain  brings  about  rapid  improve- 
ment; the  simultaneous  administration  of  digitalis 
leaf  maintains  this  improvement,  decreases  or  abol- 
ishes the  gap  between  the  beginning  of  digitaliza- 
tion and  the  establishment  of  a  maintenance  dose; 
is  more  rapid  than  the  usual  method  of  digitaliza- 
tion; is  no  more  likely  to  produce  toxicity;  applic- 
able to  patients  with  normal  sinus  rhythm,  as  well 
as  those  with  auricular  fibrillation;  the  technic  of 
administration  is  relatively  easy.  Complicated 
calculations  are  not  necessary  to  estimate  the  ini- 
tial and  subsequent  doses  fo  digitalis. 


DISCUSSION  ON   INJURIES  OF  THE  EAR 
(Proc.  Royal  Soc.   of  Med.,  Lond.,  Nov.) 

Some  patients  complained  a  week  or  a  fortnight  after  the 
injury  of  great  sensitiveness  to  slight  sound.  They  were 
grossly  disturbed  by  the  footsteps  of  people  walking  in 
the  ward.  One  out-patient  complained  that  whereas  he 
used  to  amuse  himself  by  tinkling  on  the  piano  he  was  now 
unable  to  do  so  because  of  the  intense  irritation  which  was 
ets  up. —  R.  J.  Cann. 

ShrapnelPs  membrane  was  never  ruptured  by  blasts.  The 
damage  was  always  to  the  tense  membrane.  Therefore  if  a 
man  came  and  claimed  that  the  condition  of  his  ear  was 
due  to  explosion,  yet  there  was  perforation  of  Shrapnell's 
membrane,  then  one  could  be  quite  certain  that  the  claim 
was  without  basis. — Lionel  Colledge 


SOUTHERN  MEDICINE  &  SURGERY 


March   1941 


SOUTHERN  MEDICINE  &  SURGERY 

Official  Organ 

TRI-STATE    MEDICAL    ASSOCIATION    OF    THE 

CAROLINAS  AND   VIRGINIA 

James  M.   Northlncton,   M.D.,   Editor 

Department  Editors 

Human   Behavior 

James    K.    Hall,    M.D Richmond,    Va. 

Orthopedic    Surgery 

Oscar  Lee  Miller,  M  D.I Charlotte.  N    C 

John  Stuart  Gaul,  M.D.  I 

Urology 

Hamilton  W.  McKay,  MD  I  ...Charlotte,  N    C 

Robert  W.  McKay,  M.D.     .  | 

Surgery 

Geo.  H.  Bunch,  M.D Columbia,  S.  C. 

Obstetrics 

Henry  J.  Langston,  M.D Danville,  Va. 

Ivan  M.  Procter,  M.D Raleigh,  N.  C 

Gynecology 

Chas.  R.  Robins,  M.D ..Richmond,  Ya. 

G.  Carlyle  Cooke,  M.D Winstor. -Salem,  N.  C. 

Pediatrics 

G.  W.  Kutscher,  Jr.,  M.D Asheville,  N.  C. 

General  Practice 

J.  L.   Hamner,  M.D Mannboro,   Va. 

VV.   J.   Lackey,  M.D ..: Fallston,   N.   C. 

Clinical  Chemistry  and  Microscopy 

C.  C.  Carpenter,  M.D | 

„„    /..Wake   l-onst.  N.   C 
R.  P.  Morehead,  B.S.,  M.A.,  M.D.) 

Hospitals 
R.   B.   Davis,   M.D.. Greensboro,   N    C. 

Cardiology 
Clyde  M.  Gilmore,  A.B.,  M.D Greensboro.  N.  C. 

Public  Health 
N".  Thos.  Ennett,  M.D Greenville,  N.  C 

Radiology 
Wright  Clarkson,  M.D.,  and  Associates....Petersburg,  Va. 
R.  H.  Lafferty,  M.  D.,  and  Associates,     Charlotte,  N.  C. 

Therapeutics 
J.  F.  Nash,  M.  D., Saint  Pauls,  N.  C. 

Tuberculosis 
John    Donnelly,   M.D Charlotte,   N.    C. 

Dentistry 
J.   H.   Guion,  D.  D.  S Charlotte,   N.   C 

Internal  Medicine 
George  R.  Wilkinson,  M.D Gnenvile,  S.  C 

Ophthalmology 
Herbert  C.  Neblett,  M.  D., Charlotte,  N.  C. 

Rhino-Oto-Laryngology 
Clay  W.  Evatt,  M.  D.,  Charleston,  S.  C. 

Offerings  for  the  pages  of  this  Journal  are  requested  and 
given  careful  consideration  in  each  case.  Manuscripts  not 
found  suitable  for  our  use  will  not  be  returned  unless 
author  encloses  postage. 

As  is  true  of  most  Medical  Journals,  all  costs  of  cuts, 
etc.,  for  illustrating  an  article  must  be  borne  by  the  author 


THE  TRI-STATE  MEETING  AT 
GREENSBORO 

From  dozens  of  those  who  participated  in  this 
meeting  held  last  month  have  come  expressions  of 
opinion  that  it  was  the  best  of  a  long  series  of 
extra  good  meetings.  The  addresses  were  praised 
highly,  but  no  more  so  than  the  excellent  clinics 
given,  some  wholly  and  others  partly,  by  our 
Greensboro  members.  And  the  essays  came  in  for 
high  praise.  One  of  our  veterans  who  participated 
in  the  formation  of  the  association  forty-three 
years  ago  said  it  was  the  best  medical  meeting  he 
had  ever  attended. 

The  attentions  of  Dr.  Gilmore  and  his  commitee 
were  constant  and  showed  foresight  and  discrim- 
ination.   For  these  much  appreciation. 

The  attendance  was  not  quite  what  such  a  meet- 
ing should  have  commanded,,  but  about  what  was 
anticipated  from  letters  and  telephone  and  tele- 
graph messages  that  so  many  doctors  were  being 
kept  at  home  bv  illness  in  their  own  persons,  in 
their  families  or  in  a  great  many  of  their  patients, 
A  good  Charlotte  doctor  telephoned  that  epidemics 
had  kept  him  from  every  Tri-State  meeting  for  ten 
years,  and  moved  that  the  meeting  time  be  chang- 
ed. He  said  a  change  to  mid-March  would  be  a 
great  improvement.  A  quiet  canvas  revealed  a 
general  opinion  that  a  better  meeting-time  should 
be  chosen.  Every  member  is  urged  to  think  over 
this  matter,  taking  into  consideration  the  meeting- 
time  of  other  medical  bodies,  particularly  the  State 
Societies  of  the  two  Carolinas  and  Virginia,  then 
to  write  the  secretary  his  choice  of  dates;  including 
whether  to  have  a  two-day  or  a  three-day  meeting. 

A  dereliction  for  which  we  must  make  amends 
was  the  unfavorable  placing  of  our  exhibitors  and 
their  wares.  All  of  us  regret  this  and  by  way  of 
amends  will  bear  it  in  mind  to  show  special  con- 
sideration to  the  representatives  of  Hynson,  West- 
cott  and  Dunning,  Mead  Johnson  and  Company, 
Lederle  Laboratories.  Eli  Lilly  and  Company,  Pow- 
ers and  Anderson,  Valentine  Company,  Van  Pelt 
and  Brown,  Winchester  and  Winchester-Rich  Sur- 
gical Supply  Company,  and  John  Wyeth  and 
Brother. 

Comments  on  results  of  the  election  with  photo- 
graphs of  th°  handsomest  products  are  reserved 
for  next  month's  issue. 


GOUT  NOT  A  RARE  DISEASE 
We  have  come  to  regard  gout  as  a  rare  condi- 
tion, formerly  very  prevalent  among  port-drinking, 
beef-eating     Englishmen,     and     fairly     prevalent 


March   1941 


SOUTHERN  MEDICINE  &  SURGERY 


151 


among  Bostonians  of  the  like  habit.  In  the  past 
few  years  a  good  many  articles  have  appeared 
suggesting  that  we  still  have  gout  with  us  in  con- 
siderable quantity. 

An  article-  in  the  current  issure  of  a  western  jour- 
nal rather  convincingly  presents  the  case  for  gout 
as  a  condition  to  be  considered  in  arriving  at  a 
decision  as  to  the  nature  of  any  case  of  joint  dis- 
ease. 

This  article  tells  us  that  the  cause  of  gout  is 
unknown,  its  incidence  is  probably  as  high  as  it 
ever  was,  though  it  affects  chiefly  men  past  40  and 
may  attack  girls  under  10,  the  deforming  stage 
with  tophi  does  not  come  for  years.  The  familial 
tendency  is  considerable  and  may  be  helpful  in 
diagnosis.  The  greater  number  of  men  among  its 
victims  is  attributed,  not  to  the  over-eating  and 
over-drinking  of  men,  but  to  gout  being  of  a  sex- 
linked  character. 

The  periodicity  of  early  mild  attacks  leaving  no 
disability,  and  later  joint  changes  with  urate  de- 
posits producing  mechanical  interference  are  out- 
lined. The  acute  attacks  may  involve  almost  any 
joint,  which  by  its  red,  hot,  swollen  appearance 
suggest  a  septic  process,  even  a  cellulitis.  Attacks 
have  been  brought  on  by  a  high-purin  meal,  by  a 
dose  of  liver  extract,  by  a  spree,  by  trauma,  by 
cold  or  damp.  Confusion  with  acute  rheumatic 
fever  is  said  to  be  not  uncommon. 

Chronic,  deforming  joint  changes  are  rather  to 
be  expected,  and  renal  impairment,  probably  with 
urate  calculi,  is  given  as  a  common  sequel. 

The  diagnosis  in  advanced  cases  should  present 
no  difficulties,  once  suspicion  of  gout  is  aroused. 
Early  repeated  attacks  of  joint  pain  with  freedom 
from  pain  between  attacks  and  an  increase  of  uric 
acid  in  the  blood  serum  or  plasma  fairly  establish 
the  diagnosis. 

The  condition  can  not  be  cured,  in  the  sense  of 
restored  to  the  former  state.  It  is  quite  amenable 
to  cure  in  the  original  sense  of  being  cared  for. 
Bed  rest,  fluids  in  excess,  purin-free  diet,  a  bed 
cradle  and  anodynes — aspirin,  codeine — or  mor- 
phine even:  and  hot  pads  and  soaks  are  to  be  or- 
dered during  the  acute  attack. 

The  most  important  drug  for  gout,  now  as  a 
hundred  years  ago,  is  colchicum,  the  best  prepara- 
tion colchidine,  in  doses  of  1/120  gr.  every  one  or 
two  hours  until  eight  to  twelve  or  more  doses  have 
been  taken.  Adequacy  is  indicated  bv  nausea,  colic 
or  diarrhea.  Enough  should  be  given.  Pain  should 
disappear  with  in  48  hours.  Indications  of  satura- 
tion may  be  treated  symptomatically,  after  dis- 
continuing the  colchidine.  Occasionally  it  is  neces- 
sary to  repeat  the  doses.    In  such  case  an  interval 


of  two  or  three  days  should  be  allowed. 

This  article  should  serve  to  cause  us  to  keep  in 
mind  the  likelihood  of  a  patient's  joint  trouble — 
acute  or  chronic — being  of  gouty  origin.  It  is 
unlikely  that  there  is  as  much  gout  among  us  as 
among  the  Back  Bay  folks.  It  is  very  likely  that 
there  is  a  good  deal  more  among  us  than  is  being 
discovered. 

By  an  odd  coincidence,  the  evening  of  the  day 
this  comment  on  gout  was  made,  the  editor  hap- 
pened to  choose  to  read  from  the  Letters  of  Pliny 
the  Younger,  and  there  to  come  across  a  letter  to 
Calestrius  Tiro,  in  which  is  lamented  the  death  of  a 
mutual  friend,  driven  to  suicide  by  the  pains  of 
gout. 

Says  this  letter: 

Corellius  is  dead,  in  his  sixty-seventh  year.  In 
his  thirty-third  year  he  was  seized  with  gout  in 
his  feet.  This  was  hereditary.  A  life  of  sobriety 
and  continence  had  enabled  him  to  keep  down  the 
disease  while  he  was  still  young.  Latterly  he  suf- 
fered the  most  incredible  agonies,  for  the  gout  was 
now  not  only  in  his  feet,  but  spread  over  his  whole 
body.  . .  .  His  malady  increased.  .  .  He  refused  all 
sustenance.  .  .  .  and  said  to  his  physician  who  press- 
ed him  to  take  nourishment,  "It  is  resolved". 

And  so  we  have  evidence  that  in  the  First  or 
early  in  the  Second  Century  A.  D.,  gout  was  re- 
cognized to  be  hereditary,  it  persisted  despite  plain 
living,  it  extended  to  many  joints  and  parts  be- 
yond the  feet,  and  its  pains  were  so  intolerable 
as  to  cause  a  strong  man  to  starve  himself  to  death. 


by  J.   B.  Talbott,  Boslo 


Rocky  Ml.  Med. 


A  MODERN  HEALTH   PROGRAM 

From  the  author1  has  come  a  reprint  bearing 
this  title,  with  request  for  opinion.  On  reading  the 
details  of  the  plan,  the  editor  is  impressed  with 
the  idea  that  the  carrying  out  of  such  a  plan  would 
establish  the  foundation  for  a  structure  which 
would  meet  practically  all  the  demands  that  are 
being  made  by  the  people.  As  to  the  demands  be- 
ing made  by  politicians — who  knows? 

The  objective  is  to  bring  about  improvement  in 
the  distribution  of  medical  care  without  disturbing 
the  personal  relationship  between  patient  and  phy- 
sician and  without  lowering  the  standards  of  med- 
icine. It  is  with  the  aim  of  retaining  and  probably 
enlarging  the  present  facilities  for  preventive  and 
curative  medicine,  as  well  as  for  research,  that  the 
plan  has  been  evolved.  Tt  requires  no  legislation, 
no  compulsion,  and  no  pavment^  for  time  lost 
through  sickness:  onlv  a  ruling  or  ordinance  by 
local  authorities  which  would  administer  it  with 
available  or  an  increased  personnel  and,  of  course, 
with  the  full  cooperation  of  the  profession  and  the 


1.  Wm    Thau,   M.D.,   Boston,   article   in  Medical  Times,  Feb. 


SOUTHERN  MEDICINE  &  SURGERY 


public. 

This  plan  comprises  three  essential  features: 

I.  A  single  annual  health  report  of  every  indi- 
vidual, 

II.  Public  Health  Education,  and 

III.  Compensation  for  every  physician  and  hos- 
pital for  services  rendered. 

I.     The  Annual  Health  Report 

1.  The  purpose  oj  the  report:  The  annual  health 
report  for  every  individual,  or  at  least  for  the 
greater  number  of  individuals,  is  the  most  impor- 
tant feature  of  this  plan.  The  other  two  features 
are  designed  to  make  this  plan  possible  and  effec- 
tive. 

In  Massachusetts  and  no  doubt"  in  most  States, 
every  motor  vehicle  is  thoroughly  inspected  twice 
yearly,  and  a  report  of  its  condition  is  filed  with 
the  proper  authority.  Many  drivers  die  of  cardiac 
or  other  disease  while  operating  their  vehicles.  Sim- 
ilar accidents  occur  during  the  performance  of 
other  duties.  It  ought  to  be  regarded  as  fair  that 
such  drivers  or  other  persons  called  upon  to  do 
strenuous  physical  and  mental  work  be  thoroughly 
examined  once  a  year  and  their  condition  reported 
to  proper  authorities.  And  since  any  individual 
may  at  one  time  or  another  be  called  upon  to  per- 
form such  duties;  and,  since  children  and  the  aged 
are  more  likely  to  be  affected  by  diseases,  a  single 
annual  thorough  examination  recorded  and  filed 
appears  a  necessity. 

2.  The  reliability  of  the  report:  The  family  phy- 
sician is  the  most  appropriate  and  the  most  relia- 
ble person  to  make  the  necessary  examination  and 
report.  The  simplest  wav  to  achieve  prompt  results 
in  carrying  out  this  plan  is  to  begin  with  the  school 
children  from  the  kindergarten,  and  follow  through 
the  college  years.  Every  child  would  be  expected 
to  bring  such  a  health  report  from  the  family 
physician.  This  would  enable  the  school  physician 
to  know  better  the  health  condition  of  each  child 
under  his  supervision,  and  to  carry  out  his  duties 
as  school  hygienist.  He  could  concentrate  more  on 
instructing  the  nurse,  the  teacher,  the  parent,  and 
the  pupil,  while  the  family  physician,  to  whom  the 
child  could  be  referred  whenever  necessary,  would 
do  all  the  work  which  is  properly  his.  Those  who 
have  no  family  physician  would,  in  accordance 
with  the  principle  of  this  plan,  be  able  to  choose 
any  practitioner  for  such  an  examination.  Dunns 
these  examinations,  the  physician  and  specialist 
would  have  an  excellent  opportunity  to  show  every 
parent  and  guardian  the  need  for  such  an  exam- 
ination so  that  they  also  might  take  it.  As  to 
adults,  similar  arrangements  could  be  made.    Em- 


2.  Wherein  Dr.  Thau  is  greatly  mistaken,  but  no  harm  is 
done  his  thesis. — Editor 


ployees  would  be  expected  to  bring  a  note  from 
the  family  physician,  stating  that  the  annual  exam- 
ination has  been  made,  and  the  report  filed. 

3.  The  contents  oj  the  report:  The  report 
should  be  based  on  a  complete  history,  and  on  an 
examination  to  find  physical  defects,  and  to  test 
the  functioning  of  every  organ.  It  should  include 
records  of  tuberculosis  tests,  of  all  necessary  im- 
munizations (against  smallpox,  diphtheria,  whoop- 
ing cough,  typhoid,  undulant  fever,  etc. — depend- 
ing on  the  patient's  age  and  on  the  district),  as 
well  as  results  of  analyses  of  urine,  blood  (Wasser- 
mann),  sputum,  and  reports  on  examinations  by 
any  specialist  such  as  the  family  doctor  may  deem 
needful  in  any  certain  case.  The  forms  to  be  filled 
out  would  be  furnished  by  the  local  authorities, 
who  would  receive  a  carbon  copy  of  each  report 
carrying  the  identification  number  of  the  record, 
but  not  the  patient's  name,  which  would  appear 
only  on  the  original  copy  remaining  with  examining 
and  treating  physician.  On  each  report  should  be 
noted  whether  it  is  the  first  annual  report  of  the 
patient,  and  if  not,  the  record  number  of  the  last 
report,  or  the  name  of  the  physician  who  made 
such  a  report,  so  that  trends  of  conditions  and  the 
health  progress  of  individuals  may  be  followed  up 
and  studied  through  the  compiled  annual  reports 
over  a  long  period,  or  even  of  a  whole  life  record. 
Finally,  the  report  should  contain  the  recommen- 
dations made  by  the  physician,  who  would  assume 
full  responsibility  for  treatment  and  correction  of 
any  defect.  In  the  case  of  a  school  child,  the 
physician  would  only  transmit  to  the  school  phy- 
sician a  note  stating  that  he  had  made  the  annual 
examination  and  report,  and  whether  the  given 
child  may  participate  in  all  or  only  in  sdrne  of  the 
school  activities,  or  whether  he  should  be  taught  in' 
special  classes,  or  be  exempt  from  certain  duties. 
In  the  case  of  adults,  the  employer,  or  plant  physi- 
cian, would  be  informed  that  such  a  report  has 
been  filed,  and  whether  or  not  the  individual  per- 
son may  do  certain  work. 

4.  The  nature  and  value  oj  the  report:  The  an- 
nual reports  would  be  strictly  confidential.  The 
carbon  copies  of  the  original  records  would  contain 
only  the  record  number  and  name  of  the  examin- 
ing physician,  but  not  that  of  the  patient.  Access 
to  such  records  would  be  permitted  only  for  the 
purpose  of  follow-up,  or  research  activities.  The 
local  health  authorities  would  keep  such  records  on 
file  and  report  annually  the  number  of  normal  and 
abnormal  conditions  to  the  State  authorities  who 
would  in  turn  forward  the  assembled  data  to  the 
Federal  health  service  where  all  the  nation's  statis- 
tics could  be  compiled  and  published. 

5.  The  adaptability  oj  the  report:    The  plan  for 


March   1941 


SOUTHERN  MEDICINE  &■  SURGERY 


153 


such  an  individual  annual  examination  and  report 
could  be  adapted  by  any  community.  The  prob- 
lem of  rural  districts  could  be  solved  by  increasing 
the  existing  facilities  with  the  help  of  local,  State, 
and  national  authorities,  by  making  the  living  con- 
ditions for  a  physician  more  attractive,  and  also  by 
the  cooperation  of  medical  schools  which  could 
establish  rules  that  every  graduate  should  spend 
one  year  in  rural  practice. 

II.    Public  Health  Education 

For  any  other  health  program  the  full  coopera- 
tion of  the  profession  and  the  public  is  necessary, 
and  the  best  way  to  obtain  it  is  through  health 
education.  While  a  platform,  radio  and  lay  or 
medical  press  campaign  would  be  helpful  if  kept 
alive  for  some  time  through  frequent  reports  of 
progress,  it  is  chiefly  the  family  physician,  who, 
being  more  than  anybody  else  in  touch  with  and 
able  to  influence  the  patient,  is  in  the  best  position 
to  assure  good  results  for  this  or  any  other  health 
program. 

III.     Compensation 

It  seems  certain  that  this  would  be  very  far 
less  expensive  than  any  other  plan,  because  most 
people  would  see  their  private  physician  and  pay 
for  his  services.  Those  unable  to  pay  for  private 
consultations  might  be  allowed  to  choose  their 
physicians  and  specialists  (either  in  their  offices,  or 
in  the  hospitals),  who  could  be  compensated  bv 
the  authorities  on  a  per  capita,  or  part-time,  or 
full-time  basis  according  to  a  pre-arranged  sched- 
ule. It  is  only  just  that  the  physician  who  has 
always  given  freely  of  his  time  and  services  for 
charitable  purposes  should  receive  adequate  com- 
pensation for  his  work.  This  expense  would  be 
small,  indeed,  if  compared  with  the  benefits  it 
would  assure. 

This  program  contains  no  provision  for  pay- 
ments for  time  lost  during  sickness,  or  disability 
for  any  cause.  Such  payments  mav  be  assured  by 
small  salary  deductions  for  a  health  or  accident 
insurance.  If  put  into  operation  and  well  admin- 
istered, the  above  program  would  have  the  follow- 
ing advantages: 

1.  Medical  care  would  be  extended  to  people  in 
cities  and  towns  who,  because  of  ignorance  or  lack 
of  facilities,  never  before  asked  for  or  received  it. 

2.  Many  physical  defects  in  both  paying  and 
non-paying  patients  could  be  discovered  and  cor- 
rected, and  thus  public  health  greatly  improved. 

3.  Tuberculosis  testing,  and  immunizations 
against  any  disease,  could  be  efficiently  carried  out 
everywhere. 

4.  The  problem  created  bv  deficient  vital  statis- 
tics would  be  solved. 

5.  The    income    of    every    practicing    physician 


would  be  bound  to  increase. 

6.  There  would  be  no  plethora  of  physicians. 

7.  After  a  few  years'  operation  of  such  a  pro- 
gram the  health  of  the  people  would  be  improved 
and  curative  medicine  would  gradually  give  way 
to  preventive  measures  and  health  education. 

8.  Through  health  and  safety  education  health 
consciousness  could  be  so  aroused  as  to  bring 
about  a  reduction  of  accidents  in  industries,  in 
homes,  and  on  the  highways. 

9.  The  choice  of  physicians  would  remain  free, 
and  the  personal  relationship  between  patient  and 
physician  unimpaired.  Far  from  thwarting  initia- 
tive and  progress,  research  would  be  fostered  and 
encouraged. 

10.  It  would  always  be  possible  to  know  the 
state  of  the  nation's  health,  to  study  its  progress, 
to  concentrate  on  improvements  whenever  and 
wherever  necessary,  and  to  have  an  exact  idea  of 
the  available  man  material  in  a  given  emergency. 

The  putting  into  operation  of  such  a  program 
would  certainly  go  far  toward  doing  justice  to  the 
family  doctor,  would  solve  most  of  our  immuniza- 
tion problems,  would  curb  harmful  activities  of 
school  and  other  public  nurses,  would  reduce  the 
cost  of  health  care  and  much  improve  the  distri- 
bution of  money  paid  out  on  health. 

That  it  would  do  as  much  as  its  proponent  thinks 
it  would,  we  do  not  believe.  But  no  man  is  a  com- 
petent judge  of  his  own  dog,  his  own  horse,  or 
his  own  idea. 


THE  CURATIVE  VALUE  OF  CRYING 
In  this  era  of  "PolIy-Anna-ism,"  of  over-done 
and  often  entirely  spurious  "optimism,"  it  is  well 
to  call  attention  to  the  fact  that  it  is  as  physiolo- 
gic, as  healthful,  to  cry  when  one  feels  like  crying 
as  it  is  to  laueh  when  one  feels  like  laughing.  It  is 
well  to  go  further  and  inform  the  shallow-pated 
chanters  of  "smile,  smile,  smile,"  that  tears  have  a 
time  and  a  place  in  the  scheme  of  things,  and  that's 
what  a  wise  doctor1  uses  a  few  pages  of  a  valued 
exchange  in  doing. 

A  certain  amount  of  stoicism  generally  is  consid- 
ered to  be  a  wholesome  nualitv  in  any  human  be- 
''n^'  but  one  must  seriously  ouestion  that  type  of 
cf-n'n'cm  which  is  e"hibited  where  there  is  no  real 
need.  Self-mortification  at.  times  can  lead  only  to 
varvine  degrees  of  suicide. 

Th^re  are  manv  nsvcholosical  situations  that  will 
hrincr  nn  crvinf.  As  a  rule,  it  is  considered  a  weak- 
ness to  crv.  Tn  some  it  seems  almost  an  impossi- 
bility, and  it  is  in  iust  these  cases  that  a  spell  of 
rrviner  would  do  most  good. 

I.  A.   X.   Foxe,  New   York,   in  Med.   Rec,  Mar.   5th 


SOUTHERN  MEDICINE  6r  SURGERY 


March   1941 


Crying  with  a  person  binds  one  to  that  person. 
Crying  over  the  loss  of  a  person  or  separation  from 
a  person  helps  one  to  separate  himself  even  more 
from  that  person.  Those  who  do  not  cry  at  a 
funeral  where  thev  are  expected  to  cry  are  consid- 
ered to  have  had  no  love  for  the  one  who  died.  The 
full  acceptance  of  death  of  a  loved  person  without 
crying  is  that  refusal  to  accept  the  fact  of  death 
which  leads  to  many  attempts  to  communicate  with 
the  dead. 

A  child  that  cries  bv  itself  achieves  a  great  de- 
gree of  independence  from  personal  attachment  to 
others.  Many  mothers  carry  this  out  under  con- 
siderable emotional  stress  and  wish  to  go  to  the 
infant. 

The  mother  who  lets  the  infant  cry  it  out  makes 
it  a  lot  easier  for  herself,  but  one  wonders  if  the 
mother  who  prolongs  this  kind  of  weaning  over  a 
number  of  years  does  not  in  the  long  run  accom- 
plish more  for  her  child.  As  you  will  see.  these  are 
not  easv  problems  and  perhaps  the  solution  lies  in 
neither  extreme. 

There  are  some  natients  who  have  cried  so  long 
and  hard  as  to  have  cried  themselves  out.  Often 
thev  are  cold  and  nhWmatic.  though  highlv  sensi- 
tive and  deeDlv  unhapnv  nersons.  There  are  some 
who  have  never  known  what  it  is  to  crv.  Thev  are 
also  sensitive  and  e^nect  a  great  deal  to  be  done 
for  them.  Then  there  are  all  trades  in  between, 
including  those  whoso  nrohlems  date  fiom  situations 
nartlv  the  result  of  infantile  training  and  nartlv 
the  result  of  real  and  unavoidable  situations.  Crv- 
ing  in  itself  mav  rparh  a  decree  that  is  in  itself 
harmful,  rather  than  theraneutic. 

Tn  no  two  natients  a™  the  situations  ah'ke  and 
in  no  onp  natient  is  trip  situation  the  same  at  all 
times.  Tt  is  a  nrohlpm  in  both  men  and  wompn. 
Tn  wnmpn  the  time  of  menstrual  flow  is  often  the 
period  of  tearful  outbursts. 

The  significance  of  crying  is  so  momentous  that 
one  wonders  how  it  is  that  some  form  of  tear  gas 
has  not  yet  achieved  any  vogue. 


BY    WAY    OF    AMENDS 


For  our  February  issue  the  Department  of  Obstetri.s 
supplied  the  substance  of  an  instructive  article  by  Dr. 
E.  D.  Colvin,  of  Atlanta,  which  article  appeared  in  Septem. 
ber  1940  issue  of  the  Journal  of  the  Medical  Association 
of  Alabama...  A  proper  credit  line  was  set,  which  was 
lost  in  make-up.  Reference  was  made  to  a  subtended 
credit  line,  which  would  make  it  obvious  that  credit  had 
been  given.  However  we  wish  to  give  credit  specifically 
to  Dr.   Colvin     and   the   Alabama   Journal. 


OLD    AGE— Barker 

(From   Page    134) 

have  been  safely  carried  out  in  persons  over  70. 
One  woman  106  years  old  was  successfully  opera- 
ted upon  recentlv  for  strangulated  hernia  and,  in 
1939,  a  110-vear-old  colored  man  underwent  pros- 
tatectomv  and  was  alive  and  well  a  vear  later. 

The  problems  of  mental  hygiene  in  old  persons 
have  recently  (1939)  been  well  discussed  by 
George  Lawton.  In  my  little  book,  Psychotherapy, 
published  last  year,  I  have  emphasized  the  details 
of  mental  hygiene  during  senescence — lessening  of 
hours  of  work,  increased  amount  of  rest  and  ;. 
recreation,  regular  gentle  exercise,  avoidance  of 
fatigue,  gradual  delegation  of  responsibilitv  to  as- 
sociates, and  cultivation  of  social,  altruistic  or 
literary  interests  as  business  interests  are  dimin- 
ished. 

Pessimistic  and  Optimistic  Views  of  Old  Age 
Medical  and  lav  writers  have  differed  much  in 
their  estimation  of  the  desirability  of  old  age. 
Many,  following  the  example  of  the  author  of  Ec- 
clesiastes,  expressed  gloomy  views;  others  have 
emphasized  the  brighter  side.  In  pathological  old 
age,  the  debit  side  greatly  exceeds,  without  doubt, 
the  credit  side;  but  as  to  physiological  old  age 
some  are  more  pessimistic,  others  more  optimistic. 
You  will  recall  that  Anthony  Trollope.  in  his  novel 
The  Fixed  Period,  suggested  the  desirabilitv  of 
putting  persons  painlessly  to  death  when  thev 
approached  the  age  of  70.  The  political  economist 
and  humorist,  Stephen  Leacock,  wrote  me  recently 
"  about  the  only  good  thing  you  can  say  about 
old  age  is  that  it  is  better  than  being  dead." 
However,  in  an  article  entitled  "This  Business  of 
Growing  Old"  published  in  the  New  York  Times 
just  after  his  70th  birthday,  he  said  "the  old 
person  has  some  consolation  if  he  has  something 
to  pass  on — the  new  life  of  children  and  of  grand- 
children, or,  if  not  that,  at  least  some  recollection 
of  good  deeds  or  of  something  done  that  may  give 
one  the  hope  to  say  non  omnis  moriar" — I  shall 
not  altogether  die. 

The  late  Sir  William  Osier,  at  the  age  of  56, 
when  under  the  emotional  strain  of  saying  good- 
bye to  his  friends  in  America,  seemed  rather  pes- 
simistic when  he  spoke  of  the  relative  uselessness 
of  persons  over  60.  He  lived,  however,  to  be  over 
70  himself  and  exerted  a  profound  influence  in 
later  years  upon  medicine  and  upon  the  general 
welfare. 

The  late  Dr.  A.  S.  Warthin  of  Ann  Arbor 
thought  that  old  age  should  be  met  with  courage. 
He  emphasized  the  many  compensations  of  the 
7th  and  8th  decades  of  life  derived  from  the  fact 
that  spiritual  and  mental  functions  are  prolonged 


OLD   AGE-^Barker 


155 


longer  than  other  functions.  He  counted  the  old 
person  fortunate,  however,  if  he  were  blessed  with 
a  speedy  release  before  the  unhappy  days  of  second 
childhood  came  upon  him. 

The  athlete  and  sculptor,  R.  Tait  McKenzie, 
looked  upon  old  age  favorably  for  its  gain  in 
physical  and  mental  poise,  for  its  accumulated 
experience  in  skills,  for  its  knowledge  of  ways  of 
saving  mental  and  physical  energy,  and  for  the 
satisfaction  of  doing  well  and  easily  things  that 
younger  men  have  to  struggle  over  unsuccessfully. 
He  valued  his  contacts  with  fine  minds  and  per- 
sonalities as  well  as  his  better  understanding  of 
fine  literature.  With  Audrey  Brown  he  said:  "I 
shall  grow  old  with  autumn  and  not  reluctantly;" 
and  he  felt  it  to  be  his  duty  "to  maintain  his 
fortitude  until  the  end." 

Personal  Experience  with   Longevity 

I  myself  have  had  the  good  fortune  to  have 
lived  longer  than  the  average  man  and,  because 
of  long-lived  Canadian  ancestors  and  a  relatively 
favorable  environment,  have  thus  far  escaped  most 
of  the  infirmities  and  disabilities  that  all-too-often 
accompany  longevity.  I  am  reconciled  to  the  fact 
that  the  duration  of  human  life  is  definitely  limit- 
ed; but,  I  shall  be  glad  to  continue  to  live  as  long 
as  I  can  be  professionally  and  socially  useful,  hop- 
ing however  that  when  usefulness  is  over,  release 
may  come  painlessly,  and  all  the  better  if  suddenly, 
without  my  being  required  to  linger  on  for  a  long 
time  as  a  burden  to  myself  or  to  others.  I  still 
have  great  pleasure  in  unravelling  the  tangled 
skeins  of  intricate  and  difficult  medical  diagnostic 
problems  in  hospitals  and  in  private  practice  and 
in  planning  comprehensive  therapeutic  regimens 
suited  to  the  management  of  multidimensional 
diagnostic  findings. 

As  to  ultimate  philosophical  considerations,  I 
can  truthfully  say  that  I  was  more  concerned  with 
them  in  my  youth  than  I  have  been  during  the 
approach  to  senescence.  I  am  grateful  for  having 
been  privileged  to  live  during  a  marvellous  period 
of  medical  and  scientific  advances.  It  has  been  a 
joy  to  watch,  and  to  endeavor  to  participate  in, 
the  conquest  of  a  large  number  of  the  infectious 
diseases  and  the  extension  of  preventive  sanitary 
measures;  to  witness  the  extraordinary  progress  of 
our  knowledge  of  nutrition,  metabolism  and  en- 
docrinology during  the  50  years  that  have  elapsed 
since  I  graduated  in  medicine;  to  learn  how  to 
make  use  of  the  newer  physical,  chemical,  biolog- 
ical and  psychological  technical  methods;  and  to 
observe  the  beneficial  effects  of  penetrating  the 
bodies  of  sick  human  beings  with  the  magic  bullets 
of  salvarsan,   sulfanilamide  and  sulfapyridine. 

Within  a  few  hours,  my  chauffeur  can  bring  me 


from  the  medical  libraries  of  the  city  fifty  books 
or  articles  in  English,  French  and  German  bearing 
upon  any  topic  in  which  I  am  interested.  The 
telephone,  electric  lighting,  the  automobile,  the 
aeroplane,  the  x-ray,  radium,  the  moving  picture, 
the  radio,  electrical  refrigeration  in  homes,  air 
conditioning,  synthetic  textiles,  and  television  are 
all  developments  of  the  period  through  which  I 
have  lived.  On  flying  to  Oklahoma  City  and  back 
recently,  it  seemed  almost  incredible  that  I  could 
reach  Chicago  in  less  than  four  hours  after  leaving 
Washington  and  that  I  could  be  in  Oklahoma  City 
in  six  and  a  half  hours  after  leaving  Chicago.  I 
flew  here  from  Baltimore  yesterday  in  less  than 
three  hours.  It  continues  to  astound  me  that  I 
can  sit  before  my  radio  in  the  evening  and  within 
fifteen  minutes  hear  short  talks  about  war  condi- 
tions from  London,  Berlin,  Vichy  and  Athens. 

I  am  daily  thankful  that  it  has  been  my  lot  to 
live  in  the  United  States  of  America  rather  than 
in  a  country  that  is  under  an  iniquitous  totalita- 
rian government.  I  have  greatly  enjoyed  reading 
Gone  With  the  Wind  and  have  been  deeply  moved 
by  the  persual  of  Grapes  of  Wrath,  and  a  little 
later  finding  it  possible  to  see  and  hear  the  char- 
acters of  both  books  in  cinematographic  presenta- 
tions. Among  my  pet  diversions  are  solving  the 
crossword  puzzles  in  the  London  Daily  Times, 
wrestling  each  week-end  with  Elizabeth  Kingsley's 
double  acrostic  in  the  Saturday  Review  of  Litera- 
ture, and  participating  in  an  occasional  game  of 
contract  bridge.  Even  to  the  Lucullian  pleasures 
I  am  not  wholly  indifferent,  for  I  enjoy  a  mild 
cigar  after  each  meal,  a  glass  or  two  of  good  wine 
at  a  dinner  party,  and  the  oysters,  terrapin,  soft- 
shelled  crabs  and  fried  chicken  of  Maryland!  In 
addition  to  unusually  happy  marital  and  familial 
experiences,  I  have  been  blessed  with  loyal  asso- 
ciates and  a  host  of  good  friends  and  acquaintances 
who  have  added  hugely  to  the  joys  of  my  life. 

With  R.  Tait  McKenzie  I  must  admit  that  I 
have  "had  a  good  run"  and  that  I  should  be  will- 
ing to  "call  it  a  day."  For  my  friends  I  can  wish 
nothing  better  than  that  they  may  have  as  many 
happy  memories  as  I  have  when  they  approach 
the  sunset  of  their  lives. 

Selected  References 
Allen    (D.   E.)    Nursing  care   of  aged   and  chronically   ill 

patient.   J.  Indiana  M.  A.,    1939,   32:    409-412. 
Barker   (L.  F.)   &  Sprunt   (T.  P.)   The  degenerative  dis- 
eases; their  causes  and  prevention.  N.  Y.,  1925,  254  pp. 
Barker    (L.  F.)    Convalescence   of  old  age   patients.  Bull. 

N.   Y.  Acad.  Med.,   1940,   16:    105-116. 
Barker    (L.    F.)    Physical    changes   in    old   age    and    their 
effects   upon   mental   attitudes  with   comments  upon   the 
care  of  the  aged.    Address  before  the  New  York  School 
of  Social  Work   (Welfare  Council),  Jan.  8,   1941. 
Cowdry    (E.   V.)    editor.     Problems   of   ageing;    biological 


156 


SOUTHERN  MEDICINE  &  SURGERY 


and  medical  aspects.  N.  Y.,   1929,  758  pp. 
Gray    (G.    W.)    The    mystery    of    aging.     Harper's    Mag., 

1941,  182:   283-293. 
Hall    (G.   S.)    Senescence:    The   last   half   of   life.   N.   Y., 

1922,  578  pp. 
Helton    (R.   L.)    Old  people;    a   rising   national   problem. 

Harper's  Mag.,  1939,   179:   449-459. 
Jennincs  (H.  S.)  On  the  advantages  of  growing  old.  Johns 

Hopkins  Alum.  Mag.,  1922,   10:   241-251. 
Lawton    (G.)    Mental  hygiene  at  senescence.  Ment.  Hyg., 

1939,   23:    257-267. 
Northington    (J.   M.)    Some    features   of   health    care    of 

the  aging.  South.  Med.  &  Surg.,   1940,   102:    561-564. 
Symposium   upon   Medical   Aspects  of   Old   Age.  M.   Clin. 

North  America,   1940,   24:    January   number. 
Symposium    upon   Surgical   Aspects   of   Old   Age.   S.    Clin. 

North  America,   1940,  20:   February  number. 
Symposium    upon    Old    Age    and    Ageing.    Am.    J.    Ortho- 

psychiat.,  1940,   10:   January  number. 
McKenzle    (R.    T.)    Compensations    at    70.    Tr.    &    Stud. 

Coll.   Physicians,   Phila.,    1938,    6:    271-281. 
Warthln    (A.  S.)    Old  age;   the  major  involution,  N.  Y., 

1930. 


GENERAL  PRACTICE 

Walter    J.    Lackey,    M.  D„    Editor,    Fallston,    N.    C. 


THE  PREVENTION  AND  CURE  OF 
PUERPERAL  SEPSIS 

Our  maternal  morbidity  and  mortality  rates 
need  to  be  reduced.  Who  of  us  can  look  back  over 
our  obstetric  experience  and  feel  that  we  have  done 
all  we  could  to  get  best  results? 

The  gist  of  an  article1  from  which  all  of  us  may 
profit,  to  the  advantage  of  patients,  our  reputations 
and  our  ease  of  mind,  is  here^presented. 

The  three  major  causes  are  trauma,  blood  loss 
and  infection.  The  frequency  (407c )  with  which 
streptococci  are  found  in  the  nose  and  throat  and 

1.  W.   E.    Brown,   Omaha,   in   Nebr.   Med.   Jl.,   March. 


11 

0 

•M- 

Major  Cross. 

0 

Minor  Cross. 

JMf^z^^^ 

A  T  C  H  I  N 
of  Blood. 

3 

vagina  of  healthy  women  indicates  that,  for  sepsis 
more  is  required  than  the  presence  of  bacteria. 
A  woman  with  streptococci  in  her  genitals  having 
an  easy  labor,  without  cervical  or  vaginal  tear  and 
no  significant  blood  loss,  is  not  likely  to  be  invaded 
by  these  organisms;  with  an  ill-chosen  forceps  de- 
livery or  injurious  use  of  pituitrin,  laceration  and 
even  moderate  loss  of  blood,  an  overwhelming  in- 
fection may  result. 

Antenatal  care  should  bring  woman  to  labor  in 
the  best  physical  condition. 

There  is  evidence  that  30  c.c.  of  1%  acriflavine 
in  glycerine  every  2-4  hours  during  labor  will  re- 
duce the  number  of  bacteria  in  the  vagina.  In  a 
recently  reported  experience  with  540  cases,  228 
vaccinated  with  pooled  culture,  the  morbidity  was 
5.4%  as  compared  with  19.5%  in  the  control 
group.  All  agree  that  transfusion,  oxytocics  and 
sulphanilamide  are  important  as  prophylactics. 

Transfusion  of  either  normal  or  immune  blood  is 
of  value.  Long  and  difficult  labor  is  prone  to  in- 
fection because  of  the  instrumentation,  exhaustion 
and  blood  loss.  The  technique  of  blood  transfusion 
is  so  well  known  that  one  hesitates  to  mention  it, 
yet  this  day  of  specialization  there  is  a  tendency 
to  make  things  appear  complicated.  One  should 
never  withhold  a  transfusion  because  of  lack  of 
facilities,  for  sufficient  equipment  can  be  obtained 
anywhere. 

Darner  gave  0.4  mgm.  ergotrate  (Lilly)  orally 
t.  i.  d.  routinely  for  4  days  to  150  alternate  pa- 
tients and  studied  its  effect  on  morbidity  as  com- 
pared with  the  control  series.  The  morbiditv  of 
the  control  group  was  20^  as  compared  with  6.8% 
for  the  ergotrate  group.  Fragments  of  placenta 
and  membrane  are  expelled,  and  the  uterus  is  kept 
free  of  blood  clots  which  mav  serve  as  excellent 


OBTAINING  4500c.   luer  oan  09  aub«tltuUa 

Blood.  for  the  max. 


This  simple  equipment  is  all  that  is  needed  for  transfusion  (Cut  lent  by  Neb.  Med.  Jl.) 


SOUTHERN  MEDICINE  <S-  SURGERY 


157 


culture  medium  for  the  growth  of  bacteria.  In  a  se- 
ries of  4,000  cases,  sulphanilamide  was  given  pro- 
phylactically  to  2,264  with  a  morbidity  of  6.6%; 
while  in  the  control  group  it  was  13.5%. 

The  treatment  of  puerperal  infection,  once  it  has 
developed,  is  chiefly  an  amplification  of  the  pro- 
phylactic measures.  Even  though  frank  peritonitis 
is  not  present,  one  should  carry  out  the  Oschner 
schedule — semi-Fowler's  position,  nothing  by 
mouth,  parenteral  fluids,  sedation,  heat  to  the  ab- 
domen, and  if  at  all  possible,  isolation  in  a  hos- 
pital. Wangensteen  suction  is  recommended  for  the 
control  of  distention  while  catharsis  and  all  forms 
of  gastrointestinal  stimulants  are  to  be  avoided. 
Transfusions  should  be  given  early  and  continued 
daily  or  every  other  day  in  200-300  c.c.  amounts; 
the  first  transfusion  should  be  larger  if  blood  re- 
placement is  a  factor. 

Divide  sulphanilamide  into  4  or  6  equal  doses 
throughout  the  24  hours. 

About  90%  of  the  patients  receiving  sulphanila- 
mide will  show  some  evidence  of  toxicity.  In  only 
14%  of  the  cases  did  symptoms  require  stopping 
the  drug.  The  milder  anemias  can  often  be  con- 
trolled by  daily  transfusions.  The  development  of 
toxic  symptoms  does  not  necessarily  call  for  stop- 
ping the  drug,  but  for  more  careful  supervision. 
Since  these  products  are  so  readily  soluble  in  water 
and  rapidly  excreted  in  the  urine,  the  best  antidote 
for  toxicity  is  water. 

For  the  125-pound  patient  4.5  gms.  (grains  70) 
is  given  as  an  initial  dose  to  saturate  the  patient 
and  this  is  followed  by  gm.  1  (grains  15)  every  4 
hours  as  a  maintenance  schedule.  In  the  average 
patient  this  will  produce  a  blood  level  above  8 
mgm.  per  cent  in  24-48  hours.  These  schedules  oc- 
casionally fail  due  to  unpredictable  factors,  and 
unless  blood  levels  can  be  checked,  a  few  patients 
will  be  inadequately  treated. 

Fever  may  be  one  of  the  toxic  manifestations  of 
these  drugs,  so  that  one  will  frequently  have  to  re- 
ly on  blood  levels. 

Fortunately  sulphanilamide  and  sulphapyridine 
may  be  given  intravenously  while  neoprontosil  can 
be  given  either  intravenously  or  intramuscularly. 
The  rectal  dose  is  twice  the  average  oral  dose, 
gives  satisfactory  results.  The  material  is  sus- 
pensed  in  a  soda  bicarbonate  solution  and  instilled 
into  the  rectum  every  4-6  hours. 

One  should  examine  a  patient  with  an  acute 
pelvic  infection  frequently  to  ascertain  the  develop- 
ment of  a  localized  collection  of  pus  in  the  pelvis 
cr  metastatic  abscesses:  drain  through  the  culdesac 
cf  Douglas.  The  treatment  of  chronic  pelvic  in- 
flammatory processes  should  include  rest,  the  va- 
rious forms  of  heat  therapy,  foreign  protein  and,  as 


a  last  resort,  surgery. 

Immediately  following  delivery  before  infection 
has  been  made  manifest  transfusion,  oxytocics  and 
sulphanilamide  should  be  used  in  all  difficult  labors 
where  complications  in  the  puerperium  are  antici- 
pated. 

The  treatment  of  the  septic  patient  should  aim 

(a)  to  localize  the  infection  by  the  Ochsner  regimen, 

(b)  to  combat  the  sepsis  by  supportive  measures, 
transfusions  and  sulphanilamide,  and  (c)  to  treat 
any  complications  by  the  usual  medical  or  surgical 
means  indicated. 


COBRA  VENOM  FOR  RELIEF  OF  PAIN  IN  HERPES 
ZOSTER 

(M  M.  McDowell,  Danville,  111.,  in  Med.  Rec,  Mar.  5th.) 
There  are  few  physicians  who  will  not  testify  to  the  in- 
tense suffering  that  some  of  these  patients  endure,  espe- 
cially when  the  lesions  are  located  on  the  head.  Herpes 
zoster  is  a  self-limited  disease  and  rarely  recurs.  Two  and 
five-tenths  mouse  units  of  cobra  venom  (Hynson,  Westcott 
and  Dunning)  were  given  intramuscularly  to  one  and  the 
next  morning  she  reported  that  she  had  slept  well  the  en- 
tire night  and  was  almost  free  of  pain.  Five  mouse  units 
(1  c.c.)  were  given  daily  for  four  days  with  complete  relief 
and  five  more  injections  given  daily  sufficed  to  cure.  In 
another  cobra  venom  (2.5  mouse  units)  gave  relief  of  pain 
within  24  hours,  five  units  were  given  every  other  day  for 
four  injections,  then  discontinued  with  no  return  of  pain. 
Relief  of  pain  does  not  follow  cobra  venom  therapy  so 
promply  in  cases  of  advanced  carcinoma  as  it  does  in  pa- 
tients suffering  from  herpes  zoster.  The  venom  seems  to 
have  an  almost  specific  action  in  relieving  pain  in  these 
cases.  There  was  no  depression  noticed  in  my  cases.  No 
reactions   local   or  general. 

Herpes  zoster  tends  to  run  its  course  regardless  of  treat- 
ment, yet  cobra  venom  relieved  the  pain  entirely  in  the 
six  severe  cases  in  which  it  was  used. 


NOTED  JELLIFFE  LIBRARY  ACQUIRED  BY 
NEURO-PSYCHIATRIC  INSTITUTE 

Acquisition  of  a  15,000  volume  medical  library  described 
by  bibliophiles  as  the  most  complete  of  its  kind  in  the 
world,  has  been  announced  by  Dr.  C.  Charles  Burlingame, 
Psychiatrist-in-Chief  of  the  Neuro-Psychiatric  Institute,  of 
Hartford,   Conn. 

The  library,  representing  a  lifetime  of  collecting  by  Dr. 
Smith  Ely  Jelliffe,  of  New  York,  nationally  known  psych- 
iatrist and  editor  of  the  Journal  of  Nervous  &  Mental 
Diseases  and  the  Psychoanalytic  Review,  is  to  be  trans- 
ferred to  the  Institute  "to  assure  a  permanent  home  for  it 
under  conditions  which  would  be  of  satisfying  benefit  to 
future  generations  of  psychiatrists  and  neurologists,"  ac- 
cording to  Dr.  Jelliffe. 

In  addition  to  the  15,000  volumes  it  contains  25,000  re- 
prints. The  psychoanalytic  section  of  the  library  is  one  of 
the  best  collections  to  be  found  anywhere. 

Included  in  the  collection  are  some  rare  historical  works 
dating  back  to  the  15th  centurj  as  will  as  practically  all 
important  psychiatric  monographs  from  the  time  of  Pinel 
and  Esquirol,  pioneers  in  the  enlightened  treatment  of  the 
mentally  ill,  down  to  the  present  day.  Reprints  include 
contributions  from   practically  even    civilized  country. 


158 


SOUTHERN  MEDICINE  &  SURGERY 


March   1941 


NEWS 


UNIVERSITY'S  POSTGRADUATE   COURSE 

A  postgraduate  course  in  medicine  beginning  on  Wednes- 
day, March  5th,  continues  each  week  through  Wednesday, 
April    16th. 

The  course  is  arranged  for  and  sold  to  the  doctors  by 
University  Extension  Division  and  the  University  Medical 
School,  will  consist  of  a  dinner  meeting  at  7  o'clock  and  a 
lecture  at  8  at  the  Hotel  Cherry  in  Wilson  each  Wednes- 
day for  six  weeks. 

The  Wilson  program: 

Dr.  E.  L.  Eliason,  University  of  Pennsylvania,  March 
5th;  Dr.  Alexis  F.  Hartman,  Washington  University,  St. 
Louis,  March  19th;  Dr.  J  E.  Moore,  Johns  Hopkins  Uni- 
versity, March  26th;  Dr.  W.  B.  Porter,  the  Medical  Col- 
lege of  Virgnia,  Richmond,  April  2nn;  Dr.  Baldwin  Lucke 
and  Dr.  Francis  Wood,  both  of  the  University  of  Penn- 
sylvania, April  9th;  and  Dr.  Edward  A.  Schumann,  Uni- 
versity of  Pennsylvania,  April  10th. 


Southeastern  Surgical  Congress. — Among  those  con- 
tributing to  the  program  at  the  Richmond  meeting,  March 
10th-12th,  were:  Drs.  W.  Lowndes  Peple,  Richmond;  Wal- 
ter B.  Martin,  Norfolk;  John  M.  Emmett,  Clifton  Forge 
(Va.);  Parker  C.  Hardin,  Monroe;  Byrd  Charles  WilUs, 
Rocky  Mount  (N.  C.)  ;  Frank  P.  Coleman,  Columbia 
(S.  C.) 


Psychiatrists  to  Nominate  Dr.  J.  K.  Hall 
(Richmond   Times-Dispatch,   Feb.   27th) 

Dr.  James  K.  Hall,  president  of  Westbrook  Sanatorium, 
will  be  nominated  for  the  office  of  president  of  the  Amer- 
ican Psychiatric  Association  when  that  body  holds  its 
ninety-seventh  annual  meeting  in  Richmond  May  5th-9th, 
it  was  announced  by  Dr.  Harvie  DeJ.  Coghill,  a  member 
of  the  nominating  committee. 

Dr.  Hall's  name  will  be  the  only  one  presented  by  the 
committee  for  the  office  of  president.  The  selection  of  Dr. 
Hall  was  unanimous,  Dr.  Coghill  said. 

Other  psychiatrists  to  be  nominated  will  be  the  follow- 
ing: 

Dr.  Arthur  H.  Ruggles,  of  Rhode  Island,  for  president- 
elect; Dr.  Winfred  Overholser,  of  Washington,  for  secre- 
tary-treasurer, and  Dr.  Chester  Carlisle,  of  California,  for 
auditor,  three-year  term. 

Nominated  for  three-year  terms  as  councillors  will  be 
Dr.  G.  H.  Stevenson,  of  Canada;  Dr.  Roscoe  W.  Hall,  of 
Washington;  Dr.  J.  D.  Reichard,  of  Kentucky,  and  Dr. 
Karl  Menninger,  of  Topeka,  Kan. 

Members  of  the  nominating  committee  are  Dr.  William 
C.  Sandy,  chairman;  Dr.  Coghill,  Dr.  Garland  H.  Pace, 
Dr.  Theophile  Raphael  and  Dr.  Kenneth  J.  Tillotson. 

Between  1,500  and  2,000  persons  are  expected  here  for 
the  association  meeting  in  May. 


TWO  VIRGINIA  DOCTORS  HONORED 
Virginians  who   served   with   distinction    as   army   med- 
ical officers  have  been  honored  in  the  naming  of  two  new 
army  general  hospitals. 

One  is  Stark  General  Hospital  at  Charleston,  S.  C. 
named  for  Colonal  Alexander  Newson  Stark,  while  the 
other  is  Lawson  General  Hospital  in  Atlanta,  named  for 
Brevet   Brigadier   General   Thomas   Edwin   Lawson. 

Colonel  Stark,  born  in  Virginia  in  1869,  later  became  a 
Colonel  in  the  Medical  Corps  in  1917  and  was  awarded 
the  Distinguished  Service  Metal  for  work  as  chief  sur- 
geon, First  Army,  A.  E.  F.     He  died  in  1926. 


General  Lawson,  born  in  1793,  began  his  career  as  a 
surgeon's  mate  in  the  navy  in  1809.  He  later  served  as 
surgeon  general  of  the  army  from  1836  to  1861,  the  year 
of  his  death.  He  received  the  rank  of  brevet  brigadier 
general  in  1845  for  service  in  the  Mexican  War. 


HEALTH    DEPARTMENTS   MERIT    BOARD   NAMED 

Dr.  Isaac  M.  Manning,  of  the  University  of  North  Car- 
olina Medical  school,  will  supervise  merit  examinations 
for  employes  of  state  and  county  health  departments. 

Dr.  Manning  will  prepare  and  administer  merit  tests  for 
about  200  health  workers,  including  all  in  state  or  county 
departments  concerned  with  expenditure  of  federal  funds. 
He  will  be  assisted  by  an  advisory  council  composed  of 
Dr.  Thurman  D.  Kitchin,  president  of  Wake  Forest  college, 
Dr.  W.  C.  Davison,  dean  of  Duke  university  medical  school, 
and  Dr.  W.  M.  Piatt,  Durham  engineer. 

The  federal  social  security  board  has  ruled  that  employes 
of  the  health  boards,  welfare  boards  and  the  unemploy- 
ment compensation  commission  who  participate  in  the 
expenditure  of  federal  funds  must  take  merit  examinations. 

UCC  employes  have  taken  their  examinations  and  Dr. 
Frank  T.  Devyver,  supervisor  of  the  USS  tests,  has  been 
picked  to  administer  the  welfare  employe  examinations. 


WILSON'S  TUBERCULOSIS  HOSPITAL  TO  OPEN 
SOON 

County  Manager  Walter  H.  Mercer  has  announced  that 
the  new  $40,000  Wilson  County  Tuberculosis  Hospital, 
one  of  the  most  modern  of  its  kind  in  the  state,  officially 
opens  for  patients  April  1st. 

The  building  is  on  the  Wilson-Smithfield  highway  a  few 
hundred  yards  south  of  the  county  home  property. 


Richmond  Academy  of  Medicine — On  Feb.  18th  at  8:30 
p.  m.  at  the  Academy,  the  Medical  Education  Committee 
presented  the  fifth  lecture  in  the  Endocrine  Symposium, 
given  by  Dr.  E.  C.  Hamblen  of  the  Duke  University 
School  of  Medicine  on  Sterility  and  Pregnancy  from  an 
Endocrinological  Standpoint. 


Dr.  E.  W.  Perkins  announces  the  opening  of  offices  for 
the  practice  of  Ophthalmology,  Medical  Arts  Building, 
Richmond,  Virginia. 


Dr.  Reece  Berryhhx,  acting  dean  of  the  University  of 
North  Carolina  Medical  School,  has  been  elected  president 
of  the  Harvard  Club  of  North  Carolina. 


Dr.  John  W.  Warren  has  been  elected  county  physician 
of  Chowan. 


MARRIED 


Miss  Elizabeth  Scott,  of  Philadelphia,  and  Dr.  George 
L.  Carrington,  of  Burlington,  were  married  March  1st  in 
Woodland  Presbyterian  church,  Philadelphia. 

DEATHS 


Dr.  John  Wyatt  Davis,  65,  died  at  his  home  at  Lynch- 
burg, February  28th,  after  an  illness  of  six  months'  dura- 
tion. A  native  of  Richmond,  Dr.  Davis  had  practiced 
medicine  in  Lynchburg  thirty-five  years  except  for  two 
periods  when  he  was  in  the  service  of  the  United  States 
Navy.  Dr.  Davis  was  popular,  and,  with  a  son,  Dr.  John 
Wyatt  Davis,  Jr.,  enjoyed  a  very  extensive  practice. 


March   1941 


SOUTHERN  MEDICINE  &  SURGERY 


159 


///HE  OLD  ORDER  does  indeed  yield 
place  to  new  and  more  advanced  ideas 
—  in  therapeutics  as  well  as  in  other 
fields  of  human  endeavor.  Thirty  years  ago, 
when  Pantopon  was  a  newcomer — and  a  bold 
one,  too,  to  challenge  the  position  of  mor- 
phine sulfate — it  was  greeted  with  a  natural, 
healthy  skepticism.  But  physicians  in  ever 
increasing  numbers  have  been  convinced  of 
the  superiority  of  Pantopon — have  been  con- 
vinced that  some  of  the  untoward  by  effects, 
so  noticeable  when  morphine  is  used,  are  ap- 
preciably reduced  by  virtue  of  the  pharma-. 
cologically    balanced    action    of   Pantopon. 


Today  there  is  hardly  a  hospital  in  the  entire 
country  in  which  Pantopon  isn't  frequently 
prescribed  by  leading  members  of  the  medi- 
cal and  surgical  staffs.  The  usual  dose:  H  gr. 
Pantopon  in  place  of  \  gr.  morphine  sulfate. 

HOFFMANN-LA    ROCHE  .  INC. 

ROCHE    PARK    .   NUTLEY    •   NEW   JERSEY 


^PANTOPON 


IN    PLACE    OF    MORPHINE 


160 


SOUTHERN  MEDICINE  &  SURGERY 


March    1941 


Dr.  Francis  C.  Benson,  69,  Hahnemann  Hospital  radiolo- 
gist who  is  credited  with  being  the  first  man  in  the  United 
States  to  use  radium  in  the  treatment  of  cancer,  died  Feb. 
ISth.  A  member  of  the  hospital  staff  since  1894.  he  was 
known  for  his  research  work  in  cancer  and  methods  he 
had  developed  for  treating  the  disease. 

Dr.  Thomas  Bernard  Latane,  of  Stevensville,  Virginia, 
died  in  a  hospital  in  Richmond  on  February  18th.  He  was 
born  in  1S72  and  graduated  in  1903  from  the  Medical 
Department  of  the  University  of  the  South.  Sewanee,  Ten- 
nessee. 


BOOKS 


BENZEDRINE  SULPHATE  IN  THE  TREATMENT  OF 
NICOTINISM 

M.    M.    Miller,   Warrensville,   Ohio,   in  Med.   Rec,   Feb.    19th. 

In  the  course  of  treatment  with  benzedrine  of  over  200 
cases  for  alcoholism  and  various  other  indications  most  of 
those  patients  who  were  indulging  rather  heavily  in  to- 
bacco suddenly  acquired  a  distaste  for  tobacco  in  any  form 
and  consequently  either  stopped  smoking  or  reduced  their 
smoking  considerably.  The  patients  remarked  that  the 
tobacco  had  lost  its  taste  and  aroma — that  it  tasted  like  a 
weed. 

The  mild  euphoria,  along  with  a  geneal  feeling  of  in- 
creased well-being,  seemed  to  diminish  the  need  for  seek- 
ing stimulation  from  tobacco.  Neurotic  patients  seemed 
less  susceptible  to  states  of  fear  and  depression. 

I  decided  to  test  benzedrine  as  a  cure  for  the  tobacco 
habit. 

Requirements  were: 

(1)  Patients  who  showed  a  desire  to  stop  or  curtail 
their  smoking  for  general  reasons  of  health   and  economy. 

(2)  A  medical  contraindication  for  smoking. 
Twenty-four   patients   were    treated   for   periods   varying 

from  three  to  six  months.  Of  these,  14  patients  were  in 
the  first  catesory.  while  10  cases  were  in  the  latter.  In 
addition,  there  were  three  control  cases  treated  with  place 
bos.  Benzedrine  sulphate  was  administered  in  doses  of  10 
mgms.  after  breakfast  and  after  lunch — none  after  1  p.  m. 
because  of  the  rather  prolonged  action  of  the  drug. 

Of  the  first  group,  six  patients  stopped  smokins  entirely. 
The  remainder  were  able  to  reduce  their  smoking  to  rela- 
tively harmless  proportions  and  admitted  that  smoking 
had  ceased  to  be  a  pleasure.  Of  these  six,  four  have  been 
abstaining  from  tobacco  for  a  period  of  more  than  six 
months  thus  far,  and  of  the  others  two  are  still  abstaining 
four  months  after  medication. 

In  the  second  group  of  the  10  patients  who  began  treat- 
ment, three  are  entirely  abstinent  after  six  months  of  treat- 
ment, and  the  rest  for  varying  periods  of  three,  four  and 
five  months,  respectively.  One  patient  has  restricted  his 
smoking  to  one  or  two  cigarettes  after  each  meal. 

The  controls  treated  with  placebos  showed  no  noticeable 
changes  in  their  smoking,  although  for  reasons  of  their 
general  poor  health  it  would  have  been  advisable  for  them 
to  stop  or  curtail  their  smoking. 

The  %vithdrawal  from  the  nicotine,  although  abrupt,  pro- 
ceeded very  pleasantly,  with  the  patients  experiencing 
agreeable  euphoria  which  almost  always  follows  the  admin 
istration  of  the  drug. 

Of  the  24,  19  showed  increase  in  weight  from  2  to  10 
lbs.  after  6  weeks  of  medication. 

The  drug  should  not  be  given  on  an  empty  stomach  be- 
cause of  its  rapid  absorption  in  the  blood  stream  under 
such  condtiions.  It  is  a  wise  practice  first  to  administer  a 
test  dose  of  5  mgs.  to  determine  the  degree  of  excitation 
produced  by  the  drug  in  each  patient.  Forbid  patients 
under  benzedrine  therapy  the  consumption  of  stimulating 
beverages,  even  strong  tea,  coffee  etc. 


DIAGNOSIS  AND  TREATMENT  OF  ARTHRITIS  AND 
ALLIED  DISORDERS,  by  H.  M.  Margolis,  M.  D.,  M.  S. 
(in  med.)  ,  F.  A.  C.  P..  Chief  Arthritis  Service,  St.  Mar- 
garet Memorial  Hospital.  Associate  in  Medicine.  Monte- 
fiore  Hospital,  Consultant  in  Medicine,  Pittsburgh  Diag- 
nostic Clinic;  with  140  illustrations..  Paul  B.  Hoeber,  Inc., 
Medical  Book  Dept.,  Harper  &■  Brothers,  49  East  33rd  St., 
New  York  City.  1941.  $7.50. 

The  author  believes  that  the  general  attitude  to- 
ward arthritis  is  not  as  hopeful  as  it  should  be,  so 
he  writes  a  book  to  supply  information  which  will 
encourage  the  general  practitioner  to  undertake 
with  confidence  the  management  of  such  cases. 
Low-back  pain  and  sciatica  are  dealt  with  in  great 
detail,  also  the  prevention  of  deformities.  Focal 
infection  is  discussed  in  a  very  conservative  man- 
ner. Anal  cryptitis  may  be  a  cause  of  arthritis. 
As  in  tuberculosis,  rest  is  given  as  the  mainstay  in 
treatment  Attention  to  nutrition  and  bowel  man- 
agement, blood  transfusions  and  removal  of  foci 
prepare  the  way  for  "specific"  measures-  The  au- 
thor's experience  with  bee-venom  and  several  other 
touted  remedies  has  been  disappointing.  A  warm, 
dry  climate  is  beneficial.  The  various  measures 
of  physical  therepy  are  reasonably  evaluated. 

The  practitioner  will  here  find  a  book  in  which 
various  and  diverse  claims  are  evaluated  on  their 
records,  in  which  there  is  hopefulness  without 
Pollv-Annaism. 


THE  YEAR  BOOK  OF  DERMATOLOGY  AND  SY- 
PHILOLOGY,  edited  by  Fred  Wise,  M.  D.  Clinical  Pro- 
fessor of  Dermatology  and  Syphilology,  New  York  Post- 
Graduate  Medical  School  and  Hospital,  Columbia  Uni- 
versity; and  Marion*  B.  Sulzberger,  M.  D..  Assistant  Cli- 
nical Professor  of  Dermatology  and  Syphilology,  New  York 
Post-Graduate  Medical  School  and  Hospital  of  Columbia 
University.  The  Year  Book  Publishers,  Inc.,  304  S.  Dear- 
born St.,  Chicago. 

A  long  special  article  on  psoriasis  offers  little 
that  is  new.  The  mycotic  infections,  occupational 
dermatoses,  allergy,  eczema  and  dermatitis  are 
treated  of  in  a  practical  way.  Drug  eruptions 
are  recognizable  if  we  look  for  them.  Sulfonamide 
medication  may  be  fatal  in  a  case  of  lupus  erythe- 
matosus. A  vital  connection  between  scleroderma 
and  the  thyroid  is  suggested. 

A  case  of  colored  sweat  and  tears  due  to  face 
powder  is  abstracted.  Overzealous  use  of  the 
toothbrush  is  credited  with  causing  ulcers  of  the 
gums  and  tongue.  Notice  is  taken  of  a  case  of 
generalized  herpes  zoster.  Recent  experiences  with 
veneral  diseases  are  narrated.  Therapy  in  this 
field  is  brought  up  to  date. 


March  1941 


SOUTHERN  MEDICINE  &■  SURGERr 


MANUAL  OF  CLINICAL  CHEMISTRY,  by  Miriam 
Reiner,  M.  Sc,  Assistant  Chemist  to  The  Mount  Sinai 
Hospital,  New  York;  introduction  by  Harry  Sobotka, 
Ph.D.,  Chemist  to  The  Mount  Sinai  Hospital,  New  York. 
With  18  illustrations.  Interscience  Publishers,  Inc.,  New 
York.  1941.  $3.00. 

Biochemistry  is  a  comparatively  new  term  coin- 
ed to  cover  the  most  intimate  changes  that  go  on 
constantly  within  the  living  body.  This  little  book 
is  made  up  of  descriptions  of  means  of  investigat- 
ing and  interpreting  the  great  number  of  these 
changes  which  we  have  learned  have  important 
health  bearings.  It  may  be  taken  as  a  conservative, 
reliable  guide  in  this  field. 


MANUAL  OF  PHYSICAL  DIAGNOSIS,  With  Special 
Consideration  of  the  Heart  and  Lungs,  by  Maurice  Lewi- 
son,  M.D.,  Professor  of  Physical  Diagnosis,  University  of 
Illinos  College  of  Medicine;  formerly  Chief  of  Tuberculosis 
Staff t  Cook  County  Hospital;  and  Ellis  B.  Freilich, 
M.D.,  Associate  Professor  of  Medicine,  University  of  Illi- 
nois College  of  Medicine ;  Professor  of  Medicine,  Cook 
County  Graduate  School  of  Medicine;  in  collaboration 
with  George  C.  Coe,  M.D.,  Instructor  of  Medicine,  Uni- 
versity of  Illinois  College  of  Medicine.  The  Year  Book 
Publishers,  Inc.,  304  S.  Dearborn  St.,  Chicago,  1941. 

The  authors  have  been  impressed  by  the  difficul- 
ties of  medical  students  and  practitioners  in  under- 
standing the  principles  governing  physical  exami- 
nation and  have  written  a  book  to  aid  in  the  solu- 
tion of  these  difficulties.  This  book  gives  essentials 
only.  There  is  no  dross.  It  is  an  intensely  practical 
work,  based  on  the  idea  that  most  cases  can  be 
diagnosticated  without  the  use  of  expensive  and 
not-always-available  special  apparatus. 


ELECTROCARDIOGRAPHY  IN  PRACTICE,  by  Ash- 
ton  Graybiel,  M.D.,  Instructor  in  Medicine,  Courses  for 
Graduates,  Harvard  Medical  School;  Research  Associate, 
Fatigue  Laboratory,  Harvard  University;  Assistant  in  Med- 
icine, Massachusetts  General  Hospital ;  and  Paul  D. 
White,  M.D.,  Lecturer  in  Medicine,  Harvard  Medical 
School;  Physician,  Massachusetts  General  Hospital,  in 
charge  of  the  Cardiac  Clinics  and  Laboratory.  319  pages 
with  272  illustrations.  Philadelpha  and  London.  W.  B. 
Saunders  Company,  1941.    Cloth,  $6.00. 

That  the  electrocardiograph  is  an  instrument  of 
value  in  the  diagnosis  of  certain  heart  conditions 
is  an  established  fact.  That  every  examination  of 
the  heart  should  include  an  electrocardiogram 
seems  unnecessary,  not  worth  the  time  and  money. 

The  authors  have  written  a  text  and  reproduced 
ecgs.  to  show  just  how  this  instrument  may  be 
made  to  best  serve  the  cause  of  heart  diagnosis, 
prognosis  and  management. 


DOCTORS  AND  DOCTORS,  Wise  and  Otherwise,  on  the 
firing  line  50  years,  by  Dr.  Charles  McDaniel  Rosser, 
with  introductory  foreword  by  Dr.  Ho- man  Taylor. 
Mathis  van  Nort  &  Company,  Santa  Fe  B'.dg.,  Dallas, 
Texas.   1941.  $3.50. 

The  author  worked  for  his  opportunity  to  be  a 


. .  .  cm/u  i/ie  b/iAl  tli 

VACOLITER 

/«,//,  PROOF  OF  VACUUM 

When  tamperproof  seal  is  removed, 
two  depressions  in  rubber  diaphragm 
indicate  vacuum  is  intact,  and  that 
parenteral  solution  in  vacoliter  is 
fresh,  pure  and  uncontaminated. 


ONLY 


BAUER 


HIS    THE 

FILTERDRIP 

A  safety  feature 
of  the  Transfuso 
Vac  technique. 
This  stainless 
steel    mesh   of 

the   FILTERDRIP 

filters  every  drop 
of  blood,  pre- 
venting clots 
from  passing 
through  tubing. 


Products  of  BAXTER  LABORATORIES 

Glenview,  III.;  College  Point,  N.  Y.;  Glendale,  Col.; 

Toronto,  Canada;  London,  England 

Produced  and  distributed  in  the  Eleven  Western  States 

by  DON  BAXTER,  INC.,  Glendale,  Cal. 

Distributed  East  of  the  Rockies  by 

AMERICAN  HOSPITAL  SUPPLY  CORP. 

CHICAGO  NEW  YORK 


SOUTHERN  MEDICINE  &  SURGERY 


March   1941 


doctor  and  he  appreciates  the  dignity  and  the  op- 
portunities of  membership  in  the  medical  profes- 
sion accordingly. 

Written  largely  on  the  personal  side  of  the  prac- 
tice of  medicine,  by  an  observant  doctor,  with  a 
well-developed  sense  of  humor,  the  book  could  not 
fail  of  being  entertaining.  This  reviewer  would 
prefer  to  read  that  a  patient  was  operated  on,  rath- 
er than  operated;  and  it  is  generally  said  that 
Nicholas  Senn  was  of  Swiss  parentage.  Possibly 
he  may  have  been  born  in  a  canton  having  a  large 
Italian  population,  but  neither  his  name  nor  his 
appearance  would  suggest  Italian  extraction. 

There  are  chapters  on  Master  Men  of  Medicine. 
The  Mayos  and  the  Mayo  clinic.  Code  of  Ethics, 
Modern  Postgraduate  Work,  Referred  Practice, 
The  Doctor  in  Court,  The  Cults  and  The  Basic 
Science  Law. 

Dr.  Rosser's  book  brings  to  mind  "The  Physi- 
cian Himself,"  by  two  Drs.  Cathell,  an  attractive 
dealing  with  the  personal  side  of  the  practice  of 
medicine  which  enjoyed  great  popularity  some  dec- 
ades ago.  An  equally  eager  reception  is  predicted 
for  "Doctors  and  Doctors." 


HEMORRHAGIC  DISEASES:  Photo-Electric  Study  of 
Blood  Coagulability,  by  Kaare  K.  Nygaard,  M.D.,  Former 
Fellow  in  Surgery,  the  Mayo  Foundation;  former  Assistant 
Surgeon,  the  University  Clinic,  Oslo;  Fellow  of  the  Alex- 
ander  Malthe   Foundation   for   Research   in   Medicine,   Sur- 


gery and  Gynecology.  Illustrated.  The  C.  V.  Mosby  Co., 
3525  Pine  Boulevard,  St.  Louis.  1941.  $5.50. 

All  prevailing  methods  of  determining  blood 
coagulability  are  surveyed  and  commented  on.  The 
photoelectric  principle  is  discussed  and  the  photel- 
graph  described.  Then  follow  interpretation  of  the 
coagelgram,  the  results  of  investigation  on  the 
coagulability  of  blood  plasma,  the  interaction  of 
fibrinogen  and  thrombin  and  the  quantitative  esti- 
mation of  prothrombin.  The  final  grand  division  of 
the  book  deals  with  classification  of  hemorrhagic 
diseases,  hemophilia,  purpura,  vitamin  K,  the  hem- 
olytic tendency  in  certain  liver  diseases  and  hem- 
orrhagic disease  of  the  newborn. 

The  book  is  the  record  of  a  vast  amount  of  work 
under  the  advice  and  criticism  of  a  number  of 
eminent  men  well  qualified  to  guide  research,  and 
it  should  prove  of  much  value  as  a  clinical  aid  in 
many  grave  conditions. 


AN  INTRODUCTION  TO  DERMATOLOGY,  by  Rich- 
ard L.  Sutton,  M.D.,  Sc.D.,  LL.D.,  F.R.S.  (Edin.),  Emer- 
tus  Professor  of  Dermatology,  University  of  Kansas  School 
of  Medicine;  and  Richard  L.  Sutton,  Jr.,  A.M.,  M.D., 
L.R.C.P.  (Edin.),  Assistant  Professor  of  Dermatology, 
University  of  Kansas  School  of  Medicine,  with  723  illus- 
trations; 4th  edition.  The  C.  V.  Mosby  Company,  3525 
Pine  Boulevard,  St.  Louis.   1941.  $9.00. 

The  authors  intend  the  book  for  the  student,  "col- 
legiate and  postgraduate."  If  more  is  needed  or 
desired  use  may  be  made  of  the  bibliography — an 


ASAC 

15%,  by  volume  Alcohol 

Each   fl.    oz.   contains: 

Sodium   Salicylate,   U.   S.  P.  Powder 40  grains 

Sodium   Bromide,  U.  S.  P.  Granular 20  grains 

Caffeine,    U.    S.   P 4  grains 

ANALGESIC,    ANTIPYRETIC 
AND    SEDATIVE. 

Average    Dosage 

Two  to  four  teaspoonfuls  in  one  to  three  ounces  oi 
water    as   prescribed    by    the    physician. 

How  Supplied 
In  Pints,  Five  Pints  and  Gallons  to  Physicians  and 
Druggists. 

Burwell  &  Dunn  Company 

Manufacturing     ^S^">     Plmrmnrhls 
Established    EUS/      in    1887 

CHARLOTTE.  N.  V. 


Sample   sent   to    any    physician    in    the    U.    S.    on 
request 


SOUTHERN  MEDICINE  &  SURGERY 


innovation  with  this  edition.  This  edition  of  the 
Introduction  is  condensed  from  the  10th  edition  of 
the  authors'  Diseases  of  the  Skin. 

Acne  may  be  cured  without  ::-rays.  The  list  of 
excitant  causes  of  dermatitis  venenata  is  almost 
interminable.  In  psoriasis  external  remedies  are  es- 
sential, and  internal  remedies  are  rarely  required. 
The  cause  of  pemphigus  is  unknown  and  it  usually 
proves  fatal.  Metabolic  dermatoses  are  not  un- 
common. "Pruritus"  is  as  bad  a  diagnosis  as  "ec- 
zema." 

Prevent  freckles  bv  protecting  against  the  sun; 
remove  them  with  \c/c  bichloride  in  25%  alcohol 
dabbed  on  with  a  small  swab  3  or  4  i.  d.  Noth- 
ing does  much  good  in  cases  of  ichthyosis.  Vascu- 
lar nevi  occasionally  disappear  spontaneously; 
small  doses  of  radium  or  x-rays  constitute  the  best 
treatment. 

For  the  cure  of  cancer  of  the  skin  the  authors 
have  come  to  depend  more  and  more  on  the  elec- 
trocautery. Pituitary  extract  sometimes  relieves 
the  pain  of  herpes  zoster  in  dramatic  fashion. 
Treatment  of  tinea  of  the  feet  must  be  carried  out 
in  great  detail.  In  seborrheic  dermatitis  x-rav 
treatment  has  nothing  to  recommend  it.  Since  re- 
growth  of  hair  is  extremely  improbable  it  i  swell  to 
help  the  patient  "to  accommodate  his  ego  to  his 
destiny." 

A  hopeful,  but  not  too-hopeful,  book. 


PHYSICIAN'S 

REQUIREMENTS 


MACLEOD'S  PHYSIOLOGY  IN  MODERN  MEDI- 
CINE, edited  by  Philip  Bard,  professor  of  Physiology, 
Johns  Hopkins  University  School  of  Medicine,  with  the 
collaboration  of  nine  additional  teachers  of  this  and  related 
subjects  in  our  medical  schools.  Ninth  edition.  Th"  C.  V. 
Mosby  Company,  3525  Pine  Boulevard,  St.  Louis.  1941. 
$10.00. 

This  edition  is  from  the  same  hands  that  pro- 
duced the  previous  edition.  It  has  been  expanded 
here,  contracted  there,  as  seemed  best  to  set  forth 
the  various  subjects  with  due  regard  to  relative 
importance  in  the  light  of  today.  It  may  be  well 
to  remind  that  the  eighth  edition  was  the  first  after 
the  death  of  Dr.  J.  J.  R.  macleod,  and  that  editions 
one  to  seven  were  the  work  of  this  Aberdeen,  Scot- 
land, and  Toronto,  Canada,  Professor  of  Physi- 
ology. 

A  hasty  perusal  impresses  the  great  need  on  the 
part  of  practitioners  of  medicine  and  surgery  for 
bringing  their  knowledge  of  the  physiology  of  the 
brain,  of  the  kidneys,  of  the  heart,  of  the  liver,  of 
the  pancreas — of  all  the  organs  and  systems — up 
to  date. 


THE  1940  YEAR  BOOK  OF  NEUROLOGY,  PSYCH- 
IATRY and  ENDOCRINOLOGY.  The  Year  Book  Pub- 
lishers, Inc.,  304  S.  Dearborn  Street,  Chicago.  Neurology, 
edited  by  Hans  H.  Reese,  M.  D.,  Professor  of  Neurology 


EYE,  EAR,  NOSE  and  throat  instruments.  Suction  and 
pressure  pumps.  Physicians'  equipment.  Cabinets.  Oper- 
ating tables.  Examining  chairs.  Sphygmomanometers. 
Trial  lenses.  New-Used.  HARRY  WREGG,  INC.  384 
Second  Ave.,  New  York  City. 

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USED  MEDICAL  HOSPITAL  AND  LABORATORY 
equipment  bought  and  sold;  estates  purchased:  sterilizers, 
microscopes,  lamps,  cystoscopes,  etc.,  always  on  hand. 
Harry  Wells,  304  E.  59th  St.  New  York  City. 

SULFOR-ALBA— A  strictly  ethical  product  for  the  con- 
trol of  acne,  acne  rosacea  and  similar  skin  affections.  1 
lb.  jar  for  $3.00  Professional  supply  for  clinical  test  sent 
on  request  to  physicians.  ALBOLAC  COMPANY,  Room 
1208  at  333  West  52nd  Street,  New  York  City. 

LUBRilOAINE— Anesthetic  Jelly  Water-Soluble,  Non- 
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AKATOS,  INC.,  55   Van  Dam  Street,  New  York  City. 

PLASTICO  MOULAGE  MATERIALS— Posmoulage  and 
process  accurately  reproduces  animate  and  inanimate  ob- 
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SILICA  GEL  FILTER— Gives  a  good  smoke  plus  low 
cost  protection  against  nicotine  and  tar.  SMOKE  THE 
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CIGARETTE  Filter  Mfg.,  Co.,  Akron,  Ohio. 

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"GONOCOCCAL  INFECTION  IN  THE  MALE"  by 
A.  L.  Wolbarst,  M.  D.,  Fellow,  American  Urological  As- 
sociation; Second  edition,  completely  revised  and  enlarged. 
140  illustrations.  7  colored  plates.  Published  at  $5.50  by 
C.  V.  Mosby  Co.;  remainder  copies  at  $1.00  each  while 
they  last.  Send  no  money.  Pay  Postman  on  delivery. 
MEDICAL  BOOKS,  ROOM  1808,  at  1440  Broadway, 
New  York  City. 

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CHAMBERS.     68  West   58th   Street,  New  York  City. 


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edited  by  Elmer  L.  Servinghaus,  M.D.,  Professor  of 
Medicine,  University  of  Wisconsin  Medical  School.  $3.00. 
In  the  last  few  years  the  advances  in  our  knowl- 
edge of  diagnosis  and  treatment  of  the  conditions 
covered  in  this  Year  Book  has  been  advanced  so 
rapidly  as  to  make  it  particularly  necessary  that 
every  doctor  in  practice  purchase  each  year's  Year 
Book  of  Neurology,  Psychiatry  and  Endocrinology 
as  soon  as  it  is  made  available. 


ANEMIA  IN  COLLEGE  WOMEN 

(Helen  Pryor  &  Mary   Ferguson,   Palo  Alto,  Calif.,  in  Northwest 

Med.,  Feb.) 

Blood  studies  done  on   364   Stanford  women  during  the 

past  two  years  suggest  that  achromic  anemia  is  found  just 


as  frequently  as  the  secondary  type  at  the  college  age  level. 
In  our  study  there  were  145  instances  of  hemoglobin  below 
70%  which  is  low  enough  to  be  classified  as  chlorosis;  the 
red  blood  cell  counts  were  relatively  high,  resulting  in  low 
color  indices  in  only  11  of  these  cases. 

Iron  was  given  in  several  forms  as  lextron,  feosal,  fe-cu- 
phyll;  jeculin,  reduced  iron,  and  iron  ammonium  citrate. 

Girls  who  received  only  lextron  made  relatively  more 
gains  in  red  cell  count  than  in  hemoglobin,  while  those  who 
received  reduced  iron,  feosal,  or  iron  ammonium  citrate 
made  larger  gains  in  hemoglobin  than  in  red  cells.  Jeculin 
gave  the  best  results  in  stimulating  increased  numbers  of 
red  blood  cells  and  building  up  hemoglobin.  Fe-cu-phyll 
was  very  consistent  in  increasing  both  red  blood  cell  counts 
and  hemoglobin.  Both  jeculin  and  fe-cu-phyll  contain  con- 
centrated vitamins. 

Eleven  cases  were  diagnosed  chlorosis  by  the  color  index 
classification. 

Good  results  in  blood  building  were  obtained  with  sim- 
ple iron  tonic  therapy. 


COOPER  CREME 

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March    1941 


SOUTHERN  MEDICINE  &  SURGERY 


165 


SOME      CHRONIC   NEURALGIAS   OF   THE   FACE: 
SUFFERER   DESERVES   RELIEF 

(E.    A.    Coates,    Melbourne,    in    Austra.    &    New    Zealand   Jl.    of 
Surg.,  Jan.) 

The  patient,  usually  a  healthy-looking  young  woman, 
complains  at  great  length  and  in  detail  of  a  constant  agon- 
izing pain  in  the  jaw  (usually  the  upper).  I  have  seen  the 
same  condition  in  a  young  man  who  smiled  as  he  related 
the  agonies  that  he  suffered,  his  sleepless  nights  et  cetera, 
best   handled  by  psychiatrists. 

Examination  reveals  nothing  definite  and  the  pain  does  not 
conform  to  a  known  area  or  radiation.    These  patients  are 

There  are  a  few  patients  for  whom  comfort  and  relief 
in  their  few  remaining  months  may  be  obtained  by  inter- 
ruption of  nerve  pathways.  The  intractable  pain  caused 
by  a  lingual  carcinoma  can  sometimes  be  relieved  by  alco- 
hol injection  of  the  mandibular  nerve.  In  other  cases  after 
radium  treatment  has  been  effectively  employed  and  the 
malignant  growth  destroyed,  the  patient  may  suffer  torture 
from  a  painful  scar  or  from  presisting  neuritis  of  the  in- 
ferior dental  or  glossopharyngeal  and  lingual  nerves.  Sec- 
tion of  these  nerves  under  local  anesthesia  is  easily  per- 
formed and  will  ensure  the  relief  which  the  sufferer  de- 
serves. There  is  a  tendency  in  some  quarters  to  disregard 
the  pain  when  the  malignant  lesion  appears  to  be  cleared 
up.  Employ  the  radical  element  by  all  means,  but  heed  the 
groans  of  the  suffering  patient.  The  human  element  tends 
to  be  submerged  in  a  maze  of  mathematical  formulas. 

Perhaps  the  history  of  the  Bloody  Assizes  would  be  a 
different  story  had  the  unfortunate  and  infamous  Jeffreys 
obtained  relief  from  his  facial  neuralgia  and  his  bladder 
stones.  In  these  days  of  mechanism  and  laboratory  inves- 
tigation, it  is  wise  for  us  to  remember  that  the  patient 
calls  the  doctor  usually  to  relieve  pain,  and  when  such 
relief  is  unobtainable  by  others  means,  interruption  of 
nerve  pathways  is  a  merciful  and  also  a  scientific  form  of 
treatment. 


DIAGNOSIS  AND  TREATMENT  OF  NEUROSYPHILIS 
(A.   L.   Sahs,   Iowa  City,  in  Northwest  Med.,   Feb.) 

The  diagnosis  of  primary  and  second  syphilis  is  made  by 
having  a  high  index  of  suspicion  of  the  disorder,  and  then 
by  proving  the  diagnosis  by  dark-field  or  serologic  meth- 
ods. Most  of  the  late  cases  will  be  discovered  by  careful 
physical  examination,  in  addition  to  the  routine  use  of 
serologic  methods  in  all  cases  which  come  under  the  physi- 
cian's care. 

Except  for  the  Special  types  of  neurosyphilis,  such  as 
paresis,  be'.'in  treatment  with  the  ieast  drastic  methods  and 
reserve  tryparsamide  and  fever  treatment  for  use  if  re- 
sponse to  arsphenaminc  and  bismuth  is  not  satisfactory. 

Treatment  of  neurosyphilis  must  be  planned  in  terms  of 
years.  After  completion  of  therapy,  repeated  physical  and 
serologic  examinations  are  necessary  to  safeguard  the  pa- 
tient. 


HYGIENE  IN  ANCIENT  INDIA 
Ciba  Symposia 
The  remains  of  a  city  uncovered  by  Sir  John  Marshall 
and  other  archaeologists  in  the  Indus  Valley  show  that  a 
primitive  culture  can  be  very  highly  developed  in  hygienic 
matters.  The  site  of  this  city  is  Mohenjo-daro — the  "city 
of  the  dead" — on  the  lower  Indus  in  Sind.  Today  this  re- 
gion is  completely  barren,  but  about  .5000  B.C.,  long  before 
the  so-called  Aryan  invasion,  cultural  conditions  existed 
here  such  as  were  never  again  achieved  in  India.  The 
houses  were  large  and  built  of  brick,  unlike  the  mud  hovels 
of  later  times.    In  the  centre  of  the  city  was  a  large  bath- 


ing establishment,  with  a  cold-water  pool  surrounded  by  a 
colonnaded  hall.  Perhaps,  there  was  even  a  heating  plant 
for  warm  water  baths.  A  subterranean  canalization  system 
received  the  waste  water  from  the  houses  and  emptied  into 
drainage  canals.  In  many  houses  bathrooms  have  been  pre- 
served. They  were  generally  furnished  with  water  which 
the  bather  poured  over  himself,  a  practice  still  common  in 
India  today.  There  were  garbage  chutes  in  the  houses, 
through  which  garbage  slid  into  clay  receptacles  outside  the 
houses. 

All  these  arrangements  were  based  upon  a  well-thought- 
out,  hygienically  unobjectionable  system  such  as  was  never 
again  developed  in  the  Orient. 


CERVICAL   CARCINOMA  WITH  PREGNANCY 
AT  FULL  TERM 
(W.   T.   STACY  and  F.  G.  THOMPSON,  Jr.,  St.  Joseph,  in 


Mo. 


3.  THOMPSON,  Jh., 
.Med.    Asso.,    Mar.) 


The  incidence  of  carcinoma  of  the  cervix  in  the  pregnant 
woman  has  been  given  as  .004  to  2.5%.  Although  the  age 
periods  of  carcinoma  and  of  pregnancy  do  not  correspond, 
one  should  examine  carefully  cases  that  might  be  diagnosed 
wrongly  as  threatened  abortion  or  placenta  praevia. 

Pregnancy  stimulates  the  growth  of  carcinoma  of  the 
cervix  and  the  symptoms  of  carcinoma  of  the  cervix  sim- 
ulate those  of  some  complications  of  pregnancy  (threat- 
ened  abortion,  placenta  praevia). 

Adequate  prenatal  care  with  complete  physical  examina- 
tion, especially  speculum  examination  of  the  cervix,  will 
disclose  cervical  polyps  and  erosions,  and,  as  in  this  case, 
carcinoma  of  the  cervix,  as  causes  of  vaginal  bleeding  dur- 
ing pregnancy. 

We  now  believe  that  in  cases  of  extensive  carcinoma  of 
the  cervix  complicating  full-term   (or  near-full-term)  preg- 


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NEWPORT,   R.   I. 


SOUTHERN  MEDICINE  &  SURGERY 


March   1941 


nancy  the  baby  should  be  delivered  by  cesarean  section 
without  removal  of  the  uterus  and  the  carcinoma  treated 
by  radium  and  deep  roentgen  ray.  The  patient  will  live  a 
much  more  comfortable  life  and  the  life  expectancy  is 
practically  the  same. 

In  the  English  edition  (1634)  of  Ambroise  Pare's  work 
Hippocrates  is  credited  with  saying,  "such  as  have  hidden, 
or  not  ulcerated  cancers,  had  better  not  to  cure  them,  for 
healed  they  quickly  dye;  not  cured,  they  live  the  longer." 
Such  was  this  case. 


CHUCKLES 


The  minister  had  received  two  tickets  for  the  opera 
from  one  of  his  parishioners.  Finding  that  he  was  unable 
to  go,  he  rang  up  some  friends  and  said:  "An  unfor- 
tunate dinner  engagement  keeps  me  from  attending  the 
opera   to-night;    could   you   use   the   tickets?" 

"We  should  be  glad  to  do  so,"  was  the  reply,  "but 
we   are   vour   unfortunate   hosts." 


Nurse:    "There's   a   patient    to    see    you    doctor,    and    she 
is   light-headed." 

Interne:    "Blond    or    delirious?" 


First    Patient:    "I    have    just    been    having    an    argument 
with    the    dentist." 

Second  Patient:    "Who  won?" 

First   Patient:    "It   ended   in   a   draw." 


"I  suppose  you  haven't  any  skin  food." 
"Only  sossidges,  miss." 


Dietitian:  "Why,  John,  all  of  those  potatoes  have  black. 
eyes." 

Kitchen  Helper:  "They  must  have  been  fighting  in  the 
pot." 

Bus  Driver:  "Did  you  get  home  all  right  last  night, 
sir?" 

Ex-Patient:   "Of  course.     Why  do  you  ask?" 

Bus  Driver:  "Well,  when  you  got  up  and  gave  the 
lady  your  seat  last  night,  you  and  she  were  the  only  two 
on   the  bus." 


Uncle  Ezry  had  been  working  industriously  with  a  stub 
of  pencil  and  a  piece  of  paper.  Suddenly  he  looked  up 
happily. 

"Doggone,"  he  exclaimed,  "If  I  ain't  learned  to  write!" 

Maw  got  up  and  looked  over  the  scrawled  lines  across 
the  paper. 

"What   do   it   say?"  she   asked. 

"I  don't  know,"  replied  Uncle  Ezry,  puzzled.  "I  ain't 
learned  to  read  yet." 

— Milwaukee   Med.    Jl. 


Maid — "Madam,  master  is  lying  unconscious  in  the  hall 
with  a  piece  of  paper  in  his  hand  and  a  large  box  by 
his   side." 

Mrs.  Green  (joyously) — "Oh,  my  new  hat  has  arrived?" 


—Van: 


Province. 


A  village  parson's  daughter  eloped  in  her  father's  clothes. 
And  the  next  day  the  Blatter  came  out  with  an  account 
of   the   elopement,   headed:      Flees  in   father's  pants. 


One  of  my  lady  patients,  a  writer  by  profession  .consult- 
ed me  on  various  occasions  regarding  some  pain  in  the  right 
lower  abdominal  region.  I  suggested  removal  of  the  af- 
fected appendix,  but  she  did  not  have  funds  and  would 
rot  go  to  a  public  hospital.  One  day  she  appeared,  her 
face  beaming.  "Well,  doctor,"  said  she,  "I  had  my  appen- 
dix removed  five  weeks  ago  by  a  big  surgeon  in  a  private 
hospital." 

"How  did  you  finance  it?" 
I  sold  an  article  to  the  Physical  Culture  Magazine,  en- 
titled— "How   I  cured  my   Appendicitis  with   Physical   Cul- 
U  ;e." — New    York  Physician. 

Just  think!  If  people  had  to  wait  as  long  for  the  doctor 
to  come  as  he  waits  for  his  monev. 


Doctor:  "Have  you  tod  Mr.  Brown  that  he  is  the  father 
-f  twins?" 
Nurse:     "Not   yet  .   He's   shaving  " 


The  doctors  now  say  that  lowneck  dresses  help  women 
ward  off  colds  and  pneumonia." 

We'l.  I  was  at  a  swell  restaurant  last  night  where  all 
the  girls  seemed  to  be  trying  to  ward  off  lumbago  as  well." 


En.ign.  very  insistent  he  must  have  leave,  was  asked 
the  reason  by  commander. 

'My   wife  is  expecting  a  baby,"  he  replied. 

"Listen,  young  man.  remember  this — you  are  only  neces- 
sary  at  the  laying  of  the  keel.  For  the  launching  you  are 
entirely  superfluous." 


'Do  you  have  anything  for  gray  hair?" 
Nothing,  sir.  but  the  greatest  respect." 


"What   happens  when  the  human  body  is  immersed  in 
vater?" 
"The  telephone  rings." 


March   1941  SOUTHERN  MEDICINE  &  SURGERY 


Southern  Railway's 

SOUTHERNER 

This  month  appears  Southern  Railway's  THE  SOUTHERNER,  to  serve  the 
territory  between  New  York  and  New  Orleans. 

Built  of  high-tensile  steel,  with  sheathing  of  stainless  steel,  THE  SOUTHERN- 
ER which  will  operate  as  three  Diesel-powered  trains,  includes  all  the  latest  refine- 
ments for  the  ultimate  in  safety,  speed  and  comfort.  Each  train  will  consist  of 
Straight,  Partition  and  Baggage-Dormitory  Chair  Cars,  Dining  Car  and  Lounge- 
Tavern-Observation  Unit,  all  reflecting  the  latest  ideas  in  structural  development 
and  modern  styling  and  beauty. 

Passenger  units  have  thermostatically  controlled  heating  and  air  conditioning, 
are  insulated  throughout.  Judicious  use  is  made  of  a  number  of  advancements  favor- 
ing gracious  living.  A  good  part  of  the  luxury  picture  appears  in  the  comfortable 
seating  arrangement  in  all  cars,  the  commodious  and  up-to-date  dining  car  arrange- 
ments and  the  facilities  for  en  route  enjoyment  offered  in  lounge,  tavern  and  obser- 
vation rooms. 

Diesel  locomotives  for  the  trains  are  built  by  the  Electro-Motive  Corporation 
a  subsidiary  of  General  Motors. 

Particularly  interesting  from  the  standpoint  of  detailed  comfort  planning  is  the 
fact  that  chair  cars  have  twin-rotating,  reclining-type  seats,  cushioned  and  attrac- 
tively finished.  The  dining  car  has  accommodations  for  48  persons  in  satin  metal 
framed  chairs  with  rubber  seats  and  back  cushions.  Settees,  lounge  chairs  writing 
desk,  card  section  and  refreshment  facilities  have  been  planned  to  fit  the  comfort 
and  utility  requirements  of  passengers  in  the  Lounge-Tavern-Observation  unit. 

A  rich  decorative  treatment  has  been  designated  for  all  units  of  THE  SOUTH- 
ERNER the  basic  colors  being  blue,  green  and  beige  in  light,  medium  and  dark 
tones.  Blue  and  beige  are  distributed  in  straight  chair  car  planning,  each  car  carry- 
ing out  variations  of  the  same  color  treatment  throughout .  Partition  chair  cars  em- 
phasize beige  and  the  Baggage-Dormitory-Chair  Cars  are  done  in  tones  of  blue 
Green  is  the  predominating  scheme  in  dining  car  and  Lounge-Tavern-Observation 
units. 

The  whole  scene  is  enriched  with  an  attractive  arrangement  of  photo-murals 
which  have  been  especially  planned  to  heighten  the  atmosphere  of  luxury  and  beautv 
in  THE  SOUTHERNER.  y  y 


167 


PROFESSIONAL   CARDS 


March  1941 


GENERAL 


Nulla  Clinic  Building 


THE  NALLE  CLINIC 

Telephone— 3-2141    (//  no  answer,  call  3-2621) 


412  North   Church   Street,  Charlotte 


General  Surgery 

BRODIE  C.  NALLE,  M.D. 
Gynecology  &  Obstetrics.. 
EDWARD   R.   HIPP,   M.D. 

Traumatic   Surgery 

PRESTON  NOWLIN,  M.D. 

Urology 


Consulting   Staff 

DRS.   LAFFERTY,   BAXTER  &  PARSONS 
Radiology 
BARRET  LABORATORY 
Pathology 


General  Medicine 

LUCIUS   G.   GAGE,  M.D. 

Diagnosis 

LUTHER  W.  KELLY,  M.D. 
Cardio-Respiratory   Diseases 

J.  R.  ADAMS,  M.D. 
Diseases  of  Infants  &  Children 

W.  B.  MAYER,  M.  D. 
Dermatology  &  Sythilology 


C— H— M   MEDICAL   OFFICES 

DIAGNOSIS— SURGERY 

X-RAY— RADIUM 

Vs..  G   Carlyle   Cooke — Abdominal  Surgery 

&  Gynecology 
Dr.  Geo.  VV.  Holmes — Orthopedics 
Dr.  C.  H.  McCants — General  Surgery 
222-226  Nissen  Bid.  Winston-Salem 


WADE   CLINIC 

Wade  Building 

Hot  Springs  National  Park,  Arkansas 


H.  King  Wade,  M.  D. 
Charles  S.  Moss,  M.D. 
Jack  Ellis,  M.D. 
Frank  M.  Adams,  M.D. 
N.  B.  Burch,  M.D.  Eye, 
Raymond  C.  Turk,  D.D 
A.  W.  Scheer 
Etta  Wade 
Marjork  Wade 


Urology 

General  Surgery 

General  Medicine 

General  Medicine 

Ear,  Nose  &■  Throat 

S.       Dental  Surgery 

X-ray  Technician 

Clinical  Pathology 

Bacteriology 


INTERNAL  MEDICINE 


ARCHIE  A.  BARRON,  M.  D.,  F.A.C.P. 
INTERNAL  MEDICINE— NEUROLOGY 
Professional  Bldg.  Charlotte 


JOHN  DONNELLY,  M.  D. 

DISEASES  OF  THE  LUNGS 

iZAV2  N.  Tryon  St.  Charlotte 


CLYDE    M.    GILMOkE,    A.  B.,   M.D. 
CARDIOLOGY— INTERNAL    MEDICINE 
Dixie  Building  Greensboro 


JAMES  M.  NORTHINGTON,  M.D. 
INTERNAL    MEDICINE— GERIATRICS 
Medical  BuUding  Charlotte 


ORTHOPEDICS 


HERBERT   F.   MUNT,   M.D. 
ACCIDENT  SURGERY  &  ORTHOPEDICS 

FRACTURES 
Nissen  Building  Winston-Salem, 


PROFESSIONAL   CARDS 


NEUROLOGY  and  PSYCHIATRY 


J.  FRED  MERRITT,  M.D. 

NERVOUS  and  MILD  MENTAL 

DISEASES 

ALCOHOL  and  DRUG  ADDICTIONS 

Glenwood   Park   Sanitarium  Greensboro 


EYE,  EAR,  NOSE  AND  THROAT 


H.  C.  NEBLETT,  M.D. 
OCULIST 

Phone   3-58S2 
Professional  Bldg.  Charlotte 


AMZI  J.  ELLINGTON,  M.D. 

DISEASES  of  the 
EYE,  EAR,  NOSE  and  THROAT 

Phones:  Office  992— Residence  761 

Burlington  North   Carolina 


UROLOGY,   DERMATOLOGY  and   PROCTOLOGY 


THE  CROWELL  CLINIC  of  UROLOGY  and  UROLOGICAL  SURGERY 
Hours-Nine  to  Five  Telephones-3-7l01_3-7102 

STAFF 

Andrew  J.  Crowell,  M.D. 

(1911-1938) 

Angus  M.  McDonald,  M.  D.  Claude  B.  Squires   M  D 

Suite  700-711  Professional  Building  Charlotte 


Dr.  Hamilton  W.  McKay  Dr   Robert  w   McK 

DOCTORS  McKAY  and  McKAY 

Practice  Limited  to   UROLOGY  and  GENITO-URINARY  SURGERY 

Hours  by  Appointment 

Occupying  2nd  Flood  Medical  Arts  Bldg.  Charlotte 


Raymond  Thompson,  M.  D.,  F.  A.  C.  S.  Walter  E.  Danid>  A  B_  M  D 

THE  THOMPSON  -  DANIEL  CLINIC 
of 
UROLOGY  &  UROLOGICAL  SURGERY 
Fifth  Floor  Professional  Bldg. 


Charlotte 


C.  C.  MASSEY,  M.D. 

PRACTICE  LIMITED 

TO 

DISEASES  OF   THE  RECTUM 

Professional  Bldg.  Charlotte 

WYETT   F.   SIMPSON,   M.D. 

GENITO-URINARY   DISEASES 

Phone  1234 


L.  D.  McPHAIL,  M.D. 
RECTAL  DISEASES 


Professional  Bldg. 


Charlotte 


Hot  Springs  National  Park 


Arkansas 


PROFESSIONAL  CARDS 


March   1941 


SURGERY 


R.  S.  ANDERSON,   M.  D. 

GENERAL  SURGERY 

144  Coast  Line  Street  Rocky  Mount 


R.    B.    DAVIS,    M.  D.,    M.  M.S.,    F.A.  C.P. 
GENERAL  SURGERY 

AND 
RADIUM   THERAPY 

Hours  by  Appointment 
Piedmont-Memorial  Hosp.  Greensboro, 


WILLIAM    FRANCIS    MARTIN,    M.D. 

GENERAL  SURGERY 

Professional   Bldg.  Charlotte 


OBSTETRICS  &  GYNECOLOGY 


IVAN  M.  PROCTER,  M.D. 

OBSTETRICS   &   GYNECOLOGY 

133   Fayetteville   Street  Raleigh 


SPECIAL  NOTICES 


THE  EDITING  OF  MEDICAL  PAPERS 

This  journal  has  arranged  to  meet  the  demand  for  the  service  of  editing  and  revis- 
ing papers  on  medicine,  surgery  and  related  subjects,  for  publication  or  presentation 
to  societies.  This  service  is  rendered  on  terms  comparing  favorably  with  those  pre- 
vailing generally  in  other  Sections  of  the  Country. 

SOUTHERN  MEDICINE  &  SURGERY. 


REPRESENTATION  WANTED 
LEADING  MANUFACTURER  of  Physical  Therapy  Equipment  has  a   few 
territories  for  reliable  dealers.    Write  giving  full  details  to  "Physical  Therapy"  c/o 
Southern  Medicine  &  Surgery,  Charlotte,  N.  C. 


DO  YOU  WRITE? 

Book  Manuscripts  Wanted  —  All  subjects 
for  immediate  publication.  Booklet  sent  free. 
Meador  Publishing  Co.,  324  Newbury  St., 
Boston,  Mass.    Established  192S. 


THE  JOURNAL  OF 
SOUTHERN  MEDICINE  AND  SURGERY 

306  North  Tryon  Street,  Charlotte,  N.  C. 

The  Journal  assumes  no  responsibility  for  the  authenticity  of  opinion  or  statements  made  by  authors  or  in  communica- 
tions  submitted   to   this  Journal   for   publication. 


JAMES   M.   NORTHINGTON,   M.  D.,    Editor 


CHARLOTTE,    N.    C.    APRIL,    1941 


Kbbs 


ress 


Present-Day  Trends  in  Obstetric  and 
Gynecologic  Practice* 

R.  Gordon  Douglas,  M.D.,  New  York  City 


DURING  the  past  two  decades,  particularly 
the  last  decade,  radical  changes  in  the 
management  of  many  common  obstetric 
and  gynecologic  conditions  have  been  effected.  For 
some  unexplained  reason  but  little  change  occurred 
in  our  national  statistics  on  maternal  mortality 
until  quite  recently.  For  instance,  during  the  past 
five  years  this  rate  has  been  almost  cut  in  half  in 
New  York  City  and  a  comparable  decrease  has 
occurred  in  the  nation  as  a  whole.  It  is  difficult, 
even  impossible,  to  obtain  a  corresponding;  decrease 
in  mortality  in  various  gynecologic  conditions. 
However,  from  the  experience  of  many  individual 
hospitals  it  would  appear  that  a  considerable  im- 
provement in  gynecologic  practice  has  also  been 
accomplished. 

GYNECOLOGY 

The  improvement  in  gynecologic  practice  ap- 
pears to  be  the  result  largely  of  a  more  logical 
management  of  our  patients.  Better  pre-  and  post- 
operative care  take  high  place.  It  appears  probable 
that  the  success  of  a  major  gynecological  operative 
procedure  as  gauged  by  mortality  is  dependent  less 
on  nature  of  procedure,  skill  of  operator  and  all 
other  technical  factors,  than  upon  pre-  and  post- 
operative care.  The  patient  that  has  vomited  long 
is  now  treated  for  avitaminosis;  adequate  bowel 
drainage  is  assured,  dehydration  and  acidosis  cor- 
rected,  prior   to    the    institution   of    the   necessary 


surgical  procedure.  Hemorrhage  requires  restora- 
tion of  the  blood  volume,  and  lowered  body  tem- 
perature must  be  brought  back  to  normal  before 
attempting  a  major  operation.  Medical  complica- 
tions are  recognized  and  appropriate  measures  in- 
stituted. The  general  condition  of  such  patients 
can  often  be  greatly  improved  so  that  they  are  able 
to  withstand  the  surgical  procedure  indicated. 

Elective  operation  may  be  best  indefinitely  de- 
ferred. Formerly,  it  was  not  uncommon  to  see  pa- 
tients with  varying  degrees  of  anemia  subjected  to 
major  operative  procedures-  Except  in  dire  emer- 
gency such  practice  is  only  to  be  condemned.  The 
anemia  is  to  be  corrected  by  transfusion  and/or 
medication;  then  the  patient  may  be  subjected  to 
the  indicated  surgery. 

General  anesthesia  has  given  way  to  local  infil- 
tration and  nerve  block  in  the  elderly  patient  re- 
quiring plastic  surgery-  Nitrous  oxide-oxygen  an- 
esthesia is  contraindicated  in  the  colored  race. 
Local  infiltration,  block  and  caudal  anesthesia  are 
much  more  frequently  than  formerly  and  have 
'reatly  reduced  the  hazards  of  any  given  operation. 
Ether  still  remains  a  valuable  agent  for  general 
mesthesia.  Ethylene  and  cyclopropane  may  at 
limes  be  used  to  advantage.  Pentothal  sodium  by 
vein  is  now  available  to  induce  general  anesthesia 
for  operations  of  short  duration  where  an  inhala- 
tion agent  is  contraindicated.    By  wise  choice  of 


•Address    delivered    by    invitation    to    the    meeting    of    the   Tri-State    Medical    Association    ot    the    Carolina*    and    Virginia,    held 
at   Greeniboro,    N.    C.,    Feb.     24th  and  25th. 


TRENDS  IN  OBSTETRIC  AND  GYNECOLOGIC  PRACTICE— Douglas 


April  1941 


the  means  of  anesthesia,  postoperative  pulmonary 
complications  have  been  greatly  reduced,  and 
postoperative  shock  has  been  so  largely  reduced 
that  its  development  following  a  well  conducted 
operation  may  usually  be  considered  as  the  result 
of  an  error  in  judgment  as  to  the  proper  prepara- 
tion of  the  patient  for  operation.  Despite  the 
greater  margin  of  safety  afforded,  conservatism  has 
been  progressive. 

The  management  of  abnormal  uterine  bleeding 
has  been  rationalized  and  more  or  less  standardized 
largely  because  of  a  better  understanding  of  the 
pathology  involved.  Before  a  major  operative  pro- 
cedure is  considered,  a  biopsy  of  the  cervix  and  a 
dilatation  and  curettage  are  usually  indicated.  In 
the  presence  of  benign  tissue  and  in  the  absence 
of  submucous  fibroids,  hysterectomy  is  not  indi- 
cated. The  presence  of  mvomata  does  not  neces- 
sarily imply  that  these  tumors  are  the  cause  of 
the  bleeding.  In  general,  curettage,  repeated  if 
necessary,  gives  excellent  results.  Occasionally,  in 
women  over  40,  it  is  necessary  to  castrate  by  x-ray 
or  radium  irradiation.  Hysterectomy  is  never  indi- 
cated for  the  cure  of  bleeding  from  a  uterus  of 
normal  size  and  with  a  non-malignant  lining. 

The  indications  for  hysterectomy  or  myomec- 
tomy for  fibroids  have  been  fairly  standardized. 
Hysterectomy  is  done  by  the  subtotal  technic  in  a 
premenopausal  patient  who  has  a  sizable  tumor 
with  menorrhagia  or  metrorrhagia,  and  myomec- 
tomy is  not  feasible.  In  the  absence  of  abnormal 
bleeding,  hysterectomy  or  myomectomy  is  indi- 
cated in  few  cases  unless  the  tumor  rises  well  up 
into  the  lower  abdomen  Simple  mvomata  rarely 
cause  pain.  Associated  bleeding  may  be  due  to 
pathology  of  the  endometrium — carcinoma,  hyper- 
plasia etc.,  the  fibroids  being  in  no  way  responsi- 
ble for  symptoms  In  many  instances  fibroids  ma- 
ture without  reaching  a  size  that,  in  itself,  indicates 
their  removal,  and  oftentimes  causes  no  symptoms 
and  constitute  no  hazard  to  the  welfare  of  the  pa- 
tient if  left  in  situ. 

Formerly,  it  was  common  practice  to  carry  out 
extensive  perineal  operations  and  immediately 
thereafter  to  perform  a  more  or  less  extensive  ab- 
dominal operation.  In  general,  this  is  now  a  com- 
pletely out-moded  procedure.  A  plastic  operation 
for  cystocele,  rectocele,  prolapse  etc.  is  preferably 
carried  out  as  a  perineal  procedure  and  a  cure 
effected  from  below.  Any  indicated  laparotomy 
should  be  carried  out  as  a  separate  procedure  at  an 
elective  date  prior  to  or  following  the  plastic  oper- 
ation. General  anesthesia  is  not  often  the  choice 
for  plastic  operations  on  patients  over  SO  vears  of 
age.  A  combination  of  pentobarbital  sodium,  mor- 
phine, scopolamine,  local  infiltration  and  pudendal 


block  gives  excellent  results. 

Prior  to  1920  removal  of  the  fallopian  tubes  be- 
cause of  inflammatory  complications  was  a  rela- 
tively common  operation.  As  has  long  been  taught, 
this  operation  should  never  be  carried  out  during 
the  acute  or  subacute  phase  of  the  disease,  and 
the  vast  majority  of  such  cases  will  respond  to  pal- 
liative measures.  The  operation  should  be  reserved 
for  those  patients  who  have  large  discrete,  thick- 
walled  tuboovarion  masses,  and  which  show  a  ten- 
dency to  spontaneous  regression.  If  surgery  is  in- 
dicated in  such  patients,  radical  measures,  includ- 
ing the  removal  of  both  adnexal  organs,  usually 
are  necessary  in  order  to  effect  a  cure. 

By  the  proper  employment  of  sulfathiazole  or 
sulfadiazene  the  gonococcus  may  be  eliminated 
from  the  genital  tract  in  a  matter  of  hours,  and 
cure  established  in  a  large  percentage  of  infected 
individuals  in  a  matter  of  days. 

Suspension  of  the  uterus  in  days  gone  by  was 
one  of  the  most  common  gynecological  operations. 
Today,  many  authorities  consider  it  inadvisable  in 
any  case  to  perform  an  abdominal  operation  solely 
for  this  purpose  Likewise  a  pelvic  laparotomy  is 
never  indicated  because  of  chronic  pain  unless 
there  is  associated  palpable  pelvic  pathology-  Am- 
putation of  the  cervix  during  the  reproductive 
years  was  formerly  very  commonly  done.  Coagu- 
lation or  cauterization  affords  excellent  results  and 
usually  makes  such  an  operation  unnecessary.  We 
no  longer  do  other  intraabdominal  operative  pro- 
cedures after  the  performance  of  a  major  gynecol- 
ogical operation-  Experience  has  taught  that  the 
average  patient  in  good  condition  can  withstand  a 
hysterectomy  or  a  cholecystectomy:  but  when  both 
procedures  are  carried  out  at  one  operation  the 
mortality  is  much  greater  than  the  sum  of  the  mor- 
talities following  the  individual  procedures. 

During  recent  years  the  medical  profession  of 
this  country  has  been  deluged  with  literature  by 
ardent  enthusiasts  and  commercial  drug  houses 
concerning  the  therapeutic  application  of  various 
endocrine  preparations,  recommended  for  vaginal 
bleeding,  dysmenorrhea,  menopausal  symptoms, 
neuroses,  sterility,  threatened  abortion,  premature 
labor,  various  psychiatric  manifestations  and  so 
on.  In  many  instances  such  treatment  is  begun 
without  even  a  casual  preliminary  pelvic  examina- 
tion. An  extensive  and  critical  review  of  the  liter- 
ature suggests  that  there  are  but  few  positive  ther- 
apeutic indications  for  the  use  of  these  extracts. 
Moreover,  one  is  impressed  with  the  fact  that  the 
leaders  who  have  done  most  of  the  fundamental 
investigations  along  these  lines  are  the  most  reti- 
cent as  to  the  clinical  use  of  these  preparations.  It 
is  true  that  the  vasomotor  phenomena  associated 


April   1941 


TRENDS  IN  OBSTETRIC  AND  GYNECOLOGIC  PRACTICE— Douglas 


with  the  menopause  may  be  temporarily  more  or 
less  completely  relieved  by  the  administration  of 
natural  or  synthetic  estrogenic  substances.  There 
is  no  indication  in  the  absence  of  vasomotor  dis- 
turbances that  these  preparations  will  in  any  way 
alleviate  the  psychiatric  abnormalities  of  such  pa- 
tients. Progesterone  may  be  of  some  value  in  rare 
instances  in  preventing  abortion,  but  this  has  not 
been  conclusively  established.  The  same  prepara- 
tion may  at  times  relieve  patients  with  severe  dys- 
menorrhea. At  the  same  time  the  establishment  of 
permanent  relief  by  such  means  can  only  rarely,  if 
ever,  be  accomplished.  It  appears  probable  that  99 
per  cent  of  endocrine  therapy,  as  practiced  at  the 
present  time,  is  not  only  useless  but  at  times  may 
be  actually  harmful.  It  does  not  rest  on  a  sound 
scientific  basis.  The  drug  houses  have  placed  a 
large  number  of  these  preparations  at  our  disposal. 
Their  exaggerated  claims  appear  attractive,  but  in 
the  last  analysis  the  medical  profession  is  responsi- 
ble for  the  treatment. 

Little  need  be  said  here  of  the  various  indica- 
tions for  the  employment  of  the  sulfonamide  group 
of  drugs  in  our  field.  Sulfanilamide  has  proven 
most  useful  in  the  treatment  of  hemolytic  strepto- 
coccus infections,  post  partum  or  post  abortion. 
However,  98  per  cent  of  such  infections  are  caused 
by  organisms  other  than  the  hemolytic  streptococ- 
cus. The  urinary  tract  may  usually  be  rendered 
sterile  after  the  administration  of  adequate 
amounts  of  the  same  drug  under  carefully  con- 
trolled conditions.  Gonorrhea  of  the  female  may 
be  cured  in  a  large  percentage  of  cases  if  the  pa- 
tient is  kept  in  bed  and  given  adequate  doses  by 
day  and  by  night-  Our  experience  with  sulfathia- 
zole  has  shown  it  to  be  superior  to  sulfanilamide 
in  the  treatment  of  gonorrhea  and  in  many  urinary- 
tract  infections.  In  addition,  it  is  valuable  in  staph- 
ylococcus infections  of  the  genital  tract  and  in 
general  it  is  much  less  toxic  than  sulfanilamide. 
My  most  recent  experience  has  been  with  sulfadia- 
zene,  which  promise  of  being  more  efficacious  than 
either  of  the  previously  mentioned  drugs,  yet 
almost  non-toxic.  It  is  largely  in  the  experimental 
stage  but  at  the  moment  it  has  supplanted  sul- 
fanilamide, sulfapyridine  and  sulfathiozole  in  the 
treatment  of  the  conditions  mentioned.  The  intro- 
duction of  these  compounds  is  of  epochal  impor- 
tance; it  remains  for  the  future  to  evaluate  their 
significance.  It  would  seem  reasonable  to  hope 
for  even  better  preparations  of  this  group. 

OBSTETRICS 

Prenatal  Care 

The  general  adoption  of  prenatal  care  has  played 

a  very  important  role  in  the  recent  reduction  of 

maternal  mortality  in  this  country.    Extensive  sta- 


tistical evidence  has  been  presented  during  the  past 
few  years  to  substantiate  the  statement.  Where 
prenatal  care  is  adequate,  and  proper  diagnostic 
and  therapeutic  measures  instituted,  we  may  expect 
the  elimination  of  congenital  syphilis.  The  inci- 
dence of  severe  preeclampsia  and  eclampsia  are 
greatly  reduced  by  the  institution  of  treatment  in 
the  incipiency.  Deaths  from  cardiac  failure  in 
patients  with  organic  heart  disease  may  be  largely 
prevented.  Extension  of  life  in  patients  with  hyper- 
tension or  renal  disease  has  been  effected  by  the 
prevention  of  conception.  Diabetic  coma  and  death 
has  been  reduced  to  negligible  proportions.  Ante- 
partum correction  of  anemia  has  been  one  of  the 
most  recent  improvements  in  obstetric  care-  Suit- 
able treatment  of  patients  with  upper-respiratory 
infections  has  reduced  significantly  the  incidence 
of  pneumonia  and  puerperal  infection-  In  general, 
the  early  detection  of  medical,  surgical  and  obstet- 
rical complications  and  the  institution  of  appro- 
priate treatment,  have  greatly  reduced  morbidity 
and  mortality. 

It  is  important  to  note  that  patients  who  give  a 
history  of  having  had  a  urinary-tract  infection 
need  careful  investigation  and  evaluation  before 
they  are  permitted  to  have  a  subsequent  preg- 
nancy. The  earlier  treatment  is  instituted  the 
more  satisfactory  the  end  results.  The  late  sequelae 
of  neglected  infections  initiated  during  pregnancy 
have  only  recently  been  generally  recognized.  Our 
most  brilliant  results  with  the  sulfonamide  drugs 
are  accomplished  in  acute  infections,  while  our 
most  disappointing  results  are  obtained  in  long- 
standing infections. 

Hemorrhage 

During  the  time  covered  in  this  survey  radically 
different  methods  of  management  of  patients  with 
antepartum  hemorrhage  occurring  during  the  last 
trimester  of  pregnancy  have  been  used.  It  is  gen- 
erally recognized  that  the  amount  of  bleeding  gives 
no  indication  as  to  the  existence  of  placenta  prae- 
via.  A  tablespoonful  of  blood  loss  at  this  time  may 
be  indicative  of  a  central  placenta  praevia,  an  in- 
significant polyp  or  an  erosion  of  the  cervix.  We 
no  longer  regard  antepartum  bleed'ng  as  an  indi- 
cation for  immediate  diagnostic  and  operative 
treatment.  The  only  emergency  is  to  immediately 
get  such  an  individual  into  a  well  equipped  hospital 
and  provid-  a  readily  available  source  of  blood. 
Local  examinations  are  deferred.  It  is  our  practice 
to  keep  such  patients  quiet  in  bed  on  the  deliverv 
floor  under  observation  for  a  few  days,  assuming 
that  the  condition  is  nlacenta  praevia.  The  intro- 
duction of  the  soft-tissue  x-ray  technic  has  pro- 
vided us  with  a  valuable  diagnostic  aid.  In  at  least 


TRENDS  IN  OBSTETRIC  AND  GYNECOLOGIC  PRACTICE— Douglas 


April    1941 


90  per  cent  of  such  patients  a  fairly  definite  diag- 
nosis can  be  made  by  this  means. 

When  pelvic  examination  is  indicated  after  a 
few  days'  observation  it  should  always  be  done  in 
an  operating  room  where  full  preparations  have 
been  made  for  the  introduction  of  a  bag,  rupture 
of  the  membranes,  or  the  immediate  performance 
of  cesarean  section.  Vaginal  or  even  rectal  exam- 
inations, in  the  absence  of  such  preparations,  are 
definitely  contraindicated.  If  blood  loss  has  been 
extensive  transfusion  before,  during  and  after  an 
operative  procedure  is  indicated.  In  the  case  of 
central  placenta  praevia,  and  of  marginal  placenta 
praevia  where  the  patient  is  not  in  labor,  cesarean 
section  is  often  indicated  On  the  other  hand,  if 
the  patient  is  in  labor  the  cervix  partially  dilated, 
rupture  of  the  membranes  or  insertion  of  a  bag 
usuallv  gives  good  results-  We  have  learned 
through  bitter  experience  that  in  this  latter  group 
of  patients,  spontaneous  delivery  is  the  method  of 
choice.  It  is  a  fatal  error  in  such  circumstances 
where  the  breech  presents,  to  exert  any  traction 
whatsoever;  this  is  because  of  likelihood  of  trauma 
to  the  lower  uterine  segment  with  resulting  shock 
and  hemorrhage. 

Thibd  Stage 

A  great  deal  of  attention  has  been  devoted  dur- 
ing the  past  few  vears  to  the  correct  management 
of  the  third  stage  of  labor-  Manv  investigators 
have  pointed  out  the  necessity  for  accurately  meas- 
uring the  blood  loss  at  this  time.  We  no  longer 
wait  for  the  development  of  shock  before  starting 
a  transfusion.  Knowing  the  cell  volume  or  hemo- 
"'obin  percentage,  the  weight  of  the  natient  and 
the  volume  of  blood-loss,  the  need  for  a  transfusion 
can  be  accurately  calculated  bv  means  for  a  for- 
mula. Extensive  investigations  of  the  pathology 
of  shock  has  been  undertaken  bv  many  and  we 
'•now  that  if  initial  shock  following  hemorrhage  is 
"it  Dromntlv  corrected,  we  mav  have  to  contend 
with  secondary  shock,  with  anoxemia  and  increas 
ed  capillary  permeahilitv.  At  this  time  mifch 
^rum  is  lost  from  the  blood  vessels  into  th» 
t:ssues  which  aggravates  the  existing  condition.  If 
"'ch  a  state  is  permitted  to  mntinue  an  irreversi- 
He  nhenomenon  develoDS.  For  these  reasons,  the 
''"ferment  of  transfusion  should  not  be  permitted, 
'"'•vstalloid  or  colloid  solutions  are  not  satisfac- 
tory for  infusion  purposes,  although  thev  may  tem- 
porarily raise  the  blood  pressure  hv  inTeacing 
Hood  volume.  The  effect  is  often  of  s^ort  duration 
""d  accordingly  mav  <*?ve  us  a  false  spnse  of  se- 
rvritv.  If  whole  Mood  is  not  available  blood 
•-'nsma  or  serum  will  give  almost  as  good  results 
'■''asma  mav  he  kent  for  relatively  long  nciods  of 
t;me  under  refrigeration  conditions  and  should  be 


available  in  smaller  institutions  where  it  is  not 
practicable  to  maintain  blood  banks,  and  for  home 
use..  This  will  undoubtedly  save  many  lives  in 
the  future  that  are  now  lost  because  of  hemor- 
rhage. 

Anesthesia  and  Analgesia 

The  large  number  of  anesthetic  agents  advo- 
cated and  the  different  methods  of  using  them  is 
evidence  of  the  fact  that  as  yet  no  entirely  satis- 
factory method  of  analgesia  is  as  yet  available. 
In  general,  the  use  of  morphine  and  scopolamine 
in  moderate  dosage  gives  fairly  good  results. 
Where  scopolamine  is  not  repeated  it  is  quite 
adaptable  to  home  practice  and  it  often  provides  a 
fair  degree  of  amnesia  and  analgesia-  Ether,  by 
rectum,  if  the  cervix  is  more  than  half  dilated,  has 
been  used  very  extensively  and  must  be  considered 
a  relatively  safe  agent.  However,  the  use  of  these 
drugs  will   increase   the   incidence  of  hemorrhage. 

Pentobarbital  sodium  is  not  primarily  an  anal- 
gesic drug  and  the  desired  result  is  accomplished 
by  exceeding  the  sedative  dosage-  Satisfactory  an- 
algesia can  often  be  accomplished  by  the  use  of 
.3-.5  gram  combined  with  one  or  two  doses  of 
scopolamine.  It  is  essential  that  the  patients  be 
constantly  supervised.  All  analgesic  drugs,  mor- 
phine in  particular,  are  contraindicated  in  prema- 
ture labors  or  where  the  expected  size  of  the  babv 
is  2500  grams  or  less.  Accordingly,  in  premature 
labors  a  month  or  more  before  the  expected  date 
of  confinement,  analgesic  agents  should  not  be  ad- 
ministered. During  the  second  stage  of  labor 
nitrous  oxide-oxygen  administered  at  the  time  of 
the  contractions  affords  very  satisfactory  analgesia. 

Anesthesia  at  the  time  of  delivery,  if  at  all  pos- 
sible, is  much  to  be  desired.  In  general,  ether  or 
nitrous  oxide  or  a  combination  of  these  agents  mav 
be  used.  It  is  of  the  greatest  importance  that  ade- 
quate amounts  of  oxygen  be  administered  to  pre- 
vent fetal  anoxemia.  It  is  usuallv  impossible  to 
attain  surgical  anesthesia  with  nitrous  oxide  alone 
without  producing  this  undesirable  effect  on  the 
baby.  During  the  past  few  years  local  infiltration 
and  pudendal  block  anesthesia  have  been  used 
with  increasing  frequency.  This  method  has  in 
general  given  excellent  results.  It  has  several  ad- 
vantages over  general  anesthesia  in  that  it  has  no 
effect  on  the  baby,  the  blood  loss  is  less,  uterine 
contractions  are  not  interfered  with  and  pulmon- 
ary complications  are  decreased.  This  form  of  an- 
esthesia appears  indicated  in  the  presence  of  toxe- 
mia, hypertensive  disease,  premature  labor,  upper 
respiratory  infections  or  other  medical  complica- 
tions- 

Cesarean  Section 

So  much  has  been  written  in  recent  years  con- 


April  1941 


TRENDS  IN  OBSTETRIC  AND  GYNECOLOGIC  PRACTICE— Doughs 


17S 


cerning  indications,  contraindications,  uses  and 
abuses  that  I  shall  confine  my  remarks  to  what  I 
believe  well  established  facts.  Morbidity  and  mor- 
tality are  several  times  greater  than  in  spontane- 
ous delivery  irrespective  of  the  care  and  the  facili- 
ties available.  For  this  reason  the  indications  must 
be  based  on  sound  judgment.  Under  ideal  condi- 
tions this  procedure  must  not  constitute  an  escape 
from  the  art  and  science  of  obstetric  care.  At  the 
same  time  it  is  often  of  the  greatest  value  to  the 
patient  with  contracted  pelvis,  placenta  praevia, 
premature  separation  of  the  placenta  and  a  num- 
ber of  other  grave  conditions. 

The  classical  type  of  operation  is  the  procedure 
of  choice  prior  to  the  onset  of  labor.  The  low 
cervical  section  (with  double  peritoneal  flaps)  is 
relatively  safe  during  the  first  12  hours  of  labor  if 
there  is  no  evidence  of  intrapartum  infection.  Fol- 
lowing the  lapse  of  this  time  the  extraperitoneal 
(Latzko,  Waters  etc.)  or  radical  (hysterectomy) 
type  of  procedure  provide  the  only  method  that  is 
reasonably  safe.  The  dangers  mount  rapidly  fol- 
lowing each  hour  of  labor  and  it  is  urgent  that  a 
decision  be  reached  early  in  labor. 

Local  infiltration  anesthesia  is  far  superior  to 
any  inhalation  anesthesia  and  decreases  the  dan- 
gers to  both  mother  and  child.  The  procedure  can 
be  carried  out  with  relatively  little  discomfort  to 
the  mother,  especially  if  nitrous  oxide-oxygen  an- 
algesia is  provided  for  a  brief  interval  during  the 
extraction  of  the  child. 

Puerperal  and  Post-abortion  Infections 

Despite  the  use  of  the  sulfonamide  drugs,  it  is 
still  essential  to  exercise  every  precaution  against 
the  development  of  infection.  Among  important 
factors  along  these  lines  are  the  treatment  of  ane- 
mia during  pregnancy,  the  prevention  and  control 
of  upper-respiratory  infections,  and  other  hygienic 
measures  that  will  insure  the  patient  being  in  an 
optimum  condition  at  the  time  of  the  onset  of 
labor.  Careful  aseptic  precautions  during  the  man- 
agement of  labor  and  a  minimum  of  interference 
in  the  birth  canal  are  still  essential. 

It  is  highly  important  to  recognize  infections 
early  and  to  identify,  if  possible,  the  nature  of  the 
infecting  organism.  If  a  hemolytic  streptococcus 
is  responsible,  sulfanilamide  or  sulfadiazene  is  the 
drug  of  choice.  For  staphylococcus  infections  sul- 
fathiazole  appears  to  be  superior.  Welch-bacillus 
infections  will  respond  to  large  doses  of  sulfanila- 
mide. The  colon-aerogenes  eroups  of  organisms 
respond  fairly  satisfactorily  to  sulfathiazole  or  sul- 
fadiazene. When  the  infection  is  severe,  a  rela- 
tively large  initial  dosage  is  advisable,  following 
which  the  drug  should  be  administered  every  four 
hours  by  day  and  by  night.  If  possible,  the  concen- 
tration of  the  drug  in  the  blood  should  be  deter- 
mined at  frequent  intervals  and  signs  and  symp- 


toms of  toxicity  looked  for-  In  general,  the  earlier 
the  therapy  is  instituted  the  better  our  results  will 
be.  It  is  for  this  reason  that  early  bacteriological 
investigation  is  so  necessary  so  that  one  can  be 
prepared  to  prescribe  the  most  appropriate  drug 
when  the  indication  arises. 

Toxemia  of  Pregnancy 

Despite  the  many  extensive  investigations  that 
had  been  and  are  being  conducted  in  an  attempt 
to  discover  the  etiology  of  these  conditions,  we  are 
still  ignorant  as  to  their  exact  nature.  Neverthe- 
less, symptomatic  treatment  is  fairly  satisfactory, 
especially  when  instituted  in  the  early  stages  of 
the  derangement.  For  this  reason  it  is  essential 
that  careful  records  of  the  weight,  systolic  and 
diastolic  blood  pressure  and  examination  of  the 
urine  be  kept.  Most  such  patients  will  respond 
satisfactorily  to  rest  in  bed  and  a  diet  with  a  low 
salt  content.  In  the  more  severe  forms,  such  as 
preeclampsia  and  eclampsia,  glucose  by  vein,  seda- 
tives and  if  an  acidosis  is  present,  sodium  lactate, 
may  be  indicated.  Radical  measures  aimed  at  de- 
livery during  the  acute  stage  of  the  disease  have 
no  place  and  are  positively  contraindicated. 

One  of  the  most  efficient  means  of  post-gradu- 
ate education  in  obstetrics  is  afforded  by  a  well- 
conducted  group  study  of  fatal  cases.  An  able 
discussion  of  such  case  records,  participated  in  by 
all  practitioners  doing  obstetrics,  will  do  much  to 
improve  obstetric  practice  in  the  future. 


A  NEW 
LUNG  DISEASE  IN  NEWBORN  INFANTS 

(J.  M.  Adams,  Minneapolis,  in  //.  A.  M.  A.,  Mar  8th) 
The  disease  appeared  in  epidemic  form  with  32  cases 
during  Jan.,  Feb.  and  March,  1937.  There  were  9  deaths. 
The  disease  is  similar  to  influenza,  but  ferrets  inoculated 
with  fresh  material  from  the  patients  failed  to  generate 
neutralizing  bodies  against  the  influenza  virus.  Further 
evidence  that  the  epidemic  infection  was  a  virus  disease 
was  indicated  by  its  extreme  contagiousness,  its  distinctive 
symptoms  (cough,  low-grade  fever,  labored  breathing  and 
skin  blueness).  characteristic  lung  and  blood  changes  and 
the  failure  of  investigators  (Minnesota  State  Board  of 
Health)   to  identify  the  causative  bacterium. 

The  mortality  was  100  per  cent  in  the  premature  infants 
affected.  Newborn  infants  have  a  short  immunity  to  other 
than  virus  diseases. 


THE  UNIVERSITY 
(J.  II.  Kildebrand,  Berkeley,  in  Jl.  Assn.  Am.  Med.  Col-,  Nov.) 
The  most  important  feature  of  a  university  education 
to  the  individual  is  not  that  it  may  enable  one  to  earn 
more  money,  but,  instead,  to  need  less.  A  person  who  has 
trained  himself  to  intellectual  companionship  with  the 
great  of  all  ages  does  not  need  to  pay  for  the  social 
splurges  that  sometimes  seem  necessary  in  order  to  main- 
tain ordinary  social  prestige.  The  one  advantage  of  being 
a  University  professor  is  that  one  belongs  to  the  greatest 
fraternity  of  all,  the  fraternity  of  scholarship.  Wherever 
a  scholar  goes  in  the  civilized  world,  he  is  welcomed  by 
equals  and  entertained  without  vulgar  ostentation.  The 
poor  business  man.  on  the  contrary,  is  forced  to  entertain 
his  colleagues  and  competitors  in  a  way  designed  to  give 
the  impression  that  he  is  one  of  the  successful. 


SOUTHERN  MEDICINE  &  SURGERY 


April   1941 


Further  Studies  on  a  Simplified  Cough-Plate  Method  For 
the  Early  Diagnosis  of  Whooping  Cough 

Evaluation  of  the  Instillation  of  Topagen  Intranasally  in  the  Prevention  and  Clinical 
Arrest  of  the  Disease 

Irvinc  S.  Baeksdale,  M.D.,  F.A.P.H.A., 
Gladys  K.  Mullenix,  R.N.,  and  L.  Bates  Fuster,  R.N. 

Greenville 


THE  PURPOSE  of  this  article  is  to  report 
further  on  our  studies  relative  to  the  sim- 
plified, more  rapid  diagnosis  of  pertussis; 
and  to  report  briefly  our  extensive  studies  on  the 
evaluation  of  the  new  Topagen  (Mulford  Biologi- 
cal Laboratories,  Sharp  &  Dohme)  in  275  cases 
of  pertussis  and  on  some  persons  who  had  been 
directly  exposed  to  the  disease. 

Our  use  of  this  simplified  cough-plate  method 
dates  from  the  severe  epidemic  of  whooping  cough 
that  prevailed  in  the  City  of  Greenville,  South 
Carolina,  in  late  1933  and  early  1934.  A  few  of 
our  local  physicians  approached  us  in  regard  to 
devising  a  more  rapid  method  of  diagnosing  the 
disease.  All  culture  media  capable  of  growing 
Haemophilus  pertussis  (B.  pertussis,  or  Bordet- 
Gengou  Bacillus)  were  difficult  to  prepare  and 
growths  of  colonies  were  slow  to  make  their  appear- 
ance. Our  first  efforts  were  aimed  at  the  prepara- 
tion of  a  simple  and  inexpensive  agar  culture 
medium  upon  which  H.  pertussis  would  grow 
quickly  and  characteristically  in  sufficient  abund- 
ance for  the  preparation  of  stained  slides  and  for 
serological  study- 
In  most  localities  having  no  facilities  for  bac- 
teriological diagnosis  the  clinician  must  diagnose 
on  the  characteristic  whoop,  first  heard  between 
the  second  and  third  week  of  the  disease  or  not  at 
all.  So  there  is  a  wait  until  the  acute  infectious 
process  of  the  bronchial  tree  has  become  establish- 
ed and  valuable  time  for  the  much-needed  treat- 
ment has  been  lost. 

Our  methods  of  attacking  the  problem  over  the 
past  seven  years  have  been  to:  (1)  isolate  H. 
pertussis  from  a  given  suspect  by  the  cough-plate 
method  as  early  as  possible  in  the  disease;  (2)  to 
bring  the  isolated  patient  under  an  approved  form 
of  treatment  as  soon  thereafter  as  is  possible. 

Preparation   of   Glycerine-free   Potato-Agar — 
Nutrient  agar   (Difco  dehydrated)   gms.  or  c.c.  11.50 
Water,  distilled,  to  make  450.00. 
This  is  prepared  in  accordance  with  the  direc- 


tions found  on  the  label  of  the  bottle  of  Nutrient 
Agar,  except  some  of  the  water  is  left  out  of  the 
medium  to  prevent  softening  and  sliding  of  the 
congealed  agar  in  the  Petri  dish. 

The  potato  extract  is  prepared  by  cooking  in 
the  usual  manner  three  pounds  of  old  potatoes, 
either  thoroughly  scrubbed  or  pealed,  in  approxi- 
mately 1500  c.c.  of  distilled  water,  then  straining 
through  several  layers  of  gauze. 

This  potato  extract  is  next  placed  in  dry  steril- 
ized containers  and  autoclaved  at  15  pounds  pres- 
sure for  twenty  minutes.  If  there  is  evidence  of 
bacterial  contamination  in  the  potato  extract,  re- 
autoclaving  is  done. 

The  plates  are  usually  prepared  extemporane- 
ously by  liquefying  the  agar  by  water-bath  in 
the  usual  manner  and  pouring  the  required  amount 
into  sterile  Petri  dishes  to  which  has  been  added 
2  c.c.  of  the  sterile  potato  extract.  After  gentle 
and  thorough  rotating  of  the  Petri  dish  the  potato- 
enriched  nutrient  agar  is  allowed  to  congeal  at 
room  temperature.  Then  the  cough-plate  is  wrap- 
ped and  held  ready  for  exposure  by  streaking  or 
coughine  during  paroxysm,  and  incubation  and 
bacteriological  study  for  identification  of  H.  per- 
tussis. 

Method  of  Exposing  or  Inoculating  the  Cough- 
Plate— 

The  cough-plate  may  be  exposed  or  inoculated 
in  two  ways: 

( 1 )  By  allowing  the  suspect,  during  a  paroxysm 
only,  to  cough  on  the  agar  held  not  more  than  five 
inches  in  front  of  the  mouth.  Voluntary  coughing 
is  too  shallow  to  bring  up  infectious  material- 
These  are  the  instructions  given  by  the  physician 
to  the  parents. 

( 2 )  The  plate  may  be  also  exposed  by  streaking 
the  surface  of  the  agar  by  the  physician  or  visiting 
nurse.  The  child  is  allowed  to  cough  or  go  through 
a  paroxysm  after  which  the  physician  or  nurse, 
using  flashlight  and  tongue  depressor,  passes  the 
sterile  swab  over  a  large  area  of  the  throat  and 


April  1941 


SIMPLIFIED  METHOD  FOR   WHOOPING-COUGH— Barksdale  et  al. 


177 


then  lightly  strokes  the  surface  of  the  potato-agar 
to  inoculate  the  surface  of  agar  not  too  sparsely 
nor  too  thickly- 

Cough-plates  treated  in  this  manner  and 
promptly  incubated  at  37.6°  should,  if  H.  pertus- 
sis be  present,  give  the  positive  presumptive  test 
in  four  hours.  The  test  may  be  called  positive  for 
H.  pertussis  when  the  characteristic  clear  zones 
occur  around  the  colonies  over  the  agar  in  the 
plate,  or  beside  the  streaked  area  in  case  the  swab 
method  was  used. 

Sufficient  pertussis  organisms  for  staining  or 
serologic  study  may  develop  on  this  potato-agar 
plate  in  from  six  to  eight  hours.  The  rapid  devel- 
opment of  the  organism  on  this  culture  medium  is 
attributed  to  the  absence  of  glycerine — in  itself  a 
preservative  or  bacteristatic.  The  presence  of 
rather  high  concentration  of  glycerine  in  the  old 
Bordet  medium  is,  in  our  opinion,  sufficient  to  re- 
tard the  development  of  H.  pertussis  for  from 
forty-eight  to  seventy-two  hours. 

Identification  of  Organism — 

McLeod1  made  the  following  important  observa- 
tions: 

(1)  B.  influenzae  grows  quickly;  B.  pertussis 
grows  slowly. 

(2)  The  appearance  of  the  colonies  on  Bordet- 
Gengou  medium  are  quite  distinct;  those  of  B. 
pertussis  being  quite  unlike  those  of  any  other 
bacterium  that  is  commonly  found  in  the  sputum, 
and  therefore  the  bacteriological  diagnosis  can 
frequently  be  made  by  inspection  of  the  plates 
alone  (with  the  unaided  eye  or  a  magnifying 
glass) . 

Our  studies  of  the  organism  over  the  past  seven 
years  lead  us  to  conclusions  in  agreement  with 
those  of  McLeod. 

Macroscopic  Appearance  oj  Colonies  of  H  Per- 
tussis— 

Kendrick  and  Eldering2  describe  the  macro- 
scopic appearance  of  the  colonies  of  the  Bordet- 
Gengou  Bacillus  as  follows: 

By  transmitted  light,  colonies  are  smooth,  rais- 
ed, "listening,  pearly  and  almost  transparent, 
while  colonies  of  the  Gram-positive  cocci  in  gen- 
eral appear  duller,  darkly  colored  and  opaque. 

Our  findings  agree  with  theirs-  We  have  also 
consistently  observed  a  clear  zone  immediately 
surrounding  a  colony  of  the  H-  pertussis,  produced 
by  a  ferment  secreted  by  the  organism  which 
breaks  up  the  starch  and  starch-like  substances  of 
the  potato  extract.  In  our  experience  only  the  H. 
pertussis  and  an  unidentified  slender  Gram-nega- 
tive bacillus  occasionally  found  in  the  saliva  and 
bronchial  secretions,  and  possibly  a  few  yeasts, 
have  caused  this  digestion  of  the  potato  medium— 


a  valuable  aid    in    locating    the    colonies    to    be 
studied. 

Preparation  of  the  Slide — 

A  loopful  of  water  is  placed  on  a  slide  and  one 
or  a  group  of  small  clear  colonies  from  the  middle 
of  a  clarified  area  on  the  potato-agar  plate  fished 
off.  Frequently,  it  is  necessary  to  use  a  watch- 
maker's magnifying  glass  or  a  simple  reading-glass 
in  the  fishing.  After  thorough  emulsification  of  the 
colony  with  the  platinum  loop  in  the  droplet  of 
water  on  the  slide,  the  specimen  is  dried  and  fixed 
in  the  flame.  The  elements  of  the  Gram-staining 
method  are  next  applied  in  their  order  of  succes- 
sion, and  the  specimen  placed  under  the  oil  immer- 
sion objective  (900X).  Occasionally  a  magnifica- 
tion of  1675  is  used  for  more  detailed  study  of 
the  cocco-bacillus. 

Microscopic  Appearance  of  H.  Pertussis — 
Using  the  usual  purple  aniline  (triphenylmeth- 
ane)  dyes — crystal  violet,  methyl  violet,  bismuth- 
violet — the  Bordet-Gengou  bacillus  is  stained  a 
deep  purple  and  appears  as  a  short,  stubby  bacillus 
or  cocco-bacillus  in  young  cultures  grown  on  po- 
tato-agar medium,  in  size  from  2.5-5  micra,  some- 
times in  chains  of  varying  length.  The  forms  of 
the  organisms  found  from  the  third  week  of  the 
disease  and  later  depart  somewhat  from  the  classic 
descriptions,  becoming  larger,  and  slenderer,  and 
even  fusiform,  and  many  strains  being  arranged  in 
chains  of  varying  length.  Whereas  the  younger 
forms  are  all  strongly  Gram-negative,  these  older 
forms  oftentimes  appear  midway  between  Gram- 
positive  and  Gram-negative-  We  have  never  found 
them  to  be  strongly  Gram-positive. 

MICROSCOPIC     AGGLUTINATION     OF      H. 
PERTUSSIS:   METHOD  CORROBORATING 
THE  IDENTITY  OR  THE  ORGANISM 

Although  pertussis  cocco-bacilli  are  very  uni- 
form in  cultural,  morphological  and  staining  char- 
acteristics, they  vary  greatly  in  size-  The  organ- 
isms which  we  have  found  invariably  in  typical 
whooping  cough  are  larger  than  specimens  of  H. 
pertussis  obtained  from  the  Northern  United 
States.  With  this  organism  as  with  many  higher 
plants  and  animals — those  inhabiting  the  southern 
and  tropical  regions  are  larger,  as  a  rule,  than 
those  occurring  in  the  more  temperate,  northern 
sections- 

On  account  of  these  variations  in  size,  and  to  a 
much  less  extent  in  form  and  in  staining  character- 
istics, we  frequently  corroborate  the  microscopic 
laboratory  diagnosis  by  microscopic  agglutination 
in  the  hanging  drop,  as  follows: 

After  the  organisms  are  isolated  on  the  cough- 
plate  in  pure  culture,  some  of  the  small  colonies 


178 


SIMPLIFIED  METHOD  FOR  WHOOPING-COUGH— Barksdah  et  al. 


April   1941 


are  fished  off  of  the  surface  of  the  potato  agar 
with  the  platinum  loop  and  thoroughly  emulsified 
in  the  middle  of  a  clean  cover-glass  in  a  small 
drop  of  sterile  water.  Using  a  double-welled  hang- 
ing-drop slide,  the  first  cover-glass  is  carefully 
inverted  over  one  of  the  wells  and  sealed  around 
with  petrolatum.  Another  cover-glass  is  prepared 
in  like  manner  only  a  drop  of  similar  size  of  H. 
pertussis  agglutinating  serum,  1:400  (Sharp  & 
Dohme)  is  added  and  thoroughly  mixed  with  the 
end  of  a  sterile  hypodermic  needle  through  which 
the  serum  was  drawn  from  the  original  container. 
The  drop  of  emulsion  over  the  control  well  is  ob- 
served for  a  few  seconds  around  the  edges  of  the 
hanging  drop,  as  usual,  in  order  that  the  appear- 
ance and  distribution  of  the  organisms  might  be 
taken  account  of,  and  then  the  organisms  in  con- 
tact with  the  immune  serum  are  quickly  moved 
under  the  usual  high-power  objective,  care  being 
taken  to  observe  the  organisms  at  or  near  the 
edges  of  the  hanging  drop.  In  the  agglutinating 
reaction,  the  organisms  are  tightly  clumped  in 
from  five  to  ten  minutes  of  contact  with  the  ag- 
glutinins of  the  serum,  whereas  no  change  what- 
ever occurs  in  the  scattered  organisms  in  the  con- 
trol or  in  the  hanging  drop  containing  none  of  the 
serum.  Thus  the  presence  or  absence  of  suspici- 
ous, atypical  forms  (from  cultural,  morphological 
or  staining  standpoints)  is  established  after  a 
standard  and  generally  accepted  method.  We  have 
observed  on  numerous  occasions  certain  uniform- 
appearing  streptococci  isolated  from  cases  of  clin- 
ical- scarlet  fever  that  behaved  in  a  similar  manner 
in  the  presence  of  scarlet  fever  antitoxin.  This 
serum  added  slightly  in  excess  to  suspensions  of 
such  streptococci  first  causes  a  clumping  of  these, 
this  is  followed  in  a  few  seconds  by  complete  dis- 
appearance of  the  streptococci  (lysis).  The  ten- 
dency of  this  immune  serum  to  cause  total  lysis  of 
the  specific  organisms  may  account  for  the  efficacy 
of  scarlet  fever  antitoxin  in  the  clinical  course  of 
the  disease. 

THE  EVALUATION  OF  A  RELATIVELY 
NEW  IMMUNIZING  AGENT  FOR  WHOOP- 
ING COUGH— TOPAGEN  (Mulford  Biological 
Laboratories,  Sharp  &  Dohme) 

In  1932,  following  the  work  of  the  Research 
Staff  of  the  Mulford  Biological  Laboratories  of 
Sharp  and  Dohme,  there  appeared  on  the  market 
a  new  product  designed  to  create  an  active  im- 
munity to  the  Bordet-Gengou  bacillus  by  nasal  in- 
stillation rather  than  by  administration  of  the 
agent  by  the  usual  parenteral  route. 

Owing  to  the  shortage  of  helpers  competent  to 
administer  a  hypodermic  or  intramuscular  injec- 
tion in  the  proper  manner,  our  need  for  such  an 


immunizing  agent  was  urgent.  Moreover,  bringing 
children  out  of  whooping  cough  isolation  to  the 
clinic  or  health  office  for  inoculation  is  not  to  be 
encouraged:  first,  because  of  risk  of  chilling  the 
sick  child;  and,  second,  because  of  possible  expos- 
ure to  other  susceptibles,  adults  as  well  as  chil- 
dren. 

Our  practice  has  been  to  establish  a  diag- 
nosis of  whooping  cough,  preferably  by  cough- 
plate  culture  as  described,  as  soon  as  possible,  and 
to  commence  the  Topagen  treatment  at  once;  also 
to  demonstrate  to  the  mother  or  some  intelligent 
neighbor  the  proper  intranasal  instillation  of  the 
soluble  antigen  as  follows: 

Administration — "The  application  of  pertussis 
topagen  is  by  intranasal  instillation.  While  the 
method  of  application  is  simple  and  painless  it 
should  be  exact.  To  be  effective  the  antigen  must 
be  applied  to  the  area  of  the  middle  and  superior 
turbinates-  The  mucous  membrane  covering  these 
turbinates  is  capable  of  absorbing  the  antigen. 
The  mucosa  of  the  inferior  turbinate  does  not  ab- 
sorb the  antigen.  For  instillation  of  the  antigen 
the  patient's  head  should  be  below  the  body  level 
(exaggerated  supine  position)"3 — for  instance  over 
the  edge  of  a  bed,  care  being  taken  not  to  force 
the  child's  head  back  too  far- 

The  dropper  in  the  original  vial  is  then  inserted 
with  the  tip  toward  the  top  of  the  head  and  turned 
toward  the  turbinate  mucosa.  The  method  of  in- 
stillation is  shown  bv  illustration  in  explanatory 
folder  (M390C,  Muiford  Biological  Laboratories, 
Sharp  &  Dohme).  The  dropper  is  then  inserted 
and  the  antigen  slowly  expelled.  "The  contents  of 
one  dropper  (%  c.c.)  is  instilled  into  each  nostril 
once  each  dav  (in  the  treatment  of  pertussis)  or 
every  other  day  (for  prophylactic  measures  in 
contacts  of  pertussis)."  The  patient  should  remain 
in  the  reclining  position  for  3  to  5  minutes  after 
the  application  of  pertussis  topagen.  Four  to  five 
treatments  are  necessary  before  improvement  may 
be  expected.  To  minimize  the  recurrence  of  the 
paroxysm  (whoop),  treatment  should  be  continued 
until  symptoms  have  completely  disappeared. 

"The  antigen  may  also  be  applied  with  long  cot- 
ton pledgets  placed  over  the  area  of  the  middle 
turbinates  for  a  period  of  5  minutes."8 

If  the  nasal  mucosa  is  markedly  congested,  it 
may  be  necessary  to  relieve  the  congestion  before 
instilling  the  antigen  by  the  local  application  of 
an  appropriate  solution  of  ephedrine-HCL  racep- 
hedrine-HCl,  or  propadrine-HCl. 

"If  the  nares  contain  an  excess  of  mucus,  clean- 
ing out  of  the  mucus  should  be  attempted  before 
applying   the  pertussis   topagen."3 

Pertussis  topagen  contains  a  minimum  of  pre- 


April  1941 


SIMPLIFIED  METHOD  FOR  WHOOPING-COUGH— Barksdale  et  al. 


servative  which  does  not  harm  or  irritate  the  deli- 
cate mucous  membranes  of  the  nasal  cavities. 

"After  each  instillation,  the  dropper,  before  it  is 
returned  to  the  vial,  should  be  carefully  wiped 
with  a  pledget  of  cotton  moistened  with  alcohol  in 
order  to  avoid  contaminating  the  antigen. 

Where  more  than  one  patient  is  being  treated, 
an  individual  vial  should  be  provided  for  each  pa- 
tient.''3 

Where  more  than  one  patient  is  being  treated, 
an  individual  vial  should  be  provided  for  each  pa- 
tient"3 

A  compilation  of  the  clinical  results  reported  by 
different  investigators  is  highly  favorable.  Of  the 
cases  treated  early  in  the  paroxysmal  stage,  85 
per  cent  are  definitely  benefited:  whereas,  of  those 
treated  late  in  the  disease,  improvement  is  produc- 
ed in  about  40  per  cent. 

Regarding  the  results  obtained  in  the  treatment 
of  whooping  cough  with  pertussis  topagen,  Slesin- 
ger'  states:  "We  feel  that  the  high  percentage  of 
favorable  results  and  the  simplicity  of  the  method 
of  treatment  class  this  intranasal  antigen  as  a  val- 
uable therapeutic  procedure  in  the  treatment  of 
active  cases  of  whooping  cough." 

Gold/'  in  reporting  a  series  of  cases  in  which 
pertussis  topagen  was  used,  commented:  "In  our 
experience,  its  control  produces  a  startling  change 
in  the  clinical  picture  of  the  children  we  treated 
with  the  soluble  antigen.  It  also  appears  to  short- 
en the  duration  of  the  disease.  We  feel  that  this 
specific  pertussis  soluble  antigen  will  prove  to  be 
a  valuable  adjunct  in  our  therapeutic  armamenta- 
rium." 

In  reporting  another  series  of  cases,  Schooten:" 
"The  clinical  improvement  noted  among  the  ma- 
jority of  patients  receiving  pertussis  soluble  anti- 
gen was  encouraging  and  warrants  its  further  trial 
and  use  by  others.  The  clinical  course  of  the 
small  infants  for  whom  therapy  was  begun  early 
in  the  disease  was  gratifying."3 

In  our  series  of  275  cases  of  whooping  cough  in 
under  privileged  children  in  which  topagen  was 
used  our  favorable  results  were  in  accord  with  the 
findings  of  earlier  investigators;  i.e.,  of  those 
treated  early  in  the  disease  80  per  cent  are  bene- 
fited by  treatment,  whereas  of  those  treated  after 
the  disease  has  been  in  progress  for  some  time 
improvement  takes  place  in  50  per  cent  of  the 
cases. 

PREVENTION 

In  our  experience  the  disease  is  made  decidedly 
lighter  or  prevented  in  approximately  60  per  cent 
of  non-immune  children. 

No  doubt,  the  earlier  the  topagen  is  adminis- 
tered in  the  incubation  period  the  more  apt  the 


child  is  to  be  protected.  There  is  more  time  for 
building  up  immunity  to  the  artificially  applied 
antigen  in  the  form  of  topagen. 

Further  studies  in  active  immunization  with 
topagen  are  in  progress  and  will  be  presented  in 
future  articles  on  the  important  subject  of  pertus- 
sis. 

Case  Reports 

Case  33. — White  girl,  aged  16  months,  had  been  cough- 
ing for  two  days;  cough-plate  inoculated  by  coughing  in 
the  routine  manner  which  proved  positive  for  H.  pertus- 
sis. Topagen  intranasally  started  on  the  fourth  day  of 
cough,  using  one  very  small  dropperful  of  the  antigen  in 
each  nostril  once  daily  with  the  head  slightly  hyper- 
extended  in  accordance  with  directions  inclosed  in  the 
original  carton. 

The  cough  and  excessive  bronchial  secretion  cleared  up 
within  ten  days  although  the  plate  remained  positive  for 
H.  pertussis  for  a  week  after  the  cough  dried  up. 

Case  103. — White  boy,  aged  2  years,  had  been  having 
very  severe  paroxysms  of  coughing  for  ten  days.  Routine 
cough-plate  was  strongly  positive  for  H.  pertussis  in  al- 
most pure  culture.  Routine  intranasal  administration  of 
topagen  instituted  at  once  and  clinical  recovery  was  com- 
plete within  ten  days. 

Case  177.. — White  girl,  aged  2  years;  cough  for  four 
days;  proved  strongly  positive  for  H.  pertussis.  After 
seven  days  intranasal  treatment  with  topagen  the  cough 
disappeared;   the  organisms  persisting  a  week  longer. 

Case  187. — White  girl,  aged  6J/2  years,  severe  paroxysms 
of  coughing  for  three  weeks.  The  child  had  gone  well  into 
the  whooping  stage  and  was  losing  much  food  by  vomit- 
iting  during  paroxysms.  The  cough-plate  revealed  almost 
a  pure  culture  of  the  Bordet-Gengou  organism  and  in- 
stillation over  the  superior  and  middle  turbinate  mucosa 
of  topagen  was  commenced  at  the  beginning  of  the  fourth 
week  of  the  disease,  a  small  dropperful  once  each  day  into 
each  nostril,  with  slightly  hyperextended  head  allowing  the 
head  to  remain  in  this  position  for  two  minutes  to  warrant 
thorough  contact  with  the  mucosa  covering  the  superior 
and  middle  turbinate  bones  (for  optimum  absorption  of 
the  antigen) . 

This  cough  disappeared  after  one  week's  medication  with 
topagen,  although  she  was  held  in  isolation  and  kept  out 
of  school  for  one  week  longer  that  the  organisms  might 
be  destroyed  or  rendered  avirulent  by  her  own  antibodies. 
She  was  clinically  recovered,  however,  after  the  fourth 
week. 

Summary 

1.  A  description  is  given  of  a  rapid,  simplified 
cough-plate  method  for  the  early  diagnosis  of 
whooping  cough  as  carried  out  in  our  laboratory 
for  the  past  seven  years. 

2.  The  great  need  for,  and  advantages  of,  such 
a  method  for  the  protection  of  the  public  health 
are  discussed. 

3.  The  essentials  of  the  methods  of  other  inves- 
tigators of  the  characteristics  of  H.  pertussis  are 
given  and  mention  made  of  our  full  agreement  and 
accord  with  their  findings- 

4.  The  preparation  of  the  simple,  glycerine-free 
potato-agar  and  the  methods  of  exposing  and  in- 
oculating the  cough-plate  are  described. 


SIMPLIFIED  METHOD  FOR   WHOOPING-COUGH— Barksdale  et  al. 


April    1941 


5.  The  preparation  of  the  specimen  for  micro- 
scopic study,  staining  of  the  organism,  its  appear- 
ance under  the  oil-immersion  objective,  prepara- 
tion of  specimen  for  agglutination  or  lysis  in  the 
hanging  drop  with  mention  of  our  current  method 
of  observing  these  phenomena  as  to  the  Bordet- 
Gengou  organism  and  streptococcus  scarlatinae  are 
in  sufficient  detail  for  practical  laboratory  use  and 
diagnosis. 

6.  Our  seven-years'  experience  with  the  rela- 
tively new  topagen  (Mulford)  as  a  therapeutic 
agent  in  under-privileged  children  has  proved  it  to 
be  clinically  of  great  value  and  its  method  of  use 
are  described. 

7.  A  few  brief  typical  reports  from  our  series  of 
275  unselected  cases  are  presented. 

Bibliography 

1.  McLeod,  J.  W.:  The  Bacteriological  Diagnosis  of 
Whooping  Cough.  The  Lancet,  217:165-167,  July  27th, 
1929. 

2.  Kendricx,  P.,  and  Elderlng,  G.:  Cough-plate  Exam- 
inations for  B.  pertussis.  Amer.  Lour.  Public  Health, 
4:   No.  4,  April,   1934. 

3.  Instruction  sheet,  M390-C,  Mulford  Biological  Labora- 
tories, Sharp  &  Dohme,  in  original  Topagen  carton. 

4.  Slesinger,  H.  A:  Treatment  of  pertussis  with  intra- 
nasal antigen;  preliminary  report.  J.  Pediat.,  9:  42-48, 
July,  1936. 

5.  Gold,  H.:  Treatment  of  pertussis  with  specific  soluble 
antigen.    /.  Pediat.,  10:   641-647,  May,  1937. 

6.  Schooten,  S.  S.:  Intranasal  administration  of  a  per- 
tussis antigen.  /.  Michigan  M.  Soc,  36:  849-851,  Nov., 
1937. 

7.  Barksdale,  I.  S.,  and  Simpson,  F.  P.:  A  simplified 
cough-plate  method  for  the  early  diagnosis  of  whoop- 
ing cough.  Sou.  Med.  Jour.,  11:  27,  pp.  943-945,  Nov., 
1934. 

—Department  of  Health,   City  Hall. 

A  CKNOWLEDGMENTS 
We  are  grateful  to  the  large  number  of  physicians  in 
this  locality  who  have  shown  interest  and  rendered  valua- 
ble assistance;  also  to  the  great  number  of  parents  and  the 
patients  themselves  for  their  indispensable  cooperation 
with  their  attending  physicians  and  with  the  laboratory  in 
carrying  out  these  important  studies.  We  are  also  grateful 
to  Florence  D.  Hicks  and  Laurette  M.  Barksdale  for  their 
assistance  in  the  preparation  of  this  article  and  to  the  re- 
search workers  and  early  clinical  investigators  of  the  Mul- 
ford Biological  Laboratories,  Sharp  &  Dohme,  for  their 
substantial  contribution  of  this  valuable  biological  product 
to  the  practice  of  medicine  and  public  health. 


THE  USE  AND   ABUSE   OF   SPINAL  ANESTHESIA 

(P.  E.   Craig,   Coffeyville.   Kansas,   in   Clin.   Med.,   Mar.) 

No  other  method  of  anesthesia  will  permit  the  use  of 
such  a  minute  dose  of  a  drug,  and  yet  maintain  complete 
and  prolonged  analgesia.  The  early  symptoms  of  vasomo- 
tor and  respiratory  depression  are  transitory  and,  upon 
disappearance,  leave  the  surgeon  free  to  perform  the  oper- 
ation under  an  ideal  condition  of  muscular  and  visceral 
relaxation. 

Injury  to  the  intraabdominal  organs  is  negligible,  be- 
cause the  intestines  are  contracted,  facilitating  easy  ma- 
nipulation; and  when  the  patient  is  placed  in  the  Tren- 
delenburg   position    the    gut    gravitates    cephalad,    making 


the  use  of  restraining  pads  unnecessary.  Peristalsis  is 
augmented  and  the  expulsion  of  flatus  stimulated;  speed 
in  the  performance  of  nontraumatic  surgery  is  greatly  fa- 
vored; and  postoperative  morbidity  and  mortality,  in 
both  clean  and  septic  cases,  are  reduced. 

While  applicable  to  the  average  surgical  risk,  it  has  defi- 
nite contraindications: 

1.  Abnormally  low  blood  pressure,  due  to  shock  or 
anemia  following  an  acute  hemorrhage.  Since  a  spinal 
anesthetic  lowers  the  blood  pressure  still  further,  it  is  nec- 
essary to  overcome  the  hypotension,  by  the  use  of  intra- 
venous saUne  infusions  or  by  blood  transfusions,  before 
the  anesthesia  is  begun. 

2.  Cardiopathies:  Heart  disease,  not  perfectly  compen- 
sated, cannot  tolerate  a  rapid  fall  in  b.  p.  A  low  pulse 
pressure  with  a  high  diastolic  reading  denotes  a  poor 
cardiovascular  reserve  and  labels  the  case  a  poor  risk. 

3.  Extreme  hypertension. 

4.  Psychoneurosis:  Patients  who  may  later  attribute 
symptoms  of  backache,  dizziness,  or  headache  to  the  spinal 
anesthetic,  and  institute  malpractice  proceedings,  should 
not  receive  it. 

5.  Active  pulmonary  tuberculosis,  and  pleural  or  peri- 
cardial effusions:  Lung  disease  decreases  pulmonary  ven- 
tilation, which  is  further  decreased  under  spinal  anesthe- 
sia. 

6.  Pott's  disease,  syphilis,  generalized  septicemia,  and 
diseases  of  the  meninges  or  spinal  cord. 

7.  Malformation  of  the  spine. 

It  is  important,  in  preparing  for  spinal  anesthesia,  not 
to  use  drugs  which  will  depress  or  fatigue  the  medullary 
centers— morphine,  avertin,  nembutal,  evipal,  etc.  Paral- 
dehyde or  scopolamine  may  be  used  with  relative  safety. 
Large  doses  of  depressing  drugs,  administered  preopera- 
tively  render  the  patient  uncooperative  and  lower  the  b.  p. 
dangerously. 

Circulatory  depression  consequent  to  spinal  anesthesia  is 
largely  the  result  of  paralysis  of  the  muscles  of  the  thora- 
cic cage,  which  exerts  a  diminished  aspirating  effect  upon 
the  blood  stream.  Weakening  or  paralyzing  respiration 
interferes  with  the  circulation  of  the  blood  in  the  coronary 
arteries  and  the  oxygen  tension  therein.  The  sudden  fall 
in  b.  p.  causes  a  feeble  heart  action,  which  interferes  with 
an  adequate  delivery  of  blood  to  the  medullary  centers. 
Respiration,  therefore,  becomes  feebler  and  a  greater  de- 
gree of  anoxemia  develops. 

Since  temporary  vasomotor  paralysis  invariably  follows 
the  introduction  of  an  anesthetic  solution  into  the  spinal 
canal,  it  is  essential  that  some  drug  be  given  to  counter- 
act the  sudden  lowering  of  vascular  tension. 

The  average  fall  of  b.  p.  following  a  spinal  anesthetic 
is  from  40  to  50  points  systolic.  This  is  a  physiologic  re- 
action and  can  best  be  met  by  the  intravenous  injection 
of  from  200  to  300  c.c.  of  a  5  per  cent  solution  of  dex- 
trose, to  which  has  been  added  2  or  3  minims  of  a  1:1000 
solution  of  epinephrine.  The  venoclysis  is  begun  as  soon 
as  the  anesthetic  is  given,  and  is  continued  throughout 
the  operation.  The  vasomotor  palsy  lasts  20  to  30  min- 
utes, or  until  the  anesthetic  is  fixed  in  the  nerve  tissue. 

Pontocaine  hydrochloride  is  instantly  soluble,  has  less 
effect  on  b.  p.,  gives  a  sustained  anesthesia  with  a  mini- 
mum of  motor  paralysis — is  an  ideal  anesthetic  for  long 
operations. 

A  1  per  cent  solution  of  neosynephrin  is  preferred  to 
ephedrine,  because  it  can  be  given  repeatedly  without 
cumulative  effects  or  toxic  reactions. 


Pernicious  Anemia. — It  is  doubtful  if  a  case  has  ever 
occurred  in  the  full-blooded  Negro.— McCracken,  of  Bos- 
ton, in  Jl.  Med.  Assn.  Ga. 


April   1941 


SOUTHERN  MEDICINE  &  SURGERY 


The  Present  Status  of  the  Treatment  of  Pneumonia* 

A  Survey  of  the  Literature 
Paul  F.  Whitaker,  M.D.,  F.A.C.P.,  Kinston 


WHITLEY'S  contribution  in  May,  1938, 
and  subsequent  articles  along  the  same 
line,  revolutionized  the  therapy  of  pneu- 
mococcic  pneumonia.  Large  series  of  cases  have 
been  treated  with  the  new  chemotherapeutic  agents, 
alone  and  in  conjunction  with  serums,  and  the 
results  reported.  In  the  light  of  these  experiences 
certain  conclusions  may  now  be  drawn- 

For  convenience  of  discussion  the  treatment  of 
pneumonia  may  be  considered  from  three  stand- 
points: first,  that  of  chemotherapy;  second,  that 
of  specific  serum,  and  third,  that  of  non-specific 
measures. 

CHEMOTHERAPY 

There  remains  little  doubt  that  the  introduction 
of  sulfapyridine  has  been  the  greatest  single  ad- 
vance made  in  the  treatment  of  pneumonia.  The 
mode  of  action  of  the  drug  is  still  a  subject  of 
intensive  study.  It  seems  plain  that  sulfapyridine 
has,  not  a  bacteric/rfa/,  but  a  bacteriostatic ,  effect, 
aiding  the  ordinary  defences  of  the  body  in  their 
battle  against  the  invading  organism.  Although 
there  is  evidence  that  its  potency  is  greater  against 
certain  strains  and  types  than  against  others,  it 
seems  safe  to  assume  that  sulfapyridine  is  useful 
in  all  infections  due  to  the  pneumococcus. 

In  hospital  and  where  suitable  facilities  are 
available  it  is  good  practice  to  delay  therapy  until 
sputum  for  typing  and  blood  for  cultures  can  be 
obtained.  However,  where  these  facilities  are  not 
available  and  the  clinical  picture  is  well  defined, 
treatment  should  be  begun  without  delay.  The 
only  contraindication  to  sulfapyridine  is  a  history 
of  previous  sensitivity  to  the  drug  as  manifested 
by  one  or  more  of  its  toxic  reactions.  In  both 
broncho-  and  lobar  pneumonia  it  is  well  whenever 
possible  to  determine  the  type  of  infecting  organ- 
ism. 

When  adequate  treatment  is  given  the  temper- 
ature will  fall  to  normal,  the  pulse  and  respirations 
will  be  slower  and  the  appearance  of  the  patient 
will  improve  within  24  hours  in  half  the  cases  .  In 
the  remaining  cases,  while  there  is  earlier  evidence 
of  improvement,  the  temperature  will  not  reach 
normal  for  48  or  72  hours,  the  fall  being  by  lysis 
rather  than  crisis.  Failure  to  obtain  these  results 
suggests:  first  (and  most  commonly),  the  case  is 
not  one  of  pneumococcic  pneumonia;  second,  a 
complication  may  be  present;  third,  dosage  may  be 
inadequate  or  absorption  faulty;  fourth,  the  disease 


may  be  of  the  fulminating  type,  in  which  case 
other  measures  in  addition  to  chemotherapy  are  in- 
dicated. 

It  is  well  to  remember  that  sense  of  wellbeing 
does  not  parallel  clinical  improvement.  This  is  due 
in  large  part  to  the  depression  caused  by  the  drug, 
and  it  is  only  when  the  drug  is  discontinued  that 
we  may  expect  a  return  of  appetite  and  content- 
ment. However,  the  drug  should  not  be  discon- 
tinued too  early,  as  recrudescence  of  the  disease 
may  occur. 

The  dosage  of  sulfapyridine  has  not  been  ade- 
quately determined.  Neither  has  the  length  of 
time  it  should  be  given.  An  average  dose  by  mouth 
for  an  adult  is  2  Gm.  (30  grains)  initially,  fol- 
lowed by  1  Gm.  (15  grains)  every  four  hours.  For 
extremely  ill  patients  the  second  dose  may  also  be 

2  Gm.  and  the  drug  may  then  be  continued  in  1- 
Gm.  doses  every  four  hours  until  the  temperature, 
pulse  and  respiration  have  been  essentially  normal 
for  a  period  of  72  hours.  It  is  probable  that  spe- 
cific immunity  develops  at  the  usual  time  in  cases 
treated  with  sulfapyridine,  and  that  the  drug  does 
not  hasten  the  development  of  this  immunity.  This 
is  rarely  before  the  fifth,  and  may  be  after  the 
tenth,  day.  Therefore,  it  is  difficult  to  make  a 
categorical  statement  as  to  how  long  the  drug  can 
be  given.  Where  facilities  are  available  for  deter- 
mining sulfapyridine  concentration  in  the  blood, 
this  should  be  done  from  time  to  time.  The  con- 
sensus is  that  blood  levels  of  the  free  drug  between 

3  and  6  mg.  per  100  c.c.  are  adequate  for  thera- 
peutic purposes.  Infants  and  children  tolerate  the 
drug  better  than  adults,  and  Hodes  recommends 
that  the  total  dose  for  24  hours  be  calculated  on 
the  basis  of  1  grain  per  pound  for  young  infants, 
.8  grain  per  pound  for  older  children.  Less  than 
IS  grains  is  seldom  given,  however  small  the  child, 
and  the  dose  usually  does  not  exceed  60  to  70 
grains  (4  to  4.5  Gm.),  however  large  the  child.  In 
hospital  practice  children  are  given  immediately 
on  admission  two-thirds  of  the  calculated  dose  for 
24  hours,  this  followed  by  one-fourth  of  the  cal- 
culated 24-hour  dose  every  six  hours.  When  the 
temperature  has  been  normal  for  36  hours  the  drug 
is  discontinued,  provided  cultures  from  the  naso- 
pharynx are  negative  for  pneumococci.  If  the 
pneumococci  are  still  present,  the  drug  is  con- 
tinued for  two  or  three  days  longer  and  then  with- 
drawn- 


•Read  by   invitation  before  the   Halifax   County   (N.    C.)    Medical  Society,  Nov.  Stb,   1940. 


TREATMENT  OF  PNEUMONIA— Whitoker 


April   1941 


Probably  through  faulty  elimination,  the  elderly 
often  build  up  extremely  high  blood  levels  on  the 
usual  dosage — a  fact  to  be  borne  in  mind-  Also, 
while  type-Ill  pneumonia  in  the  aged  responds  to 
sulfapyridine,  it  does  so  slowly,  and  it  may  be 
necessary  to  administer  the  drug  over  a  long  pe- 
riod of  time  in  order  to  bring  about  resolution. 

Here  again  caution  is  necessary. 

While  it  would  be  ideal  to  have  during  the 
course  of  treatment  reports  on  the  concentration 
of  the  drug  in  the  blood,  it  is  obvious  that  thou- 
sands of  cases  must  be  treated  without  them.  Un- 
der these  circumstances  Kneeland  has  suggested: 
first,  giving  the  standard  dose  of  6  Gm.  daily  in 
every  case,  maintaining  this  dosage  for  four  days; 
then  halving  the  dose,  giving  3  Gm.  daily  in  six 
doses  for  three  or  four  days  more.  If  an  obvious 
change  for  the  better  be  not  noted  in  24  hours, 
question  the  diagnosis  and  look  for  complications. 
If  nothing  new  is  discovered,  assume  that  the  level 
of  the  drug  in  the  blood  is  too  low  and  increase  the 
dose  by  2  or  3  Gm.  for  a  day  or  so.  No  increase 
in  dosage  should  be  made  in  the  presence  of  toxic 
manifestations  of  the  drug. 

Though  dangerous  and  fatal  reactions  are  rare, 
the  danger  is  real,  and  the  patient  should  be  ob- 
served carefully  for  early  symptoms.  Cyanosis  is 
caused  by  alteration  of  the  blood  pigment  and  is 
to  be  practically  disregarded.  Cyanosis  due  to 
pneumonia  is  usualy  relieved  by  the  administra- 
tion of  oxygen.  Nausea  and  vomiting  are  frequent 
and  are  probably  central  in  origin.  If  severe, 
proper  measures  should  be  instituted  to  control 
them.  Alkalis  are  thought  to  be  of  value,  while 
1/150  grain  of  hyoscine  followed  by  an  occasional 
1 -grain  dose  of  sodium  luminal,  both  drugs  by 
hypodermic,  has  proven  satisfactory  in  some  cases. 

Sulfapyridine,  like  other  members  of  the  sulfo- 
namide family,  affects  the  bone  marrow,  which  ex- 
plains the  occasional  development  of  neutropenia. 
Hemolytic  anemia  with  rapid  fall  in  hemoglobin 
has  occurred  as  a  result  of  destructive  action  on 
the  erythrocytes.  Both  of  these  complications  have 
usually  followed  prolonged  administration  of  the 
drug,  though  individual  idiosyncrasy  is  probably 
the  determining  factor-  Cessation  of  the  drug  and 
blood  transfusion  are  indicated- 
Drug  fever  and  rashes,  when  they  occur,  usually 
develop  after  seven  to  ten  days  of  therapy.  Their 
diagnosis  may  prove  difficult.  Whenever  suspected 
the  drug  should  be  discontinued. 

Hematuria  accompanied  by  renal  colic,  and 
even  fatal  suppression  of  the  urine,  has,  occurred. 
This  complication  appears  to  be  due  to  the  crys- 
tallizing of  inactivated  acetyl  sulfapyridine  in  the 
renal    tubules   with    resulting   serious   interference 


with  renal  function.  If  this  occurs,  prompt  cessa- 
tion of  the  drug  and  adequate  fluids  and  alkali 
are  indicated. 

It  is  good  practice  to  regard  any  unexplained 
and  unexpected  event  occurring  during  sulfapyri- 
dine therapy  as  due  to  the  drug  until  it  is  proven 
otherwise.  In  addition  it  seems  wise  to  do  daily 
urinalyses  and  complete  blood  counts  on  patients 
under  such  treatment.  Blood  complications  have 
been  reported  as  late  as  14  days  after  recovery,  so 
a  blood  examination  at  the  end  of  this  period  is 
indicated. 

There  has  recently  been  introduced  a  soluble 
sodium  salt  of  the  drug  suitable  for  intravenous 
use.  Sodium  sulfapyridine  in  a  5  per  cent  solution 
is  usually  given  intravenously  in  the  dose  of  5  Gm. 
Care  should  be  taken  not  to  spill  any  of  the  solu- 
tion under  the  skin,  as  it  is  highly  alkaline  and 
will  cause  sloughing. 

Though  most  cases  can  be  handled  by  the  oral 
administration  of  the  drug,  an  extremely  ill 
patient  may  urgently  need  a  maximum  effect,  a 
patient  may  not  be  able  to  take  it  by  mouth,  or  a 
complicating  pneumococcic  meningitis  may  require 
a  high  blood  level  at  once.  In  such  cases  intra- 
venous administration  in  the  recommended  dosage 
seems  to  be  justified. 

Another  new  sulfonamide  for  the  treatment  of 
pneumonia  is  sulfathiazole.  Flippin  et  al.  treated 
a  series  of  152  patients  with  the  new  drug  and 
162  with  sulfapyridine.  From  the  first  hundred 
cases  in  each  series  they  drew  their  comparison. 
Of  sulfathiazole  an  initial  dose  of  3  Gm-  was  given 
and  repeated  in  four  hours,  then  1  Gm-  every  four 
hours,  maintaining  an  average  concentration  in 
the  blood  of  5  mg.  per  100  c.c.  The  treatment  was 
continued  until  the  temperature  had  remained 
normal  for  48  hours,  along  with  evidence  of  general 
improvement.  The  average  total  dose  was  25  to 
40  Gm.  In  a  few  instances  they  used  intravenously 
a  S  per  cent  solution  of  sodium  sulfathiazole  (0.06 
Gm.  per  kilogram  of  body  weight).  One  intraven- 
ous dose  was  usually  sufficient  to  raise  the  blood 
level  of  free  sulfathiazole  to  8  to  10  mg.  per  100  c.c. 

They  concluded  that  the  two  drugs  were  equally 
effective  in  the  treatment  of  pneumococcic  pneu- 
monia, and  that  the  mortality  and  complications 
and  the  stay  in  the  hospital  were  the  same;  al- 
though sulfathiazole  brought  the  temperature 
down  more  rapidly,  and  nausea  and  vomiting  and 
other  toxic  manifestations  were  much  less  frequent 
and  severe  in  the  sulfathiazole  group.  In  the  light 
of  these  reports  it  is  safe  to  assume  that  sulfathia- 
zole is  established  as  a  useful  therapeutic  agent  in 
the  management  of  pneumonia. 


April    1941 


TREATMENT  OF  PNEUMONIA— Whitaker 


SERUM  THERAPY 

There  is  adequate  proof  that  specific  antipneu- 
mococcic  serums  are  effective  in  reducing  the  mor- 
tality and  bringing  about  rapid  cures  in  the  treat- 
ment of  certain  types  of  pneumococcic  infection. 
Particularly  is  this  true  in  types  I;  II,  V,  VII  and 
VIII  in  adults  and  in  type  XIV  in  infants  and 
children.  The  greatest  advance  in  serum  therapy 
has  been  in  the  introduction  of  rabbit  serums, 
which  are  now  available  for  all  types  of  pneumo- 
cocci  from  I  to  XXXIII  inclusive,  with  the  ex- 
ception of  types  XXIV  and  XXX  which  are  not 
generally  accepted  as  specific  types.  These  serums 
provide  antibodies  in  much  greater  concentration, 
and,  more  important  still,  severe  allergic  reaction 
following  their  use  is  extremely  rare. 

There  are  four  important  points  in  the  success- 
ful use  of  serum  in  pneumonia. 

First  is  careful  typing-  The  Neufeld  method  is 
simple  and  rapid  and  can  be  used  on  sputum  or  on 
exudates  from  mice  after  injection  of  the  sputum- 
Careful  bacteriologic  control  in  typing  will  ensure 
the  use  of  the  proper  type-specific  serum. 

Second,  serum  must  be  given  intravenously,  and, 
as  in  all  serotherapy,  certain  precautions  must  be 
observed  carefully.  These  include  a  meticulous 
history  of  previous  allergic  manifestations  and 
previous  serum  therapy.  Intradermal  skin  tests 
and  ophthalmic  tests  should  also  be  done  in  each 
case.  The  newer  rabbit  serums  have  reduced  the 
incidence  of  allergic  reactions. 

Third,  serum  is  most  effective  when  used  early 
in  the  disease. 

Fourth,  the  dose  of  specific  serum  must  be  ade- 
quate. The  proper  dose  must  vary  with  the  indi- 
vidual case,  and  good  judgment  is  necessary  to 
determine  it.  As  a  rule  the  smaller  doses  are  suf- 
ficient in  young  individuals  with  negative  blood 
cultures,  early  in  the  disease  before  complications 
have  arisen.  Usually  in  uncomplicated  pneumonia 
of  less  than  four  days'  duration  and  in  patients 
under  30  years  of  age,  40,000  to  80,000  units  of 
serum  will  precipitate  a  rapid  crisis.  In  infants 
and  children  10,000  to  30,000  units  are  often  ade- 
quate. The  dose  is  to  be  increased  with  age,  and 
in  cases  when  treatment  has  been  delayed,  or 
there  is  extensive  involvement  of  the  lungs.  In 
patients  with  bacteremia,  in  patients  who  are  preg- 
nant, or  in  patients  in  whom  purulent  complica- 
tions are  suspected,  the  dose  is  doubled. 

A  dose  of  100,000  units  given  within  a  period  of 
two  to  four  hours  is  considerably  more  effective 
than  the  same  quantity  divided  into  doses  of  20,- 
000  units  and  given  one  every  six  or  eight  hours. 
In  severe  bacteremia  large  doses  are  especially 
important,  since  a  single  dose  of  200,000  units 
may    bring    about    immediate    recovery,    whereas 


500,000  units  spread  out  over  a  period  of  three  or 
four  days  may  have  no  effect.  With  the  serum  now 
available  it  is  possible  to  obtain  good  results  if 
therapy  is  begun  by  the  fifth  day,  and  benefit  is 
obtained  even  later.  Mixed  infections,  errors  in 
typing  and  the  presence  of  complications  obviously 
are  productive  of  failure  in  serum  therapy. 

In  summary  it  can  be  said  that  serums  are  now 
applicable  in  the  treatment  of  approximately  two- 
thirds  of  all  cases  of  pneumococcic  pneumonia.  For 
such  cases  the  death  rate  can  be  reduced  by  more 
than  half  in  all  cases  and  by  more  than  two-thirds 
in  those  cases  treated  on  or  before  the  fifth  day. 
In  the  treatment  of  type-Ill  cases  serum  alone  has 
not  been  highly  successful,  although  striking  re- 
sponses have  occurred  in  many  cases  before  bac- 
teremia develops. 

NONSPECIFIC  MEASURES 
To  an  audience  such  as  this  it  is  hardly  neces- 
sary to  point  out  that  in  either  serum  therapy  or 
chemotherapy  other  nonspecific  measures  in  the 
management  of  the  disease  should  be  carried  out 
as  usual.  Pneumonia  patients  will  always  require 
meticulous  nursing  care.  Oxygen  therapy  will  often 
be  indicated  and  will  be  instituted  when  consid- 
ered necessary  by  the  physician.  Adequate  fluid 
intake  and  measures  to  combat  abdominal  disten- 
tion, to  control  the  acute  mania  that  occasionally 
develops  and  prevent  and  control  vasomotor  col- 
lapse, and  proper  attention  to  diet  and  elimination 
will  always  be  instituted  promptly  by  the  physi- 
cian and  the  nurse  when  the  occasion  warrants. 

Conclusions 
From   the   reports  of   numerous   observers   over 
the  past  two  and  one-half  years,   these   tentative 
conclusions  may  be  drawn: 

1.  Chemotherapy  with  either  sulfapyridine  or 
sulfathiazole  is  the  treatment  of  choice  in  the  vast 
majority  of  cases  of  lobar  pneumonia.  It  is 
certainly  the  treatment  of  choice  by  the  practi- 
tioner in  the  field  because  of  its  convenience  and 
because  it  renders  unnecessary  the  costs,  the  haz- 
ards and  the  complications  of  serum  therapy. 

2.  There  are  certain  indications  for  serum  ther- 
apy, either  alone  or  in  combination  with  chemo- 
therapy: first,  cases  in  which  chemotherapy  is  con- 
traindicated  by  reason  of  sensitivity  to  the  drug; 
second,  cases  in  which  bacteremia  is  present;  third, 
cases  of  the  aged  and  severely  toxic  cases;  fourth, 
cases  occurring  during  pregnancy  and  the  puerpe- 
rium;  fifth,  cases  in  which  there  is  no  improvement 
after  24  hours  of  chemotherapy;  and  sixth,  all 
type-Ill  cases. 

3.  Regardless  of  what  type  of  specific  therapy  is 
used,  meticulous  nursing  and  professional  care, 
with  institution  of  nonspecific  measures  when  in- 


TREATMENT  OF  PNEUMONIA— Whitaker 


April   1941 


dicated,  will  always  be  required. 

4.  When  the  effective  measures  now  available 
have  been  completely  adopted  we  may  anticipate 
a  reduction  of  at  least  SO  per  cent  in  the  mortality 
of  pneumonia.  The  beginning  realization  of  this 
hope  and  prediction  constitutes  one  of  the  greatest 
accomplishments  of  medical  science  in  many  dec- 
ades. 

Bibliography 

1.  Felton,  L.   D.:   Boston  Med.  &  Surg.  Jour.,  May   IS, 
1924. 

2.  Cooper,   G.,   et   al.:   Jour.  Exper.  Med.,  March,   1929, 
and  April  1932. 

3.  Whitley,  L.  E.  H.:   Lancet,  May  28,  1938. 

4.  Evans,  G.  M.,  and  Galnford,  W.  F.:   Lancet,  July  2, 
1938. 

5.  Finland,  M.:  Med.  Clin.  N.  A.,  Sept.,  1939. 

6.  Proc.  Staff  Meeting  Mayo  Clinic,  Dec.  6,  1939. 

7.  Schwartz,  L.,  et  al.:  Annals  of  Int.  Med.,  Dec,  1939. 

8.  Hich,  F.:  Med.  Clin.  N.  A.,  Jan.,  1938. 

9.  Wood,  W.  B.,  Jr.,  and  Long,  P  H.:  Annals  Int.  Med., 
Oct.,  1939. 

10.  Finland,  M.,  et  al.:  Annals  Int.  Med.,  Jan..  1940. 

11.  Abernathy,  T.  J.,  et  al.:  Annals  Int.  Med.,  Jan.,  1940. 

12.  Kneeland,  Y.,  Jr.:  Med.  Clin.  N.  A.,  May,  1940. 

13.  Flippin,  H.  F.:  Annals  Int.  Med.,  May,  1940. 

14.  King,  D.  S.:  Med.  Clin.  N.  A.,  Sept.,  1940. 

15.  Bull,  of  Lederle  Laboratories,  Oct.,  1940. 

16.  Hodes,  H.  L.,  et  al.:  Jour.  Ped.,  April,  1939. 

17.  Beckman:   Treatment  in  General  Practice,  Third  Edi- 
tion. 

18.  Cecil's  Practice  of  Medicine,  Third  Edition. 


MORPHINE  BY  VEIN  AFTER   OPERATION 

(H.   Neuhof,   New   York,   in  //.   Mt.    Sinai  Hosp.,   Mar. -April) 

Morphine  is  the  sovereign  remedy  for  postoperative 
pain. 

In  order  to  obtain  a  more  desirable  .and  uniform  action, 
the  drug  has  been  administered  continuously  in  saline  so- 
lution by  vein  after  operations  in  which  considerable  pain 
could  be  anticipated.  Adult  patients  usually  receive  a  hy- 
podermic dose  of  yi  gr.  morphine  before  operation.  Nor- 
mal saline  sol.  containing  morphine  sulph.  is  begun  right 
after  operation — for  adults,  per  hour,  1  16th  gr.  of  mor- 
phine sulphate  in  100  c.c.  of  saline  solution.  If  required 
as  much  as  150  c.c.  per  hour.  As  a  precaution  against 
error,  the  flask  containing  the  morphine  in  saline  solution 
is  tagged  with  the  patient's  name.  Usually  the  drug  is 
continued  for  24  to  36  hours,  morphine  Wa,  to  2^  grs. 
being  given. 

There  has  been  continuous  and  complete  freedom  from 
pain  or  discomfort  as  well  as  a  state  of  wellbeing  other- 
wise rarely  seen  after  major  operations.  The  absence  of 
drowsiness  has  been  surprising.  There  has  been  no  reten- 
tion of  urine,  distention,  or  difficulty  with  bowel  move- 
ments referable  to  morphine. 

Larger  doses  probably  would  be  safe  and  smaller  doses 
might  suffice.   Dosage  for  children  is  based  on  age. 


RENAL  INSUFFICIENCY  FOLLOWING 
TRANSFUSION 

(W.  B  Daniels,  et  al,  Washington,  in  Jl.  A.  M.  A.,  Mar.  22nd) 
Among  13  patients  with  renal  insufficiency  following 
transfusion  6  recovered  and  7  died.  An  immediate  or  de- 
layed reaction  occurred  as  a  result  of  the  transfusion  and 
was  followed  by  nausea,  vomiting,  hemoglobinuria,  jaun- 


dice, scanty  urine,  stupor  and  uremia. 

Leukocytosis  was  present  in  all  cases  in  which  the  leu- 
kocytes were  counted.  Of  6  cases  in  which  the  blood- 
grouping  and  cross-matching  were  rechecked  the  blood  in 
4  was  shown  to  be  incompatible.  Of  the  remaining  2,  in 
1  warmed,  hemolyzed,  stored  blood  8  days  old  was  given. 

Isohemolysis  unaccompanied  by  isoaggultination  was 
found  in  2  cases.  'This  accounted  for  the  error  in  cross- 
matching and  caused  the  hemolytic  reaction. 

More  careful  cross-matching  of  the  blood  of  donor  and 
recipient  by  the  use  of  tube  preparation  incubated  at  37. S 
C.  for  one  hour  will  prevent  some  of  the  errors  and  save 
lives. 

Citrated  plasma  should  probably  replace  whole  blood 
in  the  treatment   of  secondary  shock  and  hemorrhage. 

Alkalis  should  be  administered  to  all  patients  prior  to 
transfusion. 

The  pathologic  changes  in  the  kidneys  in  4  fatal  cases 
consisted  of  interestitial  edema,  leukocytic  infiltration,  de- 
generation and  necrosis  of  the  tubular  epithelium  and  the 
deposition  in  the  renal  tubules  of  granular  pigment  de- 
rived from  hemoglobin.  One  case  showed  central,  focal 
necrosis  of  the  liver  cells. 


MODIFICATION  OF  THE  USE  OF  TYPHOID 

VACCINE  IN  THE  PRODUCTION  OF 

HYPERPYREXIA 

(J.  Weinberg  &  H.  Goldstein,  Chicago,  in  ///.  Med.  Jl.,  Feb.) 
At  the  Chicago  State  Hospital  several  factors  influenced 
the  choice  of  foreign  protein  as  a  means  of  production  of 
hyperpyrexia.  Many  of  the  patients  were  colored  and, 
hence,  resistant  to  malaria;  others  were  in  poor  physical 
condition  so  that  malaria  would  have  been  dangerous. 
The  single-dose  method  with  typhoid  bacilli  was  first  in- 
stituted. 

Desiring  to  obtain  temperatures  above  103°,  various 
doses  were  experimented  with  by  the  trial-and-error 
method  until  a  schedule  of  typhoid  vaccine  administration 
was  used  which  has  been  successful  in  raising  the  t.  above 
103°  in  85.43%  of  the  801  times  it  was  used.  If  the  tem- 
perature is  103°  two  hours  after  the  first  dose,  the  second 
dose  should  be  modified.  We  have  tried  to  induce  hyper- 
pyrexia in  a  group  of  74. 

1st  day —  20  million  bacilli   followed  by 
2nd    day — i  30         "  " 


mllion 


3rd  day —  50 
4th  day —  75 
5th     day— 125 


100 
175 
300 
450 
600 
800 
1000 
1500 
2000 


6th  day — 150 

7th  day— 175 

8th  day — 225 

9th  day — 300 

10th  day — 400 

In  most  instances,  the  fever  was  fairly  well  sustained. 
Temperature,  p.  and  r.  readings  were  taken  every  hour. 
No  ill  effects  were  noted.  The  most  frequent  complaint 
was  headache  which  would  be  relieved  by  an  ice  bag. 
Chills  usually  within  the  first  hour  following  the  first  dose. 

The  schedule  was  successful  in  raising  the  t.  to  103°  or 
above  in  85.43%  of  the  times  it  was  used.  The  average 
temperature  reached  in  this  series  of  74  patients  was 
103.90°. 


RADIUM  TERATMENT  OF  BIRTH  MARKS 
(J.  E.  Breed,  Chicago,  in  Miss.  Vol.  Med.  Jl.,  Mar.) 
Radium  is  our  most  valuable  single  agent  in  the  treat- 
ment of  angiomas.  Careless  use  of  radium  may  result  in 
undesirable  effects  appearing  months  or  years  after  radium 
treatment  has  been  stopped.  The  best  results  are  usually 
obtained  in  young  children. 


April    1941 


SOUTHERN   MEDICINE  &  SURGERY 


The  Diagnosis  and  Management  of  Occiput-  Posterior 


Posit 


ions^ 


W.  T.  Head,  M.D.,  Melvin  Hill,  North  Carolina 


THE  REASON  for  presentation  of  this  dis- 
cussion is  not  to  add  to  the  multiplicity  of 
statistics  on  occiput  posterior  nor  to  sub- 
mit any  new  method  for  the  management  of  the 
condition.  The  frequency  of  its  occurrence,  the 
high  fetal  mortality  and  maternal  morbidity,  the 
frequency  of  late  and  erroneous  diagnosis  leading 
to  poor  end-results  and  the  confusion  of  thought 
relative  to  this  subject  make  it  exceedingly  impor- 
tant. 

In  1888  Barton  C.  Hirst  said:  "If  I  were  to  be 
asked  what  one  obstetrical  difficulty  in  my  experi- 
ence had  caused  the  most  maternal  and  fetal 
deaths,  what  one  had  caused  the  most  maternal 
and  fetal  accidents  (not  necessarily  fatal  acci- 
dents, however),  often  making  the  rest  of  life 
worthless  or  a  tragedy,  I  think  I  would  say  occi- 
put-posterior positions." 

Paul  T.  Harper  states  that  from  the  standpoint 
of  frequency  of  occurrence,  difficulties  encountered 
and  the  responsibilities  involved  there  is  no  condi- 
tion more  important  than  the  occiput-posterior. 
Obstetrical  authorities  have  been  making  similar 
statements  for  many  years  and  yet  occiput-pos- 
terior remains  a  major  problem  for  the  obstetrical 
specailist  as  well  as  for  the  practitioner — the  man 
who  has  the  management  of  the  great  majority  of 
obstetrical  cases. 

There  is  considerable  debate  among  obstetri- 
cians as  to  the  cause  of  posterior  positions.  Varia- 
ble statistics  from  different  medical  centers  indi- 
cate difficulty  in  diagnosis.  The  various  methods 
of  management  advocated  indicate  that  no  one 
method  has  proved  generally  efficacious. 

Incidence 
The  figures  given  for  this  position  are:  11  per 
cent  in  a  series  in  Sloane  Hospital,  17  per  cent  in 
a  Johns  Hopkins  series  of  1687  cases,  25.1  per 
cent  in  Danforths,  and  29  per  cent  in  DeLees  se- 
ries. Williams  places  the  frequency  of  left  occi- 
pito-posterior  to  right  occipito-posterior  as  one  to 
five,  and  right  occipito-posterior  to  right  occipito- 
anterior as  one  to  two.  Pride,  of  Memphis 
Hospital,  in  an  x-ray  study  of  700  primiparae  at 
term  reported  70.6  per  cent.  One  finds  it  difficult 
to  reconcile  these  figures  with  the  findings  obtained 
with   the  usual   methods  of  examination   and   one 


"Presented    to    the    January    meeting    of    the    Thermal    Belt    Mcdi 


wonders  if  the  x-ray  interpretations  are  faulty.  It 
is  conceded  by  all  to  be  the  most  common  obstetric 
anomaly  and  responsible  for  a  high  fetal  mortality 
and  greater  maternal  injury  than  almost  any  other 
condition.  The  essential  practical  points  are:  first, 
the  diagnosis  of  the  presentation;  second,  the 
methods  of  dealing  with  it  when  it  does  arise.  I 
think  it  well  to  mention  that  reliable  statistics 
show  that  85  per  cent  of  posterior  positions  will 
rotate  spontaneously,  and  of  the  remaining  15  per 
cent  one-half  will  rotate  if  given  sufficient  time. 
Consequently,  the  procedure  to  be  described  in 
this  paper  is  applicable  in  approximately  iy2  per 
cent  of  the  posterior  positions. 

Prognosis 

The  prognosis  of  these  cases  depends  almost  en- 
tirely on  the  judgment  and  patience  with  which 
they  are  treated.  The  greatest  virtue  is  patience. 
Undue  haste  to  terminate  a  prolonged  labor  is  the 
besetting  sin,  together  with  non-recognition  of  this 
condition,  as  a  cause  of  the  prolongation  of  the 
labor.  This  type  of  case  forms  the  most  common 
single  cause  of  failure  of  attempts  to  deliver  by 
forceps.  In  cases  that  rotate  the  prognosis  for  both 
mother  and  child  should  be  but  little  influenced. 
It  is  in  those  that  persist  posterior  that  damage  is 
done  to  both  parties  and  naturally  the  fetus  will 
suffer  most. 

In  occiput-posterior  positions  labor  is  generally 
slower  and  longer  because  the  occiput  has  to  rotate 
through  an  arc  of  135° — three-quarters  of  a  half 
circle — while  in  anterior  positions  it  rotates 
through  an  arc  of  only  45° — one-quarter  of  a  half 
circle.  Also,  in  occiput-posterior  cases  the  pains 
are  weak  and  irregular  both  as  to  time  and 
strength.  Early  rupture  of  the  bag  of  waters  is 
frequent  and,  in  general,  things  do  not  go  smooth- 
ly. The  head  stays  high  up  longer  than  in  anterior 
positions  and  requires  stronger  pains  to  bring  it 
down  in  the  pelvis.  Dilatation  of  the  cervix  is  in- 
complete because  the  head  does  not  fit  well  into 
the  pelvis,  does  not  press  equally  on  the  internal 
os  all  around,  and  spontaneous  delivery  requires 
great  effort  of  the  uterine  and  abdominal  muscles. 

DlACNOSIS 

The  course  of  labor  will  very  often  suggest  the 
presence  of  this  condition.    Diagnostic  features  of 

al    Society    held    at    Riithcriordton. 


OCCIPUT-POSTERIOR   POSITIONS— Head 


April   1941 


posterior  positions  are  (1)  delayed  labor — the  pa- 
tient often  goes  a  week  or  ten  days  overtime;  (2) 
irregularity  of  pains — both  as  to  time  and  force; 
(3)  constant  pain  in  the  back  and  hips;  and  (4) 
premature  rupture  of  the  membranes. 

On  abdominal  palpation  the  small  parts  are  an- 
terior, superficial  and  easily  palpated;  indeed  the 
number  of  palpated  parts  may  raise  suspicion  of 
multiple  pregnancy.  If  we  ask  where  movements 
are  felt  most  the  patient  will  say  all  over  the  abdo- 
men. The  back  is  felt  to  the  right  and  posteriorly 
and  difficult  to  palpate  with  the  shoulder  to  the 
right  of  the  median  line.  On  palpating  the  head  it 
is  generally  higher  up  in  the  pelvis  and  the  fore- 
head at  first  is  plainly  felt  above  the  left  ramus  of 
the  pubis,  while  on  the  opposite  side  there  is  more 
or  less  of  a  void.  The  heart  tones  are  deep  in  the 
flank  and  further  from  the  navel  and  also  may  be 
heard  anteriorly  to  the  left. 

On  vaginal  examination  the  head  is  felt  high  up 
and  usually  partly  deflexed.  The  cervix  is  not 
dilated  as  much  as  one  would  expect  to  find  from 
the  time  that  labor  has  been  in  progress.  The  small 
fontanelle  to  the  right  and  posterior  and  higher  up 
than,  or  at  least  on  a  level  with,  the  large.  In  cases 
seen  late  after  a  caput  has  formed  it  is  often  diffi- 
cult to  distinguish  the  sutures  and  fontanelles  and 
moulding  may  have  so  reduced  the  large  that  it 
may  be  mistaken  for  the  small.  In  such  cases  the 
sure  way  to  make  a  diagnosis  is  to  palpate  an  ear. 

Management 

My  first  endeavor  is  to  keep  the  gain  in  weight 
of  patients  down  to  twenty  pounds  or  less  during 
pregnancy.  I  cannot  say  how  much  this  influences 
the  weight  of  the  baby  but  I  do  know  that  a  wom- 
an 30  to  SO  pounds  overweight  does  not  stand 
labor  well.  This  is  especially  important  in  the  pro- 
longed labors  one  sees  with  the  posterior  positions. 
Too  often  the  result  is  like  that  of  an  athlete  going 
into  competition  in  poor  condition. 

During  active  labor  conservation  of  the  patient's 
strength  is  always  important.  Avoid,  if  possible, 
early  rupture  of  the  membranes.  The  idea  of  bear- 
ing down  and  artificial  rupture  of  the  membranes 
to  hasten  delivery  is  wrong  and  serves  only  to  pro- 
long labor.  Likewise,  the  giving  of  pituitrin  is  to 
be  condemned.  Danforth  has  well  said  that  the 
proper  management  of  occiput-posterior  positions 
should  begin  with  the  first  stage.  On  account  of 
the  frequently  long-drawn-out  first  stage  one  should 
see  that  the  patient  gets  plenty  of  rest.  What  we 
want  is  dilatation  and  rotation.  For  this  purpose  I 
still  regard  morphine  as  the  most  reliable  drug  that 
we  have  to  relieve  pain  and  produce  relaxation.  It 
is  important  for  the  patient  to  have  adequate  nour- 
ishment.  This  should  be  largely  liquid  non-residue 


diet,  for  one  should  always  keep  in  mind  the  prob- 
ability of  having  to  administer  a  general  anesthetic. 
Milk  soups  and  fruit  juices  given  every  two  or 
three  hours  is  a  good  rule.  The  importance  of 
nourishment  is  evident  as  an  aid  in  prevention  of 
exhaustion  and  constriction  ring  of  dystocia.  If 
one  will  anticipate  these  long  labors  and  insist  on 
patients  taking  nourishment,  exhaustion  and  acid- 
osis, which  Rudolph  has  demonstrated  often  to 
cause  the  formation  of  constriction  ring,  may  be 
prevented. 

No  drug  should  be  given  during  the  second  stage 
which  interferes  with  the  full  cooperation  of  the 
patient,  greatly  needed  for  bringing  the  voluntary 
muscles  into  action  and  aiding  greatly  in  moulding 
the  head  and  forcing  it  down  into  mid  pelvis  or 
better  still  to  the  perinum.  An  exception  may  be 
made  to  this  in  case  a  patient  becomes  tired  and 
no  indications  exist  for  early  delivery.  A  full  dose 
of  morphine,  giving  an  hour  or  two  of  ease  and 
rest,  will  very  often  bring  effective  pains  and  a  nor- 
mal delivery. 

While  most  cases  will  deliver  spontaneously  it  is 
true  that  in  any  case  the  natural  forces  may  fail 
and  interference  become  necessary  on  account  of 
exhaustion  of  the  mother  or  distress  of  the  baby. 
Which  method  of  delivery  is  chosen  will  naturally 
depend  upon  the  surroundings,  assistance,  personal 
ability  and  the  degree  of  descent  of  the  fetal  head. 
For  each  case  one  must  decide  the  most  suitable 
means  of  attacking  the  problem  and  too  much  dr- 
lay  must  not  be  allowed  after  there  is  complete 
dilatation  and  progress  has  stopped. 

All  are  agreed  that  the  second  stage  permitted 
to  lag  too  long  is  dangerous  to  both  mother  and 
fetus,  adding  to  the  operative  risk  when  interfer- 
ence becomes  necessary.  If  the  head  is  low  in  the 
pelvis  or  on  the  perineum  forceps  delivery  is  the 
method  of  choice.  If,  as  is  frequently  the  case,  the 
head  remains  high  and  posterior  some  method  of 
manual  rotation  must  be  resorted  to.  Instrumental 
rotation  is  advocated  by  many  obstetricians  and 
with  this  method  brilliant  results  are  often  ob- 
tained. Bill  has  long  been  an  advocate  of  the  Scan- 
zoni  maneuver.  DeLee  has  devised  a  method  of 
rotation  with  forceps  which  he  calls  the  key-in-lock 
operation,  but  he  warns  against  its  use  by  any  one 
not  familiar  with  the  technique  and  fully  aware  of 
its  possible  dangers.  In  my  opinion  forceps  rota- 
tion is  permissible  only  in  the  hands  of  an  expert, 
and  for  a  man  of  average  experience  manual  rota- 
tion is  much  safer  and  more  practicable.  The  indi- 
cations for  manual  rotation  are  failure  of  the  nat- 
ural forces  to  effect  rotation  and  delivery  within  a 
time  considered  safe  to  mother  and  child  under 
the  circumstances  of  the  case.   The  conditions  nee- 


April  1941 


OCCIPUT-POSTERIOR   POSITIONS— Head 


essary  for  rotation  are — head  in  the  pelvis  or  at 
least  engaged,  os  fully  dilated  or  easily  dilatable, 
and  complete  surgical  anesthesia  for  a  brief  time 
only. 

I  have  found  very  useful  the  method  of  manual 
rotation  recommended  by  Arnold.  Briefly  the  tech- 
nique is  as  follows:  Standing  or  sitting  in  front  of 
the  patient  with  the  left  hand  in  supination  rotate 
the  palm  outwards  until  the  little  finger  is  pointing 
upwards  and  thumb  downwards  toward  the  moth- 
er's right.  In  this  attitude  the  hand  is  inserted  into 
the  vagina  with  the  palmar  surface  of  the  fingers 
applied  to  the  right  side  of  the  baby's  head.  There 
should  be  no  attempt  to  grasp  or  hold  the  head 
with  this  hand.  The  fingers  of  the  right  hand  are 
pressed  firmly  on  the  abdominal  wall  suprapubi- 
cally  until  they  come  in  contact  with  the  left  fron- 
tal region  of  the  child's  head.  The  functions  of 
this  external  hand  are  to  hold  the  head  down  and 
keep  it  from  being  pressed  up  by  the  internal  hand, 
and  by  its  lever-like  action  to  aid  the  left  hand  in 
producing  rotation.  The  two  hands  when  thus 
properly  placed  hold  the  head  firmly  between  them. 
Rotation  is  accomplished  by  the  combined  action 
of  the  two  hands,  the  internal  hand  as  it  untwists 
making  pressure  directly  against  the  side  of  the 
occiput  crowding  it  forward  while  the  brow  is 
pressed  downward  and  backward  by  the  external 
hand.  As  the  head  is  rotated  an  assistant  makes 
manipulations  through  the  abdominal  wall  with  a 
view  to  swinging  the  child's  body  from  the  moth- 
er's right  side  to  her  left.  The  moving  of  the  child's 
body  by  the  assistant  coincidentally  with  the  rota- 
tion of  the  head  greatly  facilitates  the  latter  proc- 
ess, and  by  thus  avoiding  the  twisting  of  the  child's 
neck  removes  the  chief  cause  of  the  tendency  of 
the  head  to  return  to  the  faulty  position. 

The  depth  of  the  head  in  the  pelvis  and  the  firm- 
ness with  which  it  is  sometimes  impacted  are  not, 
as  some  have  taught,  contraindications  for  the  use 
of  this  method.  A  pelvis  that  will  permit  the  head 
in  an  occiput-posterior  position  to  descend  to  the 
midplane  or  lower  will  permit  this  method  of 
changing  that  position,  and  the  lower  the  head  the 
easier  it  is  to  rotate.  Having  rotated  the  occiput  to 
one  of  the  anterior  positions  and  having  moved  the 
child's  body  likewise  to  an  anterior  position  so  as 
to  maintain  the  head  in  its  corrected  relationship, 
the  further  conduct  of  the  case  may  proceed  ac- 
cording to  circumstances  and  conditions.  In  the 
majority  of  cases  it  is  better  to  apply  forceps  and 
complete  the  delivery  before  the  patient  awakens 
from  the  anesthetic,  while  in  others  the  normal 
forces  may  be  allowed  to  end  the  labor. 

The   unengaged    occiput-posterior   that   has   not 


entered  the  inlet  after  reasonable  trial  of  the  nor- 
mal forces  is  obviously  not  a  case  for  this  method 
of  rotation.  Manipulations  on  the  unengaged  head 
are  not  only  of  doubtful  value  but  are  usually 
sources  of  positive  danger.  Here  postural  rotation 
should  always  be  given  a  trial,  and  in  a  good  per- 
centage of  cases  will  effect  engagement  and  rota- 
tion. Postural  rotation  consists  in  placing  the  pa- 
tient well  over  on  that  side  on  which  the  back  of 
the  baby  is  located:  if  right  occiput-posterior,  then 
place  the  mother  on  her  right  side  as  far  over  on 
her  abdomen  as  she  can  go  with  any  degree  of 
comfort.  Of  course  she  can  not  be  kept  so  and  it 
would  do  little  good  if  she  could,  unless  she  be  as 
completely  relaxed  as  possible  for  one,  two  or  more 
hours  by  a  large  enough  dose  of  a  reliable  narcotic 
— morphine  or  dilaudin.  Failing  in  this,  version 
must  be  resorted  to,  but  one  should  always  keep  in 
mind  that  version  is  often  a  deadly  operation  for  a 
baby,  as  well  as  dangerous  for  the  mother.  Usually 
it  is  very  difficult  after  the  membranes  have  rup- 
tured and  most  of  the  waters  have  escaped.  Then 
the  inside  of  the  uterus  soon  moulds  itself  to  the 
fetus  making  version  extremely  difficult  and  espe- 
cially so  in  a  dry  uterus. 

In  closing  I  would  like  to  emphasize  that  occi- 
put-posterior positions  remain  a  serious  pathologi- 
cal obstetric  problem  provoking  considerable  con- 
fusion of  thought;  that  early  diagnosis,  though  dif- 
ficult, is  essential  to  best  management;  that  no  one 
method  of  management  is  applicable  in  every  case; 
that  for  the  physician  who  has  had  only  the  aver- 
age training  in  obstetrics  and  who  practices  the 
latter  along  with  other  specialties  in  medicine,  we 
believe  that  the  better  treatment  of  these  posterior 
positions  is  the  conservative,  knowing  that  a  very 
large  percentage  will  rotate  spontaneously,  then 
when  indicated  interference  may  be  resorted  to  ac- 
cording to  the  exigencies  of  the  individual  case. 
Even  for  the  physician  who  has  had  considerable 
training  and  experience,  we  still  believe  the  con- 
servative treatment  to  be  that  of  choice. 


VITAMIN  B,  FOR  ACUTE  HEART  FAILURE 

(O.  J.  Morehead,  Ritzville,  Wash  ,  in  Northwest  Med.,  Feb.) 

An  acute,  severe  attack  of  dyspnea  in  an  otherwise  nor- 
mal child  2  J/2  years  of  ace  was  apparently  relieved  at  once 
by  10  mn.  thiamine  hydrochloride  solution  hypodermically. 

Since  22  months  of  ape  she  had  been  subject  to  these  at- 
tacks in  increasing  frequency  and  severity.  At  26  months 
her  tonsils  had  been  removed  but  the  attacks  thereafter 
occurred  more  often  and  more  severely. 

Vitamin  Bi  solution  parenterally  should  be  unhesitatinfrly 
tried  in  all  cases  of  acute  heart  failure.  Vitamin  B  complex 
or  vitamin  B,  alone  may  well  be  used  prophylactically  be- 
fore any  severe  operative  ordeal  such  as  tonsillectomy, 
particularly  when  there  is  evidence  of  cardiac  weakness. 


SOUTHERN  MEDICINE  &  SURGERY 


April    1941 


The  Use  of  Encephalography  in  the  Diagnosis  of 
Subdural  Hematoma* 

William  Reid  Pitts,  M.D.,  Charlotte 


SUBDURAL  HEMATOMA  represents  a  clin- 
ical entity  which,  on  account  of  its  peculiar 
character,  has  onlv  too  often  been  overlook- 
ed and,  in  consequence,  has  fallen  into  the  hands 
of  the  pathologist  far  too  frequently.  Subdural 
hematomata  may  simulate,  and  oftentimes  their  vic- 
tims are  paraded  as  examples  of,  cerebral  throm- 
brain  laceration,  cerebral  arteriosclerosis  or  cere- 
bral edema.  It  is  conceded  that  there  is  a  classical 
syndrome  which  indicates  the  presence  of  a  sub- 
dural hematoma,  but  many  such  lesions  produce 
symptoms  and  signs  that  vary  widely  in  their  clin- 
ical manifestations:  in  fact,  one  of  the  most  strik- 
ing characteristics  of  a  subdural  hematoma  is  the 
extreme  variability  of  symptoms,  and  this  fact  in 
itself  is  a  diagnostic  point  of  the  greatest  value. 
Any  combination  of  symptoms  of  general  intra- 
cranial pressure  or  local  pressure  may  be  present 
in  atypical,  incomplete  or  fleeting  variations.  Often 
these  patients  are  disoriented,  irritable,  and  many 
forms  of  mental  disease  may  be  imitated.  There  is 
no  other  intracranial  lesion  so  difficult  to  diagnose 
accurately  upon  the  subjective  and  objective  symp- 
toms alone.  Often  a  hematoma  is  encountered  when 
least  expected.  It  has  frequently  been  said  that 
appendicitis  may  simulate  any  disease  of  the  ab- 
domen; with  equal  truth  it  might  be  said  that 
subdural  hematoma  may  simulate  any  disease  of 
the  brain.  Our  inability  to  diagnose  this  lesion 
correctly  is  attested  by  the  numerous  negative 
surgical  explorations  on  patients  suspected  of  har- 
boring a  subdural  hematoma.  It  was  because  of 
these  useless  cranial  operations  that  we  decided  to 
use  encephalography  in  an  attempt  to  make  more 
accurate  diagnoses. 

The  introduction  of  air  as  a  contrast  medium 
into  the  spaces  inside  the  skull  which  contain  cere- 
brospinal fluid,  for  the  roentgenographic  localiza- 
tion of  space-occupying  lesions,  has  been  exten- 
sively used  since  its  introduction  by  Dandy  in 
1918.  This  diagnostic  procedure,  however,  has  not 
been  advocated  to  any  extent  for  the  recognition 
of  traumatic  intracranial  hematomata  of  sufficient 
size  to  warrant  surgical  removal.  From  July  1st, 
1935,  to  July  1st.  1936,  1949  patients  with  evi- 
dence of  head  trauma  were  admitted  to  the  Neuro- 
surgical Service  of  the  Kings  County  Hospital. 
Of  this  number,  659  had  intracranial  damage  war- 
ranting hospitalization  for  two  weeks  or  longer.   In 

•Presented    to   the    meeting   of   the   Tri-State   Medical   Associatio: 
24th  and  25th. 


56  of  these  cases  the  clinical  evidence  strongly  sug- 
gesting a  subdural  or  an  epidural  hematoma, 
encephalography  was  done.  Twenty-two  of  these 
roentgenographic  studies  gave  evidence  of  the  pres- 
ence of  space-occupying  lesions,  which  proved  at 
operation  to  be  hematomata.  (There  were  eleven 
other  patients  who  had  subdural  or  epidural  hema- 
tomata who  were  not  subjected  to  air  studies.) 
Eight  of  the  56  cases  have  been  chosen  to  illustrate 
the  value  of  encephalography  in  the  differentiation 
of  traumatic  intracranial  hematomata  from  the 
intracerebral  lesions. 

Illustrative  Cases 

Case  1. — Blow  to  the  head.  Bleeding  from  the  nose  and 
mouth.  Alternate  drowsy  and  restive  state.  Diaenosis  of 
post-traumatic  psychosis.  Encephalogram.  Operation. 
R'ght  supranuclear  facial  paresis.    Recovery. 

A  32-year-old  man  was  admitted  to  the  hospital  15 
days  after  being  struck  on  the  head  with  a  section  of  lead 
pipe.  Some  hours  following  injury  he  was  found  at  home 
bleeding  from  his  nose  and  mouth  complaining  of  severe 
headache.  He  was  taken  to  a  nearby  hospital  where  a 
fracture  in  the  right  temporal  region  was  verified  by  roent- 
eenray  examination.  During  the  next  two  weeks  he  failed 
to  show  appreciable  improvement,  there  being  alternate 
periods  of  restiveness  and  drowsiness.  Finally  he  became 
=o  unmanageable  that  he  was  transferred  to  the  Kings 
County  Hospital  with  a  diagnosis  of  post-traumatic  psych- 
osis. On  entry  he  was  irritable  when  aroused  but  lapsed 
into  a  drowsy  state  when  left  alone.  At  times  he  would 
follow  simple  commands  and  answer  loudly-spoken  ques- 
tions in  a  slurred  manner.  There  was  no  external  evidence 
of  injury  over  any  part  of  the  head.  The  pupils  were  in 
middilatation  and  both  reacted  sluggishly  to  light.  The 
'eft  pupil  was  slightly  larger  than  the  right.  The  optic 
fundi  were  within  normal  limits.  No  disturbance  in  the 
function  of  the  cranial  nerves  could  be  demonstrated.  The 
extremities  were  all  used  equally  well  and  no  gross  changes 
in  cutaneous  sensation  were  present.  The  deep  reflexes  of 
the  two  sides  were  all  present  and  equally  active.  Babin- 
ski's  sign  was  not  demonstrable.  The  abdominal  reflexes 
were  not  obtained;  the  left  cremasteric  reflex  was  present, 
the  right  absent.  He  was  observed  for  three  days  during 
which  time  he  took  sufficient  food  and  fluids  to  maintain 
a  metabolic  equilibrium.  Dehydration  with  caffeine  and 
Gastrointestinal  purgation  did  not  improve  his  mental 
state.  At  this  time  130  c.c.  of  xanthochromic  cerebrospinal 
fluid  was  removed  fractionally  and  replaced  with  an  equal 
quantity  of  air.  The  roentgenographic  films  showed  two 
fracture  lines  traversing  the  left  cranial  vault,  a  marked 
displacement  of  the  cerebral  ventricular  system  to  the  right 
and  absence  of  sulcus  markings  on  the  left  side.    (Fig.  1.) 

Immediate  operation  was  performed  under  local  anesthe- 
sia. A  bluish  dura  was  exposed  through  a  left  midparietal 
opening.  Upon  incising  the  dura  a  thick  membrane  pre- 
sented, which,  being  opened,  revealed  a  completely  lique- 
fied subdural   hematoma.    This  was   removed  by  suction, 

of   the    Carolinaa    and    Virginia,    held   at    Greensboro,    February 


April   1941 


ENCEPHALOGRAPHY    OF   SUBDURAL   HEMATOMA— Pitts 


the  subdural  cavity  occupied  by  the  hematoma  irrigated 
and  the  wound  closed  with  layer  silk.  While  on  the  oper- 
ating table  the  patient  became  more  alert  and  capable  of 
following  commands.  During  the  next  two  days  he  became 
completely  oriented.  On  the  third  postoperative  day  it  was 
noticed  for  the  first  time  that  a  right  supranuclear  facial 
paresis  was  present,  but  no  speech  defect  nor  disparity  of 
function  of  the  upper  extremities  could  be  demonstrated. 
This  right-sided  facial  paresis  was  not  completely  recov- 
ered from  until  the  12th  postoperative  day.  The  patient 
discharged  from  hospital  asymptomatic,  fourteen  days  fol- 
lowing the  operation. 

Comment:  This  is  a  fair  example  of  a  patient 
with  a  traumatic  subdural  hematoma  who  present- 
ed as  the  main  clinical  feature  of  this  lesion,  an 
accelerated  psychomotor  state.  Had  his  injury  been 
more  trivial,  as  frequently  is  the  case,  he  may  have 
been  assigned  to  the  psychiatric  department  as  was 
requested  by  those  in  charge  at  the  hospital  from 
which  he  was  transferred.  In  fact,  there  were  no 
physical  signs  compatible  with  general  brain  injury 
and  edema.  Localizing  the  lesion  with  exactness 
enabled  the  operator  to  evacuate  the  liquefied 
hematoma  by  a  relatively  minor  procedure. 

Case  2. — Arteriosclerosis  and  arterial  hypertension.  Au- 
tomobile accident.  Ecchymosis  about  the  right  eye.  Pro- 
pressive  right  hemiplegia.  Speech  defect.  Headache  and 
drowsiness  progressing  to  stupor.  Encephalogram.  Recov- 
ery. 

A  77-year-old  man  was  brought  to  the  hospital  because 
of  a  paralysis  of  both  right  extremities.  Three  weeks  prior 
to  entry  he  was  knocked  down  by  an  automobile,  dazed 
but  not  rendered  unconscious.  The  right  side  of  his  face 
was  contused  and  the  right  eye  became  black.  He  was 
taken  to  a  nearby  hospital  but  shortly  after  admission  was 
permitted  to  go  home.  As  far  as  could  be  determined,  he 
had  no  complaints  for  the  next  two  weeks,  at  the  end  of 
which  time  there  was  noticed  slight  slurring  of  his  speech. 
Slowly  he  lost  the  use  of  the  right  extremities  and  was  ad- 
mitted to  the  Neurological  Department  with  a  complete 
aphasia  and  a  right  hemiplegia.  During  the  first  four  days 
in  the  hospital,  he  became  progressively  more  drowsy  and 
accordingly  was  transferred  to  the  Neurosurgical  Depart- 
ment for  air  studies. 

At  this  time  the  pulse  was  120  per  minute,  rectal  tem- 
perature 101.4  F.,  blood  pressure  198/104.  The  pupils  were 
small  and  both  reacted  to  light.  On  several  occasions  the 
left  pupil  was  noted  to  be  larger  than  the  right.  The  optic 
fundi  showed  moderate  retinal  vein  engorgement,  retinal 
artery  sclerosis  and  blurring  of  both  optic  nerve  heads 
along  their  nasal  margins.  The  right  lower  face  was  paretic 
and  a  complete  motor  paralysis  of  the  right  side  was  de- 
monstrable. The  abdominal  reflexes  were  not  obtained  on 
the  right.  The  left  cremasteric  reflex  was  present  but  the 
right  was  not  obtained.  Hyperreflexia  of  the  tendon  re- 
sponses was  present  and  Babinski's  sign  was  demonstrable 
on  the  right.  Spinal  puncture  revealed  a  xanthochromic 
cerebrospinal  fluid  under  a  pressure  of  24  mm.  He  The 
urine  contained  a  trace  of  albumin.  The  nitrogenous  con- 
tent of  the  blood  was  within  normal  limits.  There  was 
little,  if  any,  change  in  his  condition  for  the  next  three 
days  when  air  studies  were  carried  out.  Fractionally  90  c.c. 
of  cerebrospinal  fluid  was  replaced  by  an  equal  quantity 
of  air.  The  roentgenographic  films  showed  a  centrally 
placed  but  dilated  cerebral  ventricular  system,  the  left 
lateral  ventricle  being  dilated  more  than  the  right  (Fig.  2). 


At  the  time  of  the  encephalogram  the  temperature  was 
101  and  the  pulse  was  136.  Immediately  after  the  air 
studies  there  was  no  change  in  vital  signs.  Five  hours 
later  the  pulse  was  100,  the  temperature  100.2.  During 
the  next  ten  days  the  temperature  remained  at  a  level  be 
tween  100  and  100.6,  the  pulse  between  80  and  100.  Slowly 
he  became  oriented  and  was  discharged  from  the  hospital 
15  days  following  the  air  studies,  with  a  weakness  of  the 
right  arm  and  leg.  Six  months  later  the  patient  was  able 
to  walk  and  to  use  the  right  hand  when  eating. 

Comment:  The  clinical  record  strongly  suggests 
the  presence  of  a  subdural  hematoma.  The  only 
feature  against  such  a  diagnosis  was  the  appear- 
ance of  the  right  hemiplegia,  before  the  onset  of 
drowsy  state.  Without  air  studies,  one  could  have 
easily  justified  an  exploratory  operation  which,  'tis 
true,  may  not  have  militated  against  his  chances 
for  recovery  any  more  than  the  introduction  of  air 
into  the  cerebrospinal  fluid  spaces.  This  example 
illustrates  a  problem  frequently  encountered; 
namely,  differentiation  between  a  disturbance  in 
function  of  the  brain  due  to  a  primary  vascular 
lesion  and  that  resulting  from  compression  by  a 
traumatic  hematoma.  This  differential  diagnosis 
cannot  be  made  with  certainty  from  the  history 
and  physical  signs  alone. 

Case  3. — Chronic  right  otorrhea.  Arteriosclerosis.  Acute 
alcoholism.  Contusion  of  the  occipital  scalp.  Ecchymosis 
about  the  left  eye.  Stupor.  Bleeding  from  the  nose  and 
mouth.  Spinal  fluid  contaminated  with  blood.  Persistent 
headache  and  drowsiness.  Encephalogram.  Operation.  Re- 
covery. 

A  51-year-old  man  was  found  in  a  subway  station  un- 
conscious and  bleeding  from  the  nose  and  mouth.  On  ad- 
mission to  the  hospital  there  was  an  odor  of  alcohol  on 
his  breath,  profound  stupor,  a  small  area  of  contusion  of 
the  scalp  in  the  midoccipital  area  and  ecchymosis  about 
the  left  eye.  His  relatives  stated  that  the  patient  had  had 
a  purulent  discharge  from  his  right  ear  for  ten  years  and 
for  about  one  year  prior  to  the  accident  they  had  noticed 
personality  changes  and  poor  memory.  A  limited  neurol- 
ogical examination  revealed  absent  superficial  reflexes  and 
impaired  mental  state.  The  spinal  fluid  was  found  to  be 
under  a  pressure  of  14  mm.  Hg.  and  grossly  contaminated 
with  blood.  Six  hours  after  admission  the  patient  could 
be  aroused  by  strong  cutaneous  stimuli,  but  could  give  no 
account  of  events  before  the  accident,  and  cooperated 
poorly.  For  the  next  two  weeks  he  was  partially  disorient- 
ed, tended  toward  drowsiness,  complained  of  right  fron- 
totemporal  headache  and  had  poor  memory  for  recent 
events.  Twelve  days  following  entry,  there  was  observed 
slight  blurring  of  the  nasal  borders  of  the  optic  nerve 
heads.  No  disparity  of  function  of  the  extremities  nor 
changes  in  the  deep  reflexes  could  be  demonstrated.  The 
superficial  reflexes  were  present  on  both  sides. 

An  encephalogram  was  performed  14  days  after  admis- 
sion, 28  c.c.  of  xanthochromic  cerebrospinal  fluid  fraction- 
ally withdrawn  and  34  c.c.  of  air  introduced.  The  roent- 
genographic films  revealed  marked  displacement  of  the 
ventricular  system  to  the  left  side  with  dilatation  of  the 
left  lateral  ventricle  (Fig.  3).  There  was  no  increase  in 
the  drowsiness,  nor  were  there  any  remarkable  changes  in 
the  temperature,  the  pulse  or  the  blood  pressure  following 
the  air  studies.  The  encephalography  findings  clearly  indi- 
cated a  lesion  in  the  right  temporal  area;  but,  considering 


190 


ENCEPHALOGRAPHY    OF   SUBDURAL   HEMATOMA— Pitts 


April  1941 


the  history  of  the  memory  defect,  the  chronic  infection  of 
the  right  ear  and  the  recent  trauma,  one  could  not  differen- 
tiate between  tumor,  abscess  and  hematoma.  Five  days 
after  the  air  studies,  preparation  was  made  for  a  right 
lateral  bone  flap  and  a  small  incision  along  the  inferior 
part  of  the  posterior  arm  of  the  scratch  mark  for  the  bone 
flap.  Upon  making  a  burr  opening  at  this  site  (over  the 
posterior  aspect  of  the  right  temporal  lobe  of  the  brain) 
bluish  dura  was  exposed.  The  dura  and  an  underlying 
membrane  of  a  subdural  hematoma  were  incised  and  ap- 
proximately 60  c.c.  of  a  liquid  hematoma  removed  by  suc- 
tion. The  subdural  cavity  was  irrigated  and  the  brain 
expanded  within  a  few  minutes.  The  wound  was  closed 
with  layer  silk. 

Ten  minutes  following  the  operation  the  patient  was 
alert  and  conversed  intelligently.  Convalescence  was  un- 
eventful. Two  weeks  after  operation,  a  second  encephalo- 
gram was  performed  and  65  c.c.  of  clear  cerebrospinal 
fluid  was  replaced  by  an  equal  quantity  of  air.  The  roent- 
genographic  films  showed  a  centrally  placed  ventricular 
system  with  moderate  dilatation  of  the  left  lateral  ventri- 
cle (Fig.  4).  The  patient  was  discharged  from  the  hos- 
pital, asymptomatic,  five  days  following  the  second  en- 
cephalogram. 

Comment:  The  history  as  obtained  suggested 
that  this  patient  had  an  intracranial  lesion  (ab- 
scess or  tumor)  at  the  time  of  the  accident.  The 
absence  of  the  filling  of  the  temporal  horn  of  the 
right  lateral  ventricle  also  indicated  a  possible  cir- 
cumscribed lesion  in  this  region;  however,  only  a 
small  amount  of  air  had  been  introduced  into  the 
lumbar  subarachnoid  space  and  frequently  the 
temporal  horns  of  the  lateral  ventricle  are  not  de- 
monstrable when  incomplete  replacement  of  the 
cerebrospinal  fluid  with  air  has  been  carried  out. 
In  situations  of  this  character,  the  operator  should 
prepare  the  field  so  that  anv  lesion  that  may  be 
disclosed  may  he  handled  without  further  prepara- 
tion and  drapine.  This  example  illustrates  the  per- 
sistent dilatation  of  the  lateral  ventricle  of  the  pre- 
sumably unaffected  left  cerebral  hemisphere;  in 
fact,  the  postopprative  air  study  shows  (Fig.  4) 
an  increase  in  the  size  of  this  ventricle  as  compar- 
ed to  the  moderate  dilatation  demonstrated  before 
the  operation  (Fig.  3). 

Case  4. — Severe  head  im'ury.  Right  frontotemporal  scalp 
contusions.  Ecchymotic  ri<rht  eyelid.  Coma.  Dilated  and 
fixed  pupils.  Bloodv  cerebrospinal  fluid.  Prolonged  stupor. 
Encephalogram.  Improvement. 

An  8-year-old  boy  fell  30  feet  and  struck  his  head  on  a 
concrete  step.  He  was  brought  to  the  hospital  in  a  coma- 
tose condition  from  which  he  could  not  be  aroused  by 
strong  cutaneous  stimuli.  There  was  a  large  zone  of  con- 
tusion and  surface  abrasion  over  the  right  frontotemporal 
area  and  the  right  eyelids  were  swollen.  There  was  no 
evidence  of  bleeding  from  the  nose,  mouth  or  ears.  The 
pupils  were  widely  dilated,  equal  and  non-reactive  to  light. 
Both  eyes  were  directed  downward  and  inward.  The  ex- 
tremities were  flaccid,  cutaneous  reflexes  were  not  obtain- 
able and  the  deep  reflexes  of  the  upper  extremities  were 
absent.  The  knee  and  ankle  jerks  were  active  and  equal 
on  the  two  sides.  Babinski's  sign  was  not  present.  The 
cerebrospinal  fluid  had  a  pressure  of  6  mm.  Hg.  and  was 
grossly  contaminated  with  blood.   Twenty-four  hours  after 


admission,  the  patient  had  recovered  sufficiently  to  move 
his  extremities  when  painful  stimuli  were  applied  and  at 
this  time  a  weakness  of  the  right  extremities  could  be  dem- 
onstrated.   The  pupils  remained  equal. 

For  the  next  ten  days  he  was  stuporous  during  which 
time  fluid  balance  and  general  nutrition  were  maintained 
by  lavage.  Eleven  days  following  entry,  air  studies  were 
carried  out,  when  80  c.c.  of  xanthochromic  cerebrospinal 
fluid  was  fractionally  replaced  by  an  equal  quantity  of  air. 
The  roentgenographic  films  showed  a  centrally  placed  ven- 
tricular system  and  sulcus  markings  that  were  considered 
to  be  within  normal  limits.  On  the  day  following  the  air 
studies  the  patient  recognized  his  family.  A  disturbance 
of  speech  was  demonstrable  and  there  was  a  right  hemi- 
paresis.  Recovery  was  slow  but  progressive  during  the 
next  six  weeks,  and  at  the  end  of  this  time  he  was  allowed 
out  of  bed.  Eight  weeks  following  the  injury,  he  was  dis- 
charged from  the  hospital  with  a  mild  right  hemiparesis 
and  a  slight  emissive  speech  defect. 

Comment:  The  clinical  findings  and  the  hos- 
pital course  indicated  a  contusion-laceration  of  the 
left  cerebral  hemisphere:  however,  the  prolonged 
stupor  and  the  right  hemiparesis  suggested  the  pos- 
sibility of  a  subdural  hematoma  of  sufficient  size  to 
warrant  surgical  exploration.  The  air  studies  clear- 
ly excluded  this  possibility.  The  improvement  in 
this  patient's  mental  state  within  24  hours  follow- 
ing the  encephalogram  was  too  striking  to  be  at- 
tributed to  coincidence. 

Case  5. — Acute  alcoholism.  Laceration  left  parietal  scalp. 
Stupor.  Bleeding  from  left  ear  and  nose.  Fracture  of  the 
skull.  Erysipelas  of  face.  Encephalogram.  Operation.  Sub- 
dural hematoma.  Continued  stupor.  Secondary  operation. 
Death. 

A  40-year-old  man  was  admitted  to  the  hospital,  semi- 
conscious, bleeding  from  the  left  ear  and  the  nose,  com- 
pletely disoriented,  resistive  and  with  an  alcoholic  odor  on 
his  breath.  There  was  a  laceration  5  cm.  long  in  the  left 
parietal  region  which  was  surrounded  by  an  extensive  area 
of  contusion.  The  pupils  were  small,  round,  equal  and  re- 
acted to  light.  There  was  a  weakness  of  the  left  face  and 
left  arm.  The  deep  reflexes  of  the  left  extremities  were 
quicker  than  those  on  the  right  side.  The  abdominal  re- 
flexes were  not  obtained.  Babinski's  sign  was  not  demon- 
strable. The  pulse  was  70,  the  blood  pressure  140/100. 
The  cerebrospinal  fluid  was  contaminated  with  blood  and 
under  a  pressure  of  19  mm.  of  Hg.  The  neurological 
findings  remained  the  same  until  the  third  day  following 
entry,  when  there  was  evidence  of  an  infection  involving 
the  left  side  of  the  face  and  left  ear.  The  temperature  rose 
to  105.6  and  after  a  febrile  course  of  seven  days  the  ery- 
sipeloid lesion  subsided.  At  this  time,  it  was  noted  that 
in  the  course  of  a  few  hours  he  would  be  alternately  alert 
and  drowsy. 

Because  of  the  recurrent  drowsiness  and  the  left  hemi- 
paresis, 14  days  after  admission  100  c.c.  of  xanthochromic 
cerebrospinal  fluid  was  withdrawn  fractionally  and  re- 
placed by  an  equal  amount  of  air.  Roentgenographic 
studies  revealed  no  air  in  the  ventricular  system,  but 
showed  an  absence  of  cortical  markings  over  the  right 
cerebral  hemisphere  and  a  displacement  of  the  falx  cerebri 
to  the  left  (Fig.  5).  There  findings  were  sufficient  evidence 
to  warrant  the  diagnosis  of  a  right-sided  space-occupying 
lesion,  probably  a  subdural  hematoma.  Four  hours  fol- 
lowing the  air  studies,  operation  was  performed.  Through 
a   right   temporal   burr  opening,   a  bluish   discolored   dura 


Figure    I. — Roentgen     films    taken     following     encephalography    in    the     anterior-posternr> 
posterior-anterior,  right  lateral  and  left  lateral   positions  demonstrating   the   following: 
(a,  b)     A  marked  displacement  of  the  cerebral  ventricular  system  to  the  right. 
Absence  of  sulci  markings  on  the  left  side. 

(c)  Fracture  of  left  cranial  vault. 

Compression  and  downward  displacement  of  the  left  lateral  ventricle. 

(d)  Normal  right  lateral  ventricle. 

Figure  II. — (a,  b)  Encephalogram  films  taken  in  the  anterior-posterior  and  posterior-ante- 
rior views  which  show  a  centrally  placed,  but  dilated  cerebral  ventricular  system,  the  left  lateral 
ventricle  being  more  dilated  than  the  right. 

Figure  III. — Encephalograms  taken  in  the  (a)  anterior-posterior  and  (b)  left  lateral  views 
showing  (a)  marked  displacement  of  the  cerebral  ventricular  system  to  the  left  side  with  mod- 
erate dilatation  of  the  left  lateral  ventricle  and  (b)  absence  of  temporal  horn  filling  on  the  right 
side. 

Figure  IV. — i(a)  Anterior-posterior  and  ('3)  posterior-anterior  views  of  encephalograms 
down  before;  and  (c)  and  (d)  after  operation.  The  preoperative  views  (a)  and  (b)  show  marked 
displacement  of  the  cerebral  ventricular  system  to  the  left  with  dilatation  of  the  left  lateral 
ventricle.  The  postoperative  films  (c)  and  (d)  (lower  views)  show  a  centrally-placed  cerebral 
ventricular  system  with  further  dilatation  of  the  left  lateral  ventricle. 

Figure  V. — Roentgen  film  taken  in  the  anterior-posterior  view  following  attempt  at  ence- 
phalography shows  the  failure  of  the  cerebral  ventricular  system  to  fill,  absence  of  cortical  mark- 
ings over  the  right  cerebral  hemisphere  and  displacement  of  the  falx  cerebri  to  the  left.  At  oper- 
ation, the  lesion  proved  to  be  a  massive  right  subdural  hematoma. 

Figure  VI. — Encephalogram  taken  in  anterior-posterior  position  which  shows  absence  of 
ventricular  filling,  deviation  of  the  falx  cerebri  to  the  left  and  absent  cerebral  cortical  markings 
on  the  right.    Pathology  proved  to  be  a  massive  right  subdural  hematoma. 

Figure  VII. — An  anterior-posterior  view  of  roentgen  film  after  encephalography  which  shows 
slight  displacement  of  the  cerebral  ventricular  system  to  the  left. 

Figure  VIII. — An  anterior-posterior  view  of  an  encephalogram  showing  marked  displacement 
of  the  cerebral  ventricular  system  from  right  to  left.  Pathology  revealed  at  operation  was  right 
epidural  hematoma. 


April   1941 


ENCEPHALOGRAPHY   OF  SUBDURAL   HEMATOMA— Pitts 


191 


was  exposed  and  the  underlying  membrane  of  a  subdural 
hematoma  incised.  After  the  removal  of  60  c.c.  of  thick, 
tarry  blood  by  suction  the  cerebral  cortex  was  found  to  be 
4  cm.  below  the  dural  surface.  The  wound  was  closed 
with  layer  silk.  For  the  next  24  hours  the  patient  was  less 
drowsy  than  before  operation,  but  over  a  three-day  period 
he  gradually  lapsed  into  a  stupor.  At  this  time  a  cranial 
burr  opening  made  in  the  left  temporal  region  revealed  no 
evidence  of  a  subdural  hematoma.  The  right  temporal 
wound  was  then  reopened  and  the  cerebral  cortex  was 
found  to  be  well  below  the  dural  surface.  The  wounds 
were  closed  with  layer  silk.  Following  this  operation  the 
patient's  condition  grew  rapidly  worse.  The  pulse  and  the 
temperature  rose  and  he  died  twenty-four  hours  after  the 
second  operation.  At  autopsy,  there  was  found  extensive 
contusion  and  lacerations  of  the  right  temporal  lobe  of  the 
brain.  The  entire  right  cerebral  hemisphere  was  compress- 
ed as  noted  at  operation,  but  there  was  no  residual  sub- 
dural fluid  collection.  An  extensive  fracture  9  cm.  long 
was  found,  which  traversed  the  floor  of  the  left  middle 
fossa. 

Comment:  This  case  illustrates  the  fact  that  it 
is  at  times  difficult  to  replace  the  fluid  of  the  ven- 
tricular system  with  air  by  the  spinal  route  when 
there  is  a  surface  compression  lesion  of  a  cerebral 
hemisphere.  In  many  of  these  instances,  the  falx 
cerebri  is  outlined  by  air  and  frequently  the  nor- 
mal sulcus  markings  are  not  demonstrated  on  the 
side  of  the  lesion.  Recently,  I  was  confronted  for 
the  third  time  with  an  encephalographic  film  which 
showed  a  shifting  of  the  falx  cerebri  with  absence 
of  cortical  markings  on  the  side  of  the  lesion, 
whereas,  the  cortical  markings  were  normal  on  the 
opposite  side  (Fig.  6).  In  every  instance  in  our 
experience  where  this  finding  has  been  encounter- 
ed, the  lesion  has  proved  to  be  a  space-occupying 
surface  lesion,  a  subdural  hematoma.  A  shift  of 
the  falx  lateralizes  the  lesion  but  in  instances 
where  the  falx  is  not  outlined  by  air,  absence  of 
air-filled  sulci  on  the  one  side  along  with  clear 
marking  on  the  other  is  presumptive  lateralizing 
evidence.  Another  feature  of  this  case  is  the  fact 
that  the  brain  failed  to  expand  following  the  evac- 
uation of  the  subdural  hematoma.  We  have  found 
this  to  occur  in  approximately  10  per  cent  of  our 
cases. 

Case  6.— Chronic  alcoholism.  Coma.  Bleeding  from  nose 
and  mouth.  Contusion  of  rieht  parietal  scalp.  Left  facial 
paresis.  Dilated  right  pupil.  Encephalogram.  Operation. 
Recovery. 

A  45-year-old  man  fell  down  a  flight  of  steps  durin*  an 
alcoholic  debauch  and  sustained  a  contusion  of  the  right 
parietooccipital  region.  He  was  admitted  to  the  hospital 
shortly  thereafter,  in  a  deep  stupor  which  had  persisted 
since  the  time  of  the  fall.  There  was  a  moderate  amount 
of  bleeding  from  the  nose  and  mouth.  The  pupils  were 
in  middilatation,  the  richt  larger  than  the  left,  both  re- 
acted to  light.  A  left  facial  paresis  of  the  supranuclear 
type  was  present  but  there  was  no  demonstrable  weakness 
of  any  extremity.  The  deep  reflexes  were  all  depressed, 
equally  so  on  the  two  sides.  Babinski's  sign  was  not  pres- 
ent. The  abdominal  reflexes  were  absent  bilaterally.  The 
cerebrospinal  fluid  was  contaminated  with  blood  and  under 


a  pressure  of  20  mm.  Hg.  Over  a  24-hour  period,  the 
patient  gradually  recovered  from  his  stupor  and  became 
able  to  answer  simple  questions  intelligently.  He  com- 
plained of  generalized  headache  and  continuous  nausea. 

On  the  second  day  following  entry,  he  became  very 
restless  and  irritable  when  disturbed  but  drowsy  when 
quiet.  Air  studies  were  carried  out  at  this  time  and  50  c.c. 
of  bloody  cerebrospinal  fluid  was  removed  and  replaced 
by  an  equal  quantity  of  air.  Roentgenographs  studies  re- 
vealed air  in  both  lateral  and  third  ventricles,  but  no  air 
was  present  in  the  cerebral  sulci.  The  cerebral  ventricular 
system  was  found  to  be  slightly  displaced  to  the  left  with 
compression  of  the  right  lateral  ventricle  and  slight  dilata- 
tion of  the -left  lateral  ventricle  (Fig.  7).  These  findings 
indicated  a  compression  of  the  right  cerebral  hemisphere 
and  the  lesion  was  thought  to  be  a  subdural  hematoma. 
Operation  was  postponed  to  allow  time  for  the  suspected 
blood  clot  to  liquefy  and  so  become  more  readily  remov- 
able. Over  a  three-day  period  the  patient  became  brighter 
and  it  seemed  as  though  the  injection  of  air  had  been  of 
therapeutic  value.  Under  local  anesthesia,  a  faintly  blu- 
ish, discolored  dura  was  exposed  through  a  burr  opening 
in  the  right  temporal  region.  When  the  dura  was  opened, 
only  4  to  5  c.c.  of  thick,  black  blood  was  found  in  the 
subdural  space.  This  quantity  of  fluid  blood  was  not  suffi- 
cient to  produce  the  shifting  of  the  ventricular  system  as 
was  demonstrated  by  encephalography.  Following  the 
operation,  improvement  was  steady,  and  mental  alertness 
and  freedom  from  headache  were  regained  in  two  days. 
On  the  third  postoperative  day,  there  were  signs  of  bron- 
chopneumonia of  the  right  lungs  but  the  febrile  course  was 
mild  and  the  patient  was  permitted  to  be  out  of  bed  on 
the  14th  postoperative  day.  He  was  discharged  from  the 
hospital,  asymptomatic,  four  weeks  following  admission. 

Comment:  As  is  indicated  here,  a  ventricular 
shift  demonstrable  by  air  studies  in  a  patient  who 
has  recently  sustained  a  head  injury,  may  be  due 
to  intracerebral  hemorrhage  and  edema.  The  ab- 
sence of  sulcus  markings  may  have  been  due  to  a 
small  amount  of  subdural  blood  on  both  sides.  No 
doubt,  a  displacement  of  the  cerebral  ventricles 
of  this  degree  frequently  results  from  intracerebral 
edema  secondary  to  trauma. 

Case  7. — Fall  from  a  horse.  Contusion  right  parietal 
scalp.  Stupor.  Fracture  in  right  parietal  region  of  skull. 
Progressive  left  hemiparesis.  Encephalogram.  Operation. 
Right  epidural   hematoma.  Recovery. 

A  22-year-old  man  fell  from  a  horse  and  struck  his  head 
against  a  curbstone.  He  was  able  to  get  up  and  walk  50 
yards  to  the  stable  where  he  collapsed.  Forty-five  minutes 
following  the  injury,  he  was  admitted  to  the  hospital  in  a 
confused  state,  but  was  able  to  give  his  name  and  address. 
There  was  marked  swelling  and  edema  over  the  right  side 
of  the  head  extending  posteriorly  to  the  occiput,  the  site 
of  a  small  abrasion.  A  second  abrasion  surrounded  by 
slight  swelling  was  also  noted  over  the  left  frontal  region. 
The  pupils  were  in  middilatation,  equal  and  responsive  to 
light.  No  weakness  of  an  extremity  was  demonstrable  and 
the  tendon  reflexes  were  equally  active  on  the  two  sides. 
The  abdominal  reflexes  were  absent  bilaterally.  Babinski's 
sign  was  not  present.  The  pulse  was  60  per  minute.  The 
cerebrospinal  fluid  was  contaminated  with  blood  and  under 
a  pressure  of  36  mm.  of  Hg.  There  was  evidence  of  a  frac- 
ture of  the  right  clavicle.  Drowsiness  developed  and  over 
a  period  of  20  hours  there  slowly  appeared  a  left  hemi- 
paresis, more  marked  in  the  face  and  the  upper  extremity 


ENCEPHALOGRAPHY   OF   SUBDURAL   HEMATOMA— Pitts 


April   1941 


than  in  the  lower  exrtemity.  Babinski's  sign  was  now 
demonstrable  on  the  left  side  but  the  deep  reflexes  were 
equal  bilaterally.    The  pupils  remained  equal  in  size. 

The  presence  of  a  right  epidural  hematoma  was  sus- 
pected and  air  studies  were  performed  48  hours  after  the 
injury.  At  this  time,  90  c.c.  of  cerebrospinal  fluid  was  re- 
moved fractionally  and  replaced  by  an  equal  quantity  of 
air.  The  roentgenographic  studies  revealed  a  fracture  in 
the  right  parietal  region  of  the  skull  crossing  the  grooves 
of  the  branches  of  the  right  middle  meningeal  artery.  The 
cerebral  ventricular  system  was  displaced  from  right  to 
left  and  there  was  compression  of  the  right  lateral  ven- 
tricle with  slight  dilatation  of  the  left  lateral  ventricle 
(Fig.  8).  Following  the  making  of  the  encephalogram, 
stupor  became  profound  and  the  temperature  rose  from 
100.6  to  102  per  rectum.  Two  hours  following  the  air  in- 
jection, restlessness  returned  and  the  blood  pressure  rose 
to  170/120,  pulse  to  180.  At  operation,  a  large  epidural 
clot  was  exposed,  evacuated  and  hemostasis  completed. 
When  the  operation  had  been  completed,  the  temperature 
was  10S.6,  the  pulse  180.  Three  hours  later,  the  temper- 
ature had  fallen  to  101,  the  pulse  rate  to  120.  Conscious- 
ness returned,  the  patient  talked  rationally  and  took  fluids 
by  mouth.  Within  two  days,  the  weakness  of  the  left 
upper  extremity  was  recovered  from,  but  the  left  face 
weakness  persisted  for  six  days,  postoperatively.  The  pa- 
tient was  discharged  from  the  hospital,  asymptomatic,  four 
weeks  following  entry. 

Comment:  This  story  clearly  indicates  that 
there  is  great  danger  of  precipitating  a  marked 
increase  in  symptoms  and  signs  (in  fact,  death 
may  result),  by  altering  the  existing  intracranial 
tension  when  there  is  a  rapidly-expanding  lesion 
present.  This  patient  should  not  have  had  air 
studies  performed.  However,  the  signs  resulting 
from  the  presence  of  an  epidural  hematoma  are 
frequentlv  masked  bv  general  brain  damage,  and 
in  many  hospitals  more  epidural  hematomata  are 
disclosed  on  the  autopsy  table  than  in  the  operat- 
ing room.  On  this  basis,  whenever  there  is  a  sus- 
picion of  an  intracranial  blood  clot,  it  is  better  to 
localize  the  lesion  by  air  studies  followed  by  indi- 
cated surgical  procedure,  than  to  perform  blind 
exploratory  operations.  Where  a  localizable  epi- 
dural hematoma  is  suspected,  it  is  advisable  to 
make  a  ventriculogram  rather  than  to  introduce 
air  into  the  lumbar  thecal  sac. 

Case  8. — Blow  to  left  temporal  region  of  head.  Short 
period  of  unconsciousness.  Vomiting,  headache  and  drowsi- 
ness. Right  hemiparesis.  Encephalogram.  Brain  contusion- 
laceration.  Recovery. 

A  38-year-old  man  was  struck  in  the  left  temporal  re- 
gion with  a  hardwood  stick  which  produced  immediate 
unconsciousness  lasting  for  an  hour.  Upon  regaining  con- 
sciousness, he  vomited  frequently  for  24  hours  and  was 
broueht  to  the  hospital  complaining  of  severe  left  fronto- 
temporal  headache  which  had  persisted  since  the  injury. 
On  admission,  he  showed  alternate  periods  of  drowsiness 
and  restiveness  but  was  able  to  cooperate  and  to  answer 
questions  intelligently.  There  was  an  extensive  contusion 
over  the  left  frontal  region  surrounded  by  a  zone  of  edema. 
The  pupils  were  equal  and  reacted  to  light  and  accommo- 
dation. The  neurological  examination  disclosed  no  abnor- 
mal signs.    The  cerebrospinal  fluid  was  slightly  tinged  with 


blood  and  was  under  a  pressure  of  28  mm.  Hg. 

Twelve  hours  after  admission  and  28  hours  after  the 
injury,  the  patient  was  still  very  drowsy  and  complaining 
of  a  severe  left  frontal  headache.  His  pulse,  which  wai 
120  on  admission,  had  slowed  to  60.  Extensive  subcutane- 
ous ecchymosis  appeared  both  anteriorly  and  posteriorly 
to  the  left  ear.  At  this  time,  the  presence  of  a  right  hemi- 
paresis  was  first  observed,  was  most  severe  in  the  right 
face  and  the  right  upper  extremity.  The  deep  reflexes  still 
remained  equally  active  on  the  two  sides  but  an  equivocal 
Babinski's  sign  was  demonstrable  on  the  right.  The  ab- 
dominal reflexes,  present  on  admission,  were  now  absent 
bilaterally.  The  pupils  remained  equal.  Because  of  this 
clinical  course,  an  intracranial  hematoma  was  suspected 
and  air  studies  were  carried  out,  52  hours  after  the  injury. 
At  this  time,  102  c.c.  of  cerebrospinal  fluid  contaminated 
with  blood  was  fractionally  removed  and  replaced  by  an 
equal  quantity  of  air.  The  roentgenographic  films  showed 
an  extensive  vault  fracture  crossing  the  course  of  the  left 
middle  meningeal  artery.  There  was  slight,  if  any,  dis- 
placement of  the  cerebral  ventricular  system.  There  was 
no  untoward  sign  or  symptom  following  the  air  injection. 
Twenty-four  hours  later,  the  patient  was  more  alert  and 
his  headache  was  much  less.  Over  a  period  of  four  days, 
the  headache  gradually  disappeared  and  the  right  hemi- 
paresis  steadily  improved.  Fifteen  days  after  admission, 
the  patient  signed  his  release  from  the  hospital,  at  which 
time  he  was  free  of  headache  and  the  left-face  and  left- 
arm  weakness  was  very  slight. 

Comment:  Here  again  we  have  the  classical 
story  of  an  epidural  hematoma.  Without  air  stud- 
ies, surgical  exploration  would  have  been  indicat- 
ed. By  comparing  case  7,  which  ran  a  very  similar 
clinical  course,  one  can  appreciate  the  difference  in 
the  possible  reaction  which  may  occur  following 
encephalography.  One  must  be  prepared  to  carry 
out  a  surgical  procedure  immediately  after  the  air 
studies  if  operation  is  indicated. 

Summary 

1.  The  clinical  picture  of  subdural  hematoma  is 
varied,  atypical  and  may  simulate  almost  any  cere- 
bral disease.  Oftentimes  it  is  impossible  to  make 
the  diagnosis  on  the  history  and  the  physical  find- 
ings. In  such  case  air  studies  clearly  localize  the 
lesion. 

2.  Illustrative  case  histories  have  been  cited  to 
demonstrate  the  value  of  encephalography  in  the 
diagnosis  of  subdural  hematoma. 

3.  It  is  to  be  remembered  that  encephalography 
is  not  without  risk  and  not  infrequently  untoward 
effects  are  produced  by  air  studies  which  necessi- 
tate immediate  operation.  Therefore  it  should  be 
strongly  emphasized  that  patients  subjected  to  en- 
cephalographv  should  be  prepared  for  surgery  im- 
mediately after  interpretation  of  the  roentgen 
films. 

— Medical    Arts    Building. 

Discussion 
Dr.   Addison    Brenizer,   Charlotte: 

I  am  doing  exactly  what  my  wife  told  me  not  to  do 
that   is  have  anything  to  say  at  this  meeting. 

I    am    prompted    to    say    something    for    two    reasons: 


April   19<11 


ENCEPHALOGRAPHY   OF  SUBDURAL   HEMATOMA— Pitts 


193 


One.  to  commend  Dr.  Pitts  on  his  paper  and  to  remark 
that  his  encephalography  is  almost  too  good  to  be  true. 
The  ventricles  are  so  well  outlined  that  I  should  say 
that  the  air  had  first  been  injected  into  the  ventricles, 
to  pass  by  the  foramina  of  Monro  to  the  third  ventricle, 
through  the  acqueduct  of  Sylvius  to  the  fourth  ventricle 
and  thence  through  the  foramina  of  Magendie  and 
Retzius  over  the  spaces  of  the  arachnoid.  It  is  true, 
that  the  ventricles  can  be  filled  by  withdrawing  ISO  c.c. 
of  fluid  by  lumbar  puncture  and  then  air  be  injected 
in  the  reverse  order  through  the  arachnoid  into  the  ven- 
tricles by  lumbar  puncture.  But  usually,  the  ventricles 
are  not  so  well  defined. 

However,  the  pictures  are  well  defined  for  encephal- 
ography, and  the  paper  has  been  well  given,  in  proving 
the  presence  of  a  subdural  hematoma.  My  second  reason 
for  talking  is  prompted  by  the  presence  of  Dr.  Barker. 
I  am  startled  to  be  minded  of  the  fact  that  Dr.  Barker 
taught  me  medicine  thirty-six  years  ago,  and  he  was 
grown-up  at  the  time  he  did  it.  He  looks  as  well  and 
vigorous  as  he  ever  did.  You  would  think  he  were  my 
junior,    wouldn't    you  ? 

Dr.   P.    B.    Parsons,   Charlotte: 

I  have  very  little  to  add  to  the  paper  or  to  the  dis- 
cussion you  have  just  heard.  I  would  like  to  say  that  the 
plain  plate  often  gives  a  very  important  point  in  the 
diagnosis  of  these  cases  and  may  do  away  with  air  in- 
jections because  the  pineal  body  is  often  picked  up  dis- 
placed to  one  side  or  the  other  from  the  midline.  Oc- 
casionally, in  the  presence  of  large  hematoma  or  mass, 
the  plain  film  will  show  some  increase  in  density  on  the 
affected  side  or  the  presence  of  a  fracture  line. 

I'd  like  to  mention  ventriculography  versus  encepha- 
lography. I  believe  a  case  should  be  gone  into  very 
carefully  before  attempting  a  spinal  puncture  because  of 
the  danger  of  spinal  puncture  in  increased  intracranial 
pressure. 

There  is  one  other  method  of  diagnosis  in  these  cases 
or  any  other  case  of  intracranial  lesion  and  that  is  the 
administration  of  opaque  material  into  the  arterial  sys- 
tem. The  technic  is  very  difficult  and  is  not  in  general 
usage.  It  consists  of  the  injection  of  thorotrast  into  the 
carotid  artery  with  films  taken  immediately  following. 
The  normal  side  must  be  viewed  as  well  as  the  abnormal 
so  that  the  various  positions  of  the  major  vessels  can 
be  contrasted. 

As  far  as  the  roentgen  diagnosis  is  concerned,  after 
the  placing  of  the  air  in  the  ventricular  system,  the  method 
of  diagnosis  is  the  same  as  that  used  in  the  diagnosis 
of  any  other  intracranial  lesion.  This  is  done  by  vis- 
ualizing the  displacement  of  the  ventricles  and  by  noting 
any  defects  in  them. 

Dr.  Howard  Masters  Richmond:  I  certainly  want  to 
thank  Dr.  Pitts  for  his  very  excellent  discussion  and  his 
encephalographic  slides.  I  feel  that  whenever  we  have  a 
head  injury  and  within  a  few  days  progressive  signs  ot 
increased  intracranial  pressure  and  a  little  later  on  nerve 
involvement,  we  must  use  our  diagnostic  procedures, 
though  do  so  cautiously.  Now  in  some  of  these  cases 
the  onset  of  progressive  symptoms  comes  rather  soon,  with- 
in several  days  to  several  weeks.  In  others  there  are  only 
slight  changes,  such  as  in  personality,  and  these  may  per- 
sist for  many  months  before  the  real  effect  of  the  sub- 
dural hemorrhage  is  apparent.  I'd  like  to  mention  a  case 
of  that  nature. 

A  woman  in  her  early  fifties  fell  on  the  ice  and  struck 
the  back  of  her  head,  was  unconscious  for  an  hour  or  two 
but  in  a  few  days  was  up  again  and  no  particular  signs 
were  then  noted.     In  several  months  it  was  observed  that 


she  was  not  as  alert  as  previously.  In  about  eighteen 
months  she  began  to  lose  her  appetite  and  to  talk  less. 
At  the  end  of  two  years  she  was  sent  in  to  the  hospital  as 
a  psychotic  patient,  refusing  to  eat  and  refusing  to  talk. 
On  examination  we  found  this  patient  almost  in  a  state 
of  amentia.  In  the  course  of  three  weeks  she  said  two 
or  three  words.  She  followed  individuals  around  the  room 
with  her  eys  in  an  inquiring  manner  just  as  an  infant  of 
three  or  four  months  might  do.  When  given  objects, 
she  would  not  always  know  what  to  do  with  them  and  on 
neurological  examination  she  had  nothing  but  a  babinski 
sign  on  the  right  side.  She  was  awkward  in  her  movements 
and  in  her  gait.  Encephalography  revealed  very  inter- 
esting things.  On  the  right  side  the  ventricle  was  enlarged 
and  pushed  to  the  left ;  the  left  was  about  normal  in  size 
but  also  pushed  to  the  left.  In  other  words,  there  was  a 
compression  of  the  right  hemisphere  of  50%  or  more  and 
evidence  of  pressure  to  the  left.  It  was  not  a  pure 
atrophy  of  the  brain,  but  we  had  a  compression  of  the 
brain  with  pressure  to  the  left.  On  operation  the  hema- 
toma had  become  a  cyst.lt  was  evacuated  and  after  three 
months  the  patient  began  to  show  definite  improvement. 
We  see  minor  cases  of  head  injury,  just  ordinary  simple 
concussion  types  who  may  go  for  several  days  without 
headache  or  other  symptoms  and  then  have  progressive 
headache  for  a  few  weeks.  Lumbar  puncture  may  not 
reveal  any  evidence  of  blood.  Frequently  relief  from 
test  puncture  and  some  dehydration  may  be  sufficient  to 
clear  up  that  type  of  case  without  other  procedure. 

Dr.  Parsons:  I'd  like  to  say  that  when  I  brought  the 
point  up  in  reference  to  filling  the  ventricles,  they  will 
fill  equally  well  by  either  method  (Encephalography 
or  Ventriculography).  My  point  was  that  indiscriminate 
spinal  puncture  in  cases  of  increased  intracranial  pressure 
might  well  give  rise  to  untoward  symptoms  and  should 
not  be  attempted  casually. 

Dr.  Pitts  (closing) :  Mr.  Chairman,  I  want  to  thank 
Doctors  Brenizer,  Masters  and  Parsons  for  their  discussion 
and  comments. 

Ventriculography  consists  of  placing  burr  holes  in  the 
parieto-occipital  regions  and  injecting  air  directly  into  the 
lateral  ventricles  of  the  brain  and  thereby  filling  the  ven- 
tricular system.  Usually  by  this  procedure  one  does  not 
inject  enough  air  to  force  it  out  through  the  foramina  of 
Magendie  and  Luschka  into  the  cerebral  subarachnoid 
spaces.  That  is  ventriculography,  and  it  is  used  chiefly  in 
localizing  brain  tumors  or  any  other  space-occupying  lesion 
of  standing  long  enough  to  cause  papilledema. 

Encephalography  consists  of  replacing  the  cerebrospinal 
fluid  with  air  by  means  of  withdrawing  the  fluid  and  in- 
jecting the  air  by  the  lumbar  route.  This  procedure  should 
not  be  used  in  the  presence  of  papilledema.  With  ventric- 
ulography one  can  outline  the  lateral  ventricles,  the  third 
ventricle  and  the  fourth  ventricle  and  with  encephalogra- 
phy one  also  demonstrates  the  surface  cortical  marking  of 
the  cerebral  subarachnoid  space.  All  the  slides  I  have 
shown  you  were,  encephalographic  films.  Put  several  of 
them  on  the  screen,  please. 

In  ventriculography,  one  must,  of  necessity,  make  burr 
holes  in  the  back  of  the  head  to  inject  air  directly  into 
the  ventricles.  This  air  was  all  injected  through  the  lum- 
bar route.  On  no  slide  do  you  see  a  burr  opening  left  by 
the  making  of  a  ventriculogram. 

(SLIDE)     You  can  see  no  burr  holes  whatsoever.   If  it 
had   been   ventriculography,   the   bone  would  have  a  burr 
hole  here  and  here  and  here  (indicating).   These  ventricles 
were  all  filled  by  air  injected  via  the  lumbar  route. 
I  PITTS— p.  216  J 


SOUTHERN  MEDICINE  £r  SURGERY 


April  1941 


Postoperative  Distention* 

Irwin   Grier  Linton,  M.D.,  Charleston 


DISTENTION  of  the  intestines,  of  the  uri- 
nary bladder,  or  of  both,  after  operation, 
is  of  as  painful  interest  to  the  patient  as 
it  is  of  scientific  concern  to  the  surgeon.  Sleepless 
nights  of  watching  and  trying  to  relieve  patients 
whose  abdomens  were  balloon-like  stimulated  my 
interest  in  the  subject  during  a  junior  internship  in 
1932.  Why  one  patient  should  have  a  smooth  post- 
operative course  and  another  should  have  a  stormy 
one  was  a  question  to  which  there  seemed  to  be  no 
answer. 

The  answer,  if  found,  is  a  many-sided  one.  The 
general  condition  of  the  patient;  the  size  of  the 
incision  necessary  for  performing  the  operation; 
the  handling  of  tissues  and  especially  the  intes- 
tines, are  some  of  the  influencing  factors.  The 
depth,  length  and  type  of  the  anesthesia  also  play 
a  part.  Proper  preoperative  and  postoperative  care 
are  of  importance  in  preventing  postoperative  dis- 
tention. 

However,  of  the  many  factors  which  influence 
distention,  only  the  use  of  prostigmin  methylsul- 
fate  will  be  discussed  in  this  report. 

This  drug  was  first  synthesized  in  1931.  It  is 
commonly  referred  to  as  a  cholinergic,  and,  in  the 
older  nomenclature,  a  vagotonic;  drug.  Unlike  eser- 
ine,  its  homologue  in  nature,  prostigmin,  in  thera- 
peutically effective  doses  does  not  give  rise  to  dis- 
turbances of  the  eye  or  of  the  circulatory  and  res 
piratory  systems,  nor  has  it  a  toxic  irritating  influ- 
ence on  the  spinal  cord  and  brain.  By  blocking 
the  acetylcholine-destructive  action  of  cholinester- 
ase,  prostigmin  maintains  and  restores  normal  im- 
pulse conduction.  One  of  the  theories  explaining 
the  action  of  prostigmin  is  that  it  blocks  the  activ- 
ity of  cholinesterase  and  thus  permits  acetylcho- 
line to  perform  its  normal  physiologic  function  of 
carrying  the  impulse  across  the  synapses  and 
myoneural  junctions  of  the  parasympathetic  sys- 
tem, as  well  as  the  preganglionic  junctions  of  the 
sympathetic  system. 

The  first  series  of  patients  to  be  here  reported 
were  operated  on  from  July,  1935,  to  July,  1936. 
In  all  of  these  cases  prostigmin  was  given  pre- 
operatively  and  postoperatively  in  an  effort  to  pre- 
vent the  development  of  distention.  The  manufac- 
turer kindly  supplied  the  necessary  medicine  for 
this  study.  The  104  cases  were  all  gynecological 
laporatomies  performed  by  the  writer.    The  con- 

•Presented  to   the   meeting  of  the   Tri-State   Medical   Association 
24th  and  25th. 


trols  were  patients  operated  upon  by  the  chiefs  of 
the  gynecological  service,  which  gave  the  control 
group  the  advantage  of  experienced  operators. 

The  schedule  for  giving  the  drug  was  simple.  For 
twenty-four  hours  before  operation,  1  c.c.  of  1- 
4000  solution  of  prostigmin  methylsulfate  was  in- 
jected everv  six  hours.  Following  operation,  1  c.c. 
of  the  same  solution  was  given  every  five  hours 
and  continued  for  thirty-six  to  seventy-two  hours, 
depending  on  the  individual  case. 

There  were  104  treated  cases,  and  in  90  there  was 
no  distention.  In  1 1  cases  slight  to  moderate  disten- 
tion occurred,  and  in  these  the  1-2000  solution  of 
prostigmin,  rectal  tube,  et  cetera,  afforded  relief. 
Only  three  of  this  series,  and  they  were  difficult 
cases,  required  gastric  suction  in  addition  to  the 
prostigmin.    There  were  no  deaths  in  this  series. 

These  patients  were  generally  brighter  and  more 
comfortable,  but  a  few  complained  of  pain  from 
the  peristaltic  action  produced  by  the  injections. 
It  is  difficult  in  the  average  case  to  say  that  one 
patient  is  distended,  and  that  another  is  not.  How- 
ever, with  the  control  in  the  bed  beside  the  treated 
case,  it  is  easier  to  get  a  reliable  impression.  This 
series  was  convincing  as  to  the  beneficial  effects  of 
the  pre-  and  postoperative  therapy,  especially  in 
cases  which  presented  any  technical  difficulty. 

It  is  regretted  that  no  figures  were  kept,  but  the 
observation  was  made  at  the  time  of  the  study 
that  very  few  of  the  treated  cases  required  cath- 
eterization. This  feature  of  the  drug  had  not,  to 
our  knowledge,  been  reported  at  that  time,  and  we 
missed  a  scoop  by  not  publishing  it.  Since  then, 
this  effect  of  the  drug  has  been  used  to  advantage 
in  cases  in  which  difficulty  in  voiding  developed 
after  operation. 

The  ordeal  of  being  catheterized  many  remem- 
ber as  the  most  painful  experience  incident  to  an 
operation,  and  urinary-tract  infection  by  catheteri- 
zation is  a  constant  danger.  Consequently,  the 
beneficial  effect  of  prostigmin  on  the  patient  who 
is  unable  to  void  is  felt  to  be  of  prime  impor- 
tance. 

By  careful  operative  technique,  careful  selection 
of  the  anesthetic  agent  and  adequate  postoperative 
rest  of  the  gastrointestinal  tract,  distention  of  this 
system  can  usually  be  prevented.  On  the  other 
hand,  postoperative  urinary  difficulty  often  looms 
up  unexpectedly. 

of    the    Carolinas    and    Virginia,    held    at    Greensboro,    February 


April    1941 


POSTOPERATIVE   DISTENTION— Linton 


19S 


Of  25  private  patients  who  were  unable  to  void 
following  abdominal  operation,  only  three  (12%) 
required  catheterization  after  the  use  of  prostig- 
min.  These  were  cases  in  which  no  prostigmin  had 
been  given  before  operation,  and  the  postopera- 
tive injections  were  made  after  bladder  distention 
had  begun  and  the  usual  methods  used  to  stimu- 
late voiding  had  failed. 

This  action  of  prostigmin  has  been  used  to  ad- 
vantage in  obstetrical  cases  also.  As  a  result  of 
long  or  difficult  labor,  or  for  no  obvious  reason,  a 
few  women  are  unable  to  void  after  delivery.  In 
these,  this  drug  is  of  value.  Of  seven  obstetrical 
patients  who  were  unable  to  void  following  deliv- 
ery, four  were  given  two  injections  of  1-2000  so- 
lution of  prostigmin  and  were  able  to  void;  in  one, 
three  injections  were  required;  and  in  one,  cathe- 
terization was  necessary.  In  this  last  case,  the 
bladder  was  distended  before  the  drug  was  started 
and  delay  in  relieving  the  pressure  was  not  thought 
to  be  wise;  so  resort  was  had  to  catheterization. 

One  case  in  this  group  will  be  reported  briefly 
because  of  the  relief  given,  this  the  first  of  the 
writer's  patients  to  be  given  prostigmin  for  blad- 
der distention. 

This  patient  was  delivered  of  her  first  baby,  a  9-pound 
boy,  in  1936,  on  the  West  Coast,  when  she  had  to  be 
catheterized  for  18  days  postpartum  before  she  was  able 
to  void  spontaneously.  I  delivered  her  second  child,  an 
8^8-pound  girl,  in  1939.  She  had  nembutal  as  an  analgesic, 
and  the  delivery  was  performed  under  nitrous  oxide-oxy- 
gen anesthesia,  by  episiotomy  and  low  forceps  after  man- 
ual rotation  of  the  head.  Following  delivery,  she  was  un- 
able to  void  after  all  of  the  usual  tricks  had  been  tried;  so 
the  catheter  was  used.  Remembering  the  postoperative 
effect  on  the  bladder  observed  in  the  series  just  reported, 
prostigmin  1-2000  solution  was  given  every  three  hours, 
and  there  was  no  further  urinary  difficulty. 

On  the  strength  of  the  results  in  these  cases  it  is 
now  routine  procedure  to  give  prostigmin  if  the 
patient  even  threatens  to  have  difficulty  in  voiding. 
The  method  of  administration  is  simple  and  safe. 
One  ampule  of  1  c.c.  of  the  1-2000  solution  is 
given  as  soon  as  difficulty  arises  or  can  be  antici- 
pated. In  many  patients  this  in  conjunction  with 
local  maneuvers  is  sufficient.  If  the  patient  does 
not  void  in  45  to  60  minutes  the  content  of  an- 
other ampule  is  given.  In  some  cases  catheteriza- 
tion will  be  necessary  because  distention  of  the 
bladder  has  become  extreme.  However,  by  giving 
the  drug  every  three  to  four  hours  for  24  hours 
or  more,  repetition  of  catheterization  is  usually 
obviated. 

It  has  been  found  that  good  results  may  be  ex- 
pected from  the  giving  of  prostigmin  every  three 
hours  for  a  few  doses  until  there  is  satisfactory 
emptying  of  the  bladder;  then  lengthening  the 
time  between  injections  to  four,  five  or  six  hours. 


Conclusions 

The  following  conclusions  have  been  reached  as 
a  result  of  this  study  of  104  consecutive  gynecol- 
ogical laporatomies,  and  operations  upon  or  deliv- 
eries of  selected  private  patients  since  1935. 

Pre-  and  postoperative  prophylactic  use  of  pros- 
tigmin 1-4000  decreases  postoperative  intestinal 
distention  and  enables  the  patient  to  void  earlier, 
eliminating  the  necessity  for  catherization  in  most 
cases. 

Postoperative  use  of  prostigmin  1-2000  solution 
is  of  value  in  maintaining  the  muscular  tone  of 
intestines  and  bladder  when  it  is  feared  distention 
may  develop. 

The  therapeutic  use  of  prostigmin  is  of  great 
value  in  overcoming  already-developed  intestinal 
distention. 

Finally,  the  use  of  prostigmin  in  obstetrical  and 
surgical  patients  who  are  unable  to  void  is  justi- 
fied, in  that  it  will  usually  obviate  all  need  for 
catheterization. 

Discussion 

Dr.  Charles  Stanley  White,  Washington:  Members 
of  the  Tri-State  Society:  Whether  you  are  the  operated-on 
or  the  operator,  this  is  a  question  of  considerable  impor- 
tance. I  do  not  know  which  is  more  important.  Any  drug 
which  will  reduce  the  amount  of  distention  and  the  ne- 
cessity for  catheterization  is  an  important  one.  Dr.  Lin- 
ton's figures  show  that  he  has  accomplished  something.  A 
few  years  ago  an  intern  in  Washington  became  interested 
in  this.  He  later  went  to  New  York  and  recently  pub- 
lished an  article  on  this  condition  bearing  out  very  much 
as  Dr.  Linton  has  just  said,  that  75  per  cent  of  all  major 
operations  are  followed  by  distention.  This  distention  is 
difficult  to  measure  in  centimeters  or  in  any  other  way. 
After  the  use  of  prostigmin  preoperatively  as  well  as  post- 
operatively— we  feel  that  preoperative  use  is  just  as  im- 
portant as  postoperative  use — the  best  results  are  obtained 
from  the  combination  of  the  two.  If  you  can  reduce  the 
amount  of  distention,  you  have  perhaps  saved  the  patient 
some  damage  to  the  musculature  of  the  bowels,  possibly 
some  permanent  damage.  If  you  can  prevent  the  neces- 
sity for  catheterization,  you  may  have  saved  him  from  in- 
fection. You  have  made  the  patient  more  comfortable. 
You  have  reduced  the  mortality  and  the  morbidity. 

Prostigmin  will  not  take  the  place  of  proper  prepara- 
tion of  patients.  Sometimes  patients  are  sent  in  late  at 
night  before  the  operation,  or  even  on  the  day  of  opera- 
tion. That  is  a  pernicious  practice.  It  is  done  for  economic 
reasons  on  occasions  but  it  is  certainly  not  to  the  interest 
of  the  patient  to  be  operated  on  a  few  hours  after  admis- 
sion. A  patient  should  be  admitted  the  day  before.  Food 
elimination  and  the  proper  mental  state  contribute  to 
good  convalescence.  I  do  not  think  prostigmin  or  any 
other  drug  can  take  the  place  of  those  things.  Bad  anes- 
thesia, bad  preparation  of  the  patient  and  sometimes  in- 
aptitude of  the  operator,  are  all  factors  to  take  into  con- 
sideration when  we  talk  about  reducing  postoperative 
distention.  No  single  drug  will  take  the  place  of  good 
surgery. 

Dr.  George  Dawson,  Charleston:    Mr.  President,  Mem- 
bers  of   the   Tri-State   Medical   Association:     I   appreciate 
this  paper  greatly.    We  do  run  into  postoperative  disten- 
Dawson — p.    216 


SOUTHERN  MEDICINE  &  SURGERY 


April   1941 


Some  Underlying  Factors  in  Edema  and  Their 
Clinical  Implications 

William  H.  Higgins,  M.  D.,  Richmond 


ONE  OF  THE  difficult  problems  in  the 
practice  of  medicine  is  an  understanding 
of  the  physiologic  background  of  many  of 
our  clinical  observations.  Medicine  has  made  such 
unprecedented  advances  in  laboratory  procedures 
that  there  is  often  a  lag  between  the  establishment 
of  a  scientific  fact  and  its  application  to  the  treat- 
ment of  the  patient.  Unless  there  is  brought  out 
from  time  to  time  a  correlation  of  this  newer 
knowledge  with  our  clinical  problems  much  will 
be  lost  in  the  satisfaction  as  well  as  the  value  of 
applying  these  principles  in  our  daily  routine.  The 
subject  of  edema  is  illustrative  of  this  point. 

Water  normally  constitutes  about  70  per  cent  of 
the  weight  of  the  body.  The  quantitative  relation- 
ship between  the  great  fluid  compartment  of  the 
body  and  the  chief  avenues  of  water  absorption 
and  excretion  make  an  impressive  figure.  Mainte- 
nance of  a  normal  volume  of  fluid  in  the  vascular 
compartment  is  much  more  important  than  in  the 
interstitial  space.  Consequently  an  increase  in 
volume  of  the  extracellular  fluid  constituting  a 
state  of  edema  is  usually  accomplished  entirely  by 
expansion  of  the  interstitial  space:  on  the  other 
hand  loss  of  plasma  water  as  a  result  of  dehydra- 
tion is  usually  made  up  by  the  passage  of  intersti- 
tial fluid  into  the  vascular  compartment. 

The  avenues  of  intake  and  elimination  of  water 
are  now  well  established  and  require  no  elabora- 
tion- Water  is  supplied  to  the  body  by  ingestion 
of  liquids  and  solids.  The  normal  quantitative 
turnover  of  water  in  the  individual  is  enormous, 
reaching  at  times  to  16,000  c.c-  in  a  period  of  24 
hours;  much  of  which  is  due  to  secretion  and 
reabsorption.  According  to  Landis,  the  total  area 
of  capillary  endothelium  in  the  adult  individual 
may  be  visualized  as  a  microscopically  thin  mem- 
brane three  feet  wide  and  more  than  four  miles 
long.  This  enormous  filtration  surface  obviously 
facilitates  the  extremely  rapid  interchange  of  fluid 
between  the  vascular  and  the  interstitial  fluid  com- 
partments. 

Factors  Concerned  in  Edema  Formation 
The   normal   interchange   of   fluid    between   the 
vascular  compartment  and  tissue  spaces  depends 
largely  upon  four  factors: 

(1)  The  capillary  blood  pressure 

(2)  The  colloid  osmotic  pressure  of  the  blood 
plasma 


(3)  The  relative  impermeability  of  the  capil- 
lary wall  to  protein  and  its  free  permeabil- 
ity to  water  and  most  electrolytes 

(4)  The  lymphatic  circulation. 

Due  to  one  or  more  of  these  factors  edema  de- 
velops. 

( 1 )  The  Capillary  Blood  Pressure. — It  has  been 
estimated  that  the  average  pressure  at  the  arterial 
end  of  the  capillary  is  35,  at  the  venous  end 
13,  mm.  of  mercury.  Under  average  normal  con- 
ditions the  balance  between  the  opposing  forces  of 
capillary  blood  pressure  and  colloid  osmotic  pres- 
sure exerted  by  the  plasma  proteins  (average  25 
mm.  Hg.)  is  such  that  the  former  exceeds  the  lat- 
ter at  the  arteriolar  end  of  the  capillary,  and  the 
latter  exceeds  the  former  at  the  venous  end.  As  a 
result  of  this  pressure  gradient,  the  passage  of 
fluid  toward  the  interstitial  compartment  is  favor- 
ed in  the  arteriolar  portion  of  the  capillary  and 
toward  the  vascular  compartment  in  the  venous 
portion. 

Abnormal  increases  in  capillary  blood  pressure 
capable  of  producing  edema  may  result  from — 

(a)  Increased  venous  pressure 

(b)  Arteriolar  dilatation. 

Increased  capillary  pressure  due  to  arteriolar 
increased  capillary  pressure,  has  been  generally  re- 
garded as  one  of  the  most  important  factors  in- 
volved in  the  production  of  edema  in  congestive 
heart  failure-  This  increase  is  dependent  upon  a 
number  of  factors.  Among  these  factors  are  venous 
stasis  and  increased  intrapleural  pressure  due  to 
hyperpnea  and  to  pulmonary  congestion- 
Increased  capillary  pressure  due  to  anteriolar 
vasodilatation  is  seldom  responsible  for  edema; 
however,  mild  edema  may  result  in  hot  weather. 
Placing  the  hand  in  warm  water  may  bring  about 
sufficient  dilatation  to  cause  swelling.  Sometimes 
in  a  hemiplegic  edema  develops  as  a  result  of  the 
vasodilatation  secondary  to  nerve  damage. 

(2)  Colloid  Osmotic  Pressure  of  Plasma — The 
important  part  played  by  hypoproteinemia  with 
consequent  decrease  in  the  colloid  osmotic  pressure 
of  plasma  in  the  pathogenesis  of  edema  is  now  well 
established.  It  is  stated  that  edema  develops  when 
the  plasma  protein  concentration  falls  below  5  Gm. 
per  100  c.c.  and  the  albumin  concentration  below 
2  Gm.  The  plasma  albumin  is  much  more  impor- 
tant than  globulin  in  this  connection  because  of 


April    1941 


UNDERLYING  FACTORS  IN  EDEMA— Higgins 


the  smaller  size  of  its  molecule.  These  proteins 
have  been  more  recently  subdivided  into  a  number 
of  smaller  fractions  and  some  doubt  has  been  cast 
on  the  specificity  of  a  reversal  of  the  albumin- 
globulin  ratio  in  isolated  instances,  but  its  practi- 
cal application  to  the  average  case  is  still  of  value. 

Hypoproteinemia  may  result  from  malnutrition, 
or  excessive  loss  of  protein  from  the  body.  It  also 
is  a  common  manifestation  of  certain  types  of 
renal  disease;  e.g.,  nephrotic  syndrome  and  some 
forms  of  chronic  nephritis.  The  phenomenon  is 
generally  attributed  to  loss  of  protein  in  the  urine 
or  inadequate  protein  intake.  The  role  of  the  pro- 
teins in  the  maintenance  of  the  osmotic  pressure  of 
the  circulating  blood  is  well  established.  Chronic 
protein  deficiency  leads  to  edema  and  a  tendency 
to  circulatory  collapse.  In  conditions  associated 
with  protein  loss,  such  as  in  pleural  and  peritoneal 
exudates  requiring  repeated  taps,  particular  effort 
should  be  made  to  reestablish  the  normal  protein 
content  by  means  of  an  adequate  diet-  Closely  re- 
lated to  this  deficiency  state  is  the  so-called  beri- 
beri heart,  produced  by  a  lack  of  vitamin  B  and 
frequently  found  in  chronic  alcoholics.  There  is  a 
marked  dilatation  of  the  right  ventricle,  with 
dyspnea,  edema  and  general  weakness. 

This  syndrome  is  not  due  to  the  effect  of  alcohol 
per  se,  but  is  the  result  of  an  unbalanced  diet 
arising  from  the  chronic  use  of  this  beverage.  It 
has  been  shown  that  the  signs  of  beri  beri  in  alco- 
holics can  be  relieved  by  supplying  the  proper 
vitamins  without  withholding  the  alcohol. 

In  this  connection  edema  sometimes  appears  as 
an  annoying  complication  following  a  variety  of 
surgical  procedures.  The  factor  of  dietary  protein 
restriction  is  of  fundamental  importance.  Up  to  a 
certain  stage  the  nutritional  values,  the  deficiency 
of  protein  in  the  diet,  can  be  made  up  by  increas- 
ing the  intake  of  carbohydrates;  but  there  comes 
a  time  when,  as  a  result  of  protein  restriction,  tis- 
sue wastage  occurs  regardless  of  the  intake  of  car- 
bohydrates and  fat.  As  the  plasma-protein  concen- 
tration is  reduced  the  circulating  fluid  begins  to 
leave  the  vessels,  and  we  have  first  a  latent,  and 
later  an  evident,  tissue  edema.  This  point  acquires 
particular  clinical  significance  in  patients  with 
chronic  gastrointestinal  disturbances  who  are  fre- 
quently victims  of  protein  undernutrition  before 
and  after  operation.  To  this  handicap  is  often 
added  the  excessive  administration,  post-operative- 
ly,  of  fluid  and  salt  solution,  with  often  a  resulting 
edema.  Such  edema  necessarily  interferes  with  the 
healing  of  wounds  and  impairs  the  function  of  cer- 
tain vital  organs. 

It  is  understood  that  not  infrequently  the  newly 
provided  stoma  following  gastroenterostomy  may 
become  so  edematous  as  to  prevent  normal  empty- 


ing of  the  stomach.  According  to  Ravdin  gastric 
resection  and  anastomosis  can  not  be  performed 
without  causing  edema  at  the  site  of  operation.  In 
delayed  emptying  it  is  believed  by  him  that  the 
continued  edema  is  more  frequently  responsible  for 
failure  of  the  stomach  to  empty  after  operation  of 
the  Billroth,  type  one  or  type  two,  than  are  any 
technical  defects  of  the  anastomosis.  In  cases  of 
this  type  studied  at  the  Massachusetts  General 
Hospital  by  Jones  and  Eaton,  it  was  shown  that  as 
a  rule  the  patients  came  to  operation  because  of 
some  gastrointestinal  lesion  and,  with  the  further 
postoperative  restrictions  imposed  by  the  nature 
of  the  operation,  edema  developed.  The  use  of 
normal  saline  solution  in  these  patients  further 
augmented  the  swelling. 

The  following  case  history  is  illustrative  of  this 
point: 

A  67-year-old  white  woman  entered  St.  Elizabeth's  Hos- 
pital on  March  14th,  1940,  with  a  diagnosis  of  multilocular 
pseudomucinous  cystadenoma  of  the  right  ovary.  At  oper- 
ation a  63-pound  cyst  containing  more  than  four  gallons 
ol  fluid  was  removed.  From  the  beginning,  nausea  and 
vomiting  were  prominent  features,  necessitating  the  fre- 
quent intravenous  use  of  dextrose  solution.  During  the 
course  of  her  prolonged  postoperative  convalescence  evi- 
dences of  intestinal  obstruction  appeared,  for  which  a  tube 
gastrostomy  and  two  enterosomies  were  made,  which  add- 
ed to  her  digestive  difficulties.  A  generalized  edema  devel- 
oped at  which  time  her  globulin  was  2.6,  her  albumin  1.8. 
Special  protein  mixtures  were  introduced  and  within  three 
or  four  days  her  swelling  disappeared  although  her  condi- 
tion otherwise  was  stationary  and  she  made  a  satisfactory 
recovery. 

There  has  been  much  speculation  concerning  the 
cause  of  hypoproteinemia  and  edema  in  normal 
pregnancy.  Hydremia  or  plasma  dilution  resulting 
from  increased  plasma  volume  has  been  regarded 
as  an  important  factor.  Recent  studies  by  Melnick 
and  Cowgill  throw  light  upon  this  problem-  They 
showed  experimentally  that  the  pregnant  animal 
has  a  very  limited  reserve  of  plasma  protein,  and  a 
greatly  impaired  power  for  regenerating  plasma 
protein.  They  conclude  that  the  synthesis  of  body 
proteins  in  the  fetus  during  pregnancy  and  the 
milk  proteins  during  lactation  are  actually  an  in- 
ternal plasmapheresis  leading  to  a  depletion  of  the 
materials  from  which  this  complex  is  made-  These 
parasitic  effects  on  the  maternal  organism  are  be- 
lieved to  be  of  primary  importance  in  causing  the 
lowering  of  serum  protein  characteristic  of  preg- 
nancy. 

(3)  Increased  Capillary  Permeability  —  The 
normal  impermeability  of  the  capillary  wall  is  rel- 
ative and  not  absolute,  and  under  certain  condi- 
tions even  the  large  protein  molecules  may  pass 
through.  The  capillaries  ordinarily  become  more 
permeable  when  dilated  and  such  dilatation  con- 
stitutes a  third  factor  in  the  development  of 
edema. 


UNDERLYING  FACTORS  IN  EDEMA— Biggins 


April    1941 


Injury,  inflammation  and  extreme  vasodilatation 
may  alter  the  permeability  of  the  capillaries  to 
such  an  extent  that  not  only  proteins  but  also  red 
blood  cells  may  escape  from  the  blood  stream.  In 
acute  nephritis  following  any  one  of  many  infec- 
tions the  capillaries  of  the  glomeruli  and  of  other 
parts  of  the  body,  chiefly  the  dependent  portions, 
frequently  become  hyperpermeable  through  toxic 
processes,  and  edema  results.  Fluids  from  angio- 
neurotic edema  are  associated  with  some  vasomo- 
tor disturbance  which  renders  the  tissue  walls  even 
more  permeable,  thus  facilitating  passage  of  fluids 
into  the  interstitial  spaces.  Other  localized  edemas 
of  toxic  or  allergic  types  are  probably  formed  in 
the  same  manner. 

(3)  Mechanical  Pressure  oj  the  Tissue  Fluids — 
We  are  indebted  to  Landis  and  Gibbon  for  showing 
that  the  rate  of  filtration  of  fluid  into  the  tissues 
during  experimental  venous  congestion  decreases 
progressively  as  edema  develops.  These  investiga- 
tors conclude  that  the  tissue  pressure  may  be  a 
factor  of  importance  in  the  prevention  of  massive 
edema.  This  concept  is  helpful  in  explaining  the 
tendency  of  persons  who  have  lost  weight  to  have 
edema,  and  of  a  patient  with  cardiac  disease  who 
has  once  had  massive  edema  to  have  slight  swell- 
ing of  the  ankles  even  under  the  best  regimen.  In 
such  persons  the  previous  stretching  of  the  tissues 
has  apparently  diminished  their  normal  mechanical 
resistance  to  fluid  accumulation,  and  waterlogging 
of  the  interstitial  tissues  results. 

The  mechanism  of  cardiac  edema  is  chiefly  one 
of  increased  venous  pressure. 

Right-sided  failure  is  practically  always  asso- 
ciated with  a  rise  in  venous  pressure.  This  results 
in  a  damming  of  blood  into  the  capillaries  and  an 
eventual  increase  in  intracapillary  pressure.  Since 
there  is  no  effective  change  in  the  osmotic  pressure 
of  the  blood  there  is  a  marked  outpouring  of  fluid 
into  the  tissues.  This  is  compensated  in  part  by 
faster  lymph  drainage,  but  this  drainage  is  not 
sufficient  to  check  the  filtration.  Given  a  tendency 
to  edema-formation  where  there  is  an  increase  in 
venous  pressure  the  amount  of  fluid  lost  in  the  tis- 
sues will  largely  depend  on  the  sodium  chloride 
intake,  and  obviously  on  the  amount  of  water  in- 
gested. 

Some  patients  with  cardiac  failure  develop  ex- 
tensive edema  without  much  accumulation  of  fluid 
in  the  body  cavities,  whereas  in  others  the  reverse 
is  true-  There  is  evidence  that  the  capillary  per- 
meability varies  in  different  parts  of  the  body; 
e.g.,  that  the  peritoneal  capillaries  are  more  per- 
meable than  those  of  the  extremities.  The  findings 
of  Salvesen  and  Linder  of  a  higher  protein  content 
in  pleural  and  peritoneal  transudates  than  in  ede- 


ma fluid  would  suggest  that  the  capillaries  of  the 
serous  cavities  are  also  relatively  permeable  to 
protein.  Hence  the  osmotic  factors  would  seem  to 
favor  fluid  accumulation  in  the  serous  cavities, 
whereas  gravity  would  favor  accumulation  in  the 
lower  extremities.  It  is  important  to  keep  in  mind 
that  the  location  of  the  edema  has  a  direct  bearing 
on  the  prognosis  of  a  cardiopath.  When  the  swell- 
ing is  limited  to  the  lower  extremities  the  strain 
on  the  heart  is  less  than  when  it  becomes  localized 
in  one  of  the  cavities  or  diffused  throughout  the 
body.  It  is,  therefore,  of  doubtful  value  in  many 
instances  to  keep  such  patients  in  bed  where  the 
relief  of  the  dependent  edema  is  often  followed  by 
a  more  disastrous  pulmonary  congestion. 

The  difficult  type  of  edema  to  evaluate  is  that 
complicated  by  anemia,  a  common  observation  of 
every  clinician.  Addison,  in  1855,  describing  the 
anemia  which  bears  his  name,  wrote  "some  slight 
edema  is  probably  perceived  about  the  ankles." 
This  edema,  at  one  time  ascribed  to  cardiac  weak- 
ness and  more  recently  to  a  lowering  of  the  plasma- 
protein  level,  has  been  shown  to  occur  independ- 
ently of  either.  There  is  no  evidence  that  anemia 
leads  to  altered  capillary  permeability  or  to  venous 
stasis.  In  an  effort  to  solve  this  problem  Fox  and 
Strauss  found  that  when  sodium  salts  were  given 
to  anemic  patients  water  retention  followed,  the 
more  anemic  the  subject  the  greater  the  edema. 
No  satisfactory  explanation  of  this  phenomenon 
has  been  offered.  Apparently  anemia  per  se, 
through  some  unknown  mechanism,  leads  to  a  ten- 
dency to  water  retention. 

The  clinical  import  of  edema  formation  is  ob- 
vious and  an  analytical  study  of  its  mechanism  in 
each  case  gives  a  clearer  understanding  of  a  proper 
therapeutic  approach. 

The  present-day  tendency  to  restrict  proteins  in 
the  dietaries  of  many  chronic  invalids,  the  over- 
zealous  administration  of  glucose  solutions  to  the 
exclusion  of  proper  evaluation  of  the  bodily  re- 
quirements in  certain  gastrointestinal  surgical  con- 
valescents, the  injudicious  use  or  excessive  use  of 
saline  injections,  the  failure  to  recognize  the 
nephrotic  syndrome  and  the  necessity  for  combat- 
ting the  anemias  are  ample  reasons  for  seeking  to 
arrive  at  a  clear  understanding  of  the  mechanism 
of  edema. 

The  author  has  drawn  freely  from  the  following 
contributions: 

1.  Harrison,  T.  R.:    Failure  of  the  Circulation.  1939. 

2.  Canterow,   A.:     Review   of   Recent   Progress  in  Water 
Balance.    Internal.  Clin.,  Vol.  1    March,  1939. 


Cardiac  Failure. — In  the  severe  forms  oxygen  will 
bring  relief  more  promptly  than  it  would  otherwise  be 
brought. — Dry. 


April    1941 


SOUTHERN  MEDICINE  &  SURGERY 


199 


Rotenone  in  the  Treatment  of  Chigger  Disease* 

Paul  L.  Williams,  M.D.,  Sherwood  W.  Barefoot,  M.D., 
J.  Lamar  Callaway,  M.D.,  Durham 


ALTHOUGH  rarely  of  a  serious  character, 
dermatitis  due  to  chigger  infestation  (lar- 
val forms  of  various  species  of  mites  be- 
longing to  the  family  Trombidii)  frequently  brings 
the  victim  to  the  physician  for  relief  of  aggravat- 
ing skin  distress.  In  this  communication  we  wish 
to  report  an  account  of  our  clinical  experience 
with  the  use  of  2  per  cent  rotenone  lotion  as  a 
contact  insecticide  and  effective  agent  in  relieving 
the  local  symptoms  accompanying  chigger-mite 
dermatitis.  This  study  was  made  in  the  Piedmont 
section  of  the  South  where  ample  clinical  material 
is  not  wanting  among  a  rural  population,  many  of 
whom  would  thoroughly  enjoy  the  opportunities 
for  summer  outings,  picnics,  camping  etc.,  save  for 
the  distressing  consequences  from  exposure  to 
chigger  organisms. 

Rotenone,  the  active  principal  of  derris  root, 
was  first  obtained  from  the  tropical  plant,  Derris 
elliptka,  prevalent  on  the  Malay  Peninsula.  It  is 
now  more  commonly  made  from  the  South  Ameri- 
can root  (Lonchocarpus  nicou)  which  averages  a 
rotenone  content  of  approximately  7  per  cent. 
The  root  contains  a  tubotoxin  and  a  series  of  acid 
resins  which  render  it  poisonous  for  lower  forms 
of  life  but  not  for  human  beings.  This  property 
has  made  possible  its  present-day  extensive  appli- 
cation as  a  base  in  the  manufacture  of  sprays  and 
insecticides  for  agricultural  purposes. 

Rotenone  lotion  contains  rotenone  in  a  non-oily, 
emollient,  liquid  vehicle — a  mucilage  prepared 
in  proportions  of  1  per  cent  quince  seed  and  V/i 
per  cent  Irish  moss — to  which  is  added  a  solution 
of  rotenone  dissolved  in  chloroform  of  sufficient 
strength  to  form  a  2  per  cent  lotion.  Appreciable 
absorption  apparently  does  not  occur  from  its 
cutaneous  application.  Ambrose  and  Haag1  were 
unable  to  demonstrate  absorption  of  a  10  per  cent 
derris  ointment  in  lanolin  in  man  and  rats.  Haag1 
administered  a  10  per  cent  rotenone  ointment  in 
petrolatum  to  rabbits  and  guinea  pigs  without  evi- 
dence of  local  irritation  or  absorption.  Dome  and 
Friedman3  have  shown  by  negative  patch  tests  that 
this  substance  is  not  a  contact  irritant.  Patch  tests 
done  by  us  are  in  agreement  with  their  findings. 
Thomas  and  Miller*  have  found  this  drug  to  be  an 
effective  remedy  in  the  treatment  of  scabies  which 


suggested  to  us  its  use  against  chigger  infestation. 
In  our  study  the  lotion  was  made  available  to 
twenty-two  individuals  during  the  summer  months 
of  the  past  year,  selected  on  the  basis  of  history 
of  unusually  aggravating  cutaneous  discomfort 
from  chigger  bites  during  previous  seasons.  The 
majority  had  been  accustomed  to  applying  favorite 
prescriptions  and  proprietary  preparations  upon 
which  they  had  relied  for  relief  in  the  past.  How- 
ever, all  were  eager  to  find  a  remedy  which  would 
improve  on  these  in  their  own  problem,  and  co- 
operation was  readily  obtained.  Diagnosis  was 
made  in  each  instance  by  at  least  two  members  of 
the  dermatological  staff  using  the  criteria  of  his- 
tory of  exposure  along  with  the  presentation  of  the 
familiar  typical  dermatological  picture  of  chigger 
disease.  Our  patients  were  advised  to  confine  use 
of  the  lotion  to  two  applications — the  first  as  soon 
as  the  condition  was  noted,  the  second  twelve 
hours  later. 

All  of  the  twenty-two  cases  reported  some  relief 
from  the  pruritus  within  thirty  minutes,  and  in- 
variably complete  relief  within  twelve  hours  after 
the  initial  application.  Involution  of  lesions  was 
apparent  in  24-48  hours  and  this  was  consistent 
throughout  our  group.  In  two  instances  a  mild 
local  burning  sensation  was  complained  of  which 
persisted  only  for  the  few  minutes  necessary  for 
the  preparation  to  dry  on  the  skin.  Similar  exam- 
ples of  this  were  reported  in  the  article  by  Thomas 
and  Miller  who  attributed  the  effect  to  the  chloro- 
form content  of  the  lotion.  Other  than  for  this 
transient  symptom  the  preparation  was  universally 
well  tolerated.  No  complications  such  as  marked 
excoriations  or  secondary  infection  were  noted. 

We  had  one  patient  whose  hobby  it  was  to  make 
field  trips  three  or  four  times  weekly  for  the  pur- 
pose of  collecting  insects  but  her  ambition  as  an 
entomologist  was  discouraged  by  the  fact  that  she 
was  necessarily  exposed  to  attack  by  chiggers.  For 
a  period  of  three  weeks  she  applied  the  lotion  prior 
to  exposure  and  noted  diminution  in  the  number  of 
lesions  incurred  as  well  as  the  severity  of  the  itch- 
ing, as  compared  to  instances  of  exposure  without 
this  protection. 

From  our  small  experience  with  this  group,  ro- 
tenone lotion  would  seem  to  have  a  distinct  value 


•From   the   Section    of    Dermatology   nnri    Syvhilology    of   the    Department   of    Medi< 
School  of  Medicine,   Durham,   North   Carolina. 


Duke    University 


ROTENONE  IN  CHIGGER  DISEASE— Williams 


April   1941 


in  dermatologic  therapy.  The  physical  and  chem- 
ical characteristics  of  the  preparation  make  it  pos- 
sible to  have  available  an  insecticidal  agent  which 
is  not  messy,  has  no  offensive  odor,  is  not  irritat- 
ing, and  does  not  stain  the  clothing.  These  quali- 
ties would  appear  to  justify  its  preference  over 
many  of  the  present-day  remedies  advised  by  phy- 
sicians and  enumerated  in  dermatological  texts. 
Our  results  would  indicate  the  value  of  further  use 
of  rotenone  lotion  against  parasitic  affections,  and 
would  recommend  its  trial  in  such  cases  where  it 
might  be  employed  as  a  prophylactic  agent  in  oc- 
cupational and  other  activities  in  which  exposure 
is  to  be  anticipated. 

Bibliography 

1.  Ambrose,  A.  M..  and  Haag,  H.  B.:  Toxicological  Study 
of  Derris.  Jour.  Indust.  and  Engin.  Chem.,  28:815-821, 
(July)   1936. 

2.  Haag,  H.  B.:  Toxicological  Studies  of  Derris  Elliptica 
and    Its    Constituents.    Jour.    Pharmacol,    and    Exper. 

Therap.,  43:193-208   (Sept.)    1931. 

3.  Dorne,  M.,  and  Friedman,  T.  .B:  Derris  Root  Derma- 
titis. /.  A.  M.  A.,  115:1268-1270  (Oct.)   1940. 

4.  Thomas,  C.  C,  and  Miller,  E.  E.:  Rotenone  in  the 
Treatment  of  Scabies.  Am.  J.  Med.  Sc,  199-670-764 
(May)    1940. 


McGUIRE  CLINIC  STAFF  MEETING 

CLINICAL    PATHOLOGICAL    STUDY 

66-year-old  widow  farm  housekeeper  admitted 
to  hospital  Dec.  9th.  1940.  semicomatose.  Her 
daughter  stated  that  during  the  previous  12  months 
the  patient,  while  nursing  an  invalid  husband,  had 
lost  50  lbs.  On  Nov.  30th  she  had  felt  tired  and 
listless  and  had  two  liquid  stools.  A  period  of  con- 
stipation followed  On  December  8th  she  had  a 
severe  chill.  Her  b-  p-  was  said  to  be  135-  The 
following  day  she  became  drowsy  and  then  stupor- 
ous, and  she  at  times  complained  of  a  severe  pain 
in  her  left  shoulder  unaffected  by  respiration. 

She  had  had  chest  pain  for  many  years,  and 
during  the  past  year  increasing  dyspnea.  In  1939 
she  was  told  that  her  b.  p.  was  190.  She  had  ap- 
pendicitis at  16,  influenza  in  1918,  mumps  and  ma- 
laria. Six  children  are  living  and  well.  In  January, 
1938,  she  was  said  to  have  swallowed  a  pig  leg 
bone  and  after  6  months  of  wheezing,  choking  and 
coughing,  she  coughed  up  the  bone  which  was 
stated  to  be  slightly  decayed.  Her  father  died  of 
silicosis,  mother  of  cancer  of  the  breast,  one  brother 
of  cancer  of  the  liver. 

A  thin,  stuporous,  old  lady  with  a  few  carious 
teeth,  the  left  chest  restricted  in  movement  and 
dull  to  percussion  below  the  fourth  rib  posteriorly 
with  decrease  in  breath  sounds  and  moderately  fine 
rales  in  this  area.  The  heart  was  enlarged  to  the 
midclavicular  line.    There  were  no  murmurs  and 


the  sounds  were  of  fair  intensity.  There  was  a 
questionable  babinski.    The  neck  was  not  stiff. 

Laboratory  studies,  December  10th  were:  reds 
3,200,000;  hemoglobin  55%  (Dare),  whites  13,800 
— 88  polys,  9  lymphs,  2  large  mononuclears,  1 
Turk's  cell.  Urine  dark,  cloudy,  with  a  trace  of 
albumin  and  acetone,  no  sugar.  There  were  an  oc- 
casional red,  2-4  white  blood  cells,  2-4  granular 
casts  The  ne  t  day  the  urine  contained  an  occa- 
sional red  and  numerous  white  blood  cells,  a  trace 
of  albumin,  sugar  present-  Glucose  had  been  given- 
Nonprotein  nitrogen  was  54  mg.  per  100  ex.  Was- 
sermann  was  negative.  Blood  culture  negative.  Ag- 
glutinations and  culture  to  State  Laboratory  were 
negative. 

The  chest  x-ray  examination  revealed  a  general- 
ized haziness  of  the  left  lung  field  with  the  right 
lung  field  clear.  The  aortic  shadow  and  heart 
shadow  were  extremely  enlarged  and  the  question 
of  a  pericardial  effusion  was  raised  by  this  exam- 
ination. An  upright  film  indicated  a  moderate 
amount  of  fluid  in  the  left  pleural  cavity.  There 
was  a  clearly  demarcated  shadow  extending  up- 
ward apparently  from  the  left  lung  root  into  the 
left  upper  lobe. 

Hospital  course:  T.  ranged  from  98.6  to  102°, 
averaging  100.  Average  pulse  rate  100;  respiration 
30.  She  continued  to  complain  of  pain  in  the  chest, 
soreness  in  neck,  and  was  drowsy  except  for  inter- 
vals of  alertness.  While  being  turned  on  her  left 
side  she  suddenly  gasped  for  breath  and  died  6:05 
a.  m.  on  December  14th. 

(The  McGuire  Clinic  is  being  requested  to  send  re- 
port  on  Diagnosis.) 


ALLUSIONS  TO  A  "CIRCULATION"  OF  THE  BLOOD 
IN  MSS.  ANTERIOR  TO  DE  MOTV  CORDIS,  1628 

(H.   P.   Bayon.    Cambridge,   Eng ,   in  Proc.  Royal  Soc.    of  Med., 
April,  '39) 

Andrea  Cesalpino  of  Arezzo  (1524-1603)  studied  medi- 
cine at  Pisa  from  1545  to  1549,  when  Realdo  Colombo  of 
Cremona  (d.  1559)  held  the  chair  of  anatomy  there. 
Graduated  in  1551,  he  became  professor  of  medicine  and 
botany  in  1555,  and  in  1592  he  was  appointed  physician 
to  Pope  Clement  VIII  (1592-1605). 

In  1655  (during  Harvey's  lifetime)  the  "Florentine 
Aesculapius,"  Giovanni  Nardi,  had  asserted  in  his  Nodes 
geniales  that  Cesalpino  had  previously  described  the  cir- 
culation of  the  blood. 

A  statue  was  erected  in  1877  to  Cesalpino  in  Rome,  with 
an  inscription  setting  forth  that  he  had  discovered  the  cir- 
culation of  the  blood. 

The  present  position  of  this  controversy  is  that  Cesal- 
pino's  writings  contain  many  references  to  the  movement 
of  the  blood  and  the  action  of  the  heart;  but  since  these 
are  not  presented  in  a  consequent  manner,  it  has  been 
easy  to  tear  sentences  from  their  context,  and  to  suggest 
that  Cesalpino  was  referring  to  the  circulation  as  we  know 
it.  Nevertheless,  a  further  examination  of  the  text  reveals 
that  Cesalpino  supported  Aristotle's  doctrine  of  the  pri- 
•<CIRCULATWN"—p.  210 


April    1941 


SOUTHERN  MEDICINE  &  SURGERY 


SURGICAL  OBSERVATIONS 

OF 

DAVIS  HOSPITAL  STAFF 

Statesville 


WHEN  IS  GONORRHEA  CURED? 

We  have  observed  many  cases  of  pelvic  inflam- 
matory disease  in  women  married  only  a  short 
time,  who  had  been  infected  by  their  husbands. 
Careful  investigation  of  these  cases  reveals  the  fact 
that  many  of  these  men  had  been  treated  for 
gonorrhea  and  pronounced  well. 

The  fact  that  their  wives  were  promptly  infect- 
ed, and  with  more  or  less  serious  consequences, 
brings  up  the  question  of  just  what  tests  should 
be  made  before  any  man  who  has  had  gonorrhea 
can  be  pronounced  cured? 

No  patient  should  be  regarded  as  well  of  gon- 
orrhea unless  all  gonococci  have  been  eliminated 
from  the  genito-urinary  tract.  The  seminal  vesi- 
cles, epididymis  and  prostate  are  organs  in  which 
gonococci  are  prone  to  persist,  even  after  all 
symptoms  of  urethritis  have  disappeared. 

The  fact  that  a  patient  who  has  been  treated 
for  gonorrhea  and  pronounced  cured  after  a  care- 
ful examination  of  the  prostatic  secretion,  which 
apparently  did  not  harbor  any  gram-negative  in- 
tracellular diplococci,  brings  up  the  question  as  to 
just  how  reliable  these  tests  are. 

A  little  pus  in  the  prostatic  secretion  without 
the  presence  of  intracellular  diplococci  is  regarded 
by  some  as  a  cure,  in  case  there  are  no  other  signs. 
This,  however,  is  questionable. 

A  culture  of  the  prostatic  secretion  might  be  of 
help.  One  test  would  probably  not  be  sufficient  to 
make  one  certain  that  the  patient  could  be  regard- 
ed as  cured. 

Unfortunately,  one  of  the  most  difficult  things  a 
doctor  has  to  contend  with  is  the  ignorance  or  in- 
difference, or  both,  of  the  patient.  Many  patients 
regard  the  absence  of  a  discharge  as  a  cure  and 
discontinue  medical  treatment  and  medical  advice. 
This  is  responsible  for  many  of  the  tragedies 
which  we  see  daily.  It  is  most  difficult  for  anyone 
to  suggest  a  plan  which  will  prevent  the  average 
patient  stopping  medical  treatment  when  he  thinks 
he  is  well. 

The  present  methods  of  treating  gonorrhea  are 
much  better  than  we  have  ever  had  before. 
Sulfanilamide  and  sulfapyridine  are  astonishing 
drugs.  Fever  therapy  is  also  a  great  help,  and  in 
the  average  patient  the  combination  of  fever  ther- 
apy and  sulfanilamide  is  the  best  of  any  treat- 
ment we  have,  especially  where  the  prostate  or 
seminal  vesicles  are  involved. 


As  long  as  pus  is  found  in  the  prostatic  secre- 
tion, or  obtained  from  the  urethra,  it  is  our  opin- 
ion that  the  patient  should  be  given  a  course  of 
sulfanilamide,  if  necessary  combined  with  fever 
therapy,  until  all  the  gonococci  within  the  body 
are  destroyed.  Then,  and  only  then,  may  we  re- 
gard a  patient  as  cured. 

THE  INTERNAL  FIXATION  OF 
FRACTURES 

With  the  enormous  increase  in  the  number  of 
fractures  it  is  natural  that  many  of  these  fractures 
are  such  as  to  require  open  reduction  and  internal 
fixation. 

Closed  reduction  is  best  in  most  cases;  but  in 
many  cases  accurate  replacement  without  interpo- 
sition of  soft  parts  is  impossible  without  open 
operation,  and  maintenance  in  restored  position  is 
impossible  without  internal  fixation.  All  open- 
operation  cases  do  not  require  a  bone  plate  or 
band.  Some  other  method  of  holding  the  ends  of 
the  bones  together  may  be  applicable  which  will 
not  require  a  second  operation  for  its  removal.  In 
most  cases,  however,  internal  fixation  is  best  done 
by  a  bone  plate,  sometimes  with  additional  sup- 
port such  as  the  Parham  band;  or,  as  in  the  case 
of  fracture  around  the  trochanter,  the  combined 
use  of  a  Smith-Peterson  nail  and  an  angle  bar.  In 
the  application  of  bone  plates,  since  we  have  the 
Vitallium  plates  and  screws  available,  we  can  put 
these  on  with  much  greater  assurance  than  ever 
before. 

Vitallium  metal  does  not  cause  any  electrolytic 
reaction  and  the  screws  hold  much  better  than  the 
old-type  metal  screws — usually  long  enough  for 
good  union. 

Years  ago  in  using  the  steel  bone  plates  and 
screws  of  the  ordinary  type,  the  screws  would  often 
come  loose  and  the  x-ray  picture  would  show  what 
appeared  to  be  absorption  of  bony  tissues  around 
the  screws  and  this  was  sometimes  thought  to  be 
due  to  infection.  This,  however,  we  now  know  to 
be  due  to  an  electrolytic  change  caused  by  the 
metal  with  absorption  of  bony  tissue  around  the 
screws,  causing  the  screws  to  come  loose  and  the 
plate  naturally  loosen  up.  Sometimes,  however, 
this  change  did  not  take  place  and  a  plate  might 
be  left  on  for  a  long  time  before  removal  was  nec- 
essary. Removal  of  a  bone  plate  is  usually  best, 
but  preferably  done  after  union  is  well  established 
and  the  bone  is  in  good  condition. 

With  the  great  increase  in  the  number  of  severe 
fractures,  many  of  which  cannot  be  reduced  and 
held  in  place  without  internal  fixation,  we  are  for- 
tunate in  having  Vitallium  plates  and  screws  with 
which  to  repair  these  fractures. 


SOUTHERN  MEDICINE  &  SURGERY 


April   1941 


SULFANILAMIDE  IN  THE  TREATMENT  OF 
COMPOUND  FRACTURES  OF  BONES 

In  the  treatment  of  compound  fractures  of 
bones,  most  of  which  become  infected  at  the  time 
of  the  accident,  the  use  of  some  sulfonamide  is 
most  useful  in  preventing  active  development  of 
infection. 

Sulfanilamide  powder  is  applied  inside  the 
wound.  There  is  controversy  about  the  value  of 
sulfanilamide  in  such  cases  given  locally  and  given 
orally.  It  is  our  opinion  that  the  local  action  of 
the  sulfanilamide  is  a  great  help  and  that  a  lot  of 
this  is  absorbed  and  from  this  we  get  the  systemic 
effect. 

PREVENTIVE    AND    CURATIVE   TREAT- 
MENT OF  INFECTION  WITH  THE 
GAS  BACILLUS 

All  wounds  likely  to  be  infected  with  gas 
bacillus  organisms  should  undergo  very  careful 
debridement.  Sulfanilamide  locally  is  a  great  help. 
In  addition,  tetanus  and  gas-bacillus  antitoxin 
should  be  given  promptly  and  in  sufficient  dosage. 
X-ray  treatment  over  the  injured  area  discour- 
ages the  growth  of  the  gas  bacillus  organisms. 

In  a  recent  case  of  gas-bacillus  infection  in  a 
hand  injury  large  doses  of  combined  perfringens 
antitoxin  were  given  hypodermically  and  two  x-ray 
treatments  were  given  daily  for  a  period  of  three 
days,  the  dosage  in  each  case  being  small.  The 
combined  dosage  given  over  the  three  days  was 
sufficient  to  give  the  maximum  x-ray  effect  upon 
the  gas  organisms  and  yet  so  small  as  to  do  no 
harm  to  the  tissues. 


THE  DIABETIC  DIET  IN  RETROSPECT 
The  importance  of  dietary  restrictions  for  the 
victim  of  diabetes  has  been  recognized,  forgotten, 
re-recognized  and  emphasized,  these,  with  the  ad- 
vent of  insulin,  again  neglected.  An  article1  carry- 
ing a  historical  sketch  and  bringing  the  knowl- 
edge of  this  important  subject  up  to  the  present  is 
abstracted. 

If  Rollo  in  1796  had  had  a  few  units  of  insulin 
to  use  with  his  diet  he  could  possibly  have  ac- 
complished a  better  therapeutic  result  than  some 
of  our  present-day  dietary  nihilists.  Certainly  a 
diet,  which  consisted  largely  of  rancid  meat  and 
fat  would  produce  few  calories.  Bouchardat 
(1806-1886)  appreciated  the  value  of  dietary  re- 
striction as  well  as  the  importance  of  muscular 
exercise.  Following  him  came  Cantani  with  a  diet 
so  rigidly  frugal  that  he  kept  his  patients  under 
lock  and  key  to  enforce  it.  He  considered  the  pan- 

1.  G.  E  Anderson,  Brooklyn,  in  Brooklyn  Hosp.  31.,  Oct., 
1940. 


creas  defective  and  spared  it  by  rigid  carbohydrate 
restriction.  The  work  of  Naunyn,  von  Noorden 
and  Frederick  Allen  is  familiar  to  all. 

The  mother  of  a  diabetic  child,  one  of  the  wri- 
ter's patients,  brought  a  canary  and  a  pound  of 
bird-seed;  the  child  made  one  meal  of  the  entire 
pound  of  seed. 

There  is  a  false  impression  that  insulin  will  take 
care  of  any  amount  of  food.  Overnutrition,  carbo- 
hydrate or  fat,  and  too  much  dependence  on  in- 
sulin will  overwhelm  the  patient's  own  carbohy- 
drate-utilizing mechanism.  Any  endocrine  system 
not  permitted  to  function  a  little  on  its  own,  but 
depending  entirely  on  substitution  products  {e.g., 
insulin),  will  tend  to  lose  much  of  its  capacity  to 
function.  On  the  other  hand,  most  diabetic  pa- 
tients kept  on  a  mild  but  painless  restriction  of 
calories  with  relatively  liberal  intake  of  carbohy- 
drate to  stimulate  their  own  insulin-producing 
mechanism,  will  in  time  require  less  and  less  in- 
sulin. 

One  cannot  imagine  in  the  days  before  insulin 
having  the  courage  to  reverse  diet  and,  instead  of 
allowing  30  grams  of  carbohydrate  and  200  grams 
of  fat,  giving  200  grams  of  carbohydrate  and  30 
grams  of  fat. 

It  is  striking  how  well  the  average  patient  will 
do  on  18  to  20  calories  per  kilogram,  most  of  this 
carbohydrate.  The  subnutrition  is  not  complained 
of  as  it  is  on  the  even  higher-caloried  low-carbo- 
hydrate, high-fat  diets;  the  patient  experiences  a 
sense  of  well-being,  remains  aglycosuric  with 
greater  ease;  he  maintains  nitrogenous  equilibrium 
more  easily,  and  the  hazard  of  diabetic  coma  be- 
comes reduced;  there  is  progressive  decrease  in  the 
demand  for  extrinsic- insulin  from  year  to  year. 

Adequate  dietary  allowance  will  keep  the  indi- 
vidual at,  or  bring  him  to,  a  weight  just  below 
actuarial  standards,  protein  sufficient  to  maintain 
nitrogenous  equilibrium  (usually  .7  to  1.25  grams 
per  pilogram  of  body  weight),  carbohydrate  to 
stimulate  the  insulinogenic  mechanism,  fat  merely 
as  a  caloric  filler  and  to  supply  the  necessary  un- 
saturated fatty  acids  for  optimal  nutrition  (usual- 
ly from  45  to  90  grams — more  often  nearer  the 
lower  figure)  at  least  50  to  60  per  cent  of  protein 
in  the  animal  form,  adequate  mineral  and  vitamin 
values  corresponding  with  Sherman's  optima. 
Diabetic  individuals'  economy  of  the  vitamin  B 
complex  is  faulty  and  this  should  be  supplied  in 
excess  of  usual  needs — especially  for  those  patients 
on  the  higher-carbohydrate  diets. 

The  proof  of  efficacy  of  such  a  diet  must  rest 
in  the  continued  well-being  of  the  patient  and  in 
the  fact  that  the  demand  for  exogenous  insulin 
progressively  decreases  year  by  year. 


April    1941 


SOUTHERN  MEDICINE  &  SURGERY 


DEPARTMENTS 

HUMAN  BEHAVIOUR 

James   K.  Ham.,  M.  D.,  Editor,  Richmond,  Va. 

THE  AMERICAN  PSYCHIATRIC 
ASSOCIATION 
The  ninety-seventh  annual  meeting  of  the 
American  Psychiatric  Association  will  open  in 
Richmond  on  May  5th  and  last  through  the  9th. 
The  Association  is  said  to  be  the  oldest  medical 
organization  embracing  the  area  of  our  entire 
Union.  Thirteen  physicians,  probably  all  superin- 
tendents of  institutions  that  are  now  called  state 
hospitals,  met  in  Philadelphia  in  October,  1844, 
undoubtedly  as  the  result  of  correspondence  with 
each  other,  and  grouped  themselves  as  a  medical 
body.  They  named  their  organization:  The  As- 
sociation of  Medical  Superintendents  of  American 
Institutions  for  the  Insane.  They  were  engaged 
in  decidedly  realistic  work,  even  though  they  were 
caring  for  patients  whose  minds  were  out  of  order, 
and  they  used  plain  and  definite  language  in 
thinking  of  their  work  and  in  naming  their  associa- 
tion. They  thought  of  their  patients  as  being 
insane  and  they  thought  of  themselves  as  over- 
seeing the  activities  of  their  patients  and  the  work 
of  the  employees  of  their  hospitals.  I  think  it 
probable  that  at  that  distant  day  some  of  the  hos- 
pitals were  headed  by  lavmen.  If  that  were  a 
fact,  it  probably  accounts  for  the  interjection  of 
the  adjective,  medical,  immediately  in  front  of 
Superintendents.  The  word  medical  served  as  a 
protest,  too,  if  my  surmise  be  valid,  that  those 
early  psychiatrists  thought  of  their  professional 
practice  as  a  medical  specialty  that  could  be  car- 
ried on  properly  only  by  physicians. 

Some  of  the  hospitals  in  this  country  that  care 
for  mentally  sick  folks  function  now  under  the 
headship  of  laymen.  It  may  be  true  that  some  of 
the  state  hospitals  still  have  non-medical  heads.  I 
think  that  some  of  the  so-called  Veterans  Facili- 
ties of  the  United  States  government  have  non- 
medical heads  designated  as  general  managers.  I 
experience  difficulty  in  understanding  how  a  lay 
person,  untrained  and  inexperienced  in  nursing  and 
in  medicine,  can  exercise  an  intelligent  episcopacy 
over  those  who  are  actually  engaged  in  minister- 
ing to  the  sick.  But,  in  a  democracy,  almost  any- 
thing can  be  tried  until  it — fails. 

The  American  Psychiatric  Association  was  born 
in  wartimes.  The  struggle  of  Texas  to  detach  her- 
self from  Mexico  and  to  attach  herself  to  our 
Union  had  not  been  concluded  when   the  thirteen 


physicians  assembled  in  the  Jones  Hotel  in  Phila- 
delphia on  October  16th,  1844,  and  brought  into 
being  an  organization  that  has  existed  for  almost 
one  hundred  years.  Forty-six  years  after  that  in- 
ception in  Philadelphia,  the  annual  session  was 
held  in  Washington  City,  and  the  name  of  many- 
words  was  shortened,  but  it  was  still  left  lengthy 
and  ponderous:  The  American  Medico-Psychologi- 
cal Association. 

It  may  be  inferred  from  the  long  first  name  that 
only  medical  superintendents  of  what  are  now 
called  state  hospitals  could  be  members  of  the 
organization  for  the  first  forty-six  years  of  its  ex- 
istence. There  were,  in  1844,  not  many  states  in 
the  Union,  and  even  some  of  the  original  thirteen 
states  had  at  that  time  no  hospitals  for  the  care 
of  mentally  sick  folks.  North  Carolina,  for  exam- 
ple, had  no  such  hospital  for  ten  years  or  more 
after  1844.  I  think  one  may  assume  that  by  1892, 
when  the  Association  changed  its  name  mainly  by 
leaving  out  of  its  first  name  "medical  superintend- 
ents," some  physicians  who  were  not  superintend- 
ents of  state  hospitals  were  making  application  for 
membership,  probably  clamoring  for  membership. 
At  the  seventy-seventh  annual  meeting  of  the  As- 
sociation, held  in  Boston  in  1921,  the  name  was 
again  transformed,  this  time  into:  The  American 
Psychiatric  Association. 

The  membership  of  the  body  has  steadily  in- 
creased until  it  now  numbers  about  2500.  Prob- 
ably not  more  than  half  the  members  are  able  to 
attend  an  annual  meeting.  The  meeting  is  held 
frequently  near  a  border  of  the  United  States, 
and  sometimes  in  Canada;  because  of  mere  dis- 
tance and  the  expense  of  travelling,  far-away 
members  cannot  attend  the  annual  assemblages  at 
such  distant  points.  And  many  members  are  en- 
gaged in  institutional  work  from  which  not  even  a 
brief  recess  can  be  taken. 

In  1869  the  Association  met  in  Staunton,  Vir- 
ginia. The  State  Hospital  there  had  been  open 
since  1828.  I  think  that  was  the  Association's 
first  meeting  in  Virginia.  I  wonder  if  the  convoca- 
tion in  Staunton  in  1869,  only  five  years  after 
Appomattox,  was  not  a  "peace  meeting"?  The 
southern  states  were  under  military  rule,  and  many 
of  them  were  still  suffering  from  carpetbaggery. 
The  annual  meeting  has  been  held  in  Virginia  four 
times  since  1869.  The  Association  met  in  Rich- 
mond in  1925,  under  the  presidency  of  the  late 
Dr.  William  A.  White.  Two  Virginians,  superin- 
tendents of  state  hospitals,  have  been  presidents  of 
the  body— Dr.  Robert  J.  Preston,  in  1901-'02; 
Dr.  W.  F.  Drewry,  in  1909-MO.  Two  of  the  thir- 
teen founders  of  the  organization  were  superin- 
tendents of  our  Virginia  state  hospitals — Dr.  John 


SOUTHERN  MEDICINE  &  SURGERY 


April    1941 


M.  Gait,  at  Williamsburg;  and  Dr.  Francis  T. 
Stribling,  at  Staunton. 

The  Association's  membership  has  become  so 
considerable  and  the  attendance  at  the  annual 
meetings  so  large  that  a  mere  town  can  no  longer 
take  care  of  the  gathering,  as  Fortress  Monroe 
did,  for  example,  as  recently  as  1915.  And  that  is 
a  pity,  for  man  tends  to  deteriorate  when  he  lives 
congregate  and  with  his  feet  off  the  soil. 

Psychiatry  is  a  pedantic  term — too  much  so, 
quite,  for  use  with  lav  people,  or  even  amongst 
physicians.  But,  the  less  we  know  the  more  pon- 
derously polysyllabic  we  are.  Definite  knowledge, 
even  well-formed  opinions,  can  be  stated  briefly, 
in  simple  language.  Psychiatrists  are  concerned 
about  those  portions  of  a  human  being  that  can- 
not be  operated  upon  by  surgical  instruments  or 
be  directly  medicated  by  drugs.  Yet,  the  cause  of 
the  psychiatric  condition  may  be  attended  to  by 
surgery  or  by  pharmacology.  Psychiatry  is  espe- 
cially interested  in  the  attributes  of  a  mortal  and 
in  his  feeling  and  his  thinking,  as  manifested  by 
behaviour.  And  those  two  processes  may  be  af- 
fected by  many  things  within  the  individual  and 
by  many  things  external  to  the  dermal  capsule. 
Man's  emotional  and  intellectual  and  spiritual 
health  are  of  much  more  importance  than  the  con- 
dition of  his  mere  physical  body.  For  out  of  fear 
and  revenge  and  hatred  come  war;  and  out  of  the 
devastation  and  disaster  and  the  despair  after  the 
battles  must  come  reconstruction. 

Most  people  do  not  realize  how  important  it  is 
that  the  emotions  be  understood  and  protected 
and  cared  for.  The  psvchiatrists  of  the  world 
should  be  as  alertly  concerned  about  the  emotional 
state  of  the  people  as  a  mother  is  about  the  feel- 
ings of  her  children.  Statesmen  and  so-called 
financial  buccaneers  and  military  leaders  some- 
times insidiouslv  induct  a  people  into  war.  And 
the  same  sort  of  group  later  mismake  the  so-called 
peace.  Psychiatrists  should  view  the  behaviouris- 
tics  of  all  such  actors  with  detachment  and  with 
unperturbed  scrutiny  and  with  understanding — in 
the  very  incipiency  of  the  discord.  And  when  the 
arms  have  been  slacked  psvchiatrists,  if  any  are 
still  existent,  should  be  insistent  that  the  emotions 
and  the  spirits  of  the  overwhelmed  people  be  dealt 
with  considerately,  and  that  they  be  not  robbed 
and  enslaved. 

Richmond  is  a  good  place  for  the  American 
Psychiatric  Association  to  meet,  now,  when  the 
world  is  so  disturbed.  Our  lovely  old  city  is  ringed 
all  around  by  earthworks  and  by  battle-fields  and 
by  populous  military  cemeteries.  Hereabouts  man 
has  tip-toed  in  exultation  as  he  has  given  his  fel- 
low-man in  the  heat  of  battle  the  glistening  cold 
steel  and  the  singing  bullet.    Has  man's  character 


been  improved  by  such  behaviour?  Has  civiliza- 
tion been  advanced,  or  has  it  been  retarded,  by 
such  group-activitv?  The  material  of  war  now 
rumbles  through  our  peaceful  old  city;  and  some 
of  it  flies,  in  this  direction  and  in  that,  far  up  in 
the  blue  sky. 

With  our  neighbour  on  the  north  the  people  of 
the  United  States  have  lived  peacefully  for  more 
than  one  hundred  years.  After  fighting  each  other 
we  seemed  to  learn,  finally,  the  importance  of  liv- 
ing side  by  side  neighbourly.  Might  not  the  prac- 
tice be  extended,  southward,  everywhereward ? 

Canada,  too,  is  a  member  of  the  American 
Psychiatric  Association,  and  has  been  probably 
since  the  beginning  of  the  organization  in  1844. 
Dr.  George  H.  Stevenson,  Canada-born,  the  super- 
intendent of  a  state  hospital  at  London,  Ontario, 
is  president  of  the  Association.  He  will  preside 
over  the  meeting  in  Richmond. 

The  assemblage  should  evoke  substantial  dis- 
cussion of  the  irrationality  of  man's  warfare 
against  his  fellowman.  Has  it  a  meaning?  What 
does  it  mean?  Which  is  the  more  important,  to 
carry  on  warfare,  or  to  prevent  it?  Can  it  be  pre- 
vented? Has  man  any  interest  in  trying  to  prevent 
warfare?  The  time  is  at  hand  to  think,  to  speak 
out,  to  act.  Dr.  Stevenson's  home-country  is  at 
war.  Let  us  pray  that  soon  our  Association  may 
hold  a  great  jubilee  in  Canada! 


HOSPITALS 


R.  B.  Davis,  M.  D.,  Editor,  Greensboro.  N.  C. 


HOSPITALS  IN  THE  FUTURE 
All  of  the  countries  now  at  war  have  begun 
planning  how  they  will  exist  when  peace  comes. 
It  would  be  wise  for  the  hospital  people  to  give 
careful  consideration  to  their  future.  The  hand- 
writing on  the  wall  is  plain  and  only  the  deaf, 
dumb  and  blind  will  be  unable  to  discern  the 
meaning  thereof. 

There  has  been  a  great  deal  of  talk  in  the 
civilized,  Christian  would  about  might  not  making 
right.  Those  of  us  who  believe  this  cling  des- 
perately to  the  promise  in  the  Scriptures,  but 
we  are  not  living  in  a  world  of  that  nature.  The 
fact  is  might  makes  right  in  this  generation  in 
almost  all  of  the  countries  upon  the  face  of  the 
earth.  It  is  granted  that  this  might  is  much  more 
abused  in  some  countries  than  it  is  in  others.  We 
in  America  should  thank  our  Creator  that  here 
this  might  is  not  as  destructive  and  degrading  as 
it  is  in  those  countries  under  the  rule  of  dicta- 
tors. This  does  not  mean,  however,  that  to  a 
large  extent  might  has  not  trampled  right  under 


April   1941 


SOUTHERN  MEDICINE  &■  SURGERY 


its  feet,  even  in  our  Country. 

Let  us  look  for  a  moment  at  some  of  the  dic- 
tations of  might.  The  law-making  bodies  which 
govern  our  Country  make  gambling  a  crime;  but 
there  are  many  of  them  who  play  poker  by  the 
hour  with  the  law-enforcement  officers  of  their 
county  or  city.  This  same  group  will  vote  for 
and  pass  laws  designed  to  prohibit  drinking.  There 
are  many  of  them  who  keep  whiskey  in  their  homes 
and  offices  and  drink  it,  many   times  to  excess. 

Among  that  august  body  known  as  judges, 
or  justices,  more  than  in  any  other  group,  we 
should  find  right  making  might.  It  is  a  well 
known  fact,  nevertheless,  that  the  crime  of  a  rich 
and  influental  man  is  seldom  punished  to  the 
extent  of  that  of  a  poor  man.  I  am  informed 
that  it  is  a  very  serious  charge  for  a  lay  person 
to  discuss  with  any  judge  his  decision  in  a  case 
All  human  beings  are  subject  to  errors  but  to 
make  it  a  crime  for  any  person  to  discuss  one's 
errors  with  him  seems  to  be  leaning  away  from 
democracy. 

We  may,  along  with  others,  analyze  the  law- 
enforcement  agencies  of  our  Country.  On  our 
highways  a  person  may  be  arrested  for  speeding  by 
an  officer  who  only  a  few  days  before  drove  over 
the  same  piece  of  road,  to  attend  the  marriage 
of  a  distant  relative,  at  a  far  greater  rate  of  speed 
than  was  made  by  the  motorist  who  was  just 
given  a  ticket.  How  many  times  has  it  been 
brought  to  the  attention  of  the  public  how  un- 
fortunate it  is  to  be  a  poor  white  man  or  a  negro 
when  he  figures  in  a  wreck  with  some  influental 
person.  The  might  to  arrest  and  lock  up  in  jail 
lay  in  the  hands  of  the  officer.  Sometimes  this 
officer's  decision  is  based  upon  this  might  rather 
than  the  right  of  the  situation. 

At  one  time  the  banking  business  stood  ace 
high  in  our  Country.  The  reason  was  it  possessed 
the  might.  What  happened  to  this  great  institu- 
tion is  well  known  to  us  all.  The  catastrophe 
which  befell  those  banks  and  bankers  was  not 
centered  around  small  legitimate  loans  of  the  av- 
erage citizen  but  rather  around  the  large  illegiti- 
mate loans.  And,  especially  was  this  true  of  those 
which  had  their  beginning  around  a  poker  table 
and  around  a  flask  of  "bottled-in-bond,"  or  per- 
haps were  concocted  when  the  recipients  of  the 
loan  had  lavishly  entertained  the  bankers  at  some 
fashionable  resort.  Sound  business  integrity  al- 
ways had  a  right  to  expect  a  fair  deal  but  it  did 
not  possess  the  might  to  demand  md  the  results 
in  many  cases  were  disastrous. 

The  present-day  administrative  inclinations 
make  us  frown,  perhaps,  upon  labor  where  labor 
would  not  have  deserved  it  under  a  different  ad- 


ministration. When  an  individual  or  a  company 
has  kept  his  and  its  obligations  to  employees 
there  is  no  legal  right  for  employees  to  dictate 
what  that  business  shall  do  in  the  future.  As- 
suredly there  can  not  possibly  be  any  right  or 
justice  for  the  employee  to  take  charge  of  the 
employer's  property  or  determine  who  shall  or 
shall  not  work  in  his  place  should  he  decide  to 
quit.  There  is  no  democracy  and  there  is  no  jus- 
tice when  one  individual  or  group  of  individuals 
unlawfully  seize  or  possess  the  private  property 
of  another.  But,  because  the  employees,  through 
numbers  alone,  possess  the  might  they  make  these 
things  right  in  their  minds,  put  democracy  on  the 
scaffold  and  hang  justice  by  the  neck. 

Now  to  examine  our  own,  the  hospital,  business. 
We  hear  from  many  sides  the  demand  for  shorter 
hours  and  more  pay.  One  sometimes  wonders 
what  the  average  individual  profits  by  less  labor- 
ing hours  and  increased  pay.  It  does  seem  that 
people  are  much  more  restless  and  ofttimes  in 
more  of  a  financial  strait  than  ever  they  were  be- 
fore. It  might  be  best  for  these  things  to  come 
to  pass  but  I  have  my  serious  doubts  as  to  whether 
we  are  yet  prepaired  to  accept  them  and  use 
them  to  the  best  advantage. 

It  is  easy  to  point  out  the  shortcomings  of  so- 
ciety, politics  or  religion.  It  is  not  so  easy  to  say 
what  is  the  cure.  It  is  the  writer's  earnest  desire 
to  now  point  out  some  of  the  remedies. 

We  must  not  start  with  the  humble  maid  and 
orderly  and  vent  our  spleen  on  these  poor  individ- 
uals who  probably  do  better  considering  their  op- 
portunities than  a  great  many  of  the  leaders  of 
our  Country.  Instead  we  must  start  with  the 
trustees  or  directors  of  hospitals.  It  is  not  exag- 
gerating to  state  that  four-fifths  of  the  person- 
nel of  this  group  are  either  criminally  indifferent 
or  mentally  lazy  insofar  as  their  duty  to  the  hos- 
pitals is  concerned.  This  group  of  individuals 
in  the  future  hospitals  must  change.  Every  man 
or  woman  must  be  honest  enough  not  to  accept 
appointment  on  a  hospital  board  tor  prestige  or 
authority,  but  rather  must  be  willing  to  give  of 
his  or  her  time  and  talent  freely  to  the  problems 
pertaining  to  such  a  position.  And,  further  each 
must  make  up  his  or  her  mind  in  the  beginning 
that  such  is  no  easy  job. 

Next  in  order  comes  the  business  manager  or 
superintendent.  Here  is  a  great  opportunity  for 
direct  authority  to  attempt  to  make  might  right. 
In  the  future  there  will  be  no  place  for  the  hot- 
headed, dogmatic,  partial  dictator  to  operate  a 
hospital;  instead,  those  in  charge  of  hospitals 
must  be  patient,  longsuffering,  and  yet  at  the  same 
time  demand  good  service  for  the  patients.    They 


SOUTHERN  MEDICINE  &  SURGERY 


April    1941 


must  always  be  willing  to  give  time  and  thought 
to  any  troubled  employee.  A  decision  made  in 
the  heat  of  temper  by  an  official  head  of  an  in- 
stitution does  that  institution  a  great  deal  of  harm. 

In  the  nursing  staff  the  picture  changes  from 
individual  might  and  authority,  as  in  the  case  of 
the  business  manager  or  superintendent,  to  col- 
lective might  and  authority.  The  writer  does 
not  believe  that  methods  of  unionism  should  ever 
prevail  in  this  most  noble  profession.  It  is  too 
far  beneath  a  true  nurse's  dignity  and  noble  as- 
piration to  sell  herself  to  any  type  of  unionism. 
Therefore,  the  nursing  profession  should  steer 
clear  in  the  future  hospitals  of  any  semblance  of 
a  mercenary  strike.  If  it  does  not  the  lay  public 
will  soon  lose  its  deep  love,  admiration  and  re- 
spect which  it  now  has  for  it.  We  cannot  be- 
lieve the  nurses  want  this  to  occur.  Nurses  must 
be  loyal  to  their  superiors  and  their  patients 
as  well  as  to  themselves.  However,  loyalty  to 
their  great  aspirations,  which  lie  deeply  buried  in 
the  bosom  of  every  true  nurse,  gives  more  satis- 
faction than  anything  else. 

The  last  group  to  be  considered  is  that  of  the 
orderlies  and  maids.  For  the  opportunities  which 
these  people  have  had  in  life  they  certainly  do 
well,  but  the  future  hospitals  will  demand  of  them 
a  little  more  determination,  a  little  more  satis- 
faction out  of  a  job  well  done.  They  must  learn 
to  purpose  their  lives  as  orderlies  and  maids  and 
not  to  consider  themselves  as  simply  laborers. 
This  ideal  can  be  instilled  in  the  average  man  or 
woman  in  the  boginnine  of  his  and  her  services 
if  only  the  nurses  will  take  a  little  time  to  encour- 
age and  instruct  them. 

Therefore  the  future  hospital  will  be  bigger 
and  better  if  all  concerned  will  see  the  handwriting 
on  the  wall  and  do  something  about  it. 


CARDIOLOGY 

Clyde  M.  Gtxmore,  M.  D..  Editor,  Greensboro,  N.  C. 


THE  PREVENTION  OF  RECURRENCES  OF 
RHEUMATIC  FEVER 

It  is  now  generally  agreed  that  sulfanilamide  is 
not  only  worthless  in  the  treatment  of  an  acute, 
attack  of  rheumatic  fever,  but  also  that  its  use 
there  tends  to  provoke  many  to^ic  reactions. 
Thomas.  France  and  Reichsman,  of  Baltimore,  in 
an  article  in  the  Journal  of  the  American  Medical 
Association  of  February  l.Sth.  report  the  results 
of  a  four-year  studv  on  the  use  of  sulfanilamide 
to  prevent  recurrences  of  rheumatic  fever. 

Their  work  was  done  on  adults  who  had  had  at 


least  one  major  episode  of  rheumatic  fever  in  the 
preceding  three  years.  The  first  two  years  of  their 
study  they  gave  each  patient  S  grains  of  sulfanil- 
amide t.i.d.,  and  in  the  second  two  years  10  grains 
b.i.d.,  daily  during  the  rheumatic  fever  season — 
from  October  to  June.  They  found  toxic  effects 
to  be  very  rare,  and  had  to  discontinue  the  treat- 
ment of  only  two  patients  because  of  toxicity; 
and  were  able  to  continue  the  treatment  even  when 
the  white  blood  cells  stayed  around  4,000,  as  they 
did  in  many  cases. 

The  incidence  of  hemolytic  streptococcus  infec- 
tion in  general  in  the  treated  group  was  found  to 
be  markedly  reduced;  and  there  was  a  greatly 
diminished  ratio  of  positive  throat  cultures.  There 
were  no  major  attacks  of  rheumatic  fever  (patient 
confined  to  bed  a  week  or  longer)  in  the  treated 
group,  consisting  of  79  patient-seasons;  while 
there  were  IS  attacks  in  the  control  group  of  150 
patient-seasons.  In  the  treated  group  there  were 
two  minor  atacks,  as  against  six  in  the  controls. 
There  were  four  deaths  in  the  control  group,  two 
being  from  subacute  bacterial  endocarditis. 

The  authors  feel  that  sulfanilamide  is  of  great 
prophylactic  value  in  rheumatic  fever,  and  should 
be  given  regularly  to  children  after  their  first  at- 
tack. However,  before  the  use  of  sulfanilamide  as 
a  preventive  of  rheumatic  fever  is  generally  ac- 
cepted, these  studies  should  be  substantiated  from 
other  sources. 

STREPTOCOCCUS  VIRIDANS 
ENDOCARDITIS 

There  have  recently  been  some  cures  reported 
from  this  disease,  formerly  thought  incurable, 
which  makes  early  diagnosis  important.  In  this 
and  in  other  forms  of  subacute  bacterial  endocard- 
itis, bacterial  vegetations  form  on  the  endocar- 
dium, usually  a  previously  damaged  or  diseased 
valve.  These  vegetations  grow,  and  finally  break 
off  into  the  blood  stream,  causing  death  by  oc- 
cluding vital  arteries. 

A  new  method  of  treatment  uses  sulfanilamide 
as  a  bacteriostatic,  combined  with  heparin  to  pre- 
vent the  formation  of  clots  at  the  infected  sites, 
thereby  preventing  fatal  emboli.  Obviously,  this 
treatment,  to  be  effective,  must  be  started  early, 
before  blood  clots  have  already  formed,  and  before 
the  streptococci  are  buried  in  the  vegetations 
where  the  therapeutic  sulfanilamide  can  not  get  at 
them. 

Dr.  Henry  A.  Christian,  of  Boston,  reported  a 
study  of  ISO  patients  with  streptococcus  viridans 
endocarditis  in  the  Journal  of  the  American  Med- 
ical  Association  of  March  15th.  He  says  that  the 
early   symptoms   are    those    of    toxemia,   and    are 


April   1941 


SOUTHERN  MEDICINE  &  SURGERY 


marked  enough  for  the  patient  to  remember  the 
time  of  onset.  Malaise  and  ready  loss  of  energy 
were  symptoms  in  46  per  cent  of  the  patients, 
many  of  whom  were  also  feverish;  joint  and  mus- 
cle pains  similar  to  those  present  in  la  grippe, 
were  present  in  42  per  cent;  nausea  and  anorexia 
in  24  per  cent;  headache  less  frequently. 

These  symptoms  of  toxemia  could,  of  course, 
mean  almost  any  infectious  disease.  However,  Dr. 
Christian  emphasizes  that  in  any  case  in  which 
these  symptoms  persist  for  more  than  one  week, 
with  no  definite  evidence  of  any  other  disease,  sub- 
acute bacterial  endocarditis  should  be  suspected. 
This  is  especially  true  of  any  patient  having  pre- 
vious heart  disease,  such  as  rheumatic  fever  or 
congenital  heart  disease.  These  patients  should 
have  repeated  blood  cultures  in  an  effort  to  estab- 
lish the  diagnosis.  However,  even  in  those  where 
the  cultures  remain  negative,  unless  the  patient  is 
proven  meanwhile  to  have  some  other  disease, 
chemotherapeusis  should  be  started.  Dr.  Christian 
considers  it  far  better  to  treat  early  for  a  mis- 
taken diagnosis  than  to  wait  until  vegetations 
have  formed  and  success  in  treatment  becomes 
very  unlikely. 


SURGERY 

Geo.   H.   Bunch,  M.   D.,   Editor,   Columbia,   S.   C. 


RUPTURE  OF  THE  SPLEEN 
Rupture  of  the  spleen  is  an  intraabdominal 
tragedy  which,  even  today,  has  an  appalling  mor- 
tality rate.  Up  to  1890  cases  as  a  rule  were  treat- 
ed expectantly.  Of  Elder's  series  of  52  uncompli- 
cated cases  not  operated  upon  55  died.  Eisendrath 
in  1902  collected  a  series  of  50  cases  operated 
upon  with  a  mortality  rate  of  22.  Vedova  in  1913 
reported  a  mortality  of  one-third  in  194  cases  of 
splenectomy  for  traumatic  rupture.  Today  the 
mortality,  although  appreciably  lower,  is  still 
high. 

Rupture  of  the  spleen  may  be  spontaneous  or 
traumatic.  Spontaneous  rupture  in  most  cases  fol- 
lows splenic  disease,  particularly  splenomegaly  in 
some  form.  As  the  spleen  enlarges  it,  from  conges- 
tion and  from  disease,  tends  to  become  more  fria- 
ble and  less  resistant  to  force.  Except  in  cases  of 
chronic  fibrous  splenitis  the  capsule  and  the  sup- 
porting structure  of  the  enlarged  spleen  are  not 
thickened,  although  they  are  necessarily  subjected 
to  increased  tension  from  within  and  from  with- 
out. As  the  spleen  extends  below  the  costal  mar- 
gin the  protection  of  the  overlieing  ribs  is  lost. 


Spontaneous  rupture  is  becoming  absolutely  less 
because  cases  of  splenomegaly  are  now  operated 
upon  early,  and  relatively  less  because  of  the  in- 
creased incidence  of  motor  traffic  injuries. 

However,  a  spleen  normal  in  size  and  consist- 
ency, without  atheromatous  arteries  or  disease  mav 
rupture  spontaneously  even  in  a  child.  A  healthy 
boy  of  eleven  recently  entered  the  Columbia  Hos- 
pital after  having  been  in  bed  for  two  days  com- 
plaining of  pain  in  the  left  upper  abdomen.  His 
temperature  was  99°  F.  There  was  leucocytosis, 
with  the  hemoglobin  index  50.  At  operation  mas- 
sive intraperitoneal  hemorrhage  from  a  small  rent 
in  the  spleen  near  the  hilus  was  found.  The  boy 
recovered  after  splenectomy.  The  spleen  was  not 
enlarged  and  was  grossly  and  microscopically  nor- 
mal in  every  way.  No  history  of  a  preceding  blow, 
fall,  kick  or  trauma  of  any  kind  that  might  have 
caused  rupture  could  be  obtained. 

Traumatic  rupture  occurs  more  often  in  males 
for  in  industrial  life  men  are  more  exposed  to  trau- 
ma. An  enlarged  spleen  is  readily  ruptured  if  the 
force  is  properly  applied,  and  a  normal  spleen, 
although  lieing  under  the  diaphragm  and  protect- 
ed by  the  lower  libs,  may  also  be  ruptured  if  the 
force  is  sufficient. 

The  urgency  of  the  symptoms  of  rupture, 
whether  spontaneous  or  traumatic,  depends  upon 
th*  extent  of  the  rupture,  as  this  largely  deter- 
mines the  rapidity  of  the  hemorrhage.  Although 
the  spleen's  parenchyma  is  honeycombed  with 
large  spaces  filled  with  venous  blood,  gross  bleed- 
ing does  not  always  immediately  follow  traumatic 
injury.  Hemorrhage  may  at  first  be  intracapsular 
and  massive  intraperitoneal  extravasation  may  not 
occur  for  three  or  four  days  after  injury. 

Symptoms  are  those  of  shock  and  of  internal 
hemorrhage.  There  is  tenderness  over  the  left 
upper  abdomen.  Pain  is  not  severe.  There  is 
shifting  dullness  on  change  of  position.  There 
may  be  pain  in  the  left  shoulder  from  irritation  of 
the  phrenic  nerve. 

When  rupture  is  suspected  exploratory  laparo- 
tomy should  be  done  after  reaction  from  shock  has 
taken  place.  Donors  for  transfusion  should  be 
typed  and  ready  for  emergency  use,  if  necessary, 
both  before  and  immediately  following  operation. 
Autotransfusion  may  be  done,  if  there  is  no  con- 
tamination from  bowel  contents  in  traumatic  cases. 
The  object  of  the  operation  is  to  control  bleeding 
and  to  save  life.  Although  tamponade  or  suture 
of  small  rents  may  sometimes  suffice,  splenectomy 
insures  permanent  control  of  hemorrhage  and  in 
most  cases  is  the  operation  of  choice. 


SOUTHERN   MEDICINE   <S-   SURGERY 


April  1941 


OPHTHALMOLOGY 

Herbert  C.  Neblett,  M.  D„  Editor,  Charlotte,  N.  C. 


ROUTINE   VISUAL   FIELD    EXAMINATION 
IN  OFFICE  PRACTICE 

For  the  past  15  years  the  writer  has  made  it 
routine  to  examine  the  visual  fields  of  every  pa- 
tient who  comes  to  his  office.  The  procedure  is 
simple,  consumes  not  more  than  two  minutes  un- 
less disease  is  discovered,  and  routinely  can  be 
adequately  done  by  any  intelligent  office  nurse 
who  has  had  practical  training  in  this  work.  The 
results  are  interesting  and  instructive,  frequently 
including  valuable  information  of  an  unsuspected 
nature.  Few  difficulties  are  met  with  in  its  accom- 
plishment and  these  are  in  children  under  4  years 
of  age,  those  too  blind  to  see  form  or  a  small  dim 
light,  and  certain  types  of  mental  defectives.  In 
highly-nervous  patients  and  in  those  of  poor  co- 
ordination and  those  whose  attention  is  hard  to 
keep,  patience,  perseverance  and  a  pleasant  mein 
on  the  part  of  the  examiner  will  usually  result  in 
procuring  satisfactory  field  data.  Time  is  saved 
and  results  of  the  test  are  more  accurate  if  a  brief 
but  clear  explanation  is  made  to  the  patient  of 
what  is  expected  of  him  in  the  test.  If  the  ap- 
proach is  that  of  making  a  game  of  the  test  occult 
fears  are  dispelled,  hence  cooperation  is  enhanced 
and  the  results  are  more  accurate. 

The  tangent  screen  or  some  simple  modification 
of  it  is  quite  sufficient  for  rapid  preliminary  test- 
ing. 

In  making  the  test  it  seems  best  not  to  delimit 
the  blind  spot  until  the  rest  of  the  visual  field  has 
been  examined,  or  many  patients  will  become  nerv- 
ous and  their  cooperation  will  be  poorer,  because 
of  learning  for  the  first  time  that  there  is  a  blind 
spot  in  the  eye.  An  explanation  of  its  significance 
is  in  order  at  the  conclusion  of  the  test  and  it  will 
be  found  that  nearly  all  patients  are  greatly  inter- 
ested. If  the  field  findings  are  suggestive  or  are 
definitive  of  intraocular,  optic  nerve  or  intracra- 
nial disease,  more  conclusive  data  may  be  had  by 
more  refined  testing.  If  a  pathological  field  is 
uncovered,  and  many  are  so  found  by  it.  and  if 
thoroughly  worked  out  other  methods  of  field 
testing,  from  a  constructive  clinical  standpoint,  do 
not  add  a  great  volume  of  evidence  to  that  found 
by  this  method.  It  is  realized  that  in  clinics  where 
a  graduate  perimetrist  is  available  the  refinement 
in  testing  and  with  the  use  of  special  visual  field 
instruments  more  diagnostic  evidence  will  be 
found,  and  made  available,  especially  in  border- 
line and  unusual  visual-field  pathologic  states. 
However,  in  the  office  of  the  great  majority  of 


oculists  such  refinements  in  instrumental  technique 
can  not  be  had,  or  utilized  if  available,  because  of 
the  time  required;  but  the  use  of  the  screen  as 
briefly  outlined,  with  an  intelligent  appraisal  of  its 
real  value,  will  uncover  the  great  majority  of  path- 
ological conditions  and  lead  to  an  accurate  diagno- 
sis of  the  problem  presented. 

Brief  routine  use  of  the  test  is  not  without  merit 
in  evaluating  the  psychic  reactions  and  the  nerv- 
ous stability  of  the  patient.  It  is  found  that  those 
who  have  much  difficulty  in  fixing  their  attention 
on  the  center  of  the  screen,  or  who  can  not  do  so, 
greatly  magnify  their  real  or  imaginary  ailments, 
and  otherwise  show  evidence  of  an  unstable  nerv- 
ous system. 


UROLOGY 

For  this  issue,  Homer  M.  Daniel,  M.D.,  Anderson,  S.  C. 


CARBARSONE   SUPPOSITORY   IN   VAGINA 

CASTING  X-RAY   SHADOW   MISTAKEN 

FOR  STONE  IN  BLADDER 

Report  of  Case  Further  Complicated  by  Stricture  of 
Ureter  Giving  Classical  Symptoms  of   Renal  Colic 

A  white,  single,  saleswoman,  aged  25,  consulted 
her  family  physician  two  months  ago  about  pain 
in  the  lower,  left  abdominal  quadrant,  and  soreness 
and  tenderness  in  region  of  left  kidney.  Symptoms 
came  on  gradually.  Her  medical  advisor  made  a 
tentative  diagnosis  of  ureteral  colic.  The  pain  was 
so  severe  it  was  necessary  to  give  opiates  for  relief. 
The  patient  was  unable  to  work  for  several  weeks, 
the  symptoms  being  aggravated  by  her  being  on 
her  feet.  Symptomatic  treatment  was  given  with 
the  belief  that  the  patient  would  probably  pass  a 
small  stone  and  thereby  be  relieved.  The  condi- 
tion gradually  grew  worse  and  the  patient  was  re- 
ferred to  the  Anderson  County  Hospital  X-ray 
Service  for  intravenous  pyelogram. 

Both  kidneys  appeared  normal  in  size  and  loca- 
tion. Slight  left  hydronephrosis.  In  the  bladder 
region  a  shadow  the  size  and  shape  of  a  pigeon's 
egg  was  noted.  No  other  shadow  that  might  be 
interpreted  as  stone  was  found  in  kidney,  ureter 
or  bladder.  Urine  analysis  showed  albumin  and 
sugar  to  be  negative  with  10  pus  cells  to  each  high- 
power  microscopic  field. 

X-ray  Diagnosis:  Stone  in  bladder. 

Urological  Examination:  Patient  referred  to 
the  writer  for  crushing  and  removal  of  bladder 
stone.  Examination  of  the  x-ray  plate  convinced 
me  that  the  shadow  was  a  stone  in  the  bladder. 
The  patient  was  sent  to  the  cystoscopic  room  for 
the  stone  to  be  crushed.  Under  caudal  anesthesia 
an  observation  cystoscopy  was  done.    No  stones 


April   1941 


SOUTHERN  MEDICINE  Sr  SURGERY 


Shadow  in  bladder  area  mistaken  for  stone 

nor  diverticula  were  present  in  the  bladder;  the 
ureteral  orifices  were  normal  in  location  and  ap- 
pearance except  that  the  left  was  slightly  engorg- 
ed. A  number-6  catheter  was  passed  into  the 
right  kidney  without  meeting  obstruction;  but  I 
was  unable  to  pass  a  number-6  on  the  left.  A 
number-5  was  finally  passed  with  much  difficulty 
due  to  spasm  of  ureter  and  10  c.c.  of  residual  urine 
was  drawn  off.  This  specimen  showed  from  10  to 
IS  pus  cells  per  high-power  microscopic  field.  The 
urine  from  the  right  kidney  was  normal.  Catheter 
on  the  left  was  left  in  overnight  for  dilatation  with 
irrigation  ever  ythree  hours  with  1  to  3  aqueous 
solution  of  merthiolate  and  distilled  water.  The 
catheter  was  removed  the  next  day  and  the  patient 
discharged. 

Urological  Diagnosis:  Pyelitis  and  stricture  of 
left  ureter. 

Explanation  oj  Bladder  Shadow.  Upon  further 
questioning,  the  patient  stated  she  had  been  taking 
treatment  from  her  family  physician  for  tricho- 
monas vaginalis  and  that  a  part  of  this  treatment 
consisted  of  the  vaginal  insertion  of  a  carbarsone 
suppository  the  night  before  the  x-ray  examination 
of  the  kidney  and  bladder  region  was  made. 


Subsequent  History:  The  reaction  to  the  urol- 
ogical treatment  was  stormy  and  lasted  two  or 
three  days.  One  week  later  the  left  ureter  was 
dilated  at  the  office,  and  this  was  followed  by  se- 
vere reaction.  Since  then  she  has  had  three  dilata- 
tions at  office.  At  the  last  treatment  a  number-8 
catheter  was  passed  with  some  difficulty,  but  no 
reaction  followed  tht  last  three  dilatations.  The 
patient  was  discharged  as  cured  and  is  now  per- 
forming her  usual  work. 

Summary  and  Conclusions 

1.  A  case  is  reported  wherein  pyelitis  and  stric- 
ture of  the  ureter  gave  the  classical  symptoms 
usually  associated  with  ureteral  <:olic. 

2.  A  carbarsone  suppository  inserted  in  the 
vagina  12  hours  before  x-ray  examination  cast  a 
shadow  that  was  almost  pathognomonic  of  blad- 
der stone. 

3.  The  inherent  danger  in  a  situation  of  the 
type  confronted  here  is  that  in  the  absence  of  a 
thorough  cystoscopic  examination  it  is  highly 
probable  that  a  patient  might  be  subjected  to  cys- 
totomy. 

4.  It  is  apparent  that  the  lesson  taught  here 
would  lead  to  the  conclusion  that  it  is  the  part  of 
wisdom  to  do  cystoscopic  examination,  and  to  re- 
check  an  intravenous  pyelogram  with  a  retrograde 
pyelogram,  whenever  possible,  before  any  opera- 
tive procedure  is  undertaken  on  kidneys,  ureters 
or  bladder. 


OBSTETRICS 

Henry    J.    Langston,    M.    D.,   Editor,    Danville,   Va. 


REMOTE  VASCULAR  LESIONS  OF  THE 
TOXEMIAS  OF  PREGNANCY  AND 
THEIR  CLINICAL  SIGNIFICANCE 

The  conditions  which  go  under  the  name  of 
toxemias  of  pregnancy  are  various  and  confusing. 
An  abstract'  of  a  helpful  article  on  this  subject  is 
here  given  in  some  detail. 

The  type  of  toxemia  here  discussed  recurs  in 
each  pregnancy,  is  more  severe  and  begins  earlier 
in  the  pregnancy,  and  tends  to  end  in  uremia  and 
death.  The  renal  retinitis  and  the  uremia  confuse 
with  the  end  result  of  chronic  glomerulo-nephritis. 
This  condition  is  a  vascular  disease  manifesting 
itself  first  in  the  arterioles,  and  is  indistinguishable 
from  essential  hypertension.  The  kidney,  as  the 
most  sensitive  structure  involved,  may  be  relied 
upon  for  a  manifestation  of  disturbance.  Hyper- 
tension and  albuminuria  are  the  earliest  findings. 
Their  persistence  in  the  non-pregnant  state  is  diag- 

I.  J.    L.    McKelvcy,    Minneapolis,   in   Jl. -Lancet,    Feb 


SOUTHERN  MEDICINE  (r  SURGERY 


April    1941 


nostic  of  the  condition  in  the  absence  of  other  ob- 
vious cause. 

Evidences  of  one  or  another  form  of  toxemia 
appear  usually  in  the  last  half  of  pregnancy.  After 
delivery  hypertension  and/or  albuminuria  persist 
Blood  pressure  above  140/90  or  traces  of  albumin 
in  the  catheter  urine  are  abnormal  findings-  Strik- 
ing is  the  frequency  of  cardiovascular  disease  in  the 
parents  of  these  patients-  Observation  and  record- 
ing of  blood  pressure  and  urinary  findings  at  an 
interval  of  at  least  six  weeks  postpartum  is  a  sine 
qua  non  of  adequate  obstetric  care. 

In  subsequent  pregnancies,  increases  in  the  de- 
gree of  these  findings  will  occur  earlier  in  each. 
The  arteriolar  damage  advances  more  rapidly  in 
the  Negro. 

Kidney  function  is  normal  to  all  tests  save  preg- 
nancy until  the  terminal  stages,  when  uremia  and 
the  clinical  picture  is  unmistakable.  Albumin  is 
less  in  the  urine  of  the  arteriolosclerotic  toxemia 
than  in  that  of  the  acute  pregnancy  toxemia  of  a 
similar  degree  of  hypertension.  Blood  chemistry 
studies  are  at  normal  save  for  normal  pregnancy 
variations  until  the  terminal  stages. 

The  ophthalmoscopic  examination  is  of  great 
value  in  the  diagnosis.  Differentiation  between 
moving  localized  spasm  and  fixed  irregularities  due 
to  arteriolosclerosis  may  be  readily  made  on  re- 
peated examination. 

In  advanced  arteriolosclerosis  the  retinal  vessels 
show  tortuosity,  gross  irregularities  of  size,  arterio- 
venous crossing  phenomena  and  still  later,  associ- 
ated retinal  exudates.  Retinal  hemorrhages  at  any 
stage  is  a  grave  prognostic  sign. 

Care  of  the  toxemias  of  pregnancy  is  incomplete 
unless  it  includes  careful  observation  of  the  eye- 
grounds. 

Patients  may  undergo  multiple  pregnancies  with- 
out destruction.  Pregnancy  may  produce  a  speedy 
destruction-  The  condition  follows  the  general 
course  of  essential  hypertension- 

The  pregnancy  itself  may  be  prejudiced-  Ablatio 
placentae  fairly  closely  parallels  the  severity  of  the 
arteriolosclerosis  and  the  height  of  the  blood  pres- 
sure. 

Only  about  half  of  the  cases  of  premature  sep- 
aration show  any  evidence  of  toxemia. 

A  decision  as  to  a  residual  arteriolosclerosis  after 
preeclampsia  or  eclampsia  must  often  be  put  off 
until  six  weeks  postpartum.  Occasionally  evidences 
of  abnormality  disappear  after  an  eclamptic  is  dis- 
charged before  the  blood  pressure  and  urinary  find- 
ings have  returned  to  normal.  Occasionally  a  pa- 
tient discharged  with  apparently  normal  findings 
returns  with  evidence  of  arteriolosclerosis.  Obser- 
vations following  pregnancy  of  women  who  have 


had  toxemias  of  pregnancy  are  of  great  importance. 
About  one-third  of  the  total  toxemias  seen  in  clinic 
practice  are  of  this  nature.  One-quarter  of  eclamp- 
tics may  be  shown  to  develop  arteriolosclerosis. 

For  every  day  a  patient  is  allowed  to  continue 
with  a  toxemia  of  pregnancy  showing  hypertension 
and/or  albuminuria,  the  chance  of  the  establish- 
ment of  permanent  vascular  change  is  increased. 
Induction  of  labor  before  term  may  be  the  method 
of  choice.  No  patient  with  an  established  arteriolo- 
sclerosis should  be  advised  to  undertake  pregnancy. 
Sterilization  is  indicated.  Occasionally  these  pa- 
tients abort  spontaneously  in  time  to  save  them- 
selves. 

Careful  watch  should  be  kept  on  patients  suffer- 
ing from  pyelitis  of  pregnancy  in  order  to  recognize 
and  treat  at  the  earliest  possible  moment  an  exten- 
sion to  the  production  of  a  clinical  pyelonephritis. 
Drowsiness,  increased  protein  metabolites  in  the 
blood,  early  interference  with  kidney  function, 
renal  acidosis  etc.,  are  the  hallmarks  of  this  con- 
dition. 

The  various  forms  of  nephritis  may  heal  under 
adequate  therapy  and  subsequent  pregnancies  may 
then  be  undertaken  without  the  expectation  of  dif- 
ficulty provided  as  is  usual  in  young  people,  suffi- 
cient kidney  parenchyma  is  left  to  carry  on  func- 
tion This  is  in  striking  contrast  to  arteriolosclero- 
sis in  which,  once  established,  the  disease  process 
advances  with  each  pregnancy. 

Chronic  glomerulonephritis  is  seldom  an  obstetri- 
cal problem  ■  It  tends  to  occur  in  later  life,  with 
malaise,  anemia,  interference  with  nutrition,  all  of 
which  make  it  unusual  for  conception  to  occur-  If 
pregnancy  does  supervene,  the  problem  is  similar  to 
that  in  acute  nephritis- 


SHOULDER     AILMENT     TREATED     EFFECTIVELY 
BY  MEDICAL  MEANS 

(G     F.   Dick  et  al.   in  Jl.  A.   M.    A.,   March   22nd) 

A  fairly  common  condition,  calcification  in  the  supra- 
spinatus  tendon,  with  pain  and  limitation  of  motion  of  the 
shoulder,  most  frequently  between  the  ages  of  30  and  45, 
often  erroneously  diagnosed  as  bursitis,  arthritis,  neuritis, 
paralysis  of  the  radial  nerve  or  rheumatism,  is  amenable 
to  medical  treatment.  The  treatment  is:  (1)  rather  large 
doses  of  ammonium  chloride,  (2)  rest  of  the  part,  (3)  re- 
moval of  foci  of  infection,  (4)   physical  therapy. 


"CIRCULATION"— From  P.  200. 
macy  of  the  heart  and  at  the  same  time  did  not  oppose 
Galen's  opinion  regaiding  the  straining  of  the  blood  across 
the  perforate  interventricular  septum  of  the  heart;  more- 
over, though  Cesalpino  did  employ  the  word  circulatio,  it 
seemed  to  have  a  different  meaning  to  that  it  obtains 
nowadays  in  relation  to  the  blood.  These  two  important 
facts — that  Colombo  lectured  on  anatomy  at  Pisa  in  1545, 
during  Cesalpino's  student  days  and  that  the  word  "cir- 
culation" in  the  latter's  writings  seemed  to  have  a  peculiar 
meaning — have  been  overlooked. 


April    1941 


SOUTHERN  MEDICINE  &■  SURGERY 


GENERAL  PRACTICE 

Walter  J.  Lackey,  M.D.  Editor,  Fallston,  N.  C. 


HOPE  FOR  PIMPLY-FACED  YOUTH 

Most  of  the  writings  on  acne  vulgaris  are  pessi- 
mistic. They  say  this  and  that  may  be  done,  but 
the  general  idea  conveyed  is  that  if  the  patient 
lives  long  enough  he  will  probably  get  well,  all 
scarred  up. 

Here  comes  the  son1  of  a  great  dermatologist 
and  lion-hunter,  saying  a  certain  method  of  treat- 
ment will  cure  in  most  cases,  in  a  reasonable  time 
period,  usually  with  little  or  no  scarring.  And  the 
treatment  requires  no  expensive  apparatus. 

Here  it  is  in  abstract: 

Any  nonmedicated  soap  is  to  be  used  gently  with 
tepid  water.  By  skillful  removal  of  comedones 
scarring  is  minimized.  Remove  gently  without 
crushing  particles  of  lipoid  into  surrounding  tissues. 
The  pustule  containing  a  semidigested  comedo 
must  be  slit  just  widely  and  deeply  enough  to  let 
out  the  contents.  Compress  by  stretching  rather 
than  by  squeezing. 

Forbid  any  fatty  foods.  Allow  freely:  bread  and 
cakes  made  with  little  butter  or  lard,  cereals;  lean 
meat,  fowl,  or  fish  once  a  day,  all  vegetables  and 
fruits  (evcept  as  noted  in  low-carotene  diet  for 
certain  cases).  Allow  sugar,  preserves,  jam,  jelly, 
honey,  molasses,  candy  made  of  sugar,  but  not  of 
butter,  nuts  or  chocolate. 

Iodized  salt,  pepper  and  spices  are  allowed.  Al- 
cohol is  restricted  greatly;  tobacco  is  allowed;  cof- 
fee, tea  and  coca-cola  are  restricted  to  two  cupfuls 
a  day  of  any  one  of  them. 

The  low-carotene  diet  for  cases  mainly  of  the 
rosacea-like,  zanthoma-like  type  forbid:  carrot, 
pumpkin,  squash,  sweet  potato,  spinach,  yellow 
corn,  highly  colored  vegetables  and  fruits  in  gen- 
eral, catsup.  Allowed  are  rice,  beans,  peas,  pale 
corn,  grapefruit,  pears,  peach,  apple,  banana. 

Iodized  salt  should  be  used  in  cooking.  The 
diet  must  be  followed  strictly  and  continually.  The 
diet  is  so  low  in  calcium  that  in  pregnancy  calcium 
must  be  provided.  It  is  low  in  vitamin  A,  but 
harmlessly  for  a  period  of  four  months. 

Thyroid  extract  is  in  all  cases  given  to  tolerance 
without  regard  to  b.  m.  r.  or  the  chemistry  of  the 
blood.  Coffee  in  excessive  amounts  often  masks 
some  of  the  symptoms  of  hypothyroidism.  Given 
to  chronically  fatigued,  thin,  worried  patients,  thy- 
roid dosage  improves  sleep  in  part  rids  them  of 
their  nervousness  and  helps  them  to  gain  in  appe- 
tite and  weight.    Desiccated  whole  gland  substance, 

1.     R.  L.  Sutton,  Jr  ,  Kansas  City,  Mo.,  in  //.  Mo.  Med.  Assn., 
Feb. 


2  grains  each  day  with  the  evening  meal  or  twice  a 
day  with  breakfast  and  dinner,  increased  to  just 
less  than  the  amount  which  produces  symptoms  of 
excess.  After  two  weeks,  the  need  may  have  been 
made  up  so  that  a  smaller  dose  will  maintain. 

Objective  improvement  is  visible  in  a  week,  is 
well  defined  in  the  month  and  is  excellent  within 
six  months. 

Acne  vulgaris  is  a  metabolic  disease.  It  depends 
on  imbalance  between  the  dietary  intake  of  lipoids 
and  the  patient's  capacity  for  metabolizing  lipoids. 

Lipoid  deposits  in  comedones,  cysts  and  acne- 
form  lesions  must  for  the  most  part  be  removed 
mechanically,  for  if  allowed  to  remain  they  provoke 
inflammatory  reactions.  In  roseacea-like  cases  this 
cannot  be  done  but  the  low-carotene  diet  is  fol- 
lowed by  spontaneous  resorption. 

Milk  and  milk  products,  being  particularly  rich 
in  fat,  are  the  commonest  harmful  ingredients  of 
the  diets  of  patients  with  acne;  their  baneful  effect 
has  nothing  to  do  with  allergy. 

There  you  are — something  definite  and  positive 
and  cheerful. 

In  our  observation  acne  vulgaris  has  not  been  as 
obstinately  resistant  to  treatment  as  it  is  generally 
represented  to  be;  but  it  has  been  persistent. 

The  method  Dr.  Sutton  outlines  is  well  worthy 
of  hearty  welcome  and  honest  application. 

We  express  to  Dr.  Sutton,  in  the  name  of  all  the 
readers  of  this  journal,  the  most  sincere  thanks. 

COMMON  ERRORS  IN  THE  DIAGNOSIS 
AND  TREATMENT  OF  ANORECTAL 

DISEASES 

Osler  is  said  to  have  remarked  that  the  differ- 
ence between  a  good  doctor  and  a  poor  doctor  is 
that  the  good  doctor  examines  the  rectum.  There 
are  few  ways  in  which  a  general  practitioner  can 
better  serve  his  patients  than  by  making  rectal  ex- 
aminations, then  treating  most  of  the  conditions  he 
finds. 

An  excellent  paper  illustrating  this  point  is  ab- 
stracted. 

Most  diagnostic  errors  in  anorectal  diseases  are 
due  to  failure  to  make  the  simple  digital  examina- 
tion of  the  rectum  which  should  be  a  part  of  every 
physical  examination.  A  proctoscopic  examination 
should  be  carried  out  when  anything  abnormal  is 
found  on  digital  examination,  or  when  the  patient 
has  any  symptoms  referable  to  this  region.  Most 
carcinomas  of  the  terminal  portion  of  the  colon  are 
within  reach  of  the  finger. 

Ectropion  of  the  rectal  mucosa  is  commonly  en- 
countered   after   "Whitehead    operation,"   not   the 


1.  R.    J.    Jackn 


Roccster.    Minn 
Mar. 


//.    Iowa   Med.   Soc. 


SOUTHERN  MEDICINE  6r  SURGERY 


April    1941 


operation  Whitehead  described.  In  this  erroneous 
operation  the  rectal  mucosa  has  been  sutured  to 
the  skin  outside  the  grasp  of  the  anal  musculature. 
The  discharge  and  moisture  resulting,  excoriated 
and  infected,  burning  and  itching,  frequently  is 
treated  as  anal  ulceration  or  anal  fissure.  Applica- 
tion of  various  cauterizing  agents  to  the  exposed 
mucosal  surface  is  made  under  the  physician's  false 
impression  that  he  was  dealing  with  a  fissure. 
Treatment  is  dissection  of  the  exposed  mucosa  and 
restoration  to  the  normal  protected  position  inside 
the  anal  musculature. 

All  anal  fistulas  originate  in  the  crypts  at  the 
dentate  margin.  Treatment  is  to  convert  all  fistul- 
ous tunnels  into  open  ditches;  all  tissue  overlying 
or  external  to  the  probe  must  be  incised,  and  de- 
ridement  of  the  margins  of  the  resultant  wound 
whether  or  not  muscle  intervenes.  Anal  inconti- 
nence is  more  often  the  result  of  inadequate  opera- 
tion than  of  completed  fistulectomy  in  which  part 
or  all  of  the  anal  musculature  has  been  severed 
once  or  several  times. 

Rectal  bleeding  is  too  frequently  assumed  to  be 
hemorrhoidal  in  origin. 

One  patient  who  consulted  her  physician  1J^ 
years  previous  to  being  relieved,  during  the  two 
months  ensuing  received  23  injections  of  some 
sclerosing  agent  for  internal  hemorrhoids,  but  the 
bleeding  had  persisted.  Several  months  of  a  spe- 
cial diet  and  various  drug  and  vaccine  therapies  for 
colitis  had  not  produced  any  change  in  symptoms. 
On  proctoscopic  examination  a  pedunculated  polyp 
2.S  x  2.5  cm.  was  found,  destroyed  by  fulguration 
and  the  bleeding  promptly  subsided. 

Hypertrophy  of  the  anal  papillae  is  the  result 
of  infection  in  the  anal  canal  or  crypts.  After  the 
process  has  subsided  complete  recession  of  the  pa- 
pilla is  rare.  The  hypertrophied  papilla  is  part  of 
the  dentate  margin  covered  by  squamous  epithe- 
lium, the  same  color  as  the  skin.  Polyps  usually 
arise  above  the  dentate  margin  from  the  columnar 
epithelium,  have  a  typical  polypoid  appearance, 
are  more  friable  and  bleed  easily.  The  malignant 
propensities  of  the  polyp  are  well  known  whereas 
hypertrophied  papillae  cause  trouble  only  to  the 
extent  of  protrusion,  sensation  of  rectal  fullness, 
pressure  or  pain. 

Most  small  sessile  and  pedunculated  polyps  in 
this  region  can  be  destroyed  very  simply  by  fulgur- 
ation without  resort  to  anesthesia.  Any  attempt  at 
removal  of  enlarged  papillae  will  require  some  form 
of  anesthesia. 

Rectal  tumors  of  chemical  origin  result  from  the 
use  of  various  sclerosing  preparations  in  the  injec- 
tion treatment.  From  oil,  particularly  mineral  oil, 
the  resultant  fibrous  tumor  may  persist  for  years 


as  a  single  nodular  mass  or  an  annular  stricture. 
The  condition  has  been  mistaken  for  a  carcinoma, 
and  radical  operation  has  been  performed  to  re- 
move the  supposedly  malignant  tumor.  The  pa- 
tient's report  receiving  injection  treatments;  the 
overlying  mucosa  is  usually  normal,  although  it 
may  be  scarred  and  adherent.  The  condition  also 
may  be  confused  with  a  chronic  internal  abscess 
or  fistula,  and  examination  with  the  patient  under 
anesthesia  may  be  necessary  to  rule  out  this  possi- 
bility. 

An  extrarectal  mass  in  the  pouch  of  Douglas  or 
rectovesical  space  metastasis  from  a  carcinoma  in 
the  upper  part  of  the  abdomen,  or  some  intraab- 
dominal inflammatory  disease,  may  impinge  on  the 
anterior  rectal  wall  and  produce  a  mass  confused 
with  primary  rectal  carcinoma.  In  such  cases,  the 
patient's  principal  complaint  may  be  referable  to 
the  rectum,  and  the  finding  of  the  rectal  shelf  may 
be  the  first  significant  clue  to  discovery  of  some 
obscure  abdominal  disease. 


THERAPEUTICS 

J.  F.  Nash,  M.  D.,  Editor,  Saint  Pauls,  N.  C. 


FITS  IN  ADULTSi 

The  first  thought  is  stop  the  fit.  In  status  epi- 
lepticus  the  patient  has  a  series  of  fits  without  re- 
gaining consciousness  and  death  may  ensue  unless 
the  seizures  are  promptly  relieved. 

A  physician  always  ought  to  have  in  his  bag 
paraldehyde  and  sodium  phenobarbital.  Paralde- 
hyde may  be  given  by  mouth,  vein,  muscle  or  rec- 
tum. For  an  adult  having  fits  begin  treatment 
with  an  intravenous  injection  of  1  to  2  c.c.  of  pa- 
raldehyde (drawn  from  a  stock  bottle  as  the  solu- 
tion is  sterile).  This  usually  will  result  in  prompt 
cessation  of  the  seizure.  A  second  injection  of  1 
c.c.  may  succeed  after  the  first  has  failed.  This 
dosage  should  be  less  if  the  patient  has  had  any 
other  narcotic  in  one  or  two  hours.  If  the  seizures 
continue,  4  to  6  grains  of  sodium  phenobarbital 
intravenously  or  intramuscularly,  preferably  by  the 
route  not  used  for  the  paraldehyde.  The  patient 
may  remain  in  stupor.  Then  pass  a  nasal  tube 
into  the  stomach  so  that  fluids  and  dilantin  sodium 
may  be  administered  at  regular  intervals  until  the 
patient  recovers  consciousness.  If  there  is  fever 
repeated  tepid  or  cool  sponging  is  indicated. 

Repeated  attacks  jacksonian  in  type  do  not  re- 
spond so  readily  to  therapy. 

In  the  absence  of  paraldehyde  or  sodium  pheno- 
barbital  use  morphine,   ether  or  chloroform  with 

1.   C.    D.   Aring,   Cincinnati,   in  Vino   Med.   Jl.,   Mar 


April   1941 


SOUTHERN  MEDICINE  &■  SURGERY 


to 


caution.  Keep  in  mind  that  one  of  the  symptoms 
to  be  combated  in  status  epilepticus  is  coma. 

In  grand  mal  seizures  a  l/2  grain  capsule  of 
dilantin  sodium  t.  i.  d.  is  the  usual  dose.  Six  cap- 
sules (9  grains)  should  be  the  maximum  per  day. 
It  is  strongly  alkaline  and  must  be  taken  during 
or  immediately  after  meals  to  prevent  gastric  dis- 
tress. 

The  patient  should  live  as  normally  as  society 
and  his  disease  will  allow  him  to  live.  Young  per- 
sons afflicted  with  convulsions  should  continue  in 
school.  If  school  authorities  object,  it  falls  to  the 
duty  of  the  physician  to  enlighten  them.  Children 
will  accept  much  about  which  they  are  given  a  rea- 
sonable explanation. 

Persons  subject  to  seizures  have  a  smaller  num- 
ber of  them  in  a  normal  environment  than  in  a  re- 
stricted one.  The  use  of  alcohol  must  be  inter- 
dicted. 

With  the  intelligent  patient  always  hold  out  hope 
of  something  better,  for  the  reason  that  many  keen 
minds  are  on  the  trail  of  his  disase.  I  have  encour- 
aged all  of  my  intelligent  patients  to  join  the  Lay- 
men's League  Against  Epilepsy,  whose  offices  are 
at  the  Harvard  Medical  School. 

Those  with  low  intellectual  levels  who  are  hav- 
ing many  fits  despite  medication  should  be  sent  to 
institutions. 

Petit  mal  therapy  is  not  satisfactory.  The  anti- 
convulsants should  be  juggled  about  in  an  attempt 
to  find  something  that  may  benefit. 

Jacksonian  seizures,  the  attack  begins  in  one  part 
of  the  body,  usually  in  the  face,  fingers  or  the  toes. 
The  convulsion  may  remain  localized  or  it  may 
spread  and  the  patient  may  feel  the  numbness  ad- 
vance, or  watch  the  twitching  progress  up  an  ex- 
tremity. If  the  convulsion  spreads  to  the  other 
side  of  the  body  the  patient  may  lose  consciousness 
and  the  attack  become  a  grand  mal. 

The  treatment  usually  is  eventually  surgical, 
although  it  is  well  for  the  patient  to  have  had  a 
trial  of  dilantin  sodium,  phenobarbital  or  bromide 
before  the  operation.  This  trial  of  drug  therapy 
should  not  delay  surgery  indicated. 

Psychomotor  epilepsy  manifestations  are  pro- 
tean. The  patient  in  an  attack  may  walk  about 
mumbling  and  picking  at  his  clothes  or  he  may 
commit  some  evert  act.  The  amnesia  may  last  for 
long  periods,  and  the  person  may  travel  great  dis- 
tances and  regain  his  senses  in  a  distant  city.  The 
patient  is  usually  morose  during  the  attack,  but 
may  be  violent.  The  pattern  of  the  attack  is  usu- 
ally the  same  from  time  to  time.  There  may  be  in 
the  attack  tonic  spasm,  or  twisting  of  the  body  and 
suffusion  of  the  face;  there  may  be  no  fall  and 
there  never  are  the  clonic,  jerking  movements  of 


the  grand  mal  type.  A  psychic  seizure  may  be 
manifested  as  a  period  of  altered  disposition  or  of 
aggressive  behavior,  entirely  foreign  to  the  nature 
of  the  individual.  If  the  patient  suffers  from  grand 
mal  or  petit  mal  in  addition  to  the  psychic  equiv- 
alents, or  if  an  electroencephalogram  is  made,  the 
diagnosis  usually  may  be  arrived  at. 

Brilliant  results  have  been  obtained  in  psycho- 
motor seizures  with  the  use  of  dilantin  sodium. 

It  is  extremely  dramatic  to  see  a  potential  mur- 
derer changed  into  a  useful  citizen  practically  over- 
night. 

Though  the  opinion  that  heredity  is  an  impor- 
tant influence  in  epilepsy  is  widespread,  only  one 
epileptic  person  in  five  is  able  to  name  any  relative 
who  has  been  similarly  affected. 


EARLY  CARE  OF  DEPRESSED  FRACTURES 
OF  THE  MALAR  BONE 

Few  textbooks  of  surgery  give  any  information 
on  what  to  do  about  these  fractures.  There  are 
few  articles  on  the  subject  in  the  journals.  Yet  the 
number  of  such  fractures  is  great;  and  they  are 
important,  threatening,  as  they  do,  not  only  the 
comfort  and  the  life  of  their  victims,  but  destruc- 
tion of  whatever  of  pulchritude  one  may  be  blessed 
withal.  Vanitas  vanitatum. 

Here  is  the  substance  of  an  article1  of  great  help- 
fulness to  those  of  us  who  have  to  take  care  of 
such  cases. 

A  rather  strong  bone  in  an  exposed  position,  on 
four  weak  supports,  accounts  for  the  variety  and 
number  of  these  fractures. 

There  may  be  so  much  swelling  that  depression 
may  not  be  noticed  on  inspection;  but  if  palpatory 
evidence  of  depression  is  present,  one  can  rest  as- 
sured of  the  diagnosis. 

These  fractures  unite  as  a  rule  by  the  end  of  the 
third  week;  therefore  treatment  should  be  insti- 
tuted promptly. 

The  hair  is  shaved  from  the  temporal  region, 
and  a  transverse  (lying  down)  incision  one  inch 
long  is  made  well  within  the  hairline.  The  edges 
are  retracted,  and  a  nick  is  made  in  the  fascia, 
then  enlarged  so  that  a  bone  skid  one-half  inch 
wide,  and  eight  inches  long,  with  curved  blunt  ends 
passed  between  the  fascia  and  muscle  downwards, 
the  convex  curve  of  the  instrument  rests  against 
the  posterior  aspect  of  the  malar  bone.  This  is 
surprisingly  easy  to  accomplish. 

A  pad  of  gauze  or  cotton  along  the  upper  edge 
of  the  incision  to  protect  the  skin  from  too  much 
pressure  and.  using  the  skull  as  a  fulcrum,  lever 
the  bone  into  position.  The  skin  closed  with  clips, 
black-silk,    horse-hair    or    Allegheney    steel,    inter- 

1.  V    E.  Johnson,  Atlantic  City,  in  Jl.  Med.  Soc.  N.  J.,  Mar. 


SOUTHERN  MEDICINE  tr  SURGERY 


April    1941 


rupted  sutures  to  allow  for  possible  drainage. 
Don't  drain  the  wound. 

After  reducing,  if  the  bone  slips  out  of  place 
easily  the  antrum  has  been  crushed.  In  this  case 
retract  the  angle  of  the  mouth  and  make  a  one- 
inch  incision  in  the  canine  fossa  down  to  the  bone; 
push  the  periosteum  away  from  the  maxilla,  feel 
for  the  zygomatic  ridge  and  open  the  antrum  just 
anterior  to  this  ridge,  using  a  quarter-inch  gouge. 
Pass  a  suitably  curved  instrument  into  the  antrum 
and  elevate  the  wall  of  the  antrum  and  the  malar 
will  remain  properly  reduced. 

Pack  the  antrum  with  one-inch  vaseline  gauze, 
and  close  the  mucous  membrane  around  the  gauze 
with  black  silk.  Place  a  gauze  pack  in  the  labio- 
gingival  fold. 

Pack  the  antrum  for  one  week,  remove  packing, 
irrigate  daily  for  one  week  and  then  twice  a  week. 
The  oral  opening  into  the  antrum  will  usually  close 
in  three  weeks. 

The  patient  should  not  be  allowed  to  sleep  on 
the  injured  side  for  three  weeks.  A  bandage  around 
the  head  with  knot  on  the  side  of  injury  will  help 
to  prevent  turning  on  that  side  in  sleep. 


TREATMENT  OF  THE  MENOPAUSE 
Welcome  is  any  offering1  with  promise  of  relief 
at  this  time,  especially  welcome  is  a  light  in  the 
dark  places  of  endocrine  therapy  of  this  period. 

One  of  the  surprising  results  has  been  the  dem- 
onstration that  estrone  can  be  applied  on  the  skin 
in  alcohol  solution  and  that  there  is  prompt  and 
efficient  absorption  of  the  estrogen,  while  the  alco- 
hol evaporates  quickly.  I  have  repeatedly  demon- 
strated that  this  method  will  control  climacteric 
symptoms  satisfactorily.  In  one  case  in  which  daily 
intramuscular  administration  of  10,000  units  of 
estrone-1  had  long  been  given,  it  was  possible  to 
transfer  to  the  same  dose  of  10,000  units  of  estrone 
in  alcohol  on  the  skin.  Later,  as  is  the  case  with 
oral  therapy,  the  dose  was  gradually  reduced  with 
continued  control  of  symptoms.  The  application  of 
from  5,000  to  10,000  units  of  estrogen  daily  to  the 
skin  of  the  abdomen  for  more  than  28  months  has 
led  to  no  sign  of  any  dermal  change.  The  possi- 
bilities of  surface  application  of  estrogen  are  en- 
couraging because  of  ease  of  application,  ease  with 
which  the  dose  can  be  measured  and  greater  effi- 
ciency per  unit  than  by  any  other  route  of  admin- 
istration save  oil  injection. 

Estrogenic  therapy  by  the  oral  route  is  depend- 
able. The  choice  of  preparation  to  be  used  is 
largely  a  matter  of  price,  save  that  it  is  not  practi- 
cable to  give  estriol  glucuronide  in  large  doses. 
The  mixed  estrogens  known  now  as  estrogenic  sub- 

1.  E.  L.  Sevringiajis,  Madison,  in  Jl.  A.  M.  A.,  March  22nd 


stances  and  estriol  glucuronide  appear  to  have  an 
advantage  per  unit  over  the  pure  estrone,  which  is 
the  chief  constituent  of  the  mixture.  Estradiol  is 
not  better  clinically  and  is  costly.  Price  adjusted, 
one  may  use  whichever  preparation  he  prefers  and 
get  equally  good  control  of  climacteric  symptoms. 


TUBERCULOSIS 

J.  Donnelly,  M.  D.,  Editor,  Charlotte,  N.  C. 


ARTIFICIAL  PNEUMOTHORAX  IN 
TUBERCULOSIS  TREATMENT 

Artificial  pneumothorax  is  probably  the 
greatest  addition  to  tuberculosis  therapy  since  the 
discovery  of  the  cause  of  the  disease.  However, 
many  physicians  fail  to  consider  that  it  is  not  a 
universal  cure;  and  that  in  some  cases  it  is  un- 
suitable, in  others  unnecessary.  A  few  sanatoria 
report  as  high  as  80-90  per  cent  of  patients  re- 
ceiving pneumothorax  treatment,  although  in  the 
opinion  of  most  physicians  of  large  experience  in 
this  field  the  treatment  in  the  really  minimal  cases 
is  not  justified.  In  advanced  disease  the  addition 
of  collapse  therapy  to  rest  treatment  has  been 
instrumental  in  saving,  or  at  least  prolonging, 
many  lives. 

In  the  February  issue  of  the  Journal  oj  Thora- 
cic Surgery  there  is  an  article  by  R.  G.  Bloch 
et  al.  which  covers  rather  fully  the  indications  and 
contraindications  for  artificial  pneumothorax.  The 
authors  emphasize  that  they  are  discussing  the 
medical  standards  of  the  question  only,  and  not 
variations  in  treatment  which  are  frequently  nec- 
essary from  a  public  health  standpoint. 

According  to  these  authors,  the  present  rather 
widespread  recommendations  of  collapse  therapy 
in  early,  even  minimal,  tuberculosis  is  not  justi- 
fied, because  the  majority  of  such  lesions  will  soon 
heal  spontaneously,  frequently  without  ever  hav- 
ing been  recognized  and  without  any  treatment 
whatever.  The  persistent  presence  of  sputum  posi- 
tive for  tubercle  bacilli,  even  without  x-ray  evi- 
dence of  cavity,  means  destruction  of  tissue  and 
at  least  beginning  cavity  formation,  but  not  all 
cavities  are  an  absolute  indication  for  this  proce- 
dure. On  rest  treatment  alone  filled-up  caseous 
areas  frequently  remain  so  permanently,  all  symp- 
toms and  bacilli  disappearing.  Such  areas  may  be 
reabsorbed,  may  calcify  entirely,  or  may  split  up 
into  several  calcareous  areas.  In  the  opinion  of 
the  authors  thin-walled  cavities  in  caseous  tuber- 
culosis often  become  distended  because  of  the  ex- 
ertions of  an  active  life,  but  quickly  shrink  on 
complete  bed  rest,  and  heal  eventually  by  calcifi- 


April   1941 


SOUTHERN  MEDICINE  &  SURGERY 


cation.  The  authors  do  not  to  imply  that  all  such 
cavities  should  be  expected  to  heal  spontaneously, 
since  tuberculosis  once  known  to  produce  cavity 
should  be  under  observation  for  many  years,  even 
with  apparently  complete  clinical  recovery.  Often 
collapse  therapy  is  indicated  after  a  period  of  bed 
rest,  even  though  a  certain  amount  of  spontaneous 
healing  has  been  observed.  The  old,  thick-walled, 
unchanging  cavity  demands  a  collapse  procedure, 
for  the  patient  can  never  be  cured  if  the  cavity 
remains  open,  but  if  collapse  by  air  cannot  be  ob- 
tained in  a  reasonable  time  some  other  form  of 
surgical  collapse  should  be  resorted  to. 

Artificial  pneumothorax  is  not  for  extensive, 
acute  pneumonic  tuberculosis.  These  patients  are 
as  a  rule  very  ill  and  can  not  properly  expectorate 
the  large  amounts  of  sputum  produced  by  the  lung 
collapse.  Furthermore,  early  collapse  tends  to  in- 
crease the  chance  of  bronchogenic  spread  of  the 
disease  with  a  resultant  increased  toxemia  from 
the  absorption  of  greater  areas  of  caseating  dis- 
ease. Artificial  pneumothorax  should  not  be  in- 
stituted until  the  process  becomes  localized  and 
chronic  with  a  reduction  of  the  acute  symptoms. 
Those  having  little  opportunity  to  observe  the 
pathologic  changes  and  the  natural  healing  proc- 
esses of  the  disease  may  be  imbued  with  the  idea 
that  artificial  pneumothorax  is  applicable  in  al- 
most every  case.  Spontaneous  healing  is  frequently 
called  by  them  exceptional  and  accidental.  Ex- 
perienced tuberculosis  physicians  know  that  such 
results  are  not  exceptions,  but  are  natural  healing 
changes  which  cannot  be  followed  in  the  collapsed 
lung. 

In  the  authors'  opinion  the  treatment  by  artifi- 
cial pneumothorax  preferable  to  all  others  is  the 
combination  of  lung  collapse  with  extended  and 
supervised  bed-rest.  The  practice  of  ambulatory 
pneumothorax  treatment  is  deprecated  as  danger- 
ous. Discontinuance  of  the  regular  work  is  often 
considered  as  adequate  rest,  but  oftentimes  not 
even  this  advice  is  given.  Such  management  in- 
duces the  patient  to  consider  his  disease  as  not  a 
serious  matter,  and  he  looks  upon  the  pneumotho- 
rax treatment  as  a  sure  cure.  Wrong  methods  of 
tabulating  the  results  of  pneumothorax  treatment 
are  considered  largely  responsible  for  the  over- 
enthusiasm  for  this  method  of  treatment. 

The  medical  aim  of  any  treatment  is  the  cure 
of  disease,  and  the  return  of  the  patient  perma- 
nently to  his  former  life  and  work.  The  fact  that 
a  tuberculous  patient  returns  to  work  symptom- 
free  does  not  mean  that  he  is  cured.  Freedom 
from  symptoms  and  a  gain  in  weight  do  not  prove 
a  cure,  and  oftentimes  has  no  relation  to  the  end 


result.    As  long  as  a  lung  remains  collapsed  one 
cannot  say  that  the  patient  is  cured. 

The  authors'  criteria  for  determining  the  cura- 
tive results  of  pneumothorax  treatment  are:  (1) 
restoration  of  the  lung  to  full  reexpansion ;  (2) 
adequate  x-ray  evidence  of  healing;  (3)  return  of 
the  patient  to  normal  life,  with  (4)  persistent  ab- 
sence of  tubercle  bacilli  from  the  sputum;  (5) 
persistent  absence  of  all  symptoms  of  activity,  and 
(6)  complete  disappearance  of  all  extrapulmonary 
complications.  There  is  added  as  a  final  admoni- 
tion: "Only  after  at  least  two  years  of  satisfactory 
application  of  these  criteria  should  a  patient  be 
considered  as  cured  by  the  treatment." 

Summary 

1.  Indications  for  artificial  pneumothorax 
should  be  more  clearly  defined. 

2.  The  tuberculous  cavity  is  the  most  impor- 
tant factor  in  the  indication  for  collapse  therapy. 

3.  At  least  two  years  should  elapse  after  re- 
expansion  of  the  lung  before  considering  a  patient 
cured. 

4.  Rest  with  collapse  is  a  necessity. 

5.  Surgical  collapse  should  follow  as  soon  as 
failure  of  pneumothorax  to  close  cavities  has  be- 
come evident. 


DENTISTRY 

J.   H.    Guion,   D.D.S.,   Editor,   Charlotte,    N.    C. 

THE  DEVITALIZED  TOOTH:  A  FACTOR  IN 
OPHTHALMOLOGY 

Some  under-  and  some  over-estimate  the  im- 
portance of  dental  infection  in  causing  disease 
elsewhere.     Here1  is  a  fair  appraisal. 

Dental  sepsis  is  responsible  for  much  ill  health 
in  other  parts  of  the  body. 

Acute  tonsillitis,  acute  and  chronic  cervical 
adenitis,  Ludwig's  angina,  retropharyngeal  ab- 
scesses, acute  parotitis,  acute,  subacute  and  chronic 
laryngitis — all  of  these  might  well  result  from  den- 
tal sepsis. 

The  sinus  most  frequently  observed  to  harbor 
infection  is  the  maxillary  antrum ;  many  cases  of 
pansinusitis  are  also  traceable  to  a  maxillary  em- 
pyema. Hayfever  and  allergic  rhinitis  are  caused 
by  irritating  discharges  from  an  infected  maxillary 
sinus  which  renders  these  membranes  sensitive  to 
almost  any  inspired  irritant.  Many  of  these  pa- 
tients have  been  greatly  relieved,  if  not  entirely 
cured,  by  the  removal  of  infected  teeth. 

Endotoxins   absorbed    into   the   general   circula- 


1.    B.    II.    Pain 


//.  Fla.  Med.  Assn.,  Mar. 


SOUTHERN  MEDICINE  &■  SURGERY 


April    1941 


tion  have  produced  a  direct  effect  on  the  ciliary 
muscles,  thereby  weakening  the  accommodation, 
causing  headaches  and  general  nervous  instability. 

Many  cases  of  chronic  conjunctivitis  result  from 
dental  sepsis,  upward  through  the  nasoacrimal  duct 
into  the  lacrimal  sac  and  canal. 

Blepharitis  marginalis,  and  not  infrequently 
some  types  of  corneal  ulcerations,  may  continue 
in  activity  as  long  as  a  devitalized  tooth  remains. 
Obstinate  cases  of  traumatic  iritis  are  so  often 
traceable  to  dental  sepsis.  In  case  after  case  le- 
sions of  various  types  were  traceable  to  devitalized 
teeth  which  roentgenographic  studies  had  shown  to 
be  apparently  uninfected. 

Some  permit  devitalized  teeth  to  remain  in  and 
suffer  no  dire  consequences  therefrom;  yet  the 
general  health,  vigor  and  vitality  of  even  these 
people  might  be  greatly  improved  were  they  rid  of 
them. 

The  experience  of  a  vast  number  of  ophthal- 
mologists have  proved  that  devitalized,  pulpless 
teeth  play  an  important  part  in  certain  diseases  of 
the  eye. 


SUBDURAL    HEMATOMA— Pitts 
I  was  particularly  interested  in  Dr.  Masters'  case  which 
had  as  the  most  prominent  feature  mental  change.    I  think 
one  can't  stress  that  point  too  much,  for  it  is  probably  the 
most  constant  change. 

The  other  point  about  the  early  onset  of  signs  of  com- 
pression coming  within  48  hours  is  well  taken.  At  that 
stage,  the  situation  is  confusing.  It  is  difficult  to  recognize 
hematoma  at  that  time  or  to  differentiate  it  from  cerebral 
edema.  That  is  where  air  studies  are  of  the  most  value. 
One  very  rarely  finds  a  shift  of  the  ventricular  system 
produced  by  cerebral  edema.  When  present,  it  is  never  as 
marked  as  that  produced  by  subdural  hematoma,  and  one 
does  not  find  the  obliquity  of  the  third  ventricle  which  is 
associated  with  subdural  hematoma. 

The  other  point  about  the  triviality  of  the  injury: 
There  is  a  case  reported  from  the  Brigham  Hospital,  in 
which  there  was  no  history  of  trauma  other  than  the  fact 
that  the  patient  was  a  tinner,  accustomed  to  lifting  trap 
doors  in  the  attics  with  his  head  instead  of  with  his  hands. 
However,  I  might  say  that  in  all  neurological  clincs 
about  once  a  year  a  patient  is  admitted  without  a  history 
of  trauma,  with  signs  and  symptoms  of  intracranial  pres- 
sure without  localization.  The  patient  is  taken  to  the 
operating  room  for  ventriculography  to  localize  a  would- 
be  brain  tumor  and  to  the  surprise  of  all  concerned,  an 
unsuspected  subdural  hematoma  is  encountered. 


POSTOPERA  TIVE  DISTENTION— Linton 
tion  in  major  orthopedic  work — as  in  the  scoliosis  cases 
which  have  been  bent  far  laterally  in  the  wedging  jacket 
before  the  spinal  fusion.  The  thing  that  gives  us  the  most 
distention  is  hyperextension  of  the  spine — as  in  head  trac- 
tion, in  treatment  of  compression  fractures,  and  after 
spinal  fusions.  I  have  had  a  spinal  fusion  myself  and  felt 
as  if  I  could  just  sit  in  the  flexed  or  jackknife  position  a 
while  my  distention  would  have  been  relieved — and  such 
is  the  case;  for  when  we  decrease'  hyperextension  or  flex 
the  spine  distention  is  decreased.  I  have  used  this  drug  in 
a  few  cases  with  gratifying  results. 


Dr.  Donald  Daniels,  Richmond:  I  am  glad  Dr  Linton 
brought   us   this   paper.     I   agree   fully   that  prostigmin   is 

;;:';;  rnderful  adiunct  in  ^PeJive  ST 

think,  though,  that  we  should  be  very  careful  in  using 
P  ostigm.n.  particularly  in  cases  of  intestinal  obstruction 
before  you  decide  what  the  cause  is.  If  vou  operate  for 
carcnoma   around   the   proximal    gut,   it   makes  "a   pati en 

iTeu  vou"™'0  g™  ^^^  H  ^  have  £E 
ITu  X  ,  u '  3Ve  P°st°Perative  trauma.  Sometimes 
1  '  slfh„test  Provocation  you  can  have  an  embolus 
regardless  of  how  good  the  surgery.  I  have  seen  tremen 
dous  ileus  following  an  eye  operation,  following  „Z  . 
orny  or  even  broken  back.  Putting  a  patient  in  a  ast 
«'.l  give  ,leUS  or  paralysis  of  intestines.  A  man  is  by 
nature  a  person  of  habit.  When  we  are  voung  it  take" 
three   or   four   years   to   break   us   from   wetting   the   be" 

when  ,  r  g°°d  ^^  3nd  r  h3Ve  USed  !t  occasiona  ly 
when  selecting  operative  patients,  to  teach  patients  to 
void  lying  down.  I  find  that  lots  of  them  can  learn  to 
void  before  they  are  operated  on  when  it  is  not  an  emergen- 
cy.  That  helps  quite  a  lot.  Dr.  T.  E.  Lind.  of  Baltimore 
started  using  some  mercurochrome  postoperatively.  He 
claims  that  cuts  down  a  bit  of  bladder  discomfort  and 
causes  voiding  to  be  much  easier. 

Dr.  Linton  (closing) :  I  wish  to  thank  Dr.  Dawson  for 
his  remarks  on  using  the  drug  from  an  orthopedic  point 
of  view  and  Dr.  Daniels  for  his  emphasis  on  the  need  for 
learning  to  void  before  operation.  That  is  a  point  of 
value.  It  seems  most  logical.  I  noticed  just  the  other  day 
an  article  which  stated  that  the  giving  prostigmin  in  cases 
in  which  peritonitis  was  anticipated  or  present  was  debata- 
ble, but  we  have  had  no  bad  results  by  giving  it. 

Dr.  White  makes  me  indebted  to  him  for  one  more 
kindness.  He  was  one  of  my  chiefs.  If  I  have  absorbed 
but  little,  it  was  not  because  I  was  not  exposed  to  a  great 
deal. 


USE   OF   DIURETICS   IN  THE   TREATMENT  OF 

CERTAIN  LOCALIZED  EDEMAS 
(M    A.    Schnitker,    Toledo,    in    Ohio    State   Med.   JI-,   April) 

Twelve  cases  of  localized  edema  of  an  extremity  are 
reported.  These  include  obstructional,  traumatic,  inflam- 
matory, and  thrombophlebitic  edema,  and  swelling  of  the 
arm  following  radical  amputation  of  the  breast.  The 
cases  were  selected  on  the  basis  that  cardiac  or  renal  fac- 
tors played  no  part  in  the  cause  of  the  edema.  Eight  of 
the  12  patients  responded  very  satisfactorily  to  one  or 
several  injections  of  2  c.c.  mercupurin  intravenously  alone. 
Two  patients  required  acid-salt  preparation  with  ammo- 
nium chloride,  after  which  they  responded  fairly  well  to 
the  mercurial  diuretic.  Another  patient  did  not  respond 
at  all,  which  is  explained  probably  by  the  chronicity  of 
the  edema  with  resulting  induration.  One  patient  had 
complete  subsidence  of  edema  by  elevation  alone  of  the 
part. 

This  method  of  treatment  is  simple  and  seems  to  be 
quite  effective  in  the  control  of  acute  edema  of  an  ex- 
tremity, irrespective  of  the  cause.  The  method  consists  in 
elevation  of  the  extremity  to  allow  the  full  effect  of  grav- 
ity, followed  by  the  intravenous  injection  of  a  mercurial 
diuretic,  either  salyrgan  or  mercupurin. 

Ammonium  chloride  has  been  shown  to  be  a  distinct 
adjunct  in  the  use  of  salyrgan.  In  this  study  it  was  ob- 
served that  with  mercupurin  (salyrgan  with  theophylline) 
a  satisfactory  diuretic  response  could  be  obtained  fre- 
quently without  the  preliminary  administration  of  ammo- 
nium chloride. 


April    1941 


SOUTHERN  MEDICINE  &  SURGERY 


INTERNAL  MEDICINE 

George    R.   Wilkinson,   M.  D.,   Editor,   Greenville,    S.    C. 


THE  PROBLEM  OF  ESSENTIAL 
HYPERTENSION 

Rare  is  the  day  on  which  some  patient  does 
not  ask  you  about  his  blood  pressure.  A  fair 
statement1  of  our  knowledge  of  this  state  is  con- 
densed for  helping  you  to  answer  these  questions. 

Normal  arterial  blood  pressure  may  be  the  re- 
sult of  cardiac  output,  peripheral  resistance  (arte- 
riolar) and  arteriolar  tonus. 

It  has  been  surmised  that  at  the  onset  the  peri- 
pheral resistance  has  been  increased  by  spastic  con- 
striction of  the  arterioles  in  a  large  area;  i.e.,  pos- 
sibly the  splanchnic  area,  with  the  result  that  the 
heart  must  beat  with  greater  force  to  overcome 
this  resistance;  the  result  is  a  rise  in  blood  pres- 
sure. 

If  the  elevation  in  b.  p.  continues,  it  is  conceiv- 
able that  the  tonus  of  the  arterioles  would  increase 
and  the  heart  muscle  would  have  to  hypertrophy 
in  order  to  be  capable  of  maintaining  an  elevated 
b.  p. 

Apparently  in  the  earlier  stages  of  hypertension, 
Nature  makes  these  automatic  adjustments  so 
gradually  and  effectively  that  the  individual  is  un- 
aware of  his  altered  cardiovascular  condition  until 
the  systolic  blood  pressure  is  found  to  be  160  to 
200  mm.  At  this  stage  the  individual  may  be  with- 
out symptoms  or  other  signs.  The  heart  may  be 
normal  in  size,  the  urine  free  from  albumin  and 
casts  and  the  blood  metabolites,  urea  and  chlorides 
at  normal  levels. 

This  pressure  may  become  arrested  at  this  level 
and  the  patient  live  for  years,  especially  if  the 
diastolic  pressure  remains  relatively  low.  Or  the 
arterial  pressure  may  continue  to  rise;  but,  as  long 
as  the  heart  remains  competent  and  is  able  to 
counteract  the  arterail  resistance,  symptoms  are 
minimal  or  absent.  Eventually  comes  dizziness, 
headache,  ringing  in  the  ears,  palpitation,  slight 
dyspnea  on  effort,  a  sense  of  weight  in  the  chest, 
nose  bleed  and  mental  irritability  and  such  pa- 
tients come  with  severe  symptoms,  notably  cardiac, 
cerebral  or  gastric. 

Essential  hypertension  is  the  most  important 
type.  Bell  estimated  to  be  responsible  for  at  least 
15%  of  all  deaths  after  the  age  of  SO. 

"Essential  hypertension  is  a  functional  disorder, 
of  unknown  cause,  characterized  by  a  progressive- 
ly increasing  elevation  of  both  systolic  and  dias- 
tolic blood  pressure;   the  mechanical  strain  of  the 

1.   C.    N.    Hensel,    St    Paul,    Minn.,    in  Jl.-Lmcet,   Mar. 


high  arterial  tension  produces  changes  in  the 
heart,  and  in  the  arteries,  especially  the  arteries  of 
the  heart,  brain,  and  kidneys,  often  with  fatal  re- 
sult." (Mosenthal.) 

There  is  a  tendency  for  essential  hypertension 
to  be  transmitted  from  one  generation  to  the  next. 
In  its  inheritance  it  follows  the  Mendelian  law  and 
is  a  dominant  characteristic. 

Vladimir  Stefansson  spent  the  better  part  of  a 
decade  in  the  Arctic.  While  there,  he  lived  on  an 
exclusively  meat  diet.  For  one  continuous  period 
of  nine  months  he  ate  nothing  but  meat.  Yet  Lieb 
found  Stefansson  to  be  in  perfect  physical  condi- 
tion, heart,  blood,  blood  chemistry,  and  urine  nor- 
mal, b.  p.  115/55. 

All  kinds  of  smoked  and  preserved  meats  and 
fish,  cheese  and  cream  cheese,  baker's  bread  and 
all  cake  and  pastry  contain  salt,  prepared  cereals, 
canned  fruits  and  vegetables  containing  salt,  most 
kinds  of  molasses  and  syrup,  salted  butter — all 
are  to  be  denied. 

A  small  minority  of  patients  on  such  a  salt  re- 
striction within  one  to  two  days  may  have  marked 
prostration,  anorexia,  nausea,  perhaps  vomiting, 
headache  and  pain  in  the  calves  of  the  legs,  the 
heart  action  may  be  weak  and  irregular.  Given 
two  grams  of  sodium  chloride  in  soup  or  plain 
water,  symptoms  are  cleared  up  like  magic  in  a 
few  hours  or  within  24  hours.  If  the  symptoms 
persist,  they  are  due  to  other  causes. 

Blood  pressure  in  practically  all  people  varies 
greatly  from  hour  to  hour  and  day  to  day,  a  fact 
to  be  borne  in  mind  when  considering  a  diagnosis 
of  hypertension.  Patients  with  essential  hyperten- 
sion exhibit  wider  fluctuations  than  those  with 
normal  pressures.  Rest  in  bed  often  has  marked 
lowering  effect  on  blood  pressure. 

Malignant  essential  hypertension  is  merely  a 
terminal  phase  of  the  disease,  in  which  the  process 
of  hyaline  degeneration  and  vascular  sclerosis, 
even  vascular  necrosis,  is  for  some  reason  greatly 
speeded  up. 

Cases  with  diastolic  level  below  100  mm.  usual- 
ly need  very  little  treatment.  Where  blood  pres- 
sure elevation  is  discovered  accidentally,  the  pa- 
tient should  be  told  that  he  has  a  slight  elevation 
of  blood  pressure  which  may  be  of  no  significance 
and  asked  to  return  for  further  observations. 

If  the  elevation  be  present  at  the  second  visit, 
an  investigation  into  the  patient's  family  history 
should  be  made,  and  inquiries  as  to  strain  or  anx- 
iety in  domestic  or  business  life.  If  the  patient  is 
accustomed  to  take  large  quantities  of  liquids  and 
use  salt  heavily,  restriction  along  these  lines  and 
effect  noted.  Phenobarbital  or  bromides  quiet  and 
(Hypertension  P.  228) 


SOUTHERN  MEDICINE  &  SURGERY 


April  19U 


SOUTHERN  MEDICINE  &  SURGERY 

Official  Organ 

TRI-STATE    MEDICAL    ASSOCIATION    OF    THE 

CAROLINAS  AND  VIRGINIA 

James  M.  Northdjgton,  M.D.,   Editor 

Department  Editors 

Human   Behavior 

James   K.    Hall,   M.D Richmond,   Va. 

Orthopedic    Surgery 

Oscar  Lee  Miller,  M  D.I Charlotte.  N.  C. 

John  Stuart  Gaul,  M.D.I 

Urology 

Hamilton  W.  McKay,  M.D.  I  Charlotte,  N.  C. 

Robert  W.  McKay,  M.D ) 

Surgery 

Geo.  H.  Bunch,  M.D Columbia,  S.  C. 

Obstetrics 

Henry  J.  Langston,  M.D Danville,  Va. 

Ivan  M.  Procter,  M.D Raleigh,  N.  C. 

Gynecology 

Chas.  R.  Robins,  M.D Richmond,  Va. 

G.  Carlyle  Cooke,  M.D Winston-Salem,  N.  C 

Pediatrics 

G.  W.  Kutscher,  Jr.,  M.D Asheville,  N.  C 

General  Practice 

J.   L.   Hamner,   M.D Mannboro,   Va. 

W.   J.   Lackey,  M.D Fallston,   N.   C. 

Clinical  Chemistry  and  Microscopy 

C.  C.  Carpenter,  M.D |    m  ,  vT    „ 

„c     w  .     ,,t.    f  Wake  Forest,  N.  C. 
R.  P.  Morehead,  B.S.,  M.A.,  M.D.) 

Hospitals 
R.  B.  Davis,  M.D Greensboro,   N.   C. 

Cardiology 
Clyde  M.  Gilmore,  A.B.,  M.D Greensboro.  N.  C. 

Public  Health 
N.  Thos.  Ennett,  M.D Greenville,  N.  C. 

Radiology 
Wright  Clarkson,  M.D.,  and  Associates. ...Petersburg,  Va. 
R.  H.  Lafferty,  M.  D.,  and  Associates,     Charlotte,  N.  C. 

Therapeutics 
J.  F.  Nash,  M.  D., Saint  Pauls,  N.  C. 

Tuberculosis 
John    Donnelly,   M.D Charlotte,   N.    C. 

Dentistry 
J.  H.  Guion,  D.  D.S Charlotte,   N.   C. 

Internal  Medicine 
George  R.  Wilkinson,  M.  D Greenville,  S.  C. 

Ophthalmology 
Herbert  C.  Neblett,  M.  D., Charlotte,  N.  C. 

Rhino-Oto-Laryngology 
Clay  W.  Evatt,  M.  D.,  Charleston,  S.  C. 

Offerings  for  the  pages  of  this  Journal  are  requested  and 
given  careful  consideration  in  each  case.  Manuscripts  not 
found  suitable  for  our  use  will  not  be  returned  unless 
author  encloses  postage. 

As  is  true  of  most  Medical  Journals,  all  costs  of  cuts, 
etc.,  for  illustrating  an  article  must  be  borne  by  the  author. 


THE  TREATMENT  OF  CHRONIC 
INDIGESTION 

When  most  of  us  were  medical  students  indi- 
gestion was  a  term  tabooed.  Now,  greatly  through 
Alvarez's  influence,  it  is  back  with  us.  The  article' 
here  abstracted  deals  helpfully  with  a  great  prob- 
lem. 

The  essayist  says  his  is  a  misnomer,  for  true 
indigestion  is  seen  only  in  sprue,  celiac  disease, 
carcinoma  of  the  pancreas,  and  similar  conditions. 
This  discussion  is  of  the  management  of  chronic 
abdominal  distress  rather  than  indigestion. 

The  history  should  include  an  appraisal  of  the 
social  status  of  the  patient,  of  his  adjustment  to 
his  environment,  and  the  possible  role  of  emotional 
factors  in  his  complaints.  One  must  think  not  only 
of  diseases  of  the  abdomen  but  of  pulmonary  tu- 
berculosis, thyrotoxicosis,  migraine,  brain  tumor, 
pelvic  inflammatory  disease,  and  so  on. 

Peptic  ulcer  is  always  to  be  suspected,  and  is  to 
be  diagnosed  or  excluded  on  the  basis  of  the  his- 
tory and  laboratory  examination  and  studies  with 
the  x-ray  and  perhaps  the  gastroscope.  The  x-ray 
examination  of  the  stomach  can  almost  never  be 
omitted  in  the  examination  of  a  patient  with 
chronic  abdominal  distress.  The  report  of  the 
roentgenologist  must  present  the  evidence.  It  is 
not  possible  for  the  gastroscopist  to  photograph 
the  picture  he  sees,  but  he  must  describe  it  clearly. 
The  treatment  of  peptic  ulcer  is  primarily  a  med- 
ical problem. 

Gastric  cancer  causes  more  deaths  than  any 
other  neoplasm  of  the  body.  The  symptoms  are 
most  insidious  in  onset  and  most  indefinite.  Any 
individual  over  thirty  who  develops  indigestion 
should  be  examined  for  cancer,  have  an  analysis  of 
the  stool  for  occult  blood  and  a  roentgenologic 
study  of  the  digestive  tract.  Some  means  must  be 
found  for  reducing  the  cost  of  the  x-ray  examina- 
tion in  order  that  it  may  be  used  as  routinely  in 
the  diagnosis  of  digestive  disease  as  the  Wasser- 
mann  test  is  used  in  the  diagnosis  of  syphilis.  The 
public  must  realize  that  cancer  can  be  diagnosed 
early  and  that  surgery  offers  hope  of  cure. 

There  has  been  great  discussion  lately  of  "gas- 
tritis." By  and  large  it  is  not  of  great  practical 
significance.  Atrophic  eastritis  is  related  to  achlor- 
hydria,  to  pernicious  anemia,  and  very  likely  to 
carcinoma  of  the  stomach.  Aside  from  the  im- 
provement which  seems  to  occur  often  in  cases 
following  the  administration  of  liver,  or  liver  ex- 
tract, or  ventriculin,  there  is  no  therapy. 

1.  W.   L.   Palmer.    Chicago,  in  four.   Kansas  Med.  See.,   Mch.) 


April   1941 


SOUTHERN  MEDICINE  &  SURGERY 


There  is  no  evidence  that  chronic  distress  may 
be  attributed  to  disturbances  in  emptying  of  the 
otherwise  normal  gallbladder.  The  one  important 
thing  to  know  about  the  gallbladder  is  whether  it 
contains  stones  or  not.  The  roentgenological  diag- 
nosis of  cholelithiasis  is  highly  accurate.  The  im- 
portant question  to  ask  of  patients  found  to  have 
gallstones  is,  Does  the  patient  have  biliary  colic? 
Diet  and  various  medicines  are  of  little  avail.  The 
one  satisfactory  treatment  of  cholelithiasis  is 
cholecystectomy-  In  the  absence  of  biliary  colic, 
fullness,  belching  and  generalized  abdominal  dis- 
comfort is  probablv  not  related  to  the  gallbladder 
at  all,  but  is  a  bowel  disturbance  which  may  be 
corrected  by  regulation  of  the  diet  and  bowels. 
The  distinction  between  cholelithiasis  and  biliary 
colic  on  the  one  hand,  and  chronic  cholecystitis 
and  gallbladder  dyspepsia  on  the  other  hand  is 
important.  Biliary  colic  should  be  treated  surgi- 
cally; the  dyspepsia  is  probablv  not  related  to  the 
gallbladder  at  all  and  can  be  handled  satisfactorily 
bv  medical  measures.  Biliary  dyskinesia  or  spasm 
of  the  sphincter  of  Oddi — if  the  condition  occurs 
at  all,  is  of  little  clinical  significance. 

Recurrent  appendicitis  is  an  indication  for  ap- 
pendectomy. However,  appendectomy  is  not  like- 
ly to  cure  those  individuals  who  have  chronic, 
daily-recurring  abdominal  distress  even  though  it 
be  fairly  well  localized  in  the  right  lower  quadrant. 
Many  such  patients  have  regional  ileitis.  Fortu- 
nately, the  terminal  ileum  is  the  portion  of  the 
bowel  most  frequently  involved  and  can  be  exam- 
ined easily  roentgenological^.  When  higher  por- 
tions of  the  bowel  are  affected  the  diagnosis  may 
be  quite  difficult.  Resection  of  the  diseased  por- 
tions of  the  bowel  is  indicated.  However,  the  dis- 
ease often  recurs  following  resection;  therefore 
the  patient  should  be  given  a  long  period  of  rest, 
high-calorie  diet,  and  general  care  such  as  one 
would  give  to  a  patient  with  tuberculosis.  Rest  is 
very  important,  preferably  bed  rest  for  a  long 
period  of  time — until  the  proctoscope  shows  the 
rectum  to  be  normal.  Tn  the  more  severe  cases  the 
patients  find  it  difficult  to  eat  adequate  amounts 
and  the  parenteral  administration  of  vitamins  may 
be  indicated.  Blood  transfusions  are  often  of  great 
value,  particularly  if  anemia  is  present.  Tn  some 
patients  who  continue  to  have  diarrhea  for  many 
years,  ileostomy  mav  be  indicated,  or  even  total 
colectomy.  Both  of  these  procedures  are  hazard- 
ous and  should  be  undertaken  with  ereat  reluct- 
ance. Tn  the  acute  fulminating  cases,  surgery  and 
indeed  all  other  measures  are  of  little  avail.  In 
the  general  management  of  ulcerative  colitis 
psychotherapy  is  of  the  utmost  importance.  Every 
possible  effort  must  be    made    to    build    up    the 


morale.  Phenobarbital  is  of  considerable  value. 
Belladonna  is  helpful.  A  hot-water  bottle  or  an 
electric  pad  on  the  abdomen  is  usually  soothing. 
Narcotics  may  be  necessary  for  severe  pain,  but 
in  the  absence  of  pain  are  best  omitted.  Bismuth, 
kaolin  and  similar  powders  are  of  little  value. 
The  vaccines  offer  no  specific  help. 

Chronic  amebic  dysentery  is  usually  differenti- 
ated easily  by  the  demonstration  of  Entamoeba 
histolytica  in  the  stool.  If  any  doubt  exists,  ther- 
apeutic trial  is  indicated.  Emetin  intramuscularly, 
1  gr.  daily  for  10  or  12  days  combined  with  the 
use  of  yatren  or  vioform  is  very  satisfactory.  Car- 
bosone  and  other  arsenical  drugs  are  of  value  but 
occasionally  give  an  arsenical  dermatitis.  Lympho- 
pathia  venereum  is  seen  as  a  stenosing  lesion  of 
the  rectum.    The  Frei  test  is  quite  reliable. 

Carcinoma  of  the  colon  should  always  be  sus- 
pected in  patients  with  abdominal  distress.  It  is 
usually  found  readily  by  x-ray  examination.  How- 
ever, it  may  be  easily  overlooked,  often  because 
the  examiner  fails  to  manipulate  the  loops  of  sig- 
moid free  from  each  other.  The  continued  pres- 
ence of  gross  blood  in  the  stool  is  very  significant. 
Repetition  of  the  e-amination  may  lead  to  the 
finding  of  the  lesion.  Proctoscopic  examination  is 
particularly  valuable  in  carcinomas  of  the  recto- 
sigmoid. 

Diverticulitis  of  the  colon  is  not  infrequent  in 
patients  having  recurring  attacks  of  acute  lower 
lift  quadrant  pain,  tenderness,  some  rigidity  and 
fever.  Usually  the  attacks  subside  with  rest,  the 
application  of  heat  to  the  abdomen,  and  regulation 
of  the  bowel  by  means  of  diet.  Belladonna  and 
phenobarbital  are  helpful.  Diverticufow's  is  com- 
mon, but  few  develop  the  acute  attacks  of  diver- 
ticalitis. 

The  great  majority  of  patients  with  chronic  ab- 
dominal distress  will  be  found  to  have  no  organic 
disease  to  account  for  their  distress.  They  have 
fullness  or  discomfort  after  eating,  rumbling,  gur- 
gling and  soreness  of  the  abdomen,  and  very  often 
cramp-like  abdominal  pain.  There  is  usually  a 
tendency  to  diarrhea,  or  the  patient  may  be  con- 
stipated. After  organic  disease  has  been  excluded, 
the  abdominal  discomfort  can  usually  be  relieved 
by  regulating  the  bowels  so  that  normal,  formed 
movements  are  obtained  without  the  use  of  laxa- 
tives. Start  off  with  a  diet  of  cereals,  custards, 
puddings,  eggs,  rice,  macaroni,  cheese,  bread,  but- 
ter, milk,  cream,  potatoes  and  a  stipulated  amount 
of  cooked  fruit  and  vegetables,  (o  be  increased  if 
necessary.  Very  often  the  patient  is  benefited  by 
being  instructed  to  lie  down  for  an  hour  after  each 
meal. 

The   majority  of   patients   with   psychoneuroses 


SOUTHERN  MEDICINE  &  SURGERY 


April  1941 


and  functional  abdominal  distress  are  relieved  by 
such  procedures,  and  by  the  reassurance  which 
comes  both  from  the  knowledge  that  organic  dis- 
ease is  not  present,  and  from  the  relief  of  distress. 
If  such  measures  do  not  suffice,  usually  the  diag- 
nosis is  incorrect,  or  emotional  factors  are  found 
to  be  overpowering. 

The  author  does  not  believe  that  allergy  plays 
an  important  role  in  chronic  abdominal  distress. 


THE  GENERAL  PRACTITIONER  IN 
THE  CURE  OF  CANCER 

A  general  practitioner  intelligently  outlines 
the  duties  and  responsibilities  of  the  general  prac- 
titioner in  regard  to  cancer1.  Persistent  effort  along 
this  line  can  not  fail  to  greatly  reduce  the  death 
rate  from  this  scourge. 

There  must  be  an  unyielding  insistence  that  our 
patients  submit  to  such  examinations  as  will  clear 
up  the  diagnosis  of  Questionable  signs  or  symp- 
toms. Whether  this  be  done  by  means  of  biopsy, 
or  with  the  aid  of  the  roentgen  ray;  whether  it 
necessitates  the  use  of  the  bronchoscope,  the  eso- 
phagoscope,  the  laryngoscope,  the  proctoscope,  or 
the  vaginal  speculum,  the  patient  must  be  brought 
to  see  the  necessity  for  the  procedure.  The  general 
practitioner  must  find  words  to  explain  the  need. 

The  people  generally  have  been  brought  to  sus- 
pect that  ill-healing  skin  blemishes  or  lumps  in 
the  breast  or  bleeding;  from  the  rectum  or  vagina 
may  mean  cancer.  The  essayist  has  found  the 
question  "I  suppose  you  are  worrying  about  can- 
cer, aren't  you?",  helpful  while  taking  a  history. 
When  the  answer  is  '-Yes,"  the  way  is  open  for 
saying,  "That  being  the  case,  we  must  leave  no 
stone  unturned  to  discover  the  truth;"  adding, 
"but  even  should  it  be  cancer,  it  surely  is  an  early 
one  which  can  be  cured.  '  While  the  second  part 
of  this  quotation  may  b°  pure  casuistry,  it  is  fair, 
because  it  gives  hope,  and  allays  fear.  If  the  can- 
cer is  probably  incurable,  even  though  the  sufferer 
is  suspicious,  it  may  he  well  to  mislead.  If  curable 
the  patient  should  he  told:  which  indeed  a  large 
majority  insist  on  if  given  the  chance;  for  there  is 
necessity  for  follow-up  evaminations. 

The  family  doctor  will  need  to  keep  himself  in- 
formed regarding  the  various  methods  of  attack. 
In  New  York  State  cancer  has  been  made  a  re- 
portable disease.  Thus  we  will  eventually  discover 
the  outcome  following  different  types  of  treatment; 
the  length  of  time  elapsed  from  appearance  of  first 
symptoms  until  the  patient  reported  to  a  physi- 
cian;   the  length  of  time  before  proper  diagnosis 


was  made,  once  the  patient  did  report;  and  the 
names  of  all  physicians  entering  the  picture  in  each 
case. 

Ten  aids  are  offered  that  may  suggest  ways  of 
preventing  disasters: 

A  nodular  goiter  has  no  place  in  the  neck. 

A  bowel  which  functions  normally  for  years, 
then  suddenly  changes  this  habit,  demands  inves- 
tigation by  digital  rectal,  sigmoidoscopic,  or  gas- 
trointestinal x-ray  examination. 

It  is  disquieting  to  have  another  do  a  biopsy  on 
the  cervix  which  you  have  cauterized  and  tam- 
poned for  6  months,  and  find  a  grade-2,  or  -3 
epithelioma. 

What  chagrin  to  be  called  to  see  the  mother 
who  has  been  a  regular  office-caller  for  years,  only 
to  learn  that  an  abdominal  pain  which  is  accom- 
panied by  a  mass  in  the  abdomen,  turns  out  that 
day  to  be  a  ruptured  malignant  cystadenoma  of 
the  ovary! 

How  sleep  well  when  a  mass  can  finally  be  felt 
in  the  epigastrium  of  a  man  you  have  given  casual 
treatment  for  his  indigestion  for  years  without  one 
x-ray  examination  of  his  stomach? 

The  ointment-treated  chronic  ulcer  which 
finally  calls  for  iodex  treatment  of  the  regional  en- 
larged gland,  is  also  a  cause  for  chagrin,  if  possi- 
ble. 

The  woman  who  bleeds  after  her  delivery,  more 
and  more  profusely;  who  is  given  ergot  and/or 
pituitrin,  until  her  lungs  protest  by  spewing  out 
the  blood  of  a  metastatic  chorionepithelioma,  is 
not  a  good  picture  to  sleep  on. 

Nor  the  elderly  lady  whose  vulval  leukoplakia 
is  seen,  but  not  recognized  as  a  precursor  of  ma- 
lignancy. 

When  there  is  a  family  history  of  carcinoma  of 
the  breast,  it  is  well  not  to  administer  estrogenic 
substances  to  a  woman  of  that  family. 

VIRUS  INFECTIONS 

Viruses  are  commonly  thought  of  as  myste- 
rious things.  A  good  many  doctors  are  skeptical 
about  viruses  as  the  cause  of  diseases.  An  author- 
itative presentation1  on  this  subject  emphasizes  the 
fact  that  certain  viruses  are  as  well  established  to 
be  the  causes  of  certain  diseases  as  are  certain  bac- 
teria to  be  the  causes  of  certain  other  diseases,  and 
summarizes  the  knowledge  to  date  of  these  morbi- 
fic agents. 

In  1898,  it  was  discovered  that  tobacco  mosaic 
is  produced  by  an  agent  capable  of  passing 
through  earthenware  filters,  impervious  to  ordi- 
nary  bacteria.    Shortly    following   this,    numerous 


1.    F.    S.    Wetlierell,    Syracuse,    X.    Y. 
Mar 


Southwestern    Med., 


IT.    M.    Rivers,    Ne 
April 


Bull.   N.    Y.   Acad,   of  Med., 

-    _J3 


April   1941 


SOUTHERN  MEDICINE  &  SURGERY 


agents,  including  those  causing  smallpox  and  vac- 
cinia, were  shown  to  pass  such  filters  and  to  be  so 
small  that  it  was  impossible  to  see  them  by  means 
of  ordinary  microscopes. 

As  soon' as  this  group  of  viruses  was  recognized, 
there  arose  lengthy  discussions  regarding  their  na- 
ture and  the  character  of  diseases  produced  by 
them.  Among  these  to  which  man  is  subject  are 
smallpox,  yellow  fever,  measles,  chickenpox,  polio- 
myelitis and  several  kinds  of  encephalitis.  Even 
the  useful  bacteria,  without  which  life  of  all  forms 
would  quickly  become  extinct,  are  subject  to  their 
own  virus  disease. 

The  diameters  of  these  virus  particles  range 
from  250  mw  to  8  ma.  Those  of  poliomyelitis,  be- 
cause of  their  small  size,  will  never,  it  is  said,  be 
resolved  by  means  of  ordinary  light. 

It  has  been  shown  that  there  are  several  anti- 
gens associated  with  vaccinal  infections  and  that 
they  probably  derive  from  the  virus.  It  appears 
that  there  are  at  least  two  soluble  antigens,  one 
heat-stable,  the  other  heat-labile,  which  occur  sep- 
arately or  as  a  complex.  In  addition  at  least  two 
others,  an  agglutinogen  and  a  substance  that  gives 
rise  to  neutralizing  antibodies  following  an  infec- 
tion with  the  virus.  No  virus  has  as  yet  been  in- 
duced to  multiply  in  the  absence  of  living  host 
cells.  In  virus  diseases  the  inflammatory  reaction 
is  usually  characterized  by  a  great  increase  in 
mononuclear  cells. 

Although  viruses  often  attack  more  than  one 
kind  of  cell,  the  clinical  pictures  produced  by  them 
are  usually  consistent,  but  all  virus  diseases  can 
be  diagnosed  without  the  aid  of  laboratory  tech- 
niques. 

One  goes  about  diagnosing  virus  diseases  just  as 
other  infectious  maladies.  One  attempts  to  isolate 
and  identify  the  virus  responsible,  employs  living 
media,  small  laboratory  animals,  developing  chick 
embryos,  or  modified  tissue  cultures;  and  turns 
for  aid  to  agglutinations,  precipitin  reactions, 
complement-fixing  reactions,  and  neutralization  or 
protective  tests. 

About  40  years  ago  it  was  shown  in  regard  to 
virus  disease,  e.g.,  in  the  case  of  smallpox  and  vac- 
cinia, that  serum  from  a  convalescent  animal  mix- 
ed with  the  virus  responsible  for  the  malady  pro- 
tects a  susceptible  individual. 

Although  we  had  a  few  bacterial  sera  and  anti- 
toxins, the  treatment  of  bacterial  infections  until 
recently  was  largely  expectant.  Chemotherapy  in 
the  last  few  yars  has  changed  the  whole  picture. 
As  yet,  however,  no  great  advance  in  this  direction 
has  been  made  in  the  virus  field;  however,  this 
seems  to  be  the  most  likely  source  of  curative 
agents  for  this  type  of  malady. 


Most  of  the  virus  diseases  have  been  treated  by 
immune  sera,  but  the  results  have  not  been  encour- 
aging. Serotherapy  of  the  diseases  caused  by  these 
agents  is  not  likely  to  yield  desired  results.  Since 
antibodies  do  not  enter  cells,  and  the  viruses  are 
intracellularly  situated,  it  is  impossible  for  the 
antibodies  in  therapeutic  sera  to  reach  the  infec- 
tious agents.  A  good  deal  of  evidence  exists  which 
indicates  that  in  most  virus  diseases,  by  the  time 
signs  and  symptoms  of  infection  are  manifest,  all 
of  the  cells  that  are  going  to  be  infected  in  that 
particular   host   have   already  been   entered. 

Spread  of  the  majority  of  virus  diseases  of 
man  seems  to  be  accomplished  through  contact  or 
by  means  of  droplet  infection.  In  the  prevention 
of  virus  diseases  there  is  little  to  offer  except  quar- 
antine measures,  and  several  convalescent  sera. 
Most  of  these  quarantine  measures  seem  useless. 
It  is  doubtful  whether  measles,  chickenpox,  polio- 
myelitis, influenza  and  smallpox  are  influenced  in 
the  least  by  the  quarantine  measures. 

Perhaps  in  Horsfall's  recent  work  with  influenza 
and  distemper  there  lies  a  method  of  preventing 
influenza.  Tests  of  this  influenzal  vaccine  are  now 
under  way,  but  it  will  be  some  time  yet  before  an 
answer  will  have  been  obtained.  There  is  every 
reason  to  suppose  that  eventually  many  more  virus 
diseases  will  come  under  control  through  the  use 
of  properly  prepared  vaccines. 

In  spite  of  the  facts  that  viruses  are  invisible, 
that  they  multiply  only  in  living  susceptible  host 
cells,  that  all  of  them  may  not  be  alike  in  nature, 
and  that  some  are  crystalline  proteins,  the  prob- 
lems resulting  from  the  invasion  of  a  single  host 
by  a  virus  or  from  epidemics  of  virus  diseases,  and 
the  general  principles  underlying  methods  of  solv- 
ing these  problems  are  similar  to  these  encoun- 
tered in  other  infectious  fields. 

Apparently  influenza  is  more  than  one  disease.3 
Probably  different  influenzas  may  bear  a  relation- 
ship to  one  another  somewhat  like  that  of  typhoid 
to  paratyphoid  fever. 

The  symptomatology  of  epidemic  influenza  has 
for  centuries  presented  an  amazing  uniformity. 
The  frequency  of  the  recurrences  in  adult  popula- 
tions indicate  that  either  immunity  is  of  brief 
duration  or  that  serologically  divergent  strains  of 
virus  are  disseminated  in  different  outbreaks,  and 
that  the  strains  vary  in  virulence  and  infectivity. 
Influenza  virus  was  isolated  in  1933  by  Smith, 
Andrewes  and  Laidlaw. 

Serum  of  a  ferret  recovered  from  infection  neu- 
tralized other  strains  of  virus  and  mice  vaccinat- 
ed with  one  strain  have  proved  immune  to  other 
strains. 


2.  Thcs.    Francis,    Jr.,    New    York, 


Trans.    Col.    of    Phys. 


SOUTHERN  MEDIC  IKE  &■  SURGERY 


April    1941 


Strains  of  the  same  virus  can  be  differentiated 
serologically;  they  are,  nevertheless,  closely  relat- 
ed through  possession  of  common  antigens.  Diag- 
nostic tests  with  one  strain  appear  capable  of  de- 
tecting infection  with  another.  Strains  from  the 
same  epidemic  tend  to  exhibit  similar  serological 
features.  Immunization  with  one  strain  may  noi, 
under  certain  conditions,  give  rise  to  complete  im- 
munity to  all  strains.  Whether  these  serological 
variations  are  sufficiently  great  that  one  strain 
may  become  epidemic  in  a  human  population  im- 
mune to  another  is  not  yet  known. 

It  has  been  suggested  that  the  term.  Influenza 
A,  be  applied  for  identification  of  this  disease 
caused  by  strains  of  the  aforementioned  virus  de- 
rived  from  human  sources. 

A  widespread  epidemic  of  influenza  occurring  in 
the  early  months  of  1936,  in  which  35  to  40  per 
cent  of  the  population  \^s  attacked  with  an  un- 
usual preference  for  those  persons  under  20  years 
of  age,  has  been  called  Influenza  B.  One  can 
seriously  question  whether  cross  immunity  obtains 
between  Influenza  A  and  Influenza  B. 
^  As  measured  by  the  complement-fixation  reac- 
tion, infection  with  one  strain  of  Influenza  A  virus 
gives  rise  to  antibodies  which  reach  uniformity 
with  all  strains  of  that  virus  and  with  swine  influ- 
enza virus. 

The  two  large  outbreaks  of  Influenza  B  in  1936 
and  1940  began  in  the  early  months  of  the  year, 
while  the  tendency  of  the  4  epidemics  of  Influenza 
A  in  alternate  years  since  1932-33  has  been  to  gain 
momentum  in  November  or  December.  One  might 
suggest,  therefore,  that  Influenza  A  recurs  bien- 
nially while  Influenza  B  is  a  quadrennial  croup. 
In  any  case,  the  two  diseases  appear  to  travel  in- 
dependently, although  indications  exist  that  they 
may  occur  simultaneously  or  continuously. 

In  1936  an  entirely  different  virus  was  encoun- 
tered and  repeatedly  isolated;  this  virus  was  re- 
covered from  ferrets  which  had  received  throat 
washings  of  patients  at  that  time.  Its  identity  was 
not  established. 

It  has  been  seen  that  variations  in  the  clinical 
severity  of  the  disease  have  been  associated  with 
quantitative  differences  in  the  pathogenicity  of  the 
associated  strains  of  virus:  that  within  the  con- 
fines of  what  has  been  called  Influenza  A  signifi- 
cant immunological  differences  in  the  strains  of 
that  virus  occur.  Moreover,  at  least  two  wide- 
spread epidemics  of  influenza  have  been  found  to 
be  caused  by  a  virus  which  is  sufficiently  distinct 
serologically  as  to  establish  it  as  entirely  differ- 
ent virus.  It  is  obvious,  therefore,  that  there  are 
fundamental  differences  in  the  causative  agents  of 
epidemic  recurrences  and  that  these  differences 
are  of  primary  significance  for  an  understanding 


of  immunity  and  the  development  of  prophylactic 
measures. 


NEWS 


MEETING    OF    THE    NORTH    CAROLINA    NEURO- 
PSYCHIATRY ASSOCIATION  AT  DUKE 
HOSPITAL 

March  2Sth 
This  meet  was  with  Dr.  Raymond  S.  Crispell,  of  the 
hospital,  as  chairman  of  arrangements  and  program.  An 
attractive  feature  was  an  inspection  of  the  new  out-patient 
and  in-patient  psychiatric  clinics  of  Duke  Hospital  and 
with  demonstrations  of  electroencephalographies.  This  was 
followed  by  a  scientific  meeting  in  the  hospital  amphi- 
theatre, with  a  paper  on  Electroencephalography  by  Di 
Hans  Loewenbach,  on  The  Rorschach  Tests  by  Dr.  Ed- 
ward Stainbrook,  both  of  the  psychiatric  staff  of  Duke 
Hospital.  Dr.  W.  P.  Beckman.  of  the  Columbia,  S.  C, 
State  Hospital,  spoke  on  Problems  and  Progress  in  Men- 
tal Hygiene  in  South  Carolina.  The  last  presentation  of 
the  meeting  was  by  Dr.  Walter  Freeman,  of  Washington, 
D.  C,  on  Indications,  Procedures  and  Results  in  Pre- 
frontal Lobotomies.  Dr.  Freeman  has  had  great  experienct 
with  this  new  and  unusual  form  of  treatment,  and  his 
investigations  have  revealed  much  concerning  the  function 
of  the  prefrontal  lobes  of  the  brain,  and  the  nature  of 
certain  mental  diseases. 

There  are  fifty-six  active  members  of  the  North  Caro- 
lina Neuropsychiatric  Association,  all  of  whom  are  practic- 
ing physicians  in  North  Carolina,  members  of  the  North 
Carolina  Medical  Society  and  engaged  or  interested  in  the 
treatment  and  prevention  of  mental  and  nervous  diseases. 
In  addition,  among  the  fifteen  honorary  members  are  dis- 
tinguished physicians  from  North  Carolina  and  distin- 
guished neuropsychiatrists  from  outside  the  State  who 
have  made  contributions  to  the  Association  and  to  Neuro- 
psychiatry in  North  Carolina.  The  Association  has  been 
meeting  regularly  since  its  organization  in  January,  193S. 
The  score  or  more  meetings  since  this  time  have  been 
held  in  various  parts  of  the  State,  from  Kinston  in  the 
east  to  Asheville  in  the  west. 

Among  the  aims  and  functions  of  the  Association  is  the 
extension  of  the  latest  knowledge  concerning  mental  and 
nervous  diseases,  not  only  to  its  own  members,  but  to  the 
medical  profession  at  large.  In  addition,  the  Association 
has  always  been  interested  in  the  application  of  Neuro- 
psychiatry and  in  the  prevention,  as  well  as  the  treatment, 
of  mental  and  nervous  diseases  and  in  the  closely  related 
and  applied  subject  of  mental  hygiene.  A  paper  bearing 
on  some  aspect  of  mental  hygiene  is  usually  included  on 
every  program.  The  North  Carolina  Neuropsychiatric 
Association  has  always  been  so  constituted  that  it  can  at 
any  appropriate  time  become  a  section  on  Neurology  and 
Psychiatry  of  the  North  Carolina  Medical  Society.  This 
has  been  discussed  at  various  times  since  the  organization 
meeting  in  1935,  but  so  far  it  has  been  thought  that  it 
was  not  advisable  to  do  this  and  that  the  points  of  view 
and  the  information  and  knowledge  concerning  Neuro- 
psychiatry and  mental  hygiene  could  best  be  communi- 
cated to  the  medical  profession  in  North  Carolina  by  the 
participation  of  the  neuropsychiatrists  in  the  general  ses- 
sions and  in  the  meeting  of  the  various  special  sections  of 
the  State  medical  society.  The  Association  is  usually  ex- 
tended the  privilege  of  having  a  paper  read  at  the  general 
session  of  the  meeting  of  the  State  society  either  by  one  of 
its  representatives  or  by  some  visiting  neuropsychiatrist. 
Advantage  has  usually  been  taken  of  this  privilege  each' 
year. 


April    1941 


SOUTHERN   MEDICINE   &   SURGERY 


If  you  wish  to  avail  yourself  of  pure  vitamin-E  therapy  in  your  E-hypovitaminotic 
patients  we  suggest  that  you  prescribe  Ephynal  Acetate.  This  is  the  acetic  acid  ester 
of  pure  synthetic  vitamin  E,  made  by  a  process  characterized  by  exclusive  Roche 
refinements.  Ephynal  Acetate  is  exceptionally  well  tolerated  and  is  about  170  times 
more  active  than  crude  wheat  germ  oil.  Chief  indications  are  amyotrophic  lateral 
sclerosis,  threatened  and  habitual  abortion,  and  abruptio  placentae. 

•  Ephynal  Acetate  is  available  in  oral  tablets  only,  as  follows:  3-mg.  tablets,  bottles 
of  30  and  100;  10-mg.  tablets,  bottles  of  50  and  250;  25-mg.  tablets,  bottles  of  50. 
HOFFMANN-LA    ROCHE,    INC.,     F  OCHE     PARK,     NUTLEY,    NEW    JERSEY 


EPHYNAL    ACETATE,    Synthetic  Vitamin  E  Acetate 


224 


SOUTHERN  MEDICINE  6-  SURGERY 


April    1941 


The  past  presidents  of  the  Association  have  included: 
Dr.  Ernest  Poate,  Dr.  John  McCampbell.  Dr.  Raymond  S. 
Crispell.  Dr.  Julian  Ashby.  Dr.  James  Vernon  and  Dr. 
W.  D.  Hall.  During  the  first  few  difficult  years  of  organi- 
zation Dr.  Sylvia  Allen  was  the  secretary-treasurer  of  the 
Association.    She  was  followed  by  Dr.  Claude  Bozeman. 

The  officers  of  the  Associtaion  for  1940-41  were:  Presi- 
dent. Dr.  Mark  A.  Griffin,  of  Asheville;  Vice-President. 
Dr.  Archie  A.  Barron,  of  Charlotte;  Secretary-Treasurer. 
Dr.  Malcolm  Kemp,  of  Pinebluff.  The  officers  elected  at 
the  recent  March  meeting  or  the  ensuing  year  were:  Dr. 
Archie  A.  Barron,  President;  Dr.  Frank  B.  Watkins.  of 
Morganton,  Vice-President;  Dr.  R.  Burke  Suitt,  of  Dur- 
ham, Secretary-Treasurer.  At  the  last  meeting  ten  new 
active  and   three  new  honorary   members   were   elected. 

While  the  meeting  in  the  Duke  Hospital  amphitheatre 
on  March  28th  was  of  a  somewhat  technical  and  scientific 
nature,  it  was  open  to  all  of  the  medical  profession,  also 
to  a  few  interested  laymen.  There  was  an  attendance  of 
over  one  hundred,  and  the  meeting  was  concluded  with  a 
collation  at  the  home  of  Dr.  Crispell  on  the  West  Duke 
campus. 


THE  AMERICAN  ACADEMY  OF  PHYSICAL  MED- 
ICINE will  hold  its  Nineteenth  Annual  Meeting  on  April 
28th-30th  in  New  York,  headquarters  at  the  Hotel  Penn- 
sylvania. Clinics  will  be  held  at  the  Medical  Center,  the 
New  York  Orthopaedic  Hospital,  the  Post  Graduate  Hos- 
pital, and  the  Skin  and  Cancer  Hospital.  There  will  be 
an  evening  session  at  the  Academy  of  Medicine  Building 
and  a  banquet  at  the  Hotel  Pennsylvania. 

Physical  medicine  in  relation  to  general  medicine  and 
the  specialties  will  be  the  underlying  theme  of  the  topics 
under  discussion.  These  include  new  developments  in  elec- 
trotherapy, electrosurgery,  radiation  therapy,  hydrology, 
physical  education,  military  medicine,  aviation  medicine, 
and  laboratory  reports  on  related  investigation. 

All    members    of    the    medical    profession    and    those    of 


related  interests  are  invited  to  attend  the  scientific  pro- 
gram. There  will  be  no  registration  fee.  Address  inquiries 
to  Herman  A.  Osgood.  M.D.,  Secretary,  144  Common- 
wealth Avenue,  Boston. 


Dr.  L.  R.  O'Brian,  Jr.,  for  more  than  a  year  a  member 
of  the  staff  of  the  Davis  Hospital.  Statesville.  has  gone  to 
Lynchburg  to  be  associated  with  Dr.  Don  Preston  Peters 
in  the  practice  of  surgery. 


Dr.  Finley  Gayle,  Jr.,  Richmond,  is  a  member  of  the 
recently-appointed  National  Advisory  Council  on  Nervous 
and  Mental  Diseases. 


Dr.  P.  P.  McCain,  Supt.  of  the  North  Carolina  Tuber- 
culosis Sanatorium,  made  an  address  to  the  Virginia  Tu- 
berculosis Society,  at  a  meeting  held  at  Richmond.  March 
13th. 


Dr.  Julian  L.  Rawls,  Norfolk,  is  the  new  president; 
and  Dr.  Frank  S.  Johns.  Richmond,  the  new  vice  presi- 
dent, of  the  Southeastern  Surgical  Congress. 

MARRIED 


Dr.  Edwin  L.  Kendig,  Junior,  of  Victoria,  Virginia,  and 
Miss  Emily  Parker,  of  Appalachia,  Virginia,  on  March 
22nd.  Dr.  and  Mrs.  Kendig  will  make  their  home  in 
Richmond. 

DEATHS 


Dr.   L.  H.  Lewis,  of  Elkton,  Va„  died  suddenly  at  his 
home   March   8th. 


Dr.  Jesse  Armed  Strickland,  who  once  practiced  at 
Zebulon,  N.  C,  and  later  conducted  a  hospital  at  Nor- 
folk, died  at  St.  Petersburg,  Fla.,  March  14th.  Dr.  Strick- 


0  L  I  0  D  I  N  For  Head  Colds, 

( lodinized  Oil  Compound)  Nose  and  Throat 

Its  action  produces  a  mild  hyperemia  with  an  exudate  of  serum,  thus  depleting  the  tissues.  Oliodin 
improves  breathing,  soothes  nose  and  throat.  Try  it  after  nasal  tamponage,  suction  irrigation. 
etc.,  and  note  improved  results. 


FOR  THE  EYES 

Use  it  as  an  antiseptic  collyrium;  to  relieve  catarrhal  affections 
of  the  eye;  before  and  after  operations;  for  routine  treatment 
after  eye  injuries;  to  relieve  irritation  caused  by  wind,  dust, 
bright  lights,  etc. 


DeLEOTON  NASAL  DOUCHE  POWDER 


OPHTHALMIC 
Solution  No.  2 

With   Mercury 
Oxycyanide  and 
Zinc   Sulfate 


Action:  Cleansing— Deodoran' — Astringent.  Uses:  In  solution  removes  most  of  the  germ-laden 
secretion  and  fetid  crusts  which  collect  in  the  nose.  Prescribe  it  for  relief  in  head  colds  and  also 
sinus  irrigations.  [Follow  by  the  use  of  OLIODIN  Nasal  Oil.]  Contains:  Zinc  Phenolsulphonate, 
Sodium  Benzoate.  Methenamine.  Amaranth,  Menthol,  Methyl  Salicylate,   Dextrose   (Base). 

Samples  from:    The  De  LEOTON  COMPANY,  Capitol  Station,  Albany,  N.  Y. 


COOPER  CREME 

ONE  SPERMICIDAL  CREME  GIVEN  HIGHEST  RATING  BY  THE  PROFESSION 

TESTED    BY    TIME  PROVED    BY    EXPERIENCE 

WHITTAKER     LABORATORIES,     INC.  250    WEST    S7th     STREET  NEW    YORK,    N.    Y. 


April    1941 


SOUTHERN  MEDICINE  &  SURGERY 


225 


land  was  graduated  by  the  University  of  North  Carolina 
Medical  School  in  1910.  He  had  practiced  a  number  of 
years  at  St.  Petersburg. 


Lt.  Colonel  John  C.  Dye,  56,  retired,  formerly  of 
Statesville,  died  in  the  United  States  Veterans  Hospital  in 
Fayetteville,  March  13th.  Dr.  Dye  was  a  graduate  of 
Oak  Ridge  Academy,  Davidson  College,  the  North  Caro- 
lina Medical  College.  Charlotte,  and  the  Post-Graduate 
Hospital  in  New  York.  After  completing  his  internship 
he  became  a  member  of  the  staff  of  St.  Luke's  Hospital  in 
Fayetteville.  In  1908  he  moved  to  Statesvile  and  special- 
ized there  in  eye,  ear,  nose  until  he  entered  army  medical 
duty  in  1917.  After  the  World  War  he  remained  in  the 
army  until  he  was  retired  about  three  years  ago.  He  had 
been  in  ill  health  for  a  number  of  years. 


University   of  Virginia 

On  March  11th,  Dr.  Oscar  Swineford.  Jr.,  addressed  the 
South  Carolina  Medical  Society,  meeting  in  Charleston. 
His  subject  was  The  Management  of  Asthma.  At  a  meet- 
ing of  the  Tidewater  Technicians'  Society  at  Newport 
News  on  March  12th,  he  discussed  Observations  on  Im- 
munology. 

The  Virginia  Section  of  the  American  College  of  Physi- 
cians met  at  the  University  of  Virginia  on  March  13th. 
The  following  program  was  presented:  Drs.  Dudley  C. 
Smith  and  Walter  Herold  spoke  on  Gonorrheal  Keratosis; 
Drs.  Andrew  D.  Hart,  Jr..  and  Ralph  B.  Houlihan  dis- 
cussed Haverhill  Fever  Following  Rat  Bite ;  Dr.  Staige  D. 
Blackford  presented  a  paper  on  Abnormal  Cholecysto- 
grams:  Developments  in  Ninety  Untreated  Patients;  Drs. 
Edwin  P.  Lehman  and  George  M.  Lawson  discussed  Clin- 
ical and  Bacteriological  Studies  with  Sulfanilylguanadine; 
and  Dr.  Gilmore  Holland  spoke  on  Electroencephalo- 
graphic  Studies  in  Myoclonia. 

On    March    17th   to    20th,   Dr.    Fletcher    D.   Woodward 


gave  a  series  of  Postgraduate  Lectures  before  the  Dallas 
Southern  Clinical  Society.  His  subjects  were:  Fractures 
of  the  Face  and  Sinuses ;  Diseases  of  the  Nasopharynx ; 
Treatment  of  Acute  and  Chronic  Ear  Infections;  Treat- 
ment of  Sinusitis;  and  The  Value  of  Chemotherapy  in 
Otitic  Infections.  At  the  meeting  of  the  Academy  of  Med- 
icine in  Houston  on  March  21st,  he  discussed  the  Treat- 
ment of  Certain  Malignancies  of  the  Nose,  Throat  and 
Larvnx. 


Meoical  College  of  Virginia 

On  February  24th,  Dr.  F.  M.  Hanes,  Professor  of  Med- 
icine at  Duke  University  School  of  Medicine,  addressed 
the  University  of  Virginia  Medical  Society  on  Sprue. 

At  the  meeting  of  the  University  of  Virginia  Medical 
Society  on  March  7th,  Drs.  Walter  Freeman,  Professor  of 
Neurology  at  George  Washington  University  School  of 
Medicine,  and  James  Watts,  Associate  Professor  of  Neuro- 
surgery at  George  Washington  University  School  of  Med- 
icine, spoke  on  the  subject.  Prefrontal  Lobotomy  in  Men- 
tal Disorders. 

On  March  10th,  Dr.  E.  P.  Lehman  spoke  before  the 
Norfolk  Academy  of  Medicine  on  the  subject,  The  Prob- 
lem of  Acute  Hematogenous  Osteomyelitis. 

On  March  7th,  Dr.  Oscar  Swineford,  Jr.,  participated 
in  the  Postgraduate  Course  in  Medicine  and  Surgery  for 
the  Elizabeth  City  County  Medical  Society  conducted 
under  the  auspices  of  the  Department  of  Clinical  and 
Medical  Education  of  the  Medical  Society  of  Virginia. 
His  subject  was  Chronic  Rheumatism.  On  March  14th, 
Dr.  J.  Edwin  Wood,  Jr.,  presented  a  lecture  before  this 
Society  on  Cardiac  Irregularities. 

On  March  14th,  Dr.  Walter  E.  Vest,  of  Huntington, 
West  Virginia,  spoke  on  Some  Medical  Aspects  of  Shake- 
speare.   Sponsored  by  Phi  Beta  Pi  Medical  Fraternity. 

The    annual    Stuart    McGuire   lecture    and    spring   post- 


ASAC 

15%,  by  volume  Alcohol 
Each   fl.   oz.   contains: 

Sodium  Salicylate,  U.  S.  P.  Powder 40  grains 

Sodium  Bromide,  U.  S.  P.  Granular 20  grains 

Caffeine,    U.    S.   P 4  grains 

ANALGESIC,    ANTIPYRETIC 
AND    SEDATIVE. 

Average    Dosage 
Two  to  four  teaspoonfuls  in  one  to  three  ounces  of 
water   as   prescribed   by   the   physician. 
How   Supplied 

In  Pints.   Five  Pints  and   Gallons   to   Physicians  and 
Druggists. 

• 

Burwell  &  Dunn  Company 


Manufacturing 
Established 


m 

CHARLOTTE,  N.  C. 


Pharmacists 
in    18S7 


Sample    sent    to    any    physician    in    the    U.   S.    on 
request 


226 


SOUTHERN  MEDICINE  &  SURGERY 


April    1941 


graduate  clinics  are  scheduled  for  April  24th  and  25th. 
Dr.  Alfred  Blalock,  of  Vanderbilt  University,  will  give  the 
lectures.  In  connection  with  the  lectures  the  ex-internes 
of  the  hospital  division  of  the  college  will  hold  their  an- 
nual reunion. 

Drs.  M.  H.  Bland,  H.  G.  Byrd,  W.  L.  Nails,  Lewis  E. 
Jarrett,  P.  S.  Richards,  W.  Cardwell.  R.  C.  Cecil,  L.  B. 
Todd,  R.  L.  Clark,  Jr.,  J.  C.  Parker,  A  E.  Powell.  A.  B. 
Croom,  Jose  Bou  Lopez,  M.  J.  Hoover,  Jr.,  and  Walter 
E.  Vest.  Jr.,  were  recently  initiated  into  Alpha  Omega 
Alpha,  honorary  medical  society.  Dr.  William  T.  Sanger, 
president,  was  made  an  honorary  member  of  the  society. 


SALES  TAX  ON  BLOOD! 
Denver — Tax   collectors   have   often   been   called   blood- 
suckrs,   sometimes   in   jest   and   sometimes   in   earnest.    At 
last  they  are  taxing  blood  itself. 

New  regulations  issued  by  the  sales,  service  and  use  tax 
division  of  the  Colorado  state  treasurer's  office  decree: 

"Blood  is  in  some  instances  obtained,  classified,  stored 
and  sold  in  a  manner  similar  to  other  items  of  tangible 
personal  property,  by  what  are  usually  termed  'blood 
banks.' 

"Where  this  item  is  handled  in  this  manner  and  dealt 
with  at  a  definite  commercial  price,  and  purchased  from 
a  person  or  persons  engaged  in  the  business  of  selling 
such  item,  the  sale  shall  be  deemed  to  be  the  sale  of  tangi- 
ble personal  property,  and  subject  to  the  sales  tax." 


BOOKS 


FIRST  AID  IN  EMERGENCIES,  by  Elbridge  L. 
Eliason,  A.B.,  M.D.,  Sc.D.,  F.A.C.S.,  Professor  of  Surgery, 
University  of  Pennsylvania  School  of  Medicine.  Tenth  edi- 
tion completely  revised  and  reset;  126  illustrations.  J.  B. 
Lippincotl  Company,  Philadelphia;  Montreal;  London. 
1941.  $1.75. 

This  book  is  intended  to  meet  the  needs  of  fire- 
men, life-guards,  sailors,  boy  scouts  and  the  like. 
This  edition  has  been  thoroughly  revised  to  carry 
the  latest  information.  The  book  serves  its  pur- 
pose of  supplying  instructions  for  certain  groups 
especially  likely  to  witness  need  for  first  aid.  It 
might  be  well  for  most  practitioners  to  read  it, 
and  so  keep  from  being  embarrassed  at  having  boy 
scouts  meet  health  emergencieT  with  more  skill 
than  we  are  able  to  display. 


THE  1940  YEAR  BOOK  OF  GENERAL  THERAPEU- 
TICS, edited  by  Oscar  W.  Bethea,  Ph.M.,  M.D.,  F.A.C.P., 
Professor  of  Clinical  Medicine,  Tulane  University  School 
of  Medicine;  Senior  in  Medicine,  Southern  Baptist  Hos- 
pital; Senior  Visiting  Physician,  Charity  Hospital;  mem- 
ber of  the  Revision  Committee  of  the  U.  S.  Pharmacopeia. 
1930-40.  The  Year  Book  Publishers,  Inc.,  304  S.  Dearborn 
St.,  Chicago.    $2.50. 

Xo  doctor  should  undertake  to  do  for  patients 
without  keeping  informed  on  all  advancements  in 
treatment.  This  yearly  review  of  therapy  offers 
the  best  and  cheapest  means  of  accomplishing  this 
end. 


TECHNIQUES  OF  CONCEPTION  CONTROL,  by 
Robert  Latou  Dickinson,  M.D.,  Formerly  President, 
American  Gynecological  Society,  and  Woodbridge  Morris, 
M.D.,  General  Medical  Director,  Birth  Control  Federation 
of  America.  Fifty  illustrations.  The  Williams  and  Wilkins 
Co.,  Mt.  Royal  &  Guilford  Aves.,  Baltimore.    1941.    50c. 

One  of  the  great  impediments  to  the  use  of 
contraception  methods  where  they  are  most  indi- 
cated has  been  the  lack  of  simple  instruction  in 
reliable  technique.  This  little  book  supplies  such 
instruction. 


THE  MASK  OF  SANITY:  An  Attempt  to  Reinterpret 
the  So-called  Psychopathic  Personality,  by  Hervey 
Cleckley,  B.S.,  BA.  (Oxon.),  M.D.,  Professor  of  Neuro- 
psychiatry, University  of  Georgia  School  of  Medicine. 
Augusta,  Ga.  The  C.  V.  Mosby  Company,  St.  Louis.  1941. 
$3.00. 

The  preface  tells  us  that  this  book  grew  out  of 
the  unsatisfactory  state  of  knowledge  of  that 
large  group  of  psychiatric  cases,  which  we  desig- 
nate psychopathic  personality.  Dr.  Cleckley  has 
studied  the  persons  so  afflicted,  studied  them  as- 
siduously, and  he  has  come  to  a  helpful  under- 
standing of  them.  A  valuable  book  is  this,  one  in 
which  any  busy  doctor  will  find  help  in  caring  for 
a  good  many  of  his  most  trying  patients.  And  it  is 
delightful  as  a  bit  of  literature. 


April    1941 


SOUTHERN  MEDICINE  &  SURGERY 


221 


MALARIA  AND  HISTORY 
In  1523,  the  entire  Atlantic  seaboard  of  North  America 
from  Florida  to  Labrador  technically  became  part  of  the 
ancient  and  powerful  Holy  Roman  Empire  for,  in  that 
year,  Charles  V  granted  a  charter  for  this  immense  tract 
to  one  of  his  explorers  and  colonizers,  Lucas  de  Ayllon. 
de  Ayllon  landed  with  a  large  body  of  followers  at  a  site 
said  to  be  the  same  as  that  of  the  later  Jamestown,  Vir- 
ginia, and  there  established  San  Miguel  de  Guadalupe. 
This  attempt  to  acquire  the  Atlantic  seaboard  for  Spain 
died  aborning,  however,  for  a  large  proportion  of  the  col- 
onists, including  Ayllon  himself,  di  :d.  mostly  from  an  epi- 
demic of  "fever,"  which  was  undoubtedly  malaria. 

When  the  Pilgrims  were  weighing  whether  to  go  to 
bleak  New  England  or  to  tropical  South  America,  they 
decided  upon  the  colder  clime  chiefly  because  "such  hott 
countries  are  subject  to  greevous  diseases,  and  many  noy- 
some  impediments,  which  other  more  temperate  places 
are  freer  from,  and  would  not  so  well  agree  with  our  Eng- 
lish bodys."  The  choice  of  sites  for  many  future  southern 
cities  was  partly  determined  by  the  presence  or  absence 
of  malaria. 

Many  believe  that  malaria  was  partly  instrumental  in 
establishing  slavery  in  the  United  States,  thus  having  a 
profound  influence  on  its  history.  In  the  malarious  terri- 
tories white  labor  could  not  compete  with  the  more  im- 
mune Negroes. 

In  the  second  wave  of  migration  which  carried  settlers 
over  the  Alleghenies  and  into  the  Mississippi  lowlands, 
malaria  took  a  terrific  toll.  The  first  settlements  were 
along  the  river  valleys  and  the  clearing  of  forests  and 
damming  of  streams  led  to  a  great  increase  in  the  breed- 
ing of  Anopheles.  After  futile  attempts  to  establish  them- 
selves on  the  river  bottoms,  the  pioneers  were  forced  to 
abandon  such  settlements  and  build  new  towns  several 
miles  from  the  river  to  escape  the  "deadly  miasma  of  the 
lowlands." 


PALLIATIVE    TREATMENT    OF   ACUTE   UNDIAG- 
NOSED SKIN  DISEASES 
(S    E.   Light,  Tacoma,   in  Northwest  Med.,  March) 

Diagnosis  of  acute  skin  conditions  is  very  difficult  to 
most  practitioners;  in  many  of  the  early  acute  conditions, 
the  dermatologist  may  also  find  it  difficult  to  make  a 
diagnosis;  and  often  an  exact  diagnosis  is  unnecessary. 
The  basic  principles  of  treatment  are  the  same  for  many 
regardless  of  etiology.  Alter  d  few  days  many  of  these 
skin  conditions  will  subside  without  further  care,  and 
those  which  do  not  subside  will  develop  typical  diagnostic 
characteristics. 

Unrelenting  itching  can  be  intolerable.  The  patient 
will  be  satisfied  without  an  exact  diagnosis,  providing  his 
symptoms  are  cured. 

I  am  using  the  term  "acute"  to  include  not  only  recent 
sudden  severe  skin  conditions,  but  also  acute  exacerbations 
or  recurrences  of  previous  conditions,  more  specifically  any 
acutely  irritated  skin  accompanied  by  itching  or  burning, 
whether  edematous,  erythematous,  weeping,  serous,  puru- 
lent, urticarial  or  papular. 

Allow  no  nuts,  cheese,  cocoa,  chocolate,  fried  food,  gra- 
vies, pastries,  mustard,  catsup,  peppers,  chili,  cured  meats, 
alcohol,  tea,  coffee  nor  coca-cola;  in  urticarial  types  of 
eruptions  stop  all  coarse  and  raw  foods. 

In  urticarial  conditions  or  suspected  food  idiosyncracies, 
give  an  initial  saline  purge;  in  other  conditions,  cascara, 
milk  of  magnesia,  mineral  oil.  etc.,  but  no  phenolphthalein. 

Keep  free  from  all  skin  irritants  and  contacts  with 
chemicals,  plants,  paints,  dusts,  animals.  No  wool  or  fuzzy 
materials    should     be     permitted.    Clothing    and    bedding 


"""' 


PIONEER     "READY-TO-USE" 
SOLUTIONS     IN    VACOLITERS 


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just 


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fUtvgeI':s    A.ca- 

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TRA1ISFUS0-YAC 

PROVIDES    DEPENDABLE 
VACUUM    FOR    TRANSFUSIONS 


Products  of 
BAXTER    I.  AROR  ATOR  I  IS 

Glenview,  111.;  Collece  Point,  N.  Y.; 

Glendale,  Cal.;  Toronto,  Canada;  London,  England 

Produced  and  distributed  in  the 

Eleven  Western  States  by 

DON  BAXTER,  INC.,  Glendale,  Cal. 

Distributed  East  of  the  Rockies  by 

AMERICAN    HOSPITAL    SUPP1A 

CORPORATION 
Chicago  New  York 


SOUTHERN  MEDICINE  &■  SURGERY 


April  1V41 


PHYSICIANS' 

REQUIREMENTS 


EYE,  EAR,  NOSE  and  throat  instruments.  Suction  and 
pressure  pumps.  Physicians'  equipment.  Cabinets.  Oper- 
ating tables.  Examining  chairs.  Sphygmomanometers. 
Trial  lenses.  New-Used.  HARRY  WREGG,  INC.  384 
Second  Ave.,  New  York  City. 

KARA'S  NEW  OTOSCOPE— Finest  in  quality.  Excep- 
tional low  cost:  complete  with  3  specula  and  medium  bat- 
tery handle  and  extra  lamp  in  modern  walnut  case.  Ask 
your  dealer  or  write  to  KARA  SURGICAL  SUPPLY  CO. 
5  E.  Gun  Hill  Rd.,  New  York  City. 

USED  MEDICAL  HOSPITAL  .AND  LABORATORY 
equipment  bought  and  sold;  estates  purchased:  sterilizers, 
microscopes,  lamps,  cystoscopes,  et,c,  always  on  hand. 
Harry  Wells,  304  E.  59th  St.  New  York  City. 

SULFOR-ALBA— A  strictly  ethical  product  for  the  con- 
trol of  acne,  acne  rosacea  and  similar  skin  affections.  1 
lb.  jar  for  $3.00  Professional  supply  for  clinical  test  sent 
on  request  to  physicians.  ALBOLAC  COMPANY,  Room 
1208  at  333  West  52nd  Street,  New  York  City. 

LUBRIOAINE— Anesthetic  Jelly  Water-Soluble,  Non- 
Toxic,  Non-Irritating.  A  valuable  aid  for  the  painless 
examination  of  mucous  membranes.  Marked  surface  an- 
esthesia develops  within  one  minute.  For  use  in  Rectum, 
Urethra,  Ear,  Nose,  Throat.  Sample  to  Physicians. 
AKATOS,  INC.,  55   Van  Dam  Street,  New  York  City. 

PLASTICO  MOULAGE  MATERIALS— Posmoulage  and 
process  accurately  reproduces  animate  and  inanimate  ob- 
jects. Simple  teehnic.  Moderate  cost.  Write  for  cata- 
logue PM  510.  WARREN-KNIGHT  CO.,  136  N.  12th 
Street,  Philadelphia,  Pa. 

SILICA  GEL  FILTER— Gives  a  good  smoke  plus  low 
cost  protection  against  nicotine  and  tar.  SMOKE  THE 
HEALTHY  WAY.  Sample  to  physicians,  no  obligation. 
CIGARETTE  Filter  Mfg.,  Co.,  Akron,  Ohio. 

COLLECT  YOUR  OWN  BILLS  —  An  up-to-date 
method  of  collecting  delinquent  bills.  Not  a  harsh  dun- 
ning method.  Debtor  remits  directly  to  you.  Sample 
book  on  request.  Total  cost  $1.00  only  if  you  decide  to 
keep  it.  Send  no  money.  Medical  Statistics  125  W.  40th 
Street,  New  York,  N.  Y. 

"GONOCOCCAL  INFECTION  IN  THE  MALE"  by 
A.  L.  Wolbarst,  M.  D.,  Fellow,  American  Urological  As- 
sociation; Second  edition,  completely  revised  and  enlarged. 
140  illustrations.  7  colored  plates.  Published  at  $5.50  by 
C.  V.  Mosby  Co.;  remainder  copies  at  $1.00  each  while 
they  last.  Send  no  money.  Pay  Postman  on  delivery. 
MEDICAL  BOOKS,  ROOM  1808,  at  1440  Broadway, 
New  York  City. 

ARE  YOU  VISITING  NEW  YORK  CITY?  If  so  stop 
at  the  Hotel  Park  Chambers.  Modern,  yet  retaining  the 
old  fashioned  hospitality  of  yesterday's  inns.  5  minutes 
from  Radio  City;  One  block  from  Central  Park.  Lux- 
urious rooms  from  $3.  single,  $4.  double,  suites  from  $5. 
Excellent  Food.  May  we  send  you  a  Guide-Map  of 
New  York  City?  A.  D'Arcy,  Manager.  HOTEL  PARK 
CHAMBERS.     68  West   58th  Street,  New  York  City. 


should  be  cool,  scanty,  linen  or  cotton. 

Internal  medications  of  all  kinds  should  be  stopped; 
ephedrine,  phenobarbital,  amytal  and  bromides  may  be 
used  in  most  cases.  Opiates  are  contraindicated.  Strontium 
bromide  intravenously   may  give  relief. 

Axioms: — 

Dry  a  weeping  surface;  do  not  grease  it. 

Baths,  powders,  lotions  and  wet  compresses,  but  not 
ointments,   for  weeping  surfaces. 

Antipruritic  drugs  on  the  unbroken  skin,  none  on  the 
broken   surfaces. 

Prescribe  no  opium  derivative  in  any  acute  skin  condi- 
tion. 

Weeping  surfaces;  avoid  soap,  use  oils,  emollient  baths 
or  compresses  to  cleanse. 

Use  mild  applications;  they  are  usually  quicker  in  the 
long  run. 

Eruption  of  the  hands,  examine  the  feet. 

Listen  to  the  patient.  If  he  says  an  application  arri- 
tates,  stop  it. 


MEDICAL  WRITING  AID 
Assistance  in  the  Preparation  of  Medical  Papers 
Addresses   for  Occasions  Prepared  by  Authorities 

on  Different  Subjects 
Reviews  of  the  Literature  on  the  Subject  of  Im- 
mediate Interest 
Manuscripts  Edited 
References  Verified  and  Amplified 
Outline  of  Treatment  of  a  Subject  Filled  in 


Address 


"MEDICAL  WRITING" 
c  o  Southern  Medicine  &  Surgery 


Hookworms.— According  to  The  Health  Bulletin  a 
Goldsboro  schoolboy  shouts  "down  with  hookworms." 
An  excellent  idea,  but  wouldn't  "out  with  hookworms"  be 
even  better? 


It  is  estimated  that  in  two  centuries  of  constant  beat- 
ing a  human  heart  would  produce  only  enough  electric 
current  to  light  a  flashlight  bulb  for  one  second. 


(HYPERTENSION— from  />.217) 
disclose  the  degree  to  which  the  nervous  system 
plays  a  role.  Such  patients  should  lead  a  life  of 
moderation  in  all  respects,  with  at  least  eight 
hours'  sleep  each  night  and  frequent  short  vaca- 
tions. The  overweights'  eating  habits  should  be 
adjusted;  there  is  no  sound  reason  for  withholding 
red  meat.  Low-protein  diets  reduce  muscle  strength 
in  general,  and  may  weaken  the  heart  muscle. 

Drugs  and  specific  remedies  recommend  for 
lowering  b.  p.  have  proved  ineffective. 

In  the  later  stages  when  symptoms  of  a  fatiguing 
heart  appear,  digitalis  should  be  used  even  though 
the  pulse  is  regular.  In  congestive  heart  failure, 
withdrawal  of  500  ex.  of  blood  often  produces 
prompt  relief. 


April   1941  SOUTHERN  MEDICINE  &  SURGERY 


Southern  Railway's 

SOUTHERNER 


This  month  appears  Southern  Railway's  THE  SOUTHERNER,  to  serve  the 
territory  between  New  York  and  New  Orleans. 

Built  of  high-tensile  steel,  with  sheathing  of  stainless  steel,  THE  SOUTHERN- 
ER which  will  operate  as  three  Diesel-powered  trains,  includes  all  the  latest  refine- 
ments for  the  ultimate  in  safety,  speed  and  comfort.  Each  train  will  consist  of 
Straight,  Partition  and  Baggage-Dormitory  Chair  Cars,  Dining  Car  and  Lounge- 
Tavern-Observation  Unit,  all  reflecting  the  latest  ideas  in  structural  development 
and  modern  styling  and  beauty. 

Passenger  units  have  thermostatically  controlled  heating  and  air  conditioning, 
are  insulated  throughout.  Judicious  use  is  made  of  a  number  of  advancements  favor- 
ing gracious  living.  A  good  part  of  the  luxury  picture  appears  in  the  comfortable 
seating  arrangement  in  all  cars,  the  commodious  and  up-to-date  dining  car  arrange- 
ments and  the  facilities  for  en  route  enjoyment  offered  in  lounge,  tavern  and  obser- 
vation rooms. 

Diesel  locomotives  for  the  trains  are  built  by  the  Electro-Motive  Corporation, 
a  subsidiary  of  General  Motors. 

Particularly  interesting  from  the  standpoint  of  detailed  comfort  planning  is  the 
fact  that  chair  cars  have  twin-rotating,  reclining-type  seats,  cushioned  and  attrac- 
tively finished.  The  dining  car  has  accommodations  for  48  persons  in  satin  metal 
framed  chairs  with  rubber  seats  and  back  cushions.  Settees,  lounge  chairs,  writing 
desk,  card  section  and  refreshment  facilities  have  been  planned  to  fit  the  comfort 
and  utility  requirements  of  passengers  in  the  Lounge-Tavern-Observation  unit. 

A  rich  decorative  treatment  has  been  designated  for  all  units  of  THE  SOUTH- 
ERNER the  basic  colors  being  blue,  green  and  beige  in  light,  medium  and  dark 
tones.  Blue  and  beige  are  distributed  in  straight  chair  car  planning,  each  car  carry- 
ing out  variations  of  the  same  color  treatment  throughout .  Partition  chair  cars  em- 
phasize beige  and  the  Baggage-Dormitory-Chair  Cars  are  done  in  tones  of  blue. 
Green  is  the  predominating  scheme  in  dining  car  and  Lounge-Tavern-Observation 
units. 

The  whole  scene  is  enriched  with  an  attractive  arrangement  of  photo-murals 
which  have  been  especially  planned  to  heighten  the  atmosphere  of  luxury  and  beauty 
in  THE  SOUTHERNER. 


PROFESSIONAL   CARDS 


April    1941 


GENERAL 


Natl*  Clinic  Building 


THE  NALLE  CLINIC 

Telephone— 3-2141    (//  no  answer,  call  3-2621) 


412  North   Church   Street,  Charlotte 


General  Surgery 

BRODIE  C.  NALLE,  M.D. 
Gynecology  &  Obstetrics.. 
EDWARD   R.   HIPP,   M.D. 

Traumatic  Surgery 

PRESTON  NOWLIN,   M.D. 

Urology 


Consulting  Staff 

DRS.  LAFFERTY,   BAXTER  &  PARSONS 
Radiology 
BARRET   LABORATORY 
Pathology 


General  Medicine 


LUCIUS   G.   GAGE,   M.D. 
Diagnosis 


LUTHER   W.   KELLY,  M.D. 
Cardio-Respiratory   Diseases 


J.  R.  ADAMS,  M.D. 
Diseases  of  Infants  &  Children 


W.  B.  MAYER,  M.  D. 
Dermatology  &  Syphllology 


C— H— M   MEDICAL   OFFICES 

DIA  GNOSIS— SURGER  Y 

X-RAY— RADIUM 

Dr.  G  Carlyle  Cooke — Abdominal  Surgery 

&  Gynecology 
Dr.  Geo.  W.  Holmes — Orthopedics 
Dr.  C.  H.  McCants — General  Surgery 
222-226  Nissen  Bid.  Winston-Salem 


WADE   CLINIC 

Wade  Building 

Hot  Springs  National  Park,  Arkansas 


H.  King  Wade,  M.  D. 
Charles  S.  Moss,  M.D. 
Jack  Ellis,  M.D. 
Frank  M.  Adams,  M.D. 


Urology 

General  Surgery 

General  Medicine 

General  Medicine 


N.  B.  Burch,  M.D.  Eye,  Ear,  Nose  &  Throat 
Raymond  C.  Turk,  D.D.S.  Dental  Surgery 
A.  W.  Scheer  X-ray  Technician 

Etta  Wade  Clinical  Pathology 

Marjorix  Wade  Bacteriology 


INTERNAL  MEDICINE 


ARCHIE  A.  BARRON,  M.  D.,  F.  A.  C.P. 
INTERNAL  MEDICINE— NEUROLOGY 
Professional  Bldg.  Charlotte 


JOHN  DONNELLY,  M.D. 

DISEASES  OF  THE  LUNGS 

324^  N.  Tryon  St.  Charlotte 


CLYDE   M.    GILMOivE,    A.B.,   M.D. 
CARDIOLOGY— INTERNAL    MEDICINE 
Dixie  Building  Greensboro 


JAMES  M.  NORTHINGTON,  M.D. 

INTERNAL    MEDICINE— GERIATRICS 

Medical  Building  Charlotte 


ORTHOPEDICS 


HERBERT   F.   MUNT,   M.D. 
ACCIDENT  SURGERY  &■  ORTHOPEDICS 

FRACTURES 
Nissen  Building  Winston-Salem, 


April    1941 


PROFESSIONAL  CARDS 


NEUROLOGY  and  PSYCHIATRY 


J.  FRED  MERRITT,  M.D. 

NERVOUS  and  MILD  MENTAL 
DISEASES 

ALCOHOL  and  DRUG  ADDICTIONS 

Glenwood   Park   Sanitarium  Greensboro 


EYE,  EAR,  NOSE  AND  THROAT 


H.  C.  NEBLETT,  M.D. 

AMZI  J.  ELLINGTON,  M.D. 

OCULIST 

DISEASES  of  the 
EYE,  EAR,  NOSE  and  THROAT 

Phone  3-5852 

Phones:  Office  992— Residence  761 

Professional  Bldg.                                 Charlotte 

Burlington                                   North   Carolina 

UROLOGY,   DERMATOLOGY  and   PROCTOLOGY 

THE  CROWELL  CLINIC  of  UROLOGY  and  UROLOGICAL  SURGERY 
Hours — Nine  to  Five  Telephones — 3-7101 — 3-7102 

STAFF 

Andrew  J.  Crowell,  M.D. 

(1911-1938) 

Angus  M.  McDonald,  M.  D.  Claude  B.  Squires,  M.  D. 

Suite  700-711  Professional  Building  Charlotte 


Dr.  Hamilton  W.  McKay 


Dr.  Robert  W.  McKay 


DOCTORS  McKAY  and  McKAY 


Practice  Limited  to   UROLOGY  and  GENITO-URINARY  SURGERY 

Hours  by  Appointment 

Occupying  2nd  Flood  Medical  Arts  Bldg.  Charlotte 


Raymond  Thompson,  M.  D.,  F.  A.  C.  S.  Walter  E.   Daniel,   A.  B.,  M.  D. 

THE  THOMPSON  -  DANIEL  CLINIC 

of 

UROLOGY  &  UROLOGICAL  SURGERY 

Fifth  Floor  Professional  Bldg.  Charlotte 


C.  C.  MASSEY,  M.D. 

PRACTICE  LIMITED 

TO 

DISEASES  OF   THE  RECTUM 


Professional   Bldg. 


Charlotte 


L.  D.  McPHAIL,  M.  D. 
RECTAL  DISEASES 


Professional   Bldg. 


Charlotte 


WYETT   F.    SIMPSON,   M.D. 

GENITO-URINARY   DISEASES 

Phone   1234 

Hot  Springs  National  Park  Arkansas 


PROFESSIONAL   CARDS 


April  1941 


SURGERY 


R.  S.  ANDERSON,  M.  D. 

GENERAL  SURGERY 

144  Coast  Line  Street  Rocky  Mount 


R.    B.    DAVIS,    M.D.,    M.  M.  S.,    F.A.C.P. 
GENERAL  SURGERY 

AND 
RADIUM  THERAPY 

Hours  by  Appointment 

Piedmont-Memorial  Hosp.  Greensboro, 


WILLIAM    FRANCIS    MARTIN,    M.D. 
GENERAL  SURGERY 

Professional   Bldg.  Charlotte 


OBSTETRICS  &  GYNECOLOGY 


IVAN  M.  PROCTER,  M.D. 
OBSTETRICS   &   GYNECOLOGY 

133   Fayetteville   Street  Raleigh 


SPECIAL  NOTICES 


THE  EDITING  OF  MEDICAL  PAPERS 

This  journal  has  arranged  to  meet  the  demand  for  the  service  of  editing  and  revis- 
ing papers  on  medicine,  surgery  and  related  subjects,  for  publication  or  presentation 
to  societies.  This  service  is  rendered  on  terms  comparing  favorably  with  those  pre- 
vailing generally  in  other  Sections  of  the  Country. 

SOUTHERN  MEDICINE  &  SURGERY. 


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SOUTHERN  MEDICINE  AND  SURGERY 

306  North  Trvon  Street,  Charlotte,  N.  C. 

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JAMES   M.   NORTHINGTON.   M.  D„    Editor 


CHARLOTTE,   N.    C.   MAY.    1941 


A  Consideration  cf  Healing  in  Presumably 
Clean  Wounds  * 

William  H.  Prioleau,  M.D.,  F.A.C.S.,  Charleston 


THE  term  presumably  clean  wounds  de- 
notes operative  incisions  in  uncontaminat- 
ed  fields,  and  operative  and  traumatic 
wounds  with  known  contamination,  but  which  may 
proceed  to  uninterrupted  healing  under  proper 
care.  It  is  the  factors  which  promote  and  interfere 
with  healing  which  we  propose  to  discuss.  They 
can  be  broadly  divided  into  those  of  a  general  or 
systemic,  and  those  of  a  local,  nature. 

Too  often  is  our  attention  so  focused  upon  the 
wound  itself  that  some  important  svstemic  dis- 
order is  overlooked.  Koster  and  Shaniro'  reviewed 
a  series  of  cases  comprising  clean  hernia  and  other 
abdominal  wounds,  and  deeply  infected  and  dis- 
rupted abdominal  wounds.  Their  findings  suggest 
the  idea  that  a  poor  nutritional  state  of  which  hy- 
poproteinemia  is  a  manifestation  may  favor  both 
the  development  of  infection  and  the  disruption  of 
clean  wounds.  Harvey  and  Howes"  cit*  experimen- 
tal evidence  that  a  high-protein  diet  accelerates 
wound  healing.  A  normal  fluid  and  electrolyte  bal- 
ance must  be  maintained.  Carbohydrate  and  fat 
metabolic  disorders  must  be  guarded  against. 
YVolfer  finds  cevitamic  acid-deficiencv  more  com- 
mon than  is  generally  recognized.  It  is  early  man- 
ifested by  a  deficiency  in  the  collagenous  materia! 
incident  to  wound  healing.  The  normal  blood 
cevitamic  acid  is  given  as  0.6  to  t.5  mg.  per  cent 
and  the  suggested  dose  in  case  of  deficiency  1 
gram  daily.  Proper  elimination  must  be  maintain- 
ed.   Cardiac   decompensation    must    be    prevented, 


for  the  resulting  edema  seriously  interferes  with 
wound  healing.  Systemic  conditions  attended  by 
coughing,  hiccoughing,  vomiting  and  convulsions 
throw  the  severest  of  strains  upon  wounds,  inter- 
fering with  their  healing  and  often  causing  disrup- 
tion. 

The  local  tissue  processes  concerned  with  heal- 
ing can  be  broadly  classified  as  inflammatory  and 
reparative.  While  termed  local  for  the  purposes 
of  discussion  it  must  be  borne  in  mind  that  by 
means  of  the  vascular  and  nervous  systems,  they 
are  in  great  part  dependent  upon  and  closely  re- 
lated to  the  systemic  reactions.  Furthermore  there 
is  no  sharp  dividing  line  between  the  inflammatory 
and  the  reparative  phases  of  the  local  reaction. 
The  inflammatory  phase  of  necessity  precedes  th" 
reparative — It  even  forms  a  groundwork  for  it. 

The  inflammatory  phase  has  primarily  to  do 
with  the  combatting  of  organisms  and  the  removal 
of  foreign  material  and  dead  tissue.  There  is  of 
necessity  always  a  certain  amount  of  inflammatory 
reaction,  as  even  in  an  aseptically  made  incision 
in  an  uncontaminated  field  there  are  some  non 
viable  cells  and  likely  a  few  air-borne  organisms 
requiring  disposal.  This  phase  of  the  inflammatory 
reaction  is  carried  out  l>\  the  phagocytosis  and 
Droteolytic  enzymatic  action  of  cells  and  serum, 
loth  local  and  blood-borne  to  (lie  site  of  injury. 
The  amount  and  intensity  of  the  inflammatory  re- 
action is  dependent  unon  the  nature  and  amount 
of  tissue  injury,   foreign   materials  and  organisms 


•From  ih.-   Department  of  Surgery,   Medical   Colled    of  th<    Stati    ol    ?outli    '  a  olin; 
•Presented    to    the    meeting   of   the   Tri-Statc    Medical    Association     >f    the    Carolina! 
24th   and  25th. 


HEALING   IN   CLEAN   WOUNDS— Prioleau 


present.    Accordingly  the  best  healing  is  attended 
bv    relatively    little    inflammatory    reaction.     Also 
the  inflammatory  reaction  may  be  considered  as  an 
index  of  the  nature  of  the  healing,  except  in  those 
rare  cases,  generally  in  emaciated  patients,  where 
there  is  no  evidence  of  attempt  at  healing.    The 
reparative  phase  starts  before  the  termination  of 
the  inflammatory,  but  only  after  conditions  have 
been  made  suitable  for  it.   The  actual  repair  is  by 
regeneration  of  the  injured  tissues,  or  replacement 
fibrosis  alone,  or  a   combination   of   the   two.    In 
most   instances   in   the  more   highly   differentiated 
and  parenchymatous  tissues  there  is  no  restoration 
of  function,  but  only  scar  formation.    Elimination 
or  reduction  to  a  minimum  of  those  factors  which 
provoke  an  inflammatory  reaction  will  be  followed 
by  an  earlier  and  more  orderly  reparative  process. 
The   care   of   a    wound   should   be   carried    out 
under    aseptic    conditions:    however,    it    must    be 
stressed   that   asepsis   alone   will   not   assure   good 
wound  healing.*    While  it  is  admittedly  impossible 
to  prevent  the  entrance  of  all  organisms  into  the 
wound,  the  number  can  be  reduced  to  an  inconse- 
quential minimum.    Also   they  can  be  limited   to 
those  air-borne  and  relatively  nonpathogenic,  and 
some  few  from  the  patient's  skin.   For  the  eradica- 
tion of  these  dependence    must    be    placed    upon 
healthv    tissue    in    a    properlv    cared-for    wound. 
Traumatic   wounds   are    frequently    unnecessarily 
subjected  to  contamination  by  first-aid   treatment 
carried  beyond  the  requirements  of  the  case,  and 
often    administered    under    improper    conditions.3 
Commonlv  adequate,  and   the  best,  first-aid   con- 
sists of  a  sterile  bandage  firmly  applied.    In  case 
of  free  arterial  bleeding  a  pair    of    forceps    or    a 
broad-based  tourniquet  may  be  necessary.    Explo- 
ration, especially  probing,  and  cleansing  should  be 
reserved  for  such  time  and  conditions  as  permit  of 
satisfactory    care    of    the    wound.     Contamination 
from  the  respiratory  passages  is  only  too  common 
due  to  failure  of  the  surgeon  to  cover  his  mouth 
and  nose. 

In  most  cases  anesthesia  is  necessary  for  the 
proper  care  of  a  wound.  This  may  be  general, 
regional  or  local,  according  to  the  nature  of  the 
case.  If  local,  the  anesthetic  solution  should  be 
injected  aseptically  into  healthy  tissue  at  a  reason- 
able distance  from  the  wound — and  never  through 
the  wound — on  account  of  the  danger  of  spreading 
infection.  The  skin  around  the  wound  is  thor- 
oughly cleansed  with  soap  and  water;  this  may  be 
sometimes  followed  by  the  application  of  a  chemi- 
cal antiseptic.  For  obtaining  asepsis  of  the  wound 
itself  chief  rel;ancs  is  placed  upon  a  thorough  but 
gentle  irrigation  with  soap  and  water  for  the  re- 
moval  of  dir',   organisms   and   loose   tissue.    The 


wound  is  now  ready  for  securing  accurate  hemos- 
tasis,  and  debridement  should  this  be  necessary. 

The  matter  of  antisepsis  is  still  controversial. 
Unwarranted  dependence  upon  it  is  probably  the 
most  common  error  in  wound  care.  It  is  not  a  sub- 
stitute for  asepsis.  In  the  words  of  one  author," 
•The  thoughtful  surgeon  is  not  beguiled  into  a 
false  sense  of  security  by  a  coloured  solution." 
According  to  the  same  author,6  "Any  antiseptic 
sufficients  strong  to  kill  bacteria  rapidly  will  also 
kill  living  tissue."  Furthermore  the  effect  of  anti- 
septics is  limited  to  organisms  on  the  surface,  and 
it  is  these  which  can  be  removed  by  means  less 
injurious.  Xecrotic  tissue  and  exudate  resulting 
from  the  action  of  the  antiseptic  provoke  an  in- 
flammatory reaction  and  even  predispose  to  the 
growth  of  any  organisms  remaining.  The  use  of 
antiseptics  in  the  operative  treatment  of  wounds 
is  probably  best  limited  to  application  to  the  pre- 
viously-cleansed surrounding  skin. 

The  presence  of  devitalized  tissue,  on  its  own 
account  as  well  as  its  predisposing  to  infection,  is 
an  important  cause  of  inflammation  with  its  re- 
sultant interference  with  wound  healing.  Thus 
after  the  preliminary  cleaning,  all  tissue  already 
devitalized  and  that  likely  to  become  so  from 
direct  injury  or  impaired  blood  supplv.  should  be 
excised:  an  exception  being  made  of  such  impor- 
tant structures  as  nerves,  tendons  and  large  ves- 
sels, the  survival  of  which  may  be  in  doubt.  Fur- 
thermore, it  is  important  not  to  cause  further  tis- 
sue necrosis  by  using  strong  antiseptics,  by  crush- 
ing with  forceps  or  bv  strangulation  and  cutting 
with  too-tightly-applied  sutures.  Irrigation  of  the 
wound  is  carried  out  at  intervals  during  this  de- 
bridement. 

The  proper  use  of  suture  material  is  an  impor- 
tant factor  in  preventing  inflammation.  In  secur- 
ing hemostasis  mass  ligatures  must  be  avoided  as 
they  lead  to  excessive  tissue  necrosis.  Approximat- 
ing sutures  should  not  be  under  tension,  as  this 
results  in  pressure  necrosis.  Security  of  the  suture 
line  should  be  obtained  by  a  greater  number  of  fine 
sutures  rather  than  fewer  coarse  ones.  As  suture 
material  is  both  directly  and  indirectly  a  cause  of 
inflammation,  the  amount  used  should  be  the  min- 
imum necessary  for  the  purposes  at  hand. 

The  suture  material  employed  must  be  consid- 
ered from  the  standpoint  of  absorbabilitv.  Silk  is 
the  most  commonly  used  nonabsorbable  suture.  As 
a  substance,  when  used  properly,  it  provokes  only 
slight  inflammatory  reaction  and  thus  does  not 
materially  retard  wound  healing.  A  wound  in 
which  silk  is  used  is  better  able  to  withstand  slight 
contamination  than  one  in  which  catgut  is  used.7 
Silk  is  not  destroyed  by  bacteria  and  proteolytic 


HEALING   IN   CLEAX   WOUNDS— Prioleau 


reactions,  whereas  catgut  may  early  be  destroyed 
depriving  the  wound  of  much  needed  support.  The 
absorption  of  catgut  is  effected  by  the  exudative 
and  leucocytic  phases  of  an  inflammatory  reaction 
which  retards  healing  to  a  variable  degree  and 
predisposes  to  infection.  Even  in  the  absence  of 
contamination  this  reaction  may  result  in  wound 
induration  and  the  drainage  of  serum.  The  main 
disadvantage  in  the  use  of  silk  is  that  in  the  pres- 
ence of  gross  infection,  there  may  result  sinuses 
leading  from  the  silk  sutures,  which  may  be  ex- 
truded or  may  have  to  be  removed.  In  this  respect 
fine  alloy  steel  wire  (3SG)  in  spite  of  some  disad- 
vantages in  handling,  has  enjoyed  some  popularity 
due  to  the  fact  that  healing  is  likely  to  take  place 
in  the  presence  of  infection  without  its  removal 
or  extrusion.  s  '  From  the  foregoing  it  would  ap- 
pear preferable  to  use  silk  where  the  wound  can 
be  properly  prepared  and  there  is  likelihood  of 
minimal  contamination.  On  the  other  hand,  where 
gross  infection  is  likely  to  ensue,  there  are  decided 
advantages  in  the  use  of  catgut.  Alloy-steel  wire  is 
the  choice  for  aponeurotic  sutures  in  the  presence 
of  infection. 

Before  closing  the  wound  definite  requirements 
must  be  met.  It  must  be  clean  and  dry.  Its  sur- 
faces must  be  composed  of  healthy  tissue.  Re- 
garding contamination  with  likelihood  of  resulting 
infection,  making  closure  inadvisable,  an  arbitrary 
limit  of  six  hours  between  injury  and  treatment 
is  commonly  used.  It  is  held  that  after  this,  in- 
vasion of  the  tissues  by  microorganisms  is  likely  to 
have  reached  an  extent  such  as  to  preclude  healing 
without  infection.  Even  a  shorter  time  limit  is 
placed  upon  the  advisability  of  primary  repair  of 
tendons  and  nerves.  Should  closure  not  be  advis- 
able the  wound  is  packed  with  vaselinized  or  plain 
gauze,  or  it  may  be  closed  in  part  with  provision 
for  drainage.  In  the  treatment  of  traumatic 
wounds,  sulfanilamide  and  its  derivatives  are  being 
used  both  locally  and  systemically.  It  is  still  too 
soon  to  evaluate  their  effect.10  Primary  closure  if 
decided  upon  must  be  carried  out  with  great  care. 
The  surfaces  of  the  wound  must  be  accurately  ap- 
proximated, due  care  being  taken  to  avoid  tension. 
Dead  space,  present  or  potential,  must  be  avoided, 
as  it  will  form  a  site  for  serum  collection  with  pre- 
disposition to  infection.  The  skin  edges  should  be 
accurately  approximated  with  a  nonabsorbable 
suture. 

Whether  primarily  closed,  drained  or  packed 
open,  the  wound  should  be  afforded  the  support  of 
an  adequate  dressing  firmly  applied.  In  some  cases 
immobilization  with  splints  or  plaster  may  be 
advisable.  Rest  is  most  conducive  to  healing;  an 
exception    to   its   use   being   those   cases  requiring 


motion  for  the  preservation  of  function  in  tendons 
and  joints.  Early  motion  may  be  productive  of 
exudation,  secondary  hemorrhage  and  in  some 
cases  separation  of  the  suture  line,  all  of  which 
provoke  an  inflammatory  reaction  and  retard  heal- 
ing. The  efficacy  of  rest  in  controlling  infection  is 
well  illustrated  in  Trueta's  "  u  method  of  plaster- 
immobilization  of  the  soft  tissues  in  the  treatment 
of  war  wounds — this,  of  course,  preceded  by  thor- 
ough cleansing  and  debridement.  This  is  an  ex- 
tension of  the  method  of  treating  osteomyelitis  by 
proper  drainage  followed  by  closed  dressing  with 
immobilization  of  the  parts,  advocated  by  Dr.  H. 
Winnett  Orr,  as  a  result  of  his  experiences  in  the 
World  War. 

Finally,  as  pointed  out  by  Elkin"  a  record  of 
wound  healing  should  be  kept.  It  affords  a  means 
of  a  critical  analysis  of  our  results.  Furthermore, 
it  acts  as  a  stimulus  to  better  work. 

Summary 
Systemic  factors  affecting  wound  healing  are  re- 
viewed in  brief.  Local  factors  are  considered  in 
some  detail.  Those  conditions  which  provoke  an 
inflammatory  reaction  generally  retard  healing. 
From  this  standpoint  are  discussed  operative  trau- 
ma, debridement,  suture  material,  asepsis,  anti- 
sepsis, wound  closure  and  dressings. 

References 

1.  Roster,  H.,  and  Shapiro,  A.:  Serum  Proteins  and 
Wound  Healing.    Arch.  Surg.,  41:723-729  (Sept)   1940 

2.  Harvey,  S.  C,  and  Howes,  E.  L.  :  Effect  of  High 
Protein  Diet  on  Velocity  of  Growth  of  Fibroblasts  in 
Healing  Wound.    Ann.  Surg.,  91:641-650   (May)    1930. 

3.  Wolfer,  J.  A.:  Surgical  Aspect  of  Vitamin-C  Defi- 
ciency. S.  Clin.  North  America,  20:225-240  (Feb  ) 
1940. 

4.  Whipple,  A.  O.:  Essential  Principles  in  Clean  Wound 
Healing.  Surg.,  Gynec.  and  Obst.,  70:257-260  (Feb  ) 
No.  2  A  1940). 

5.  Koch,  S.  L.:  Treatment  of  Open  Wounds.  Bull.  Am. 
Coll.  Surgeons,  25:176-17S   (June)    1940. 

6.  Couch,  J.  H:  Surgery  of  the  Hand;  Some  Practical 
Aspects.  Foreword  by  W.  E.  Gaixie.  7s  Pp.  147  Lon- 
don: Oxford  (Univ.  of  Toronto  Press,  1939). 

7.  Shambaugii,  P.:  Silk  Technique:  Experimental  Obser- 
vations.   Surgery,  7:9-23,  (Jan.)    1940. 

8.  Genklns,  M.  H.:  Alloy  Steel  Wire  (Babcock)  Suture. 
Penna.  Med.  Jour.,  41:707-709,  (May)    1938. 

9.  Preston,  D.  J.:  Effects  of  Sutures  on  Strength  of 
Healing  Wounds,  with  Notes  on  Clinical  Use  of  An- 
nealed Stainless  Steel  Wire  Sutures.  Am.  J.  Surg.,  49: 
56-63,    (July)    1940. 

10.  Buttle,  G.  A.  H:  Chemotherapy  of  [nfected  Wounds. 
Lancet,  1:890-892    (May   11,   1940). 

11.  Trtjeta,  J.,  and  Barnes,  J.  M.:  Rationale  of  Complete 
Immobilization  in  Treatment  of  [nfected  Wounds. 
Brit.  Med.  Jour.,  2:46-48   (July   13,   1940). 

12.  Girdlestone,  G.  R.:  Closed  Plaster  Treatment  of  In- 
fested Wounds.  Laurel.  2    Jl  32   (July  13,  1940). 

13.  Elkln,  D.  C:  Wound  Infection;  Comparison  of  Silk 
and  Catgut  Sutures.  Ann.  Suit;.,  112:280-283,  (Aug.) 
1940. 


HEALING   IN  CLEAN   WOIWDS— Prioleau 


Mar  1941 


Discussion 
Dr.  R.  O.  Lyoav,  Greensboro:  Mr.  President  and  Mem- 
Dr  Prioleau  apologized  to  me  last  night  lor  not 
having  sent  a  copy  of  his  paper.  Having  heard  him  be- 
fore. I  knew  he  would  cover  the  ground  so  thoroughly 
and  comprehensively  that  it  wouldn't  make  much  differ- 
ence whether  1  read  his  paper  or  not  because  I  wouldn't 
be  able  to  add  much  to  it  in  discussion. 

I  had  thought  the  few  remarks  I  might  make  would  be 
limited  to  what  we  would  expect  to  have  as  clean  wounds 
in  the  abdomen  and  I  am  very  glad  to  hear  Dr.  Prioleau 
divide  wound  healing  processes  into  general  and  local.  1 
don't  believe  that  we  lay  enough  emphasis  on  preparation 
of  the  skin  before  operation.  I  believe  we  ought  to  use 
soap  and  water  much  more  frequently  and  copiously  than 
we  do,  and  with  much  more  vigorous  scrubbing. 

Another  important  aid  is  the  contribution  of  Dr.  Hart, 
who  is  here,  in  the  fact  that  he  has  brought  to  the  atten- 
tion of  the  surgeons  and  hospitals  over  the  country  the 
dangers  that  might  be  expected  from  the  air-borne  bacte- 
ria in  the  operating  rocm.  He  also  emphasized  the  fact 
that  the  operators  and  assistants  who  have  chronic  infec- 
tions of  the  nose  and  throat  should  be  extremely  careful 
in  protecting  the  wound  from  themselves.  He  has  shown 
that  particularly  in  arthroplasty  incisions  that  the  inci- 
dence of  infections  and  the  rate  of  mortality  have  been 
tremendously  reduced  by  this  method  which  he  has  de- 
scribed and  practiced 

Dr.  Prioleau  has  emphasized  already  the  importance  of 
maintaining  a  normal  protein  level  and  we  are  all  trying 
to  do  that  now  since  we  are  using  blood  plasma  more 
freely  than  heretofore.  Certainly  transfusions  of  blood 
in  cases  of  cancer  and  other  debilitating  conditions  is  very 
important. 

I  was  interested  in  hearing  him  speak  of  the  impor- 
tance of  maintaining  a  normal  cevitamic  acid  level  in  the 
blood  in  cases  of  vitamin  C  deficiency.  Dr.  Elmer  A. 
Hallman,  of  California,  a  few  years  ago  read  a  paper  in 
Philadelphia  in  which  he  was  very  enthusiastic  about  this 
measure  as  a  preventive  of  operative  complications  and 
promoter  of  wound  healing.  He  gave  vitamin  C  as  out- 
lined by  Dr.  Prioleau  today.  Of  course  we  are  all  aware 
of  the  importance  of  using  vitamin  K  in  jaundiced  pa- 
tients.   That  certainly  does  contribute  to  wound  healing. 

Dr.  Deryl  Hart,  Duke  University  School  of  Medicine: 
I  enjoyed  Dr.  Prioleau's  paper  very  much  indeed.  Their 
.-re  so  many  factors  involved  in  the  healing  of  wounds,  we 
have  to  be  on  our  toes  all  the  time  to  be  sure  we  don't 
overlook  some  of  them — fluid  balance,  salt  balance,  pro- 
tein balance,  vitamins,  and  many  others. 

1  will  say  of  bacterial  contamination  in  wounds — every 
wound  is  bacterially  contaminated  and  there  is  no  way 
we  can  prevent  it.  We  can  cut  it  down,  but  it  can't  be 
done  away   with   entirely,  as   Dr.   Prioleau   said. 

I  have  recently  carried  out  some  studies  in  regard  to 
bacterial  contamination  of  wounds  especially  in  the  pubic 
region  and  the  neck  region.  We  can  clean  the  hip  as 
thoroughly  as  we  can  by  scrubbing  and  the  use  of  chemicals, 
and  at  the  beginning  of  the  operation,  when  we  take  a 
culture,  we  almost  never  get  a  positive  growth.  On  a 
hot  summer  day.  we  can  do  the  same  procedure  and  get 
701,000  colonies  in  the  hip  at  the  end  of  the  operation 
I  want  to  emphasize  the  importance  of  keeping  the  wound 
clean  in  doing  large  operations.  We  never  let  clamps  lie 
against  the  skin.  We  put  a  towel  under  the  clamp  and 
another  over  the  clamp  in  a  long  incision.  The  two  clamps 
are  taken  off  and  do  not  come  in  contact  with  the  gloved 
hands.  The  same  way  with  the  surgeon's  hands.  Then 
no    growth    will    start.    We    almost     never    get    pathogenic 


bacteria  out  of  the  air  provided  no  human  being  is 
occupying  that  same  region  of  air.  We  have  tested  it 
manv  times.  The  air  above  the  hospital  is  free  of  patho- 
genic organisms.  Bacteria  in  the  room  grow  in  the  throats 
of  the  occupants.  The  cr.ly  value  of  a  mask  is  to  keep 
you  from  spitting  in  the  wound.  You  can't  keep  the 
bacteria  in  the  air  going  up.  Hemolytic  staphylococcus  is  the 
organism  that  we  must  commonly  have  to  deal  with. 
It  is  in  the  air  many  days  of  the  year.  We  almost  never 
find  streptococcus  wound  infections.  In  carrying  out  our 
experiments  we  would  b!ow  air  through  the  mask  and  it 
would  show  almost  as  much  contamination  distal  as 
proximal. 

Eliminating  air  sources  of  contamination  of  wounds  I 
might  say,  is  the  last  attack,  because  we  attacked  by  skin 
preparation  and  isolating  the  wound  from  the  skin  long 
before  we  had  a  method  of  sterilization.  With  the  elimina- 
tion of  air  contamination,  we  will  be  99  per  cent  efficient. 

In  the  first  five  years  of  Duke  Hospital's  operation  out 
of  15,000  operations  of  all  types  we  had  12  deaths  from 
infections  in  clean  wounds— arthoplasty  4,  mastectomy  1, 
brain  cases  3.  orthopedic  cases  3,  dissection  of  lymphatic 
gland  1. 

After  the  elimination  of  sources  of  air  contamination 
we  cut  the  rate  to  less  than  half  of  one  per  cent.  Out  of 
the  30,000  operations  in  the  past  five  years  we  did  not 
get  a  clean  wound  infection  in  arthroplasty,  laminectomy, 
hernioplastv,  laparotomy;  nor  in  an  amputation  unless  the 
-nember  was  gangrenous.  Only  two  -larger  procedurers 
where  air  comes  into  play  became  infected.  In  a  wound  in 
which  catgut  is  used  infection  is  more  apt  to  get  a  foot- 
ho'd    than    in    one    in    which    silk   is    used. 


CLEANSING  THE  OPERATIVE   FIELD 

(Editorial  m  Rocky  Mount.  Med.  11;  April) 
Experience  is  establishing  the  fact  that  gentle  cleansing 
with  abundant  soap  and  warm  water,  cotton  balls,  and 
irrigation  with  normal  saline  solution  is  a  superior  method. 
Careful  observers  insist  upon  pure  white  soap— not  tinc- 
ture of  green  soap,  which  may  be  irritating  or  destructive 
on  account  of  its  alcoholic  content. 

Ethyl  alcohol  is  painful,  useless  and  probably  harmful 
in  open  wounds;  it  may  have  some  value  as  a  detergent 
upon  cutaneous  wound  margins  or  an  operative  field,  but 
germicidal  properties  of  ordinary  solutions  are  not  signifi- 
cant. Ether  is  an  excellent  fat  solvent,  but  its  rapid  evap- 
oration and  precipitation  of  proteins  nullifies  other  poten- 
tialities. The  value  of  ether  except  on  oily,  moist  and 
unprepared  surfaces  is  doubtful.  Acetone  is  a  very  weak 
germicide.  Water  nullifies  the  fat-solvent  properties  of 
r.cetone. 

Soap  and  water  plus  5  to  10  minutes  of  gentle  and  pa- 
tient washing,  is  thought  by  many  surgeons  to  be  the  su- 
perior method  for  preparing  the  field  in  every  type  ot 
surgerv.  Lessened  incidence  of  stitch  abscesses  and  other 
postoperative  infection  is  substantiating  their  conviction. 
(Thirty  years  ago  Dr.  Win.  H.  Taylor,  chemist  though  he 
was,  insisted  that  the  "best  antiseptic  is  an  abundance  of 
soap  and  an  abundance  of  hot  water";  and  Dr.  George 
Ben  Johnston  told  his  surgical  assistants  they  need  not 
put  their  hands  and  arms  into  the  bichloride  solution,  that 
scrubbing  for  five  minutes  in  soap  and  hot  w^ater,  and 
rinsing  well  in  hot  sterile  water  was  ample.—/.  M.  N.) 

Acute  Pancreatitis.— Think  of.  in  any  cases  of  ex- 
tremely severe  pain  in  the  left  upper  sector  of  the  abdo- 
men. 

Absence  of  the  Gallbladder.— There  is  such  a  thing 
as  congenital  absence  of  this  organ. 


May  1941 


SOUTHERN  MEDICINE  &  SURGERY 


The  Patient  and  the  Surgeon  in  Wounds  and  Fractures 

H.  Winnett  Orr,  M.D.,  Lincoln,  Nebraska 


Mr.  President,  Dr.  LeweUys  Barker,  Ladies  &  Gentlemen: 
Permit  me  to  thank  you  first  for  the  invitation 
to  come  to  this  meeting.  I  feel  very  much  honored 
to  be  the  guest  of  your  Society.  In  one  respect  at 
least  it  is  entirely  suftable  that  I  should  be  here 
on  this  occasion.  You  organized  the  Tri-State 
Medical  Society  in  1899  and  I  was  graduated  in 
medicine  in  the  same  year  from  the  University  of 
Michigan.  It  is  proper,  therefore,  that  we  should 
celebrate  the  anniversary  together. 


IT  has  been  suggested  that  I  discuss  certain 
methods  and  technics  in  the  treatment  of  in- 
fected wounds  and  compound  fractures.  I 
should  prefer  rather  to  consider  the  subject  from 
the  standpoint  of  the  patient  himself.  I  believe 
many  of  us  should  alter  our  point  of  view  as  to 
what  the  patient  himself  can  and  must  do  to  re- 
cover from  an  infected  wound  or  a  compound 
fracture.  It  is  a  mistaken  attitude  toward  such  a 
patient  that  has  made  many  difficulties  both  for 
the  patient  and  for  the  surgeon  himself.  It  is 
therefore,  not  a  technic  nor  a  method  in  which  I 
hope  to  interest  you  particularly,  but  a  point  of 
view  in  dealing  with  a  situation  in  which  it  is  the 
surgeon's  duty,  not  to  cure  a  wound  or  a  fracture, 
but  only  to  assist  the  patient  in  his  own  efforts 
toward  recovery  and  repair. 

It  is  my  belief  that  if  certain  fundamental  prin- 
ciples of  fracture  repair  and  wound  healing  are 
recognized  and  kept  constantly  in  mind,  methods 
and  technics  will  more  or  less  automatically  take 
care  of  themselves. 

Throughout  the  history  of  surgery  frequent 
dressings  have  been  a  difficult v  in  taking  care  of 
compound  fractures.  Wound  dressings  have  always 
been  thought  to  be  necessary  or  even  of  paramount 
importance.  Surgeons  have  considered  it  essential 
to  keep  the  wound  clean  and  to  treat  the  infec- 
tion— regardless  of  the  effect  upon  the  broken 
bone,  the  injured  limb  otherwise,  or  even  upon  the 
comfort  and  welfare  of  the  patient  himself. 

Cesare  Magatus,  an  Italian  surgeon  of  the  sev- 
enteenth century  (1676),  advocated  the  infrequent 
dressing  of  infected  and  inflamed  wounds.  Belloste 
(1716),  a  celebrated  French  military  surgeon  of 
the  next  centurv.  attempted  to  follow  him  in  this 
respect.    John    Hunter,   who   came   along   a   little 


later  (1794),  remarked  that  however  we  might 
wish  to  maintain  a  fractured  limb  in  correct  posi- 
tion and  leave  it  at  rest,  it  was  impossible  because 
"it  is  necessary  to  dress  the  sore  every  day." 

John  Hilton  (1863)  and  Hugh  Owen  Thomas 
(1880),  celebrated  English  surgeons,  were  distin- 
guished apostles  of  rest  in  the  treatment  of  bone 
and  joint  inflammations.  Yet  they  too  bowed  to 
the  common  custom  of  daily  dressings  for  such 
wounds  in  most  cases. 

It  remained  for  Joseph  Lister  (1867)  to  discover 
a  method  of  treatment  which  had  for  its  object  the 
exclusion  of  infection  from  and  the  protection  of 
wounds.  When  Pasteur  (1865)  discovered  germs, 
Lister  conceived  them  at  once  to  be  the  source  of 
wound  infection  (putrefaction)  and  wound  inflam- 
mation. Someone  has  remarked  that  Lister  "was 
sitting  on  the  heights  and  waiting  there  alone"  for 
this  discovery  in  bacteriology. 

Having  decided  that  germs  were  the  cause  of 
putrefaction,  it  was  Lister's  conception  that  a 
chemical  means  could  be  employed  to  exclude  or- 
ganisms of  all  kinds  from  wounds.  He  urged  at 
the  same  time  that  both  chemical  and  mechanical 
damage  to  the  wound  surface  should  be  avoided 
and  that  all  dressings  should  be  done  in  such  a 
way  as  to  protect  the  patient  against  secondary 
and  further  infection. 

Unfortunately  Lister's  associates  and  his  imme- 
diate followers  became  interested  in  the  search 
for  a  chemical  cure  for  infection.  Even  Lister, 
though  he  did  not  lose  sight  of  his  original  concep- 
tion with  regard  to  the  antiseptic  system,  joined  in 
the  search  for  a  chemical  that  would  kill  germs  in 
wounds  without  harm  to  the  patient. 

From  Lister's  time  until  the  Great  War  of  1914- 
1919  almost  every  chemical  and  every  chemical 
combination  that  could  be  thought  of  was  em- 
ployed for  wet  dressings,  compresses,  irrigations 
and  application  to  infected  wounds.  These  dress- 
ings were  done  regardless  of  disturbance  to  the 
wound,  to  the  limb  and  to  the  patient,  so  that  the 
search  for  a  specific  chemical  cur~  for  all  kinds 
of  infection  became  almost  a  panic  during  the  last 
war. 

Loss  of  confidence  in  chemicals  for  antiseptic 
wound  treatment  led  some  prominent  surgeons  to 
exclaim    that    the    Lister    antiseptic    method    had 


24th  and  25th. 


of  the  Tri-Statc   Medical   As 


,f  tin-   Carolina 


WOUNDS  &  FRACTURES— On 


failed.  This  indicated  a  lack  of  understanding  of 
Lister's  original  conception  of  "the  antiseptic  sys- 
tem." The  efforts  to  find  and  apply  a  chemical 
cure  for  the  infected  wound  failed  then  and  has 
continued  to  fail  because  more  harm  has  been 
done  by  the  chemicals,  more  trauma  has  been  in- 
flicted upon  the  wound  and  the  patient  by  dress- 
ings, and  often  more  new  infection  has  been  intro- 
duced than  the  patient  could  tolerate  during  his 
efforts  to  get  well. 

It  is  a  change  away  from  this  kind  of  treatment 
that  I  have  proposed.  The  change  that  I  have 
suggested  is  a  program  consisting  of  ( 1 )  reposition 
of  the  patient  and  his  limb  in  correct  position,  (2) 
restoration  of  circulation  and  blood  supply  to  the 
injured  parts  and  (3)  protection  of  the  wound 
and  the  patient  against  injury  and  infection.  This 
is  the  attitude  of  the  surgeon,  to  which  I  have 
referred. 

My  own  training  in  orthopedic  surgery  has  led 
me  into  lines  of  thought  regarding  these  conditions 
that  were  mapped  out  by  Hugh  Owen  Thomas 
and  his  star  pupil,  Dr.  John  Ridlon  of  Chicago. 
Thomas  insisted  that  every  injured  and  inflamed 
limb  should  have  the  benefit  of  rest,  "enforced, 
uninterrupted  and  prolonged."  That  this  succeed- 
ed so  well  in  injuries  and  diseases  of  bones  and 
joints  was  due  to  the  mechanical  efficiency  with 
which  Thomas  made  and  applied  his  splints  and 
carried  out  his  postoperative  care  in  such  cases. 
It  was  a  familiarity  with  the  splints  of  Thomas 
and  with  the  successful  use  of  plaster  as  taught  bv 
Dr.  Ridlon  in  bone  and  joint  infections  that  led 
me  to  propose  this  different  line  of  treatment  for 
the  more  acute  and  inflamed  extremities  that  we 
encountered  in  the  Great  War. 

When  I  began  my  military  service  in  British 
hospitals  in  June  of  1917,  I  found  that  a  very  ac- 
tive program  of  antiseptic  treatment  for  all  infect- 
ed wounds  and  compound  fractures  was  being 
carried  out.  At  least  a  dozen  different  kinds  of 
chemicals,  old  and  new,  were  being  used  as  wet 
dressings,  compresses,  irrigations  and  even  in  arm 
and  leg  bathing-tubs  for  these  affected  extremities. 
This  was  still  known  as  the  Lister  antiseptic 
method.  It  impressed  me  at  once  that  this  was  in 
contradiction  to  the  teachings  of  Thomas  and  a 
departure  from  the  method  that  Lister  had  pro- 
posed in  his  original  papers  in  1867.  At  that  time 
Lister  specified  particularly  that  chemicals  were 
not  to  be  applied  directly  to  the  wound  surface 
and  that  dressings  were  to  be  designed  to  afford 
protection  against  invasion  by  infectious  organ- 
isms. In  the  treatment  in  the  British  hospitals  as 
I  saw  it,  wounds  were  being  exposed  every  day  or 
several   times  a  day  so  that  much  damage  was 


being  done  to  the  wound  surface  and  many  new 
organisms  were  being  introduced  by  the  manner  in 
which  dressings  were  being  done. 

It  should  be  obvious  to  anyone  that  to  take 
the  dressings  off  an  open  wound  and  to  put  that 
extremity  into  an  open  tub,  then  to  reapply  dress- 
ings with  exposure  of  all  the  parts  to  the  air,  to 
fingers,  instruments  and  non-sterile  surroundings 
would  be  to  add  to  the  infection  of  the  wound. 
Even  antiseptic  tub  baths  or  dressings  subsequent- 
ly could  not  counteract  the  harm  done  in  the  bath- 
ing and  dressing  routine. 

About  that  time  the  Carrel-Dakin  method  was 
brought  forward  in  France  by  Alexis  Carrel  of 
New  York.  This  was  a  cleverly  designed  technic 
sponsored  and  promoted  by  the  enormous  re- 
sources of  the  Rockefeller  Foundation  and  pop- 
ularized in  France  by  an  extensive  hospital  cam- 
paign. Actually,  the  Carrel-Dakin  method  was 
only  another  refined  antiseptic  irrigation  method. 
The  chemicals  were  different,  but  not  particularly 
better,  than  many  that  had  previously  been  em- 
ployed. The  technic  had  been  worked  out  with 
great  care  in  the  laboratory  and,  as  done  by  Car- 
rel and  his  associates,  represented  greater  care 
and  precision  than  many  of  the  dressings  formerly 
used  in  military  hospitals. 

However,  the  entire  Carrel-Dakin  program  was 
simply  a  more  elaborate,  more  expensive  and 
more  highly  technical  method  of  excluding  infec- 
tion from  wounds  than  that  proposed  by  Lister  in 
years  gone  by.  The  Carrel-Dakin  method,  also, 
involved  frequent  exposure  of  the  wound,  move- 
ment of  the  injured  and  damaged  extremities,  and 
in  less  than  expert  hands  exposure  of  the  wound 
to  new  and  different  types  of  infection. 

From  my  standpoint  as  an  orthopedic  surgeon 
the  Carrel-Dakin  method  was  objectionable  be- 
cause of  the  necessity  for  adapting  splints,  plaster 
casts  and  other  immobilizing  devices  to  the  fre- 
quent disturbance  of  the  wound  and  the  injured 
limb.  For  that  reason  I  have  never  used  it.  In 
some  of  the  hospitals  I  visited  I  found  that  the 
Carrel-Dakin  method  was  doing  more  harm  than 
good  and  that  bad  results  in  many  of  the  fractures 
were  the  result  of  infections  and  injuries  incident 
to  the  dressing  program.  The  faults  of  the  Carrel- 
Dakin  method  were  the  same  faults  as  those  of 
other  frequent-dressing  methods  from  Lister's  own 
time  until  the  time  of  the  War. 

In  the  meantime  other  methods  had  been  pro- 
posed for  the  treatment  of  fractures  which  involv- 
ed a  point  of  advantage  not  commonly  recognized. 
That  is  to  say  Sir  Arbuthnot  Lane  (1893),  Lam- 
botte  (1902),  Codivilla  (1905),  Dr.  Fred  Albee 
(1911)  and  several  other  surgeons  were  employing 


WOUNDS  &  FRACTURES— On 


direct  fixation  devices  for  fractures.  By  means  of 
metal  plates  or  bone  grafts,  fracture  fragments 
were  being  restored  at  once  to  correct  position 
and  held  there  (direct  fixation)  in  correct  posi- 
tion. These  operations  had  the  ancillary  effect  of 
restoring  correct  position  to  the  nerves,  blood  ves- 
sels, lymphatic  channels  and  other  parts  of  an 
injured  limb. 

In  infected  cases  Lane,  Albee  and  others  attrib- 
uted their  results  in  the  healing  of  wounds  to  the 
Carrel-Dakin  or  other  chemical  antiseptic  methods 
they  employed.  It  seemed  to  me  that  fixation  of 
the  bones  and  restoration  of  the  contour  and  phy- 
siology of  the  limb  gave  the  patient  his  better  op- 
portunity to  defend  himself  against  infection  and 
to  reestablish  his  own  forces  of  resistance  and  re- 
pair. I  could  see,  therefore,  that  these  patients 
were  getting  well  because  of  improved  circulation, 
nerve  supply  and  lymphatic  flow  provided  by  the 
correct  position  and  protection  of  the  limb  as  a 
whole.  This  was  incidental  to  the  direct  fixation 
procedure  and  not  because  of,  but  in  spite  of, 
antiseptic  wound  dressings. 

For  my  own  fractures,  both  simple  and  com- 
pound, I  have  always  employed  indirect  fixation. 
That  is,  ice-tongs  or  pins  to  fasten  the  bone  frag- 
ments in  correct  length  and  position  and  included 
in  plaster  casts.  By  this  plan  there  is  no  occasion 
to  operate  or  do  any  surgical  damage  at  the  point 
of  fracture.  No  injury  is  done  by  operation  to  the 
bone  or  the  other  tissue  unless  the  compound 
fracture  wound  requires  debridement  or  better 
drainage.  We  do  not  put  in  bone  plates,  wires  or 
screws  at  the  point  of  fracture,  or  even  drainage 
tubes;  we  insert  only  the  vaselin  pack  to  provide 
a  saucer-like  dressing  around  the  edges  of  which 
drainage  can  take  place  if  necessary. 

Even  when  bone-plates,  screws  or  grafts  have 
been  put  in  by  others  and  when  these  have  to  be 
removed,  we  follow  the  same  plan.  Namely,  we 
fasten  the  bone  fragments  by  pins  at  a  distance 
from  the  open  wound,  provide  drainage  by  means 
of  a  vaselin  pack  and  immobilize  and  protect  the 
limb  and  the  wound  in  the  same  way  by  means 
of  a  plaster  cast. 

It  is  this  alteration  in  our  point  of  view  to 
which  I  refer.  Instead  of  considering  that  such  a 
wound,  even  when  infected,  requires  treatment  for 
the  infection  or  antiseptic  therapy  to  cure,  we 
should  consider  that  all  that  a  patient  requires  is 
correct  position,  drainage  and  protection  in  order 
to  afford  him  his  own  best  opportunity  to  recover. 

This  was  indeed  the  original  conception  of  Lis- 
ter himself.  On  several  occasions  he  reminded  us 
that  before  we  knew  anything  about  germs  or  the 
use  of  antiseptics  many  patients  recovered  follow- 


ing injury  and  operation,  because  of  their  ability 
to  resist  infection  and  to  repair  their  wounds. 
Lister  was  quite  able  to  appreciate  the  importance 
of  permitting  the  patient  to  make  use  of  these 
natural  forces  to  resist  invasion  by  organisms  and 
to  obtain  healing. 

Apart  from  the  actual  damage  done  by  frequent 
dressings  and  leaving  out  of  consideration  those 
complications  due  to  the  introduction  of  germs, 
even  taking  no  account  of  the  loss  of  position  of 
fractures  and  injured  limbs,  the  effect  of  frequent 
dressings  upon  the  patient's  general  condition  and 
morale  is  a  matter  of  great  importance.  The  dif- 
ferent (and  better)  conduct  of  the  patient  which 
follows  the  adoption  of  the  plaster-cast-and-infre- 
quent-dressing  method  is  so  obvious  that  it  always 
excites  comment. 

A  good  deal  has  been  said  in  the  literature  of 
recent  years  about  primary  or  secondary  closure 
of  infected  wounds  and  compound  fractures.  That 
matter  has  come  up  again  recently  with  the  pro- 
posal to  do  such  closures  over  wounds  or  fractures 
packed  with  sulfanilamide  or  sulfa thiazol.  //  a 
wound  can  be  truly  sterilized  either  primary  or 
secondary  closure  is  a  justifiable  surgical  proce- 
dure, not  otherwise.  That  some  brilliant  results 
have  followed  in  such  cases  is  well  known.  That 
the  method  will  ever  be  suitable  for  general  em- 
ployment is  most  unlikely. 

With  the  Carrel-Dakin  method,  with  mercuro- 
chrome,  and  now  with  sulfanilamide,  surgeons 
have  been  encouraged  to  believe  that  such  sterili- 
zation of  wounds  (or  "fixation  of  infection")  is 
possible.  All  of  our  teaching  in  bacteriology  is  to 
the  effect  that  negative  cultures  from  such  wounds 
do  not  mean  that  the  wounds  are  sterile.  They 
simply  mean  that  no  germs  have  been  seen.  Act- 
ually, a  wound  that  has  been  cultured  with  nega- 
tive results  for  several  times  or  for  several  days 
may  still  harbor  pus  organisms  or  even  anaerobes  in 
such  number  as  to  cause  postoperative  complica- 
tions of  the  most  serious  kind  if  the  wound  is  su- 
tured shut.  In  my  own  practice,  therefore,  it  is 
an  expedient  which  I  have  never  employed  and 
which  I  have  never  recommended.  I  think  one 
does  a  primary  or  secondary  closure  of  a  wound 
that  has  been  actively  or  is  potentially  infected  at 
great  risk  to  the  patient  in  every  case. 

In  depending  upon  laboratory  findings  for  the 
adoption  of  such  treatment  we  should  bear  in  mind 
that  there  is  a  science  of  the  bedside  as  well  as  of 
the  laboratory  and  our  clinical  experience  should 
guide  us  no  less  than  laboratory  findings  which  are 
often  susceptible  of  erroneous  interpretation. 

The  military  experience  of  Dr.  Trueta  in  the 
Spanish  War  has  given  the  final  and  conclusive 


WOUNDS  &  FRACTURES— Orr 


Mav  1941 


evidence  necessary  to  substantiate  the  method  I 
have  described  as  a  kind  of  surgical  treatment 
applicable  to  the  most  desperate  military  situa- 
tions. Trueta,  in  Barcelona,  treated  more  than  a 
thousand  cases  of  gunshot  wounds  and  compound 
fractures  due  to  military,  motor  and  aeroplane 
accidents — with  only  six  deaths.  In  all  these  cases 
treatment  was  primary  sterile  dressings  with  open 
wounds  and  plaster  fixation  of  the  injured  parts 
in  correct  position. 

The  principle  employed  was  that  for  which  Dr. 
Trueta  has  kindly  acknowledged  his  indebtedness 
to  me.  In  fact,  in  his  book  he  says  that  the 
method  I  have  suggested  is  destined  to  give  a  new 
direction  to  surgical  practice  in  these  cases.  Many 
recent  reports  from  Britain  confirm  the  reports 
that  I  made  to  the  British  Societies  in  19301  and 
19332  and  the  program  that  I  have  followed  for 
twenty  years. 

I  can  only  conclude  then  by  advocating,  as  I 
suggested  in  the  beginning,  that  the  program  pro- 
posed by  me  in  1923  be  followed  in  all  these  cases. 
In  other  words,  immobilize  the  parts  on  the  trac- 
tion table  in  correct  position  as  soon  as  possible 
after  injury  and  before  the  operation.  Do  the 
operation,  not  as  a  debridement,  but  as  a  drainage 
operation.  Use  a  vaselin  pack  for  drainage.  Con- 
trol the  length  and  position  of  the  limb  bv  means 
of  pins  through  the  skeletal  structures  and  im- 
bedded in  the  plaster  cast.  Leave  the  cast  closed 
and  do  not  expose  the  wound  to  further  trauma  or 
infection  by  frequent  dressings.  , 

This  regimen  has  given,   and   will   give,  better 
results  for  wounds  and   fractures  than   any  anti- 
septic wound  treatment  yet  brought  forward. 
References 

1.  Osteomyelitis  and  Compound  Fractures  and  Other  In- 
fective Wounds:  Treatment  by  the  Method  of  Drainage 
and  Rest.  Reprinted  in  British  Journal  of  Surgerv, 
October,  1929. 

2.  Prevention  of  Accidents  and  Complications  in  the 
Course  of  Osteomyelitis.  Reprinted  in  British  Medical 
Journal,  August,   1933. 


TONSILS  IN  OR  OUT 

(John  Zahorsky,  in  Bui.  St.  Louis  Med.  Soc,  April  18th) 
At  its  worst  stage,  nurses,  educators  and  parents  became 
so  imbued  with  this  prophylactic  theory  that  every  phy- 
sician was  compelled  to  bow  to  the  clamor  of  the  public. 
Not  since  the  days  when  phlebotomy  was  the  most  pop- 
ular therapeutic  measure  was  so  much  blood  shed.  After 
the  study  of  150  children,  I  concluded  that  tonsillectomy 
as  a  preventive  measure  was  a  failure.  These  conclusions 
were  laid  down: 

1.  The   removal   of  tonsils  does  not  prevent   middle-ear 
disease. 

2.  Sinus  infections  are  more  common  in  the  child  who 
has  had  his  adenoids  removed. 

3.  Tonsillectomy   does   not   prevent   colds   and   increases 
the  tendency  to  pneumonia. 


4.  Enlarged  cervical  glands  occur  very  often  in  the  child 
who  has  his  tonsils  removed. 

5.  Rheumatism,  heart  disease  and  chorea  are  not  pre- 
vented by  tonsillectomy. 

6.  Malnutrition  occurs  almost  as  frequently  in  children 
having  their  tonsils  out  as  in  those  who  have  them  in. 

These  conclusions  were  subsequently  corroborated  by 
the  studies  of  the  United  States  Public  Health  Service  of 
the  cases  of  several   thousand  children. 

The  removal  of  the  tonsils  during  childhood  as  a  pro- 
phylactic measure  became  obsolete. 

Then  another  idea  was  proposed:  The  tonsils  of  chil- 
dren are  often  diseased  and  should  be  removed.  Unfortu- 
nately, no  one  was  able  to  define  this  term,  nor  describe 
the  clinical  features  so  that  a  clear  diagnosis  could  be 
made.  Microscopical  examination  of  hundreds  of  tonsils 
removed  revealed  no  disease  in  most  of  the  tonsils  exam- 
ined. Removing  the  tonsils  or  adenoids  does  drain  the 
submucosa  surrounding  these  organs  and  temporarily  im- 
proves the  condition.  You  should  see  the  child  a  year 
later,  at  the  next  epidemic  of  respiratory  infections. 

An  obstruction  in  the  nose  due  to  an  allergic  rhinitis  is 
made  worse  by  taking  out  the  adenoids.  Asthma  is  not 
benefited  by  tonsillectomy.  Recent  studies  have  shown 
that  the  child  without  tonsils  is  more  susceptible  to  polio- 
myelitis, at  least  the  fatal  bulbar  form. 

The  indications  for  removal  must  be  very  clear  before 
such  an  operation  is  to  be  advised.  The  diagnosis  must  be 
based  on  a  complete  diagnostic  survey  of  the  child.  It  is 
crass  negligence  to  propose  tonsillar  operations  merely  on 
an  inspection  of  the  throat.  In  doubtful  cases  let  the 
tonsils  stay  in,  do  not  take  them  out.  Harm  may  be  done 
to  the  young  growing  child.  The  tonsils  are  intimately 
connected  with  the  development   of  immunity. 


THE   MALMROS-HEDVALL    LESIONS   OF    PULMON- 
ARY TUBERCULOSIS  IN  ADULTS 

(A.    T.    Laird,    Xopeming.    in   Minn.    Med.,   Feb.) 

The  adult  or  reinfection  type  of  pulmonary  tubercu'o- 
sis  is  responsible  for  most  of  the  cases  of  chronic  invalid- 
ism or  death  that  result  from  infection  with  tubercle  ba- 
cilli. Only  a  small  percentage  of  all  persons  who  acquire 
a  primary  infection  develop  this  serious  form  of  clinicaj 
disease,  but  when  the  reinfection  type  of  pulmonary  tu- 
berculosis does  result  it  is  extremely  important  that  the 
diagnosis  be  made  as  early  as  possible. 

The  presence  of  this  type  of  the  disease  may  now  be 
determined  in  certain  cases  by  the  use  of  the  newer  meth- 
ods, long  before  the  patient  shows  any  outward  indication 
of  illness  or  has  even  a  premonition  that  his  health  is  not 
perfect. 

In  the  majority  of  the  cases  in  which  the  reinfection 
type  of  tuberculosis  of  the  lungs  developed  later,  there 
were  no  subjective  symptoms  of  illness;  the  sedimentation 
test  was  normal  in  most  of  these  cases. 

The  reinfection  or  adult  type  of  pulmonary  tuberculo- 
sis in  those  primarily  infected  in  adult  life  usually  began 
with  a  lesion  called  by  Malmros  and  Hedvall  a  "subpri- 
mary  initial  lesion"  which  often  took  the  form  of  single 
or  multiple  cloudy  spots  or  flecks  on  the  x-ray  film,  usual- 
ly in  the  supraclavicular  region  or  in  the  first  interspace 
or  simultaneoutly  at  both  places. 

In  individual  cases  an  appearance  was  noted,  near  the 
area  of  flecks,  of  "early  infiltration  lesions"  dense  and 
their  edges  more  sharply  defined  than  was  the  case  with 
the  subprimary  initial  lesions. 

These  two  lesions,  the  subprimary  initial  lesion  and  the 
early  infiltrate,  were  the  first  evidences  seen  of  the  adult 
or  reinfection  type  of  pulmonary  tuberculosis. 


SOUTHERN  MEDICINE  &  SURGERY 


The  Mechanism  of  Cardiac  Pain  and  its  Differention 
From  Chest  Pains  of  Radicular  Origin* 

T.  W.  Baker,  M.D.,  Charlotte 


IN  1912  "acute  indigestion''  began  its  exit  and 
coronary  thrombosis  made  its  entrance.  It 
was  James  B.  Herrick1  of  Chicago  who  intro- 
duced the  diagnostic  concept  of  coronary  throm- 
bosis and  helped  us  to  recognize  the  aliases  under 
which  occlusion  of  the  coronary  arteries  had  been 
masquerading.  Such  diagnoses  as  "acute  indiges- 
tion," ''ptomaine  poisoning,"  and  "acute  dilatation 
of  the  stomach"  have  made  a  complete  fade-out 
from  our  vital  statistics.  This  diagnostic  transfor- 
mation has  occurred  in  much  the  same  manner  as 
appendicitis  and  peritonitis  supplanted  the  diag- 
nosis of  "locked  bowels,"  following  the  memor- 
able paper  of  Reginald  Fitz  in  1886. 

The  teachings  of  Herrick  concerning  coronary 
thrombosis  have  thoroughly  penetrated  our  medi- 
cal consciousness.  This  is  evidenced  by  the  fact 
that  in  1938  we  find  Herrick2  himself  cautioning 
us  against  his  own  brain  child  and  warning  us  not 
to  become  too  coronary  conscious.  I  quote: 
"When  a  previously  misunderstood  or  overlooked 
disease  has  been  shown  to  be  common,  when  its 
symptoms  are  first  described,  for  a  time  it  is 
likelv  to  be  a  front  page  medical  news  item.    It  is 

a  best  seller So  it  has  been  with  coronary 

occlusion."  We  are  probably  overshooting  the 
mark  in  our  tendency  to  regard  too  hastily  any 
pain  over  the  precordium  as  a  heart  attack.  We 
all  have  a  mental  leaning  towards  coronary  throm- 
bosis, due  largely  to  our  praiseworthy  desire  to 
guard  our  patient  against  the  evil  consequences  of 
overlooking  this  life-threatening  condition.  For- 
tunately the  rest  in  bed  which  we  prescribe  is  gen- 
erally harmless,  frequently  beneficial.  Unfortu- 
nately, however,  it  may  deprive  the  patient  of  the 
benefits  of  timely  and  surgical  treatment,  or  of  a 
more  suitable  medical  management,  and  all  too 
frequently  may  exaggerate  a  preexisting  cardiac 
neurosis. 

The  diagnosis  of  coronary  thrombosis  is  not 
always  easy.  Certain  cases  may  present  confusing 
differential  possibilities.  It  was  just  such  a  case 
that  increased  my  interest  in  the  character  of  car- 
diac pain,  its  mode  of  radiation,  its  similarities 
and  dissimilarities  to  other  chest  pains. 

For  the  sake  of  clarification,  chest  pains  may 
be  classified  into  three  groups,  as  suggested  by 
Gunther':  (1)  organic  pains  arising  from  thoracic 
viscera  which  are  transmitted    by    viscerosensory 


nerve  pathways;  (2)  pains  of  radicular  origin 
which  are  transmitted  by  the  spinal  nerves,  and 
(3)  non-organic  or  functional  pains,  which  are  all 
too  frequently  transmitted  and  projected  by  a  fer- 
tile imagination. 

The  organic  chest  pains  of  visceral  origin  may 
be  further  subdivided  as  follows: 

Those  arising  from  the  mediastinum: 

( 1 )  Angina  pectoris. 

(2)  Coronary  artery  occlusion. 

(3)  Acute  pericarditis. 

(4)  Acute  mediastinitis. 

(5)  Dissecting  aneurysm  of  the  aorta. 

(6)  Obstructive    lesions    of    the    esophagus    or 
bronchi. 

(7)  Diaphragmatic    hernia    into    the    mediasti- 
num. 

(8)  Cardiospasm. 
Those  of  pleural  origin: 

( 1 )  Acute    pulmonary    and    pleural    inflamma- 
tions. 

(2)  Pulmonary  embolism. 

(3)  Spontaneous   pneumothorax,   atelectasis   or 
massive  collapse  of  the  lungs. 

(4)  Shoulder    and    chest    pain    from    sub-dia- 
phragmatic lesions. 

(5)  Rare  and  unusual  pulmonary  pathology. 
This  classification  is  obviously  not  all-inclusive 

but  it  will  serve  as  a  basis  for  this  discussion. 
Neither  time  nor  your  kind  indulgence  will  permit 
a  differential  study  of  all  of  the  above  mentioned 
causes  of  chest  pain.  Therefore  I  shall  confine 
this  paper  to  a  discussion  of  elemental  principles 
concerning  the  differences  between  visceral  and 
radicular  pain  of  thoracic  origin.  A  knowledge  of 
the  radicular  syndrome  will  enable  us  to  evaluate 
chest  pain  since  its  common  occurrence  has  so 
often  been  misinterpreted  as  angina  pectoris  or  an 
acute  occlusion  of  a  coronary  artery.  When  con- 
fronted with  an  obscure  chest  pain,  we  might  well 
begin  our  analysis  by  first  asking  the  questions: 
Is  it  visceral?  Is  it  radicular?  Or  is  it  functional? 
What  do  we  understand  by  visceral  pain  and  the 
viscerosensory  reflex?  Pain  of  visceral  origin  may 
be  vaguely  localized  in  a  viscus  as  a  deep  sore- 
ness. More  frequently,  however,  the  pain  impulse 
arising  from  thoracic  viscera  or  serous  membranes 
is  projected  to  a  distant  point  of  the  body  wall 
which  is  supplied   from   the  same  posterior  nerve 

i    of   the   Carolinas   and    Virginia,    held   at    Greensboro,    February 


CARDIAC    PAIN— Baker 


May  1941 


roots  which  supply  the  viscus  or  serous  membrane. 
This  phenomenon  is  known  as  referred  pain.  The 
referred  pain  of  certain  skin  segments  in  relation 
to  most  of  the  large  viscera  is  fairly  well  known 
and  corresponds  somewhat  to  their  metameric 
origin  within  the  cord.  Referred  pain  may  arise  in 
the  dermatone  directly  over  an  organ  because  that 
may  correspond  to  the  segmental  innervation. 
However,  in  the  transpositions  of  organs  during 
embryological  development  that  viscus  may  have 
shifted  its  position  quite  a  bit.  Although  appendi- 
ceal pain  is  usually  referred  to  the  body  wall 
directly  above  it,  renal  pain  is  referred  to  the 
groin  or  testicle,  and  gallbladder  pain  is  fre- 
quently referred  to  the  right  scapular  region.  The 
embryological  shift  of  the  diaphragm  from  the 
neck  region  explains  why  pain  of  diaphragmatic 
origin  is  referred  to  the  shoulder. 

Pain  of  cardiac  origin  is  an  excellent  example 
of  referred  pain.  It  is  generally  agreed  that  severe 
pain  of  cardiac  origin  is  almost  always  the  result 
of  ischemia  of  a  portion  of  the  myocardium  pro- 
duced by  a  thrombosis  or  a  reduction  in  calibre -of 
one  of  the  coronary  arteries.  Lewis4  has  likened 
the  pain  to  that  which  may  be  produced  in  the 
arm  by  a  continuous  gripping  of  the  hand  while 
the  circulation  is  occluded  by  means  of  a  blood 
pressure  cuff.  Cardiac  pain  can  be  evoked  by 
proper  stimuli  in  any  region  of  the  heart  supplied 
by  sensory  terminals,  which  tissue  examinations 
have  shown  to  be  as  numerous  as  300  per  square 
centimeter".  The  pain  of  coronary  thrombosis  is 
usually  characteristically  referred  over  the  outer 
part  of  the  left  side  of  the  chest  wall,  down  the 
inside  of  the  arm,  up  the  neck  to  the  angle  of  the 
jaw,  and  to  both  shoulders  and  back.  The  pain 
may  be  referred  to  the  epigastrium  and  may  sim- 
ulate that  of  an  abdominal  catastrophe. 

Pain  of  cardiac  origin  is  conveyed  from  the  heart 
by  the  superior,  middle  and  inferior  cardiac  nerves 
to  the  chain  of  the  three  cervical  and  first  five 
thoracic  sympathetic  ganglia.  These  pain  impulses 
are  then  conducted  through  the  white  rami  of  the 
first  to  the  fifth  thoracic  ganglia  to  enter  the  cor- 
responding spinal  nerve  roots.  The  impulse 
reaches  the  posterior  horn  of  the  gray  matter  of 
the  upper  thoracic  cord,  from  whence  it  travels  to 
the  corresponding  segments  of  the  skin  and  body 
wall.  The  spinothalamic  tract  which  crosses  to 
the  opposite  side  of  the  spinal  cord  conveys  the 
pain  impulses  to  consciousness.  If  the  pain  is  of 
a  sufficient  degree,  the  painful  impulse  will  cause 
a  reflex  contraction  of  the  muscles  of  the  body 
wall  underlying  the  corresponding  skin  segments 
to  which  the  pain  is  referred  through  stimulation 
of  the  anterior  horn  cells.    This  last  phenomenon 


is  particularly  evident  when  pain  is  referred  to  the 
flat  muscles  of  the  abdomen,  and  is  thought  to  be 
the  physiological  explanation  of  rigidity. 

Characteristic  of  coronary  thrombosis  is  a  sense 
of  constriction  as  though  the  chest  were  gripped 
in  a  vise,  or  as  if  the  breast  bone  would  break. 
MacKenzie0  attributes  this  to  a  visceromotor  re- 
flex— that  is,  a  reflex  spasm  of  the  intercostal  mus- 
cles which  prevents  free  movements  of  the  chest. 

The  pain  of  angina  pectoris  and  the  other  or- 
ganic chest  pains  of  visceral  origin  enumerated 
previously  are  referred  over  similar  nerve  path- 
ways to  various  skin  segments  in  the  same  manner 
but  with  varying  distributions. 

Pain  of  radicular  origin  is  much  simpler  in  its 
explanation.  With  rare  exceptions,  radicular  pain 
of  thoracic  origin  is  produced  by  one  of  two 
causes:  (1)  by  mechanical  impingement  upon  the 
nerve  roots  by  new  growths  or  destructive  proc- 
esses of  adjacent  structures,  or  (2)  by  infection  of 
the  nerve  roots  or  their  contiguous  structures. 

The  organic  chest  pains  of  radicular  origin  may 
be  further  classified  into: 

(1)  Osteoarthritis  of  the  dorsal  and  cervical 
spine. 

(2)  Tuberculosis  and  osteomyelitis  of  the  tho- 
racic cage. 

(3)  Erosions  and  destruction  of  the  vertebrae, 
ribs  and  sternum  by  aneurysms,  lympho- 
blastoma, and  other  new  growths. 

(4)  Compression  fractures  of  the  vertebrae. 

(5)  Protrusion  of  the  intervertebral  discs. 

(6)  Tumors  of  the  spinal  cord,  meninges  and 
nerve  roots. 

(7)  Acute  infections  of  the  nerve  roots. 

(8)  Herpes  zoster. 

(9)  Syphilis  (tabes  dorsalis). 

(10)  Postural  root  pains  of  kyphosis  and  scolio- 
sis. 
Radicular  pain  is  projected  usually  from  a  pos- 
terior origin  to  an  anterior  terminal  along  the 
course  of  a  definite  spinal  nerve.  It  is  important 
to  remember  the  approximate  levels  of  distribu- 
tion or  dermatones  of  the  trunk  supplied  by  these 
nerves.  It  is  not  necessary  to  remember  the  exact 
distributions,  but  if  we  will  recall  a  few  landmarks 
they  will  serve  as  hitching  posts  for  our  memory  of 
this  diagram.  Recall  that  the  anterior  neck  is  sup- 
plied by  the  third  cervical  cord  segment,  that  the 
shoulder  is  supplied  by  C  4,  that  the  region  of 
the  nipple  is  innervated  by  Th.  4,  the  epigastrium 
by  Th.  6,  the  umbilicus  by  Th.  10,  the  groin  by 
Th.  12,  and  we  have  the  keys  to  the  segmental 
distribution  of  the  nerves  supplying  the  neck, 
chest  and  abdomen.  Most  of  us  cannot  trust  our 
memories  regarding  the  segmental  distribution  to' 


CARDIAC    PAIN—Saker 


the  extremities,  as  it  is  far  more  complicated,  but 
information  at  one's  finger  tips  in  the  form  of  a 
good  neurological  text  will  readily  solve  this  prob- 
lem. It  is  well  also  to  bear  in  mind  that  there  is  a 
difference  of  about  two  or  three  segments  in  the 
relation  of  the  spinal  cord  to  the  vertebrae.  Thus 
it  will  be  seen,  for  example,  that  the  6th  dorsal 
cord  segment  lies  at  a  level  of  the  4th  dorsal  ver- 
tebra. This  fact  must  be  utilized  constantly  in 
the  localization  of  cord  lesions  and  should  also  be 
borne  in  mind  when  requesting  regional  x-rays  of 
the  spine.  For  example,  if  the  radicular  pain  indi- 
cates involvement  of  a  dermatone  supplied  by  the 
third  lumbar  cord  segment,  the  bony  changes,  if 
present,  will  be  most  likely  found  in  the  region  of 
the  12  th  thoracic  vertebra. 

The  third  group  of  chest  pains,  those  of  func- 
tional origin,  usually  defies  anatomical  distribution 
of  nerve  pathways.  For  this  reason  these  pains 
are  rarely  confused  with  chest  pains  of  radicular 
origin,  but  difficulties  frequently  arise  in  the  dif- 
ferentiation of  functional  and  visceral  pain.  Par- 
ticularly is  this  true  of  organic  conditions  of  the 
chest  in  which  there  may  be  few  objective  findings, 
the  most  notable  example  being  angina  pectoris. 
Much  of  the  personal  equation  and  evaluation  of 
the  individual's  mental  and  emotional  status  enter 
into  our  conclusions  concerning  pain  of  functional 
origin.  Many  elements  of  personal  behaviour,  en- 
vironment and  situation  must  be  considered,  but 
the  scope  of  this  paper  does  not  permit  an  ade- 
quate discussion  here. 

With  this  brief  review  of  the  anatomical  and 
physiological  differences  between  thoracic  pain  of 
visceral  and  of  radicular  origin  as  a  basis,  let  us 
consider  the  differences  in  clinical  manifestations. 
Before  resorting  to  acessory  diagnostic  methods, 
such  as  roentgenograms  of  the  chest  and  spine  or 
an  electrocardiogram,  we  should  carefully  consider 
the  characteristics  of  the  pain  which  the  patient 
presents. 

For  the  sake  of  an  illustration,  we  might  con- 
trast angina  pectoris  as  an  example  of  pain  trans- 
mitted by  the  viscerosensory  pathways  with  radic- 
ular pain  which  may  originate  from   any  of  the 
i  causes  previously  enumerated.    Root  pain,  partic- 
'   ularly  from  osteoarthritis  of  the  dorsal  spine,  is 
apt  to  appear  on   the  chest   at   the   time   of  life 
i  when  cardiac  pain  most  frequently  makes  its  ap- 
pearance.   If  a  radicular  pain  originates  in  the  left 
'.  third  or  fourth  dorsal  roots  which  supply  the  skin 
,  over  the  precordial  area,  or  in  the  left  first  or  sec- 
i  ond  dorsal  roots  which  supply  the  skin  over  the 
'  inner  arm,   it   is   not   infrequently   confused   with 
pain  of  cardiac  origin. 

Root  pains  characteristically  occur  in  band-like 


zones  on  the  chest,  varying  from  one  to  several 
inches  in  width — wider  posteriorly  and  tapering  off 
anteriorly.  This  is  in  contrast  to  the  pain  of  car- 
diac origin,  which  covers  a  wide  area  in  the  pre- 
cordial region  and  which  when  it  radiates  jumps 
from  one  root  zone  to  another  without  completing 
the  entire  distribution  of  any  one  spinal  nerve. 
Thus  cardiac  pain  may  be  referred  to  the  inner 
side  of  the  arm  without  ever  radiating  to  the  back 
of  the  chest  to  complete  the  distribution  of  the 
nerve  root  in  which  it  first  had  its  onset.  This  is 
not  true  of  radicular  pain. 

Memory  for  radicular  pain  is  excellent,  even 
months  after  it  has  ceased  to  be  present.  The 
patient  will  locate  and  outline  with  his  finger  tips 
the  entire  band-like  zone  as  though  he  were  draw- 
ing this  distribution  on  himself.  Memory  for  car- 
diac pain  is  poor.  Its  borders  are  outlined  vaguely. 
Its  minutiae  are  described  with  difficulty.  The 
fingers  are  not  used  to  locate  cardiac  pain,  but 
rather  the  flat  of  the  hand  or  the  fist  will  indicate 
the  involved  area. 

The  patient's  description  of  root  pain  is  in  such 
terms  as  "a  sharp  catch,  electric  or  shooting  pain 
of  a  moment's  duration,"  or  as  "a  burning,  tingling 
and  numbness"  which  gives  the  impression  of  a 
surface  pain  with  very  little  depth.  Cardiac  pain 
is  described  as  "squeezing,  crushing,  vise-like  and 
tearing"  with  the  feeling  of  depth  and  volume  of  a 
third  dimension.  Cardiac  pain  resulting  from  cor- 
onary thrombosis  is  usually  constant  for  its  dura- 
tion and  gradually  increases  in  severity  until  it 
attains  a  peak;  whereas  root  pain  is  usually  sharp 
and  stabbing,  of  a  second's  duration,  and  occurs 
usually  in  paroxysms.  Root  pain  is  frequently 
preceded,  accompanied  or  followed  by  paresthesiae. 

The  associated  phenomena,  such  as  nausea, 
vomiting,  sweating,  and  changes  in  color — in  gen- 
eral, symptoms  of  shock — encountered  in  cardiac 
and  other  mediastinal  reflex  pains  are  not  found 
to  occur  in  root  pain,  regardless  of  its  intensity. 

The  factors  which  act  as  triggers  to  set  off  pain 
of  cardiac  origin  and  radicular  pain  are  different. 
Physical  exertion,  excitement,  and  overeating  are 
frequent  precipitating  factors  in  cardiac  pain,  al- 
though it  may  occur  when  the  patient  is  quiet  or 
during  sleep.  Radicular  pain  is  usually  precipi- 
tated by  movements  of  the  spinal  column,  and  ex- 
acerbated by  coughing,  sneezing,  yawning,  or 
straining  at  stool,  which  temporarily  increases  the 
intraspinal  pressure.  Cardiac  pain  forces  the  pa- 
tient to  cease  activities  while  continued  activity  is 
no  more  than  moderately  uncomfortable  with  ra- 
dicular pain  and  may  even  afford  relief,  presum- 
ably by  relieving  the  spasm  of  vertebral  muscles. 

In  conclusion,  I  would  not  convey  the  impres- 


CARDIAC    PAIN— Baker 


sion  that  we  should  relax  our  vigilance  concerning 
coronary  arterial  disease — certainly  not  in  this  age 
when  we  have  learned  that  coronary  accidents  may 
be  ushered  in  with  symptoms  far  less  dramatic  and 
far  less  frank  than  those  first  described,  and  when 
we  have  recognized  that  coronary  accidents  are 
occurring  all  too  frequently  in  young  individuals, 
among  our  own  comrades.  The  status  of  the  cor- 
onary  arteries  should  be  our  major  consideration 
when  the  patient  complains  of  a  chest  pain  unac- 
companied by  signs  of  an  acute  inflammation,  but 
this  should  not  lower  our  index  of  suspicion  for 
the  other  causes  of  thoracic  pain. 

Bibliography 

1.  Herrick,  J.  B.:  Clinical  Features  of  Sudden  Obstruc- 
tion of  the  Coronary  Arteries.  /.  A.  M.  A.,  59:2015. 
1912. 

2.  Herrick,  J.  B.:  On  Mistaking  Other  Diseases  for 
Acute  Coronary  Thrombosis.  Ann.  Int.  Med.,  2:2079 
(June),   1939. 

3.  Gunther,  L.:  Differentiating  Pair.s  in  the  Chest.  Mod. 
Concepts  of  Cardiovascular  Disease,  5    (August).   1936. 

4.  Lewis,  T.:  Pain  in  Muscular  Ischemia.  Arch.  Int. 
Med.,  49:713  (May),  1932. 

5    Berghoff,  R.  S..   Geraci,  A.   S.,   and  Hirsch,   D.   A.: 

The   Relief   of   Cardiac   Pain.    Med.   Clin.   .V.   America, 

25:87  (Jan.),  1941. 
6.  Mackenzie:    Quoted  from  Wright's  Applied  Physiology 

(Sixth  Edition),  New  York,  1937. 
Discussion 
Dr.  George  Wilkinson,  Greenville: 

Mr.  Chairman  and  Gentlemen:  Dr.  Baker's  paper  con- 
tains an  excellent  digest  of  the  differential  diagnosis  of 
chest  pain.  While  the  presentation  is  clear,  the  application 
is  quite  another  matter.  Aside  from  the  history,  physical 
and  laboratory  findings,  one  has  also -the  law  of  probabil- 
ity to  assist  in  making  a  diagnosis.  I  have  in  mind  partic- 
ularly the  occupations  which  entail  emotional  hazards. 
Here  the  vascular  bed  comes  in  for  much  more  punish- 
ment. Individuals  engaged  in  physical  wo'k  are  more 
liable  to  the  arthritides.  Distinguishing  pain  of  gallbladder 
origin  from  that  which  originates  in  the  coronary,  one  has 
the  sex  panel  for  guidance.  The  feminine  type  of  man 
will  be  more  likely  to  have  gallbladder  disease  than  the 
masculine  type. 


PROMISING  RESULTS  IN  HIGH  BLOOD-PRESSURE 
(H.  A.  Schroeder.  N.  Y.,  in  Science,  Jan.  31st) 

Because  the  substance  responsible  for  some  varieties  of 
arterial  hypertension  may  be  a  simple  amine,  particularly 
one  containing  a  phenolic  group,  a  pure  preparation  of 
tyrosinase,  a  phenolic  oxidase  obtamed  from  mushrooms, 
was  used  in  animals  exhibiting  "renal"  hypertension.  It 
was  found  that  tyrosinase  is  effective  in  lowering  raised 
arterial  pressure  in  rats  and  dogs  when  their  kidneys  are 
injured. 

It  appeared  necessary  to  ascertain  the  effect  of  this  en- 
zyme upon  hypertension  exhibited  by  human  beings.  Sev- 
enteen patients  suffering  from  arterial  hypertension  have 
been  treated  by  daily  subcutaneous  injections  of  varying 
amounts  of  tyrosinase  for  three  to  four  weeks.  In  fourteen 
the  systolic  pressure  had  been  persistently  above  200  mm. 
Hg.  and  the  diasto'ic  above  120.  In  all  but  one  the  blood 
pressure  fell  a  significant  amount — in  seven  to   140  to   160 


systolic,  and  80  to  100  diastolic;  and  in  six  to  160  to  180 
systolic,  and  100  to  115  disastolic.  In  the  other  three,  the 
respond  was  less.  Three  patients  in  a  late  stage  of  the 
disease  were  improved.    In  one  there  was  no  effect. 

In  seven  patients  whose  electrocardiagrams  were  altered 
a  change  in  the  direction  of  normal  occurred.  In  three  the 
hearts  became  small  as  observed  in  x-ray  photographs.  In 
all  but  one  the  level  of  the  urea  nitrogen  in  the  blood  was 
lowered,  but  the  clearance  of  urea  was  unaffected.  Symp- 
toms, when  present,  were  relieved.  In  four,  hemorrhagic 
and  exudative  lesions  were  present  in  the  eyesrounds. 
These  disappeared.  No  change  in  the  ability  of  the  kid- 
neys to  concenarte  urine  was  observed. 

When  injections  of  tyrosinase  were  stopped,  the  blood 
pressure  soon  (within  three  to  six  days)  returned  to  its 
previous  level.  Symptomatic  imp-ovemen',  as  well  as  the 
improvement  in  the  ocular  fundi,  lasted  for  weeks  or 
months. 

Injections  were  painful  at  times;  at  others  no  discom- 
fort occurred.  Occasionally  moderate  fever  followed  the 
injections.  Allergic  reactions  at  the  site  of  injection  devel- 
oped in  three  patients. 


BLOOD    PLASMA    RESERVOIR    NOW    BEING 
ESTABLISHED 

William   DeKlelne,   M.D.,   Washington 
Medical   Director  American   Red  Cross 

Abstract  of  article  received  March  31st: 
Creation  of  a  national  reservoir  of  b'ood  plasma  to  be 
used  by  the  Army  and  Navy  fcr  emergency  transfusions, 
as  well  as  for  treatment  of  civilians  injured  in  disaster. 
is  now  actively  under  way.  Plasma  has  definite  advan- 
tages over  whole  blood.  In  traumatic  shock  and  hemor- 
rhage plasma  is  ideal.  In  these  cases  speed  is  the  thing 
that  counts  and  plasma  lends  itself  to  speedy  u?e.  It  com- 
pletely eliminates  typing  or  cross-matching,  thus  saving 
time  and  lives.  Plasma  can  be  collected  and  stored  at 
central  points  for  lengthy  periods  and  may  be  transported 
any  distance.  The  administration  of  plasma  is  very  sim- 
ple. 

Last  summer  the  American  Red  Cross,  with  the  Blood 
Transfusion  Betterment  Association,  began  collecting  and 
shipping  plasma  to  Great  Britain.  February  1st.  1941,  the 
British  Red  Cross  announced  it  would  be  able  to  carry 
on  from  there.  While  the  program  was  in  operation,  ap- 
proximately 15,000  pints  of  plasma  in  saline  solution  were 
shipped,  representing  donations  from  that  number  of  per- 
sons. 

Plasma  is  now  being  prepared  in  two  forms:  (1)  lyo- 
phi'.ized.  or  dry.  powdered  plasma  which  by  the  simple 
addition  of  sterile,  distilled  water  is  ready  fcr  use.  and 
(2)  ordinary  liquid  plasma.  Present  plar.s  call  for  the 
production  of  10,000  units  of  dried  plasma,  a  unit  being 
equal  to  one  pint  of  processed  whole  blood.  The  amount 
of  liquid  plasma  to  be  stored  has  not  been  decided  on. 
Liquid  plasma  has  been  used  with  excellent  results  after 
months  of  storage:  it  is  believed  that  dried  plasma,  prop- 
erly packed  in  a  vacuum,  can  be  kept  for  years. 

Processing  of  whole  blood  for  the  production  of  plasma 
is  being  done  at  the  Sharp  and  Dohme  Laboratories  in 
Philadelphia,  where  the  product  is  also  b:ing  stored.  As 
need  arises.  Red  Cross  chapters  will  be  called  upon  to  en- 
roll donors  who  will  be  asked  to  give  a  pint  of  blood 
each. 

The  method  of  preparation  and  storage  is  described  in 
detail. 


SOUTHERN  MEDICINE  &  SURGERY 

Pulmonary  Hemorrhage* 

Karl  Schaffi.e,  M.  D.,  Asheville 


IN  1912  a  new  medical  book  appeared,  which, 
because  of  its  unique  arrangement,  its  amaz- 
ing honesty  and  the  unusual  value  of  its  con- 
tent, together  with  a  style  of  grace  and  simplicity, 
established  it  as  the  best-seller  in  its  field  for  that 
year.  It  was  Richard  C.  Cabot's  Differential 
Diagnosis.  In  the  chapter  on  hemoptysis  under 
the  causes  of  this  condition,  phthisis  headed  the 
list.  You  may  remember  the  diagram — or  schema 
— in  which  there  was  a  column  of  the  names  of 
diseases  or  causes,  with  horizontal  lines  extending 
across  the  page,  the  length  of  which  indicated  the 
relative  proportion  or  incidence  of  each.  The  fig- 
ures, from  The  Massachusetts  General  Hospital, 
at  that  time  gave  tuberculosis  as  the  cause  of 
hemoptysis  in  1723  cases;  mitral  disease  1177; 
unspecified  cause  183;  pulmonary  thrombosis  or 
embolism  141;  pulmonary  abscess  or  gangrene 
77;  bronchiectasis  58;  pneumonia  52;  aneurism 
22;  trauma  17;  neoplasm  6. 

The  most  recent  addition  to  my  library  is 
Meakins'  Practice  oj  Medicine  of  1940,  which 
gives  the  causes  of  hemorrhage  as  follows: 

( 1 )  Acute  inflammatory  lesions 

tuberculosis 
pneumonias 
typhoid   fever 
whooping  cough. 

(2)  Chronic  inflammatory  lesions 

bronchiectasis 

lung  abscess 

lung  gangrene 

actinomycosis 

echinococcus 

fibroid  pneumonia 

ulceration    of    the    larynx,    trachea    or 

bronchi 
spirochetal  bronchitis 
bronchial  fluke 
other  pulmonary  parasites 

(3)  Hemorrhagic  and  blood  diseases 

purpura  hemorrhagica 
hemophilia 
leucemia 
scurvy 
hemorrhagic  forms  of  infectious  diseases 

(4)  Cardiovascular  diseases 

myocardial  failure 
mitral  stenosis  or  insufficiency 
hypertension 
eclampsia 


pulmonary  infarcts 
pulmonary  thrombosis 
pulmonary  embolism 

(5)  New  growths 

mediastinal 

pulmonary 

bronchial 

tracheal 

laryngeal 

( 6 )  Trauma 

gunshot  wounds 
stab  wounds 
fractured  ribs 
contusions 
foreign  bodies 

(7)  Miscellaneous 

spontaneous 

vicarious  menstruation. 

Time  does  not  permit  further  consideration  of 
those  conditions  which  are  less  frequently  the 
cause  of  pulmonary  hemorrhage  and  my  own  ex- 
perience has  been  limited  largely  to  diseases  of  the 
respiratory  tract,  chiefly  tuberculosis  of  the  lungs, 
which  has  been  and  still  is  the  preeminent  factor 
in  pulmonary  hemorrhage,  in  spite  of  its  great  re- 
duction in  the  last  thirty  years  and  the  increase 
in  the  recognition  of  heart  disease,  cancer  and 
bronchiectasis.  These  last,  also  pneumonia,  spir- 
ochetel  and  fungus  diseases,  should  be  quite  easily 
differentiated  with  modern  equipment.  Regardless 
of  the  etiology,  the  immediate  treatment  is  largely 
the  same. 

In  tuberculosis  there  are  many  causes  of  hem- 
orrhage, chief  of  which  perhaps  is  the  leading 
symptom,  cough.  This,  of  course,  greatly  increases 
intrapulmonary  pressure,  putting  a  great  strain 
upon  the  bloodvessels  in  the  vicinity  of  or  passing 
into  the  lesion.  Next  to  cough  should  be  placed 
sudden  muscular  effort,  particularly  involving  the 
arms  and  frequently  of  no  great  severity;  such  as 
reaching  out  to  the  bedside  table,  to  the  radio  or 
the  bed-lamp.  It  seems  to  be  quite  common  in 
reaching  over  the  head.  I  remember  a  man  of 
about  sixty,  who  had  reached  an  apparent  cure  ten 
years  previously  and  had  resumed  his  occupation 
as  head  of  a  corporation,  who,  upon  leaving  his 
office  noticed  that  a  clerk  had  neglected  to  lower  a 
window  shade.  In  a  fit  of  temper  he  snatched  at 
it  and  had  a  sudden  severe  hemorrhage,  whicli 
caused  a  reactivation  of  his  disease.  A  younger 
man,  nearly  well,  died    of    exsanguination    from 


•Presented    to   the 
24th  and  25th. 


meeting   of   the    Tri-State    Medical    Association    of    the    Carolines    and    Virginia,    held    at    Ocensboro,    Febl 


PULMONARY   HEMORRHAGE— Schafjh 


pulling  a  chair  across  his  room;  and  I  have  known 
of  two  instances  of  alarming  hemorrhage  which 
occurred  during  or  immediately  following  sexual 
intercourse.  Vomiting  or  constipation  with  strain- 
ing at  stool,  and  flatulence  with  upward  pressure 
of  the  diaphragm,  are  also  causative  factors.  Emo- 
tional crises  may  play  a  part.  Many  times,  how- 
ever, hemorrhage  occurs  when  the  patient  is  per- 
fectly quiet,  without  any  exciting  cause.  Arterio- 
sclerosis or  nephritis  with  accompanying  high  blood 
pressure  should  be  considered  but  most  consump- 
tives have  low  blood  pressure.  It  frequently  pre- 
cedes, accompanies,  or  is  a  substitute  for  menstru- 
ation. 

Among  the  external  agents,  low  barometric  pres- 
sure and  high  winds,  particularly  when  combined, 
should  not  be  overlooked.  There  was  an  old  Negro 
at  the  Fairview  Sanatorium  of  Asheville,  who  was 
employed  to  bathe  the  male  patients.  On  certain 
days  he  would  raise  his  head,  sniff  the  air  like  a 
hound,  and  say,  '"Pears  lak  we  gonna  hab  some 
good  hemorrhage  weather"!  About  fifteen  years 
ago  an  excellent  paper  was  written  by  a  chest  spe- 
cialist of  the  Southwest  on  the  incidence  of  pul- 
monary hemorrhage  during  sandstorms.  As  to  sea- 
sonal variations,  the  late  winter  and  early  spring 
have  been  cited,  but  there  does  not  appear  to  be 
any  particular  seasonal  influence  in  western  North 
Carolina. 

At  St.  Louis,  two  years  ago,  my  friend  Howard 
Marcy  read  a  paper  on  this  subject  before  the 
American  College  of  Chest  Physicians.  On  open- 
ing the  discussion  I  was  mean  enough  to  say  that 
there  was  one  factor  which  it  was  only  natural 
for  a  man  from  Pittsburgh  to  overlook,  and  that 
was  exposure  to  the  rays  of  the  sun!  This  is 
something  that  patients  must  be  warned  against 
in  view  of  the  spread  of  the  modern  sun  cult  from 
popular  magazines  and  newspaper  articles,  the  ad- 
vocacy of  the  use  of  vitamin  D  by  the  salesmen 
of  alpine  lamps,  and  the  migration  to  southern 
beaches  in  winter  as  well  as  to  northern  shores  in 
summer.  One  patient  with  but  slight  envolvement 
had  a  small  hemorrhage  every  morning  for  over  a 
month,  after  proudly  acquiring  a  handsome  sun- 
tan  of  his  chest  in  Florida. 

The  symptoms  which  precede  or  accompany 
pulmonary  hemorhage  are  few  but  characteristic, 
consisting  of  a  sense  of  oppression  in  the  chest, 
with  or  without  slight  pain;  a  cough-provoking 
tickle  and,  at  times,  a  feeling  of  something  giving 
way,  followed  by  warmth  in  the  throat  and  a  salty 
taste.  The  pulse  is  rapid  and  the  face  pale  or 
cyanotic.  The  blood  is  usually  bright-red  and 
frothy  but  may  be  somewhat  dark,  depending  upon 
its  source.   After  the  first  day  it  is  brown  and  may 


be  granular.  A  slight  gurgling  or  a  moderate  bub- 
bling sound  may  be  heard  over  the  site  if  the 
bleeding  is  copious;  but  this  is  often  absent.  Some 
patients  are  able  to  indicate  the  point  of  origin. 

Now,  what  is  the  mechanism  that  brings  hem- 
orrhage about?  According  to  the  pathologists, 
hemorrhage  may  occur  at  any  stage  and  in  all 
forms  of  the  disease.  In  the  early  stages  slight 
bleeding  is  due  to  congestion  of  capillaries  which 
supply  the  area  involved,  with  leakage  into  the 
alveoli  and  bronchioles,  or  it  may  be  due  to  the 
erosion  of  a  small  pulmonary  vein  in  the  process 
of  softening.  Large  hemorrhages  may  occur  from 
small  miliary  aneurisms  of  pulmonary  arteries  in 
the  walls  of  young,  rapidly-developing  cavities. 
Profuse  and  suddenly  overwhelming  hemorrhages 
may  occur  from  larger  aneurisms  or  from  a  com- 
plete rupture  through  the  wall  of  an  artery  hang- 
ing free  within  an  old  cavity,  unsupported  by  sur- 
rounding tissues.  Tuberculous  ulcerations  of  the 
bronchi  occasionally  erode  branches  of  the  bron- 
chial arteries  or  of  the  accompanying  pulmonary 
arteries.  The  bleeding  from  congestion  or  leakage 
from  small  vessels  is  found  more  frequently  in  the 
exudative  form,  while  the  severe  hemorrhages  are 
more  common  in  the  proliferative  form.  In  the 
latter,  bleeding  may  occur  even  in  the  absence  of 
cavitation,  due  to  the  loss  of  elasticity  of  the  lung 
tissue,  with  increased  pressure  on  its  rigidly  con- 
fined vessels  from  cough  or  labored  breathing.  In 
old  cases  in  which  healing  has  progressed  to  the 
final  stage  of  calcification,  the  loosening  and  de- 
tachment of  sharp  pieces  of  calcium  results  in 
laceration  of  surrounding  tissues,  with  varying 
amounts  of  hemorrhage  until  the  "lung  stone" 
emerges  from  a  cavitv,  dense  mass  of  fibrous  tis- 
sue or  an  adjacent  lymphnode  into  a  bronchus 
and  is  coughed  up.  The  blood  from  pulmonary 
veins  is  bright-red,  as  they  carry  the  arterial  blood, 
while  that  from  the  pulmonary  arteries  is  dark-red 
and  more  profuse,  occurring  in  the  advanced  stages 
of  the  disease.  The  point  of  origin  is  most  fre- 
quently in  the  lower  part  of  the  upper  lobe.  Charr 
and  Savacool1  reported  a  series  of  autopsies  with 
postmortem  x-ray  studies  of  barium-injected  lungs, 
at  White  Haven,  Pennsylvania,  in  which  the  source 
was  found  to  be  the  first  branch  of  the  pulmonary 
artery,  which  corresponds  to  a  point  at  the  level 
of  the  second  costal  cartilage,  slightly  mesial  to 
the  parasternal  line;  while  Eloesser  and  Wood2  of 
San  Francisco,  using  a  similar  technique,  found 
that  in  both  tuberculosis  and  cancer,  profuse  and 
persistent  bleeding  was  from  the  bronchial  arter- 
ies, which  become  dilated  and  tortuous  when  the 
pulmonary  arteries  are  occluded. 

The  incidence  of  hemorrhage  in  cases  of  pul- 


May  1941 


PULMONAR  Y   HEMORRHA  GE—Schaffle 


monary  tuberculosis  has  been  reported  as  from  30 
to  80  per  cent.  It  was  47.6  per  cent  in  nearly 
6,000  cases  at  The  Phipp's  Institute.  It  is  fatal  in 
from  1  to  5  per  cent,  the  relatively  low  mortality 
being  due  to  a  natural  tendency  to  stop  with  low- 
ering of  the  blood  pressure  and  coagulation  from 
contact  of  the  blood  with  the  tissues  and  exposure 
to  air.  The  possibility  of  its  more  general  occur- 
rence is  also  prevented  in  spite  of  ulceration,  when 
this  is  overbalanced  by  the  reparative  process  of 
fibrosis  and  the  common  occurrence  of  thrombosis. 
Males  are  more  frequently  affected  than  females, 
probably  due  to  their  greater  physical  activity,  and 
children  are  rarely  affected,  unless  victims  of  the 
adult  type  of  involvement.  The  pneumococcus  and 
streptococcus  have  been  found  responsible  for 
hemoptysis  in  epidemics  of  acute  colds,  occurring 
in  sanatoria. 

What  are  the  results  of  pulmonary  hemorrhage? 
They  range  from  the  inconsequential  to  the  shock- 
ingly tragic!  Many  patients  suffer  no  ill  effects, 
even  when  the  bleeding  is  considerable;  while  it 
has  been  my  misfortune  to  arrive  on  the  scene  of 
a  fairly  large  number  of  almost  instant  deaths 
from  suffocation.  Surviving  a  severe  hemorrhage, 
a  patient  may  go  into  a  state  of  shock  with  all  of 
its  usual  manifestations.  If  the  hemorrhage  is  pro- 
fuse or  protracted,  there  will  be  a  secondary  ane- 
mia; if  a  clot  plugs  a  bronchiole  there  will  be 
atelectasis, — if  a  bronchus,  massive  collapse.  If 
blood  has  been  inhaled  during  hemorrhage  there 
will  be  fever  for  a  few  days  from  absorption  and 
then  possibly  subsidence,  with  no  further  disturb- 
ance. Unfortunately,  however,  aspiration  pneu- 
monia may  follow,  either  in  a  small  area  or  quite 
extensively.  This  may  be  nonspecific  and  resolve 
within  a  reasonable  time,  or  it  may  be  a  tuber- 
culous pneumonia  with  delayed  resolution.  If 
pyogenic  organisms  are  present — abscess  forma- 
tion is  likely  to  occur.  With  any  of  these  results 
there  is  likely  to  be  spread  of  the  disease  process. 
Reisner,3  from  observation  at  the  Metropolitan 
and  Sea  View  Hospitals,  New  York,  states  that 
the  most  frequent  type  of  post-hemorrhage  spread 
of  the  disease,  is  by  diffuse  focal  dissemination, 
which  occurred  in  two-thirds  of  his  cases,  most  of 
which  were  fatal.  Finally,  if  the  patient  manages 
to  survive  all  complications,  he  may  die  of  exhaus- 
tion! 

When  it  comes  to  treatment,  we  encounter 
among  the  earlier  writers  attitudes  which  vary 
from  the  didactic  advocacy  of  certain  measures 
and  drugs  to  an  almost  helpless  fatalism.  Those 
who  express  the  latter  view  believe  that  a  slight  or 
moderate  bleeding  still  stop  of  its  own  accord  (in 
spite  of  what  is  done),   while  an   overwhelming 


hemorrhage  cannot  be  stopped — whatever  may  be 
done.  The  list  of  remedies  set  forth  by  the  for- 
mer is,  to  our  present  knowledge,  both  amusing 
and  pathetic — lead,  iron,  digitalis,  aconite,  vera- 
trum,  the  nitrites,  adrenalin,  ipecac  to  induce  vom- 
iting, typhoid  and  other  vaccines,  rattlesnake  ve- 
nom, venesection  and  purgation!  Evidently  the 
old  fallacy  of  post  hoc  propter  hoc  was  responsible 
for  the  claims  of  success  from  such  procedures. 
We  need  not  feel  any  undue  superiority  to  our 
forebears,  however,  as  the  future  will  probably 
prove  our  own  ineptitude.  Illustrative  of  this  is 
the  fact  that  in  one  private  sanatorium,  with  a 
capacity  of  not  more  than  twenty  patients  but 
with  six  or  eight  physicians  in  attendance,  the 
nurse  in  charge  had  an  emergency  chart  containing 
the  standing  orders  for  immediate  use  in  case  of 
hemorrhage.  There  were  as  many  orders  as  there 
were  doctors — each  one  different  from  the  others! 

The  best  measure  which  has  come  down  to  us 
from  the  experience  of  previous  generations — is 
rest.  This  should  be  absolute,  in  bed,  with  urinal 
and  bedpan,  or  drawsheet;  spoon-feeding  (of 
cracked  ice  at  first  and  later  cool  liquids  and  soft 
foods),  with  the  constant  supervision  of  a  special 
nurse  to  carry  out  these  orders,  and  to  enforce 
silence  and  immobilization  upon  the  patient  and 
quiet  upon  the  environment.  Her  vigilance  at  night, 
particularly  during  the  early  morning  hours  when 
the  usual  evacuating  cough  begins,  is  most  im- 
portant. Next  is  the  judicious  administration  of 
morphine.  One-eighth  of  a  grain  is  sufficient  in  the 
majority  of  patients  to  quiet  the  mental  and 
nervous  excitement,  to  slow  the  pulse  and  to  modify 
the  cough  and  relieve  distressing  symptoms  within 
the  chest,  without  causing  retention  of  clots  by 
suppressing  the  cough  entirely  or  by  inducing 
stupor.  Twice  this  dose  when  the  patient  has  been 
accustomed  to  taking  considerable  codein — but  no 
more  should  be  given  than  this  initial  dose.  Often 
a  half-grain  of  codein  is  sufficient. 

The  mention  of  morphine  suggests  the  drug 
which  so  frequently  is  given  with  it,  in  this  and 
other  conditions — atropine.  When  I  came  to  Ashe- 
ville  in  1926,  to  join  the  staff  of  the  late  Dr.  Wil- 
liam L.  Dunn,  I  was  told  that  the  standing  order 
for  hemorrhage  was  morphine,  %  gr.  with  atro- 
pine, 1/30  to  1/25  gr.;  followed  by  5  c.c.  of  coag- 
ulin.  My  amazement  at  the  size  of  the  dose  of 
atropine  was  met  with  tolerant  smiles  and  I  was 
informed  that  a  small  dose,  1/100  gr.,  was  ineffec- 
tive, as  it  caused  a  vasodilatation,  while  vasocon- 
striction followed  the  larger  dose.  In  view  of  the 
very  broad  clinical  experience  of  Doctors  Dunn, 
Colby  and  Battle,  I  adopted  the  procedure  with- 
out question  and  have  continued  it  ever  since.   Re- 


PULMONARY   HEMORRHAGESchaffle 


May  1941 


cently,  however,  I  began  to  wonder  about  the  ef- 
ficacy of  this  drug,  particularly  as  I  found  nothing 
relative  to  its  use  in  hemorrhage  in  such  recent 
works  as  those  of  Goldberg,  Beckman,  Meakins, 
Cecil  or  Musser.  On  searching  farther,  I  found 
that  Klebs  (who  came  to  Asheville  in  1894,  re- 
maining several  ytars,),  quotes,  in  his  Tuberculosis 
( 1909),  N.  H.  Johnson  and  R.  H.  Babcock  as  ad- 
vocating "atropine,  gr.  1  25,  in  pulmonary  hem- 
orrhage"; Bonney  (1908)  advised  "1/50  gr.  in 
urgent  cases,"  citing  its  production  of  redness  of 
the  skin  as  evidence  of  peripheral  dilatation  inci- 
dent to  vasomotor  paresis,  with  consequent  reduc- 
tion of  pressure  in  the  pulmonary  circulation"; 
Lawrason  Brown,4  spoke  of  1/25  gr.,  "having  some 
empirical  basis  for  its  employment";  while  in  a 
German  publication,  Stepanova5  stated  in  193), 
that  "atropine  decreases  vagal  tone  with  a  conse- 
quent decrease  in  spasm  of  the  muscles  of  the 
small  bronchi." 

Wishing  for  the  latest  information,  I  wrote  to 
Doctors  Alfred  Richards,  Carl  Schmidt  and  Isaac 
Starr,  Professors  of  Pharmacology  and  Therapeu- 
tics at  the  University  of  Pennsylvania,  and  receiv- 
ed replies  from  each  to  the  effect  that  thev  could 
see  no  reason  for  the  employment  of  atropine  for 
this  purpose,  as  it  raises  blood  pressure  and  pro- 
duces dilatation  in  the  general  circulation,  while 
the  physiology  of  the  pulmonary  circulation  is  still 
obscure.  I  still  crave  advice  and  will  appreciate 
discussion  of  this  subject. 

Coagulin  or  fibrogen  is  thromboplastin  and  has 
seemed  to  be  effective  in  the  more  protracted  hem- 
orrhages and  in  the  prevention  of  recurrence.  I 
have  seen  no  unpleasant  reactions,  as  in  the  use  of 
horse  serum. 

I  have  used  considerable  calcium  lactate  and 
glucinate  orally  to  prevent  recurrence,  but  am  not 
certain  of  the  results.  I  have  not  used  parathy- 
roid extract. 

When  vitamin  K  became  available  I  hopefully 
tried  it  on  some  stubbornly  recurrent  cases,  only 
to  be  greatly  disappointed.  Later,  I  learned  that 
this  agent  was  active  only  when  there  was  a  defi- 
ciency of  prothrombin,  as  in  hemorrhagic  jaun- 
dice so  well  described  by  Nygaard.6 

The  latest  entry  in  the  field  is  an  extract  of 
shepherd's  purse,  containing  the  active  principle 
of  oxalic  acid  and  related  di-carboxyllic  acids  for 
intramuscular  and  intravenous  administration.  My 
associate,  Max  Riesenberg,  a  qualified  technolo- 
gist, has  demonstrated  that  within  an  hour  after 
its  injection  coagulation  time  is  reduced,  as  shown 
in  the  accompanying  table. 

As  to  physical  measures,  I  have  never  ligated 
the   extremities    (which   may   be   a   useful   proce- 


dure); and  I  wish  to  condemn  the  common  resort 
to  the  ice-bag  on  the  chest  as  conducive  to  what 
we  most  fear — increased  congestion  and  pneumo- 
nia. As  to  its  so-called  psychic  effect,  it  is  usually 
depressing  and  unpleasant  to  anemic  persons  with 
low  blood  pressure. 

Artificial  pneumothorax  has  been  eminently  sat- 
isfactory, when  successful.  I  have  felt  like  cutting 
a  notch  in  the  frame  of  the  apparatus  for  every 
life  saved!  Care  is  required,  however,  to  avoid 
shock  and  the  rupture  of  pleural  adhesions  by  in- 
troducing air  too  rapidly  or  in  tco  great  an 
amount,  although  I  have  given  as  much  as  1800 
c.c.  at  one  time,  without  harm.  In  addition  to 
capable  thoracic  surgeons,  we  have  three  excellent 
broncoscopists  in  Asheville,  over  the  shoulders  of 
whom  I  have  enjoyed  peering  at  various  times. 
When  the  bleeding  point  is  visible  on  the  bronchial 
mucous  membrane,  the  topical  application  of  25 
per  cent  silver  nitrate  has  proved  effective,  but  the 
treatment  may  have  to  be  repeated  in  some  cases. 

Surgery — from  phrenic  nerve  crushing,  through 
thoracoplasty,  to  lobe  ligation  and  lobectomy — 
should  be  done  earlier  than  it  usually  is.  It  is 
unfair  to  put  a  surgeon  on  the  spot,  in  a  desperate 
situation,  to  perform  as  rapidly  as  possible  an 
operation  the  indications  for  which  should  have 
been  recognized  months  before. 

The  treatment  of  the  complications  may  be 
summarized  as  follows: 

For  shock  and  anemia  the  safest  and  quickest 
restorative  is  transfusion — if  this  is  not  available, 
intravenous  saline  or  glucose,  particularly  as  food 
is  withheld  from  24  to  48  hours.  Stimulants  should 
be  avoided  at  first.  Liver,  molasses,  ferrous  sul- 
phate and  arsenic  may  be  given  later. 

For  atelectasis  we  have  the  bronchoscope. 

For  pneumonia  and  lung  abscess  oxygen,  sul- 
fathiazole  or  sulfapyridin  orally,  or,  if  nausea  is 
present  neoprontosil  intramuscularly  (watching  for 
anuria  from  the  precipitation  of  the  salts  of  these 
drugs  within  the  renal  tubules;  theocin  combats 
this).  The  sputum  should  be  typed  for  the  possi- 
bility of  pneumococcic  pneumonia.  This  takes  but 
15  minutes  by  the  Neufeld  method  and  indicates 
the  appropriate  serum,  if  such  addition  to  the 
drugs  mentioned  seem  necessary.  Counter  irritants 
are  helpful,  as  the  old-fashioned  mustard  plaster, 
in  spite  of  fears  of  recurrence  of  hemorrhage.  Am- 
monium chloride  or  citronin  thins  tenacious  sput- 
um. 

An  abscess  may  be  drained  through  the  broncho- 
scope, or  if  out  of  its  reach,  attacked  surgically 
after  becoming  well  localized  but  before  its  walls 
become  too  dense. 


PULMONARY    HEMORRHAGE— Schajjle 


COAGULATION   TIME 


D.H.  L.M.  K.N.  A.R.  R-M.  I.M 

Before 

injection  7  m.         5';m.     6!jm.  lO'-m.  14Jjm.  1354m. 

1  Hr. 

later        5  m.        2J4  m.     4  m.         6  m.         4  m.         4?4  m. 

2  Days 

later        2J4  m.       V/2  m.      2!/,m.      3  m.  5-)4      4.  m. 

4  days 
later  S  m. 

Finally,  for  exhaustion — that  anxious  sinking 
spell,  when  the  pulse  becomes  faint  and  rapid  and 
the  temperature  drops  to  subnormal,  with  gasping 
respiration  and  unconsciousness — strychnine  may 
be  useful  but  coramine  is  a  much  more  quickly- 
acting  circulatory  and  respiratory  stimulant  which 
may  be  given  safely  in  doses  of  1  c.c.  every  hour 
for  six  hours,  with,  at  times,  results  that  appear 
miraculous — almost  literally,  raising  the  dead. 
References 

1.  Charr   and    Savacool:     Amer.   Jour.   Med.   Sci.,   May, 
1940. 

2.  Elosser   and  Wood:     Jour.    Thoracic   Surgery,   Vol.    7, 
No.  6,  p.  671,  August,  1938. 

3.  Reisner:    Amer.  Rev.  Tuberculosis,  Dec,  1936. 

4.  Brown,  L.:  Practice  of  Medicine  (Tice),  Vol.  2,  Sec.  2. 
p.  510. 

5.  Stepanova:    Med.  Klin.,   1931. 

6.  Nygaard,  K.  K.:   Hemorrhagic  Diseases,  1941. 


CEREBRAL  HEMORRHAGE 

The  diagnosis  of  cerebral  hemorrhage  or  throm- 
bosis requires  the  consideration  of  injury,  diabetic 
acidosis,  hyper-insulinism.  post-epileptic  stupor, 
Stokes-Adams  syndrome,  poisoning  of  various 
kinds,  uremia,  brain  tumor  or  abscess,  alcoholism 
and  general  paresis.  The  history  of  the  attack,  the 
examination  of  the  patient  and  of  the  blood,  urine 
and  spinal  fluid  will  assist.  Between  hemorrhage 
and  thrombosis:  Hemorrhage  is  generally  hidden 
in  onset  while  thrombosis  is  slow;  spinal  fluid 
pressure  is  usually  increased  in  hemorrhage,  and 
the  fluid  is  more  likely  to  be  bloody  or  xantho- 
chromic. In  thrombosis  the  majority  of  the  cases 
will  show  a  normal  or  only  slightly  elevated  spinal 
fluid  pressure,  while  the  fluid  will  only  rarely  be 
blood-tinged  or  ranthochromic.  In  any  patient 
with  a  bloody  spinal  fluid,  spontaneous  subarach- 
noid hemorrhage  must  be  considered.  In  this  con- 
dition the  onset  is  usually  sudden  severe  headache, 
pain  down  the  neck  and  into  the  arms,  frequent 
vomiting,  rapid  development  of  a  stiff  neck,  a  posi- 
tive Kernig  sign  and  an  increasing  coma.  Typical 
hemiplegia  is  not  present,  but  weakness  may  be 
noted  on  one  side  of  the  body.  The  spinal  fluid  is 
under  increased  pressure  and  is  bloody  and  xanth- 
ochromic. 


L.Z.  E.Y.       A.MCC.  C.S.  M.M.  T.R.  J.K. 

'_''_■  m.  4  m.         7  m.  7  m.  53_j  m.  4  m.  4  m. 

3  m.  234  m.     3]/2  m.  i]4  m.  2',4m.  2]/2  m.  2  m. 

i34  m.  334m.      2}4  m.  il/2ra.  2}4m.  2  m.  2j4m. 


Treatment  of  the  apoplectic  attack  is  sympto- 
matic with  good  nursing.  Bed  with  the  head  slight- 
ly elevated;  if  respiration  is  stertorous,  a  prone 
position  may  give,  relief.  The  position  should  be 
changed  frequently  to  prevent  pneumonia  and  bed- 
sores. Venesection,  an  enema,  and  an  ice  bag  to 
the  head  may  be  of  some  value.  If  the  patient  is 
restless,  sedatives  will  be  necessary,  by  hypo- 
dermic injection  or  by  rectum. 

Care  should  be  used  in  attempting  to  give  any- 
thing by  mouth,  and  tube  feeding  may  be  neces- 
sary if  the  patient  must  have  nourishment.  As 
early  as  possible,  probably  in  the  first  week,  pas- 
sive exercise  and  massage  should  be  started.  If 
the  patient  has  any  power  at  all,  he  should  be  en- 
couraged in  practicing  active  motion.  He  should 
be  in  bed  for  at  least  three  weeks  with  even  the 
mildest  stroke.  During  convalescence,  iodides  are 
usually  started.  Certainly  the  patient  should  be 
warned  against  over-work,  evcitement,  worry,  an- 
ger and  sudden  exertion. 


USE  OF  COBRA  VENOM  FOR  RELIEF  OF 
INTRACTABLE   PAIN 

(W.   B.    Poole,   Oklahoma   City,   in   Med.   Rcc.   April    16th) 

In  the  present  Series,  23  patients  suffering  from  intrac- 
table pain  of  advanced  cancer  were  treated  with  cobra 
venom.  In  each  case  the  initial  dose  has  been  2l/2  mouse 
units  (a  mouse  unit  being  the  amount  of  venom  necessary 
to  kill  a  mouse  weighing  22  grams  in  18  hours  after 
intraperitoneal  injection) .  On  the  second  day  5  mouse 
units  were  injected.  This  dose  is  given  daily  until  there 
is  relief  of  pain,  or  until  it  is  fairly  certain  that  there 
is  to  be  no  relief.  Once  relief  is  obtained,  the  dosage  is 
regulated  to  the  individual  case  in  order  to  afford  the 
maximum  relief  with  the  minimum  amount  of  the  cobra 
venom.  If,  after  a  trial  of  10  injections,  there  is  no 
appreciable  relief  of  pain,  cobra  venom  therapy  is 
discontinued. 

My  meager  experience  in  treating  pain,  other  than  that 
of  maligancy,  with  cobra  venom  has  been  unsatisfactory. 

Cobra  venom  does  not  relieve  pain  in  every  patient 
treated.  The  fact  that  it  has  relieved  pain  in  65%  of  these 
25  patients  is  reason  for  it  being  included  in  our  armamen- 
tarium for  treating  adavneed  cancer.  When  a  patient  has 
an  almost  even  chance  for  complete  relief  from  the  agony 
of  advanced  cancer,  then  giving  every  such  person  a 
therapeutic  trial  is  demanded  in  order  that  some  of  these 
unfortunate  people  may  be  allowed  to  live  out  their 
remaining  time  in  relative  comfort  even  though  their  body 
is  being  destroyed  by  cancer. 


SOUTHERN  MEDICINE  &  SURGERY 


An  Analysis  of  Fifty  Cases  of  Shock  Treated  with  Plasma* 

Charles  Stanley  White,  M.D. — J.  Lloyd  Collins,  M.  D 
Jacob  Weinstein,  M.  D. 
Washington 

From  the  School  of  Medicine.  George  Washington  University  and  Gallinger  Municipal   Hospital 

From  the  School  of  Medicine,  George  Washington  University 

and 

Gallinger  Municipal  Hospital 


NOTWITHSTANDING  the  unprecedented 
progress  in  surgery  within  the  past  few 
decades,  some  very  specific  and  unsolved 
problems  remain  to  keep  it  within  the  realm  of 
art.  Mortality  has  not  reached  the  irreducible 
minimum.  Embolism,  massive  pulmonary  collapse, 
shock,  and  hemorrhage  still  take  their  toll.  In  this 
brief  paper  we  will  discuss  Shock: — - 

In  spite  of  the  careful  preparation  of  the  pa- 
tient, the  selection  of  anesthetic  and  the  anes- 
thetist, shock  will  occasionally  inject  itself  into  an 
otherwise  orthodox  case. 

The  great  amount  of  effort  expended  to  deter- 
mine the  nature  of  shock,  both  in  regard  to  its 
etiology  and  physiological  pathology,  has  left  a 
definite  impression  that  shock  is  concerned  largely 
with  the  behavior  of  the  capillaries  under  certain 
stimuli.  Moon,  Blalock,  Scudder  and  others  seem 
to  agree  that  dilatation  of  the  capillaries,  together 
with  abnormal  permeability,  reduces  the  volume 
of  moving  blood  in  the  circulatory  system  and 
permits  the  escape  of  plasma  in  the  perivascular 
spaces.  The  blood  remaining  in  circulation  is  con- 
centrated and  its  volume  is  less.  We  find  the  spe- 
cific gravity  higher,  the  red  cells  and  hemoglobin 
relatively  increased  and  the  protein  content  lower. 
Moon  defines  shock  as  follows:  "circulatory  defi- 
ciency, not  cardiac  nor  vasomotor  in  origin,  char- 
acterized by  a  decreased  blood  volume,  decreased 
cardiac  output  (volume  flow),  and  by  an  increas- 
ed concentration  of  the  blood." 

The  cause  of  shock  has  been  and  still  is  the 
subject  of  speculation  and  investigation.  It  suffices 
to  state  that  the  mechanism  of  shock  is  supposed 
to  be  initiated  by  the  release  or  elaboration  of  a 
substance  similar  to  histamine,  or  by  an  excess  of 
potassium  salts.  An  unnamed  hormone  of  the 
adrenal,  or  some  other  ductless  gland,  may  be  a 
contributing  factor. 

As  practical  clinicians  we  know  that  psychic  or 
mechanical  trauma  are  exciting  agents  and  to  treat 
shock  successfully,  we  must  recognize  it  promptly. 
Blood  pressure  has  been  a  very  satisfactory  index. 
A  systolic  pressure  of  80  mm.  mercury  has  been 
generally  regarded  as  the  lowest  level  compatible 


with  the  wellbeing  of  the  patient,  and  is  often  re- 
ferred to  as  the  critical  level.  We  regard  the  rela- 
tive fall  of  pressure  quite  as  important  as  the 
actual  fall.  For  instance,  a  patient  whose  initial 
systolic  pressure  at  operation  is  180.  and  falls  to 
100  before  the  operation  is  completed,  is  just  as 
much  in  shock  as  one  whose  fall  is  from  100  mm. 
to  70  mm.  We  have  used  the  systolic  and  diastolic 
pressures,  together  with  the  pulse  rate,  as  our 
chief  guides  in  the  diagnosis  of  shock,  with  due 
consideration  given  to  subnormal  temperature, 
cool,  moist  and  perhaps  cyanotic  skin.  We  have 
used  the  laboratory  to  check  blood  concentration, 
and  while  we  found  the  counts,  the  hematocrit 
and  specific  gravity  were  fairly  constant  and  early 
indices,  we  do  not  believe  they  furnish  any  more 
reliable  data  than  the  blood  pressure  and  the  pulse 
rate,  notwithstanding  the  time  and  labor  the  tests 
require. 

From  the  various  services  of  a  municipal  hos- 
pital, we  have  chosen  fifty  consecutive  cases  of 
shock  treated  with  plasma  in  which  data  were 
available  from  which  some  deductions  could  be 
made.  While  this  is  a  small  number,  it  represents 
a  large  amount  of  surgery.  The  cases  were  group- 
ed as  follows: 

General   surgical    (operative) 13 

Gynecological    4 

Traumatic   5 

Intestinal  obstruction  5 

Acute  hemorrhage  3 

Thoracoplasty 5 

Cranial  operations    2 

Obstetrical  accidents  6 

Sepsis 3 

Burns 3 

Hepatic  deficiency  -     1 

Total 50 

In  order  to  put  at  rest  any  claim  that  plasma  is 
a  cure-all,  it  should  be  stated  that  there  were  ten 
deaths  in  this  series.  Without  entering  into  the 
details  of  individual  cases  in  this  entire  group, 
some  general  observations  are  in  order: — 

We  found  in  shock  the  following  averages: 


•Presented    to   the   meeting  of   the   Tri-State    Medical   Association    of    the    Carolinas    and    Virginia,    held   at    Greensboro,    February 
24th  and  25th. 


Mav  1941 


SHOCK  TREATED  WITH  PLASMA— White  el  al. 


Average   fall   in   systolic   blood   pressure,    60 
mm. 

Average  increase  in  pulse  rate,  52  per  min. 

Average  amount  of  saline  plasma  used,   800 
c.c. 

Average  recovery  in  systolic  blood  pressure, 
47  mm. 

Average  slowing  of  pulse  in  recovery,  29  per 
min. 

Average  time  to  secure  these  changes  in  pulse 
and  pressure,  73  min. 
The  indications  for  the  use  of  plasma  were  the 
pulse  rate  and  the  presence  of  shock,  as  indicated 
by  the  blood  pressure.  If  we  found  that  the  blood 
pressure  declined  rapidly  or  the  hemorrhage  was 
obvious,  the  plasma  was  used  before  the  critical 
level  of  blood  pressure  was  reached.  In  the  trau- 
matic cases,  those  admitted  from  the  street  follow- 
ing an  injury,  the  pressure  in  some  cases  was  too 
low  to  register,  and  plasma  was  administered  with- 
out delay  with  the  thought  that  it  was  the  most 
valuable  agent  in  shock.  We  wish  to  emphasize 
that  secondary  shock  has  all  the  implications  of 
primary  shock,  and  unless  the  patient  is  kept 
under  close  observation  for  twenty-four  to  forty- 
eight  hours  after  trauma  or  operation,  secondary 
shock  may  prove  a  serious  or  fatal  complication. 
We  found  it  necessary  in  many  instances  to  repeat 
plasma  in  twelve  or  twenty-four  hours,  but  rarely 
later.  The  response  to  plasma  transfusion  was 
prompt  and  sustained  in  most  cases,  but  as  stated 
previously,  neither  plasma  nor  any  other  remedy 
can  restore  the  vital  functions  in  cases  in  which 
the  cause  has  not  been  controlled.  In  our  ten 
deaths,  two  were  traumatic  shock,  two  were  intes- 
tinal obstruction,  one  was  a  cranial  operation,  two 
were  septicemia,  one  was  a  liver  toxicity,  and  in 
the  postoperatives,  one  from  pneumonia  and  one 
from  alcoholism  and  fractured  hip.  No  attempt 
has  been  made  to  analyze  the  individual  cases,  but 
out  of  this  series  very  definite  convictions  became 
evident  to  those  who  assumed  the  responsibility 
for  their  care. 

There  was  unanimity  of  opinion  that  the  best 
remedy  for  shock,  when  all  considerations  were 
weighed,  was  undiluted  or  saline-plasma.  In  some 
instances,  notably  in  the  presence  of  hemorrhage, 
whole  blood  was  undoubtedly  the  best  antidote. 
However,  if  time  be  an  element,  or  if  a  reaction 


would  add  to  the  gravity  of  the  situation,  whole 
blood  suffers  by  comparison  with  plasma. 

The  older  the  individual,  and  longer  the  dura- 
tion of  shock,  the  larger  amounts  of  plasma  are 
necessary.  Little  permanent  benefit  may  be  ex- 
pected from  plasma  in  shock  associated  with  sep- 
sis, unless  the  sepsis  can  be  favorably  influenced 
by  other  medical  or  surgical  measures.  The  pri- 
mary improvement  in  shock  was  noted  in  the  ele- 
vation of  both  the  systolic  and  diastolic  pressures. 
The  pulse  was  much  later  in  resuming  its  normal 
rate  than  the  restoration  of  blood  pressure  to  ap- 
proximately its  normal  level. 

The  shock  of  burns  responded  more  slowly,  pos- 
sibly because  the  loss  of  protein  is  a  progressive 
process,  spread  over  a  number  of  hour  or  days. 
In  such  cases  smaller  amounts  of  plasma  should 
be  given  at  frequent  intervals  for  a  longer  period, 
guided  very  much  by  the  blood  protein  content. 

We  have  been  using  plasma  at  the  Gallinger 
Municipal  Hospital  almost  two  years,  and  dur- 
ing that  period  have  administered  more  than  800,- 
000  c.c.  of  saline-plasma,  ninety-five  per  cent  in- 
travenously, totaling  over  five-hundred  transfu- 
sions. We  have  given  as  much  as  4000  c.c.  in  one 
transfusion  and  as  much  as  40,000  c.c.  to  one 
patient  over  a  period  of  several  weeks.  There  were 
five  reactions,  none  of  which  was  serious.  There 
were  one-hundred  and  twenty-five  cases  of  shock 
in  various  degrees,  fifteen  cases  of  burns  and  twen- 
ty-five cases  of  hypoproteinemia  due  to  various 
causes,  and  fifteen  cases  of  impaired  liver  func- 
tion. 

We  have  had  no  experience  with  blood  serum 
or  concentrated  plasma.  We  are  more  concerned 
with  a  method  whereby  most  hospitals  can  prepare 
their  own  plasma  and  have  it  available  at  all  times. 

While  we  have  stressed  the  use  of  plasma  in 
shock  only,  there  are  many  other  conditions,  both 
medical  and  surgical,  in  which  plasma  can  be  used 
with  the  utmost  benefit.  There  are  many  diseases 
associated  with  hypoproteinemia  in  which  plasma 
is  positively  indicated.  In  the  premature  infant  it 
has  been  life-saving.  Dr.  Elliott  has  done  so  much 
to  perfect  a  method  of  preparation  whereby  every 
community  that  has  a  hospital  can  have  plasma 
available,  that  it  would  be  almost  a  calamity  if  the 
institutions  of  this  country  failed  to  profit  by  his 
work. 


This  and  the  next  paper  were  discussed  together.     For  discussion  of  (he  two  papers  see  Page  256. 


SOUTHERN  MEDICINE  &  SURGERY 


Blood  Plasma* 

John  Elliott,  Sc.  D.,  Salisbury,  North  Carolina 

Rowan  Memorial  Hospital 


The  view  was  expressed  in  1936  in  a  pre- 
liminary report  in  Southern  Medicine  & 
Survey  that  blood  plasma  could  be  used 
as  a  substitute  for  whole  blood,  that  is  could  be 
be  preserved  for  long  periods,  that  it  could  be  used 
without  typing  and  cross-matching.  Extensive  ex- 
prelimentation  developed  equipment  for  the  aseptic 
collection  of  blood"  and  its  conversion  to 
plasma3  '.  Numerous  titrations  of  blood  belonging 
to  groups  A,  B  and  O  for  agglutinin  content,  and 
animal  experimentation,  indicated  that  plasma 
could  be  administered  without  cross-matching,  even 
to  incompatible  recipients.  Long  storage  was  found 
to  be  safe  and  satisfactory.  Blood  plasma  has 
been  transfused  instead  of  whole  blood  in  numer- 
ous diseases,  and  with  effectiveness  equal  to  that 
to  be  expected  from  administration  of  whole  blood. 

It  is  now  possible  to  state  without  reservation 
that  the  use  of  blood  plasma  as  a  substitute  for 
whole  blood  has  passed  through  the  period  of  ex- 
perimentation and  that  adequate  clinical  trial 
has  abundantly  proved  its  great  value.  It  is 
recognized  as  a  safe  and  effective  therapeutic  agent. 
This  statement  is  possible  because  the  original  in- 
vestigations have  been  adequately  confirmed  by 
numerous  phvsicians  and  surgeons  in  many  institu- 
tions in  the  United  States,  Canada  and  Great 
Britain. 

Blood  plasma  has  been  used  instead  of  whole 
blood  with  entire  success  irn  the  treatment  of  shock 
from  trauma,  hemorrhage,  operation,  obstetrics  and 
burns;  in  the  circulatory  failure  of  medical  as  well 
as  surgical  diseases:  and  in  the  treatment  of  hypo- 
proteinemia. 

Thousands  of  transfusions  of  blood  plasma  have 
been  administered,  without  typing  or  cross-match- 
ing, many  to  patients  whose  blood  was  incompatible, 
without  a  single  reaction  due  to  incompatibility. 
The  chill-and-fever  reactions  which  so  commonly 
followed  the  transfusion  of  whole  blood  a  few  years 
ago  have  been  materially  reduced.  Most  hospitals 
using  blood  plasma  report  an  incidence  of  chill-and- 
fever  reactions  below  1  per  cent. 

Blood  plasma  has  been  transported  over  long  dis- 
tances without  special  precautions  and  when  subse- 
quently administered  was  found  to  have  retained 
therepeutic  effectiveness  without  having  developed 
toxic  properties. 

Clinical  improvement  without  untoward  reaction 
has    been    observed    following    the    transfusion    of 


plasma  stored  at  room  temperature  for  periods  up 
to  26  months.  Storage  at  refrigerator  tempera- 
ture is  probably  optimum,  but  plasma  can  be  stored 
for  long  periods  at  room  temperature  without 
becoming  unfit  for  use. 

Reaction  has  not  been  observed  following  trans- 
fusions of  unwarmed  plasma.  In  several  instances, 
transfusions  of  275  c.c.  of  plasma  in  25  per  cent 
diluent  has  been  completed  within  10  minutes  after 
the  bottles  weere  taken  from  the  refrigerator. 

In  some  diseases  the  intramusclar  and  subcu- 
taneous administration  of  plasma  has  been  found 
to  be  equally  effective  as  the  transfusion  of  blood 
plasma  into  premature  infants,  babies  and  small 
children  whose  veins  are  difficult  to  enter.  Pati- 
ents of  this  age  who  are  in  dire  need  of  blood  often 
have  normal  red  cell  counts.  Their  need  is  for 
plasma  rather  than  for  red  cells,  and  plasma  can 
be  administered  intramuscularly  in  most  cases  as 
effectively  as  intravenously. 

The  original  investigative  work  on  blood  plasma 
was  done  on  the  basis  of  its  use  as  a  substitute 
for  whole  blood.  However,  it  should  be  empha- 
sized that  blood  plasma  is  not  a  substitute  for 
whole  blood.  It  is  the  major  fraction  of  blood.  Blood 
is  composed  of  approximately  55  per  cent  plasma 
and  45  per  cent  cells.  In  the  past  the  indication 
for  transfusion  was  on  the  basis  of  the  need  for  red 
cells  and  plasma  was  rarely  considered.  Red  cells 
are  of  tremendous  importance,  but  they  have  but 
one  function — that  of  conveying  oxygen  from  the 
lungs  to  the  tissue  cells.  When  an  animal  is  de- 
prived of  oxygen  for  a  period  of  little  longer  than 
three  minutes,  death  occurs  from  oxygen  lack. 
Also  when  tissue  cells  are  deprived  of  oxvgen  for 
any  period  of  time  damage  or  death  of  the  cells 
occurs. 

More,  red  cells  will  not  restore  osmotic  pressure 
or  materially  increase  the  blood  volume  or 
blood  pressure,  and  cannot  circulate  effectively. 
Blood  plasma  has  many  functions;  not  the  least 
important  of  which  is  the  function  of  maintaining 
a  colloid  osmotic  pressure,  blood  volume,  blood 
pressure,  and  circulation  of  red  cells.  Red  cells 
cannot  carry  out  their  function  unless  they  are 
circulating,  and  plasma  volume  must  be  adequate 
to  maintain  circulation. 

The  whole  of  the  vascular  system — heart,  blood 
vessels  and  capillaries  as  well  as  the  blood  con- 
stituents— must  be  given  earnest  consideration.  The 


al    Association    of    the    Carolii 


nd    Virginia,    held    at    Greensboro,    February 


May  1941 


BLOOD   PLASMA— Elliott 


heart  is  mearly  a  pumping  and  propelling 
mechanism;  the  arteries  and  veins  supplement 
propulsion  and  act  as  a  conducting  system.  The 
vital  function  of  the  blood  is  carried  out  in  the 
capillary  bed.  There  are  thousands  of  miles  of 
capillaries  in  the  body.  The  capillary  bed  is  so 
extensive  that  if  all  the  capillaries  were  functioning 
at  a  given  time  practically  all  the  blood  in  the 
body  could  be  segregate  dthere.  However,  only  a 
part  of  the  capallaries  are  active  at  any  given  time 
They  are  so  small  that  red  cells  pass  through 
most  of  them  in  single  file  and  there  is  a 
capillary  in  close  proximity  to  almost  every  cell  in 
the  bodv.  Normally,  the  capillaries  are  freely  per- 
meable to  water,  crystalloids  and  electrolytes. 
Because  of  this  free  permeability  of  the  capillary 
walls  an  equilibrium  between  the  blood  and  tissue 
electrolytes  and  crystalloids  is  established  by  diffu- 
sion. Normally  the  capillaries  are  impermeable  to 
proteins,  with  the  possible  exception  of  a  few 
in  the  liver.  Blood  plasma  protein  is  present  in  a 
concentration  of  approximately  7  per  cent..  Tissue 
fluid  protein  averages  0.2  per  cent. 

The  many  investigators  of  shock,  since  Latta 
first  used  the  term  in  1795,  have  made  many  obser- 
vations and  have  advanced  theories  to  explain  the 
cause  of  shock.  While  most  of  these  observations 
and  theories  partially  explain  shock,  none  of  them 
seems  to  be  complete  in  itself.  There  are  however 
three  observations  that  have  been  made  by  all  in- 
vestiagtors  of  mock;  namely:  (1)  decreased  cardias 
output  of  arterial  blood,  (2)  hemoconcentration, 
(3)  reduced  blood  volume. 

Reduced  cardiac  output  of  arterial  blood  and 
hemoconcentration  are  manifestations  of  reduced 
blood  volume.  Thus,  the  one  constant  observation- 
of  importance  made  by  all  investigators  of  shock 
is  reduced  blood  volume.  The  mechanism  of  this 
reduction  seems  best  explained  by  Moon,  who  has 
demonstrated  that  the  capillary  permeability  occurs 
not  only  in  the  local  areas  but  generally  through- 
out the  body.  He,  as  well  as  others,  explains  this 
capillary  permeability  to  proteins  on  the  basis  of 
capillary  damage  by  the  toxic  action  of  substances 
released  from  traumatized  areas,  tissues  anoxia, 
poisons  and  bacterial  toxins. 

Normally,  the  cell  in  need  of  oxygen  elaborates 
a  substance  which  is  capable  of  stimulating  the 
adjacent,  inactive  capillaries  to  activity.  When 
oxygen  is  supplied  to  the  cell,  elaboration  of  the 
substance  is  discontinued  and  the  capillaries  return 
to  the  resting  state. 

When  blood  volume  and  blood  pressure  are  re- 
duced so  that  circulation  fails  and  oxygen  is  no 
longer  delivered  in  adequate  quantities  to  the 
tissues,  this  substance  is  elaborated  in  large  quan- 


tities, and  the  capillaries  generally  become  permea- 
ble to  proteins.  Protein  loss  may  be  very  great  and 
blood  volume  quickly  reduced.  When  tissue  is 
traumatized  or  burned,  the  substance  capable  of 
dilating  capillaries  is  produced  in  large  amounts, 
and  capillary  damage  is  extensive,  particularly  in 
the  traumatized  and  visceral  areas.  When  bacteria 
destroy  tissue  and  elaborate  toxins,  decomposition 
products  of  damaged  tissue  as  well  as  the  bacterial 
toxins,  act  on  capillaries  to  make  them  permeable 
to  proteins. 

Moon  has  called  attention  to  the  similarity  of 
shock  from  surgical  disease  and  circulatory  failure 
of  medical  diseases.  Both  are  characterized  by 
reduced  blood  volume,  blood  pressure  and  clini- 
cal manifestations  characteristic  of  shock.  The  clini- 
cal manifestations  of  traumatic  shock  and  hem- 
orrhagic shock  are  identical,  although  their 
mechanism  may  be  different. 

In  traumatic  shock  without  hemorrhage,  there 
is  a  loss  of  plasma  from  the  blood  vessels  through 
permeable  capillaries  into  the  tissues.  In  hemor- 
rhagic shock,  there  is  a  loss  of  cells  and  plasma 
from  the  body  followed  by  a  loss  of  plasma  from 
the  capillaries  into  the  tissues.  Loss  of  blood  from 
the  body  is  not  important  unless  shock  occurs.  In 
severe  hemorrhage  there  is  seldom  a  loss  of  red 
cells  sufficient  to  cause  death  if  the  remaining 
cells  can  circulate  adequately.  The  anemic  patient 
with  a  million  red  cells  per  cubic  millimeter  is 
seldom  in  danger  of  death  from  anoxia  or  shock. 
On  the  other  hand,  the  patient  who  has  lost  half 
his  blood  volume  by  rapid  hemorrhage  is  in  im- 
mediate danger  of  death  from  shock.  The  anemic 
patient  is  in  no  immediate  danger  because  the 
plasma  volume  is  adequate  to  maintain  circulation 
of  his  million  red  cells  per  cubic  millimeter:  where- 
as the  patient  suffering  from  rapid  hemorrhage  is 
in  immediate  danger  from  anoxia  and  shock  in 
spite  of  the  fact  that  an  adequate  number  of  red 
cells  remain.  Here  the  plasma  volume  has  been 
reduced  to  the  point  where  circulation  of  red  cells 
is  no  longer  adequate. 

Experimental  as  well  as  clinical  evidence  con- 
clusively proves  that  blood  volume  can  not  be 
restored  or  maintained  with  crystalloid  and/or 
electrolyte  solutions.  Red  cells  which  do  not 
create  colloid  osmotic  pressure  are  not  capable  of 
materially  increasing  effective  blood  volume  or 
blood  pressure.  Only  a  colloid  solution  is  capable 
of  restoring  and  maintaining  blood  volume  and 
blood  pressure.  Blood  plasma  is  the  most  effective 
colloid  solution  available. 

Plasma  cannot  be  effective  unless  it  is  used 
in  adequate  quantities.  Time  is  an  important  factor 
and   in  desperate  cases  we  urge  early  and   rapid 


BLOOD    PLASMA— Elliott 


administration.  Usually  we  have  found  the  500  ex. 
unit  of  whole  blood,  or  its  equivalent  in  plasma 
inadequate.  The  quantity  needed  is  the  amount 
which  will  restore  the  blood  volume  and  blood 
pressure  to  normal.  This  may  amount  on  rare 
occasions  to  several  liters. 

The  following  case  illustrates  the  advantages  of 
an  available  blood  substitute  administered  directly 
from  the  refrigeration  without  cross-matching. 

Case  Report 

A  white  man,  aged  26,  was  taken  to  the  operating  room 
of  the  Rowan  Memorial  Hospital,  at  9  a.m.,  April  4th, 
1941  for  removal  of  a  large  tumor  of  the  right  kidney. 
Transperitoneal  nephrectomy  was  started  under  spinal 
anesthesia  at  9:15.  difficulties  were  encountered  and  the 
spinal  anesthetic  was  fortified  by  ethylene  gas.  At  9:40 
following  some  trauma  and  moderate  hemorrhage,  the 
patient  appearing  to  be  in  deep  shock,  275  c.c.  of  plasma 
in  25  c.c.  of  diluent,  taken  directly  from  the  refrigerator, 
was  administered  as  rapidly  as  possible  by  gravity.  A 
second  bottle  was  started  as  soon  as  the  first  had  been  ad- 
ministered and  subsequently  a  third  bottle  containing 
450  c.c.  of  plasma  in  500  c.c.  of  diluent  was  given.  Con- 
siderable recovery  from  the  state  of  shock  was  noted  but 
it  was  deemed  advisable  to  give  more  plasma.  A  bottle 
of  dried  plasma,  restored  with  distilled  water  to  its  original 
volume — 250  c.c. — was  infused. 

The  first  four  bottles  of  plasma — 1225  c.c.  in  550  c.c. 
of  diluent — were  administered  in  about  one  hour.  The 
patient's  condition  was  improved  but  as  the  Operation 
progressed  the  blood  pressure  dropped  again.  By  this 
time  two  600  c.c.  collections  of  blood  were  ready.  Both 
bottles  were  infused  during  the  next  40  minutes.  Operation 
was  completed  by  11:35  (in  2l/2  hrs.)  and  the  patient  re- 
turned to  his  room  with  normal  blood  pressure,  good  pulse 
and  apparently  out  of  shock.  The  patient  had  received 
plasma  and  whole  blood  equivalent  to  3650  c.c.  of  whole 
blood. 

All  went  well  until  4.30  p.m.  when  the  patient  showed 
signs  of  secondary  shock.  Blood  pressure  had  dropped 
to  80/40,  pulse  rate  was  136  and  the  skin  was  clammy. 
An  infusion  of  600  c.c.  of  serum  was  started  and  its 
administration  completed  in  one  hour.  At  the  conclusion 
of  the  infusion  blood  pressure  was  120/65  and  the  pulse 
84.  The  patient  did  well  through  the  night  but  the  next 
morning  appeared  to  be  in  shock.  The  blood  pressure 
had  dropped  to  80/50  the  pulse  rate  increased  to  140. 
An  infusion  of  600  c.c.  of  blood  serum  was  started  and 
administered  as  rapidly  as  possible.  The  symptoms  of 
shock  were  rapidly  relieved  and  at  the  conclusion  of  the 
infusion  the  patient's  condition  appeared  much  improved. 

This  patient  received  in  24  hours  a  total  of  2425  c.c. 
of  blood  plasma  and  blood  serum,  and  1200  c.c.  of  whole 
blood  the  equivalent  of  6000  c.c.  of  whole  blood.  While 
this  seems  to  be  very  large  quantity  we  felt  that  less 
would  have  been  insufficient.  The  patient's  blood  group 
was  A;  the  blood  given  was  group  O;  the  plasma  and 
serum  pooled,  therefore  mixed.  All  of  it,  with  the  except- 
ion of  the  dried  plasma,  was  administered  directly  from  the 
refrigerator  without  warming. 

The  patient  started  voiding  after  26  hours  and  made  an 
uneventful  recoveryfl  He  was  discharged  May  3rd  19 
days  after  operation. 

Conclusion 
(1).  Blood    plasma    has    many    advantages    over 


whole  blood. 
(2).  These  advantages  would  be  unimportant  were 

not  blood  plasma  as  effective  as  whole  blood 
(3).  It  is  suggested  that  the  reduced  blood  volume 

which  occurs  in   shock  is  due   to  a  loss  of 

plasma  rather  than  loss  of  red  cells,  even  in 

hemorrhage. 
(4).  Therefore,  restoration  of  blood  volume  by  the 

transfusion  of  plasma  is  logical. 

References 

1.  Elliott  J.:  A  Preliminary  Report  of  a  New  Method  of 
Blood  Transfusion,  So.  Med.  &  Surg.  98.643  (Dec.) 
1936. 

2.  Elliott,  J.,  and  Nesset,  N.:  A  Report  of  the  Use  of  a 
Perfected  Evacuated  Unit  for  Blood  Transfusion. 
So.  Med.  &  Surg.  Vol.  102,  No.  6,  June  1940. 

3.  Tatum,  W.  L.,  Elliott,  J.  and  Nesset,  N.:  A  Technic 
for  the  preparation  of  a  Substitute  for  Whole  Blood 
Adaptable  for  Use  During  War  Conditions,  Mil.  Sur- 
geon, Vol.  85,  No.  6,  Dec.  1939. 

4.  Elliott  J.,  Tatum,  W.  L.  and  Busby.  G.  F.:  Blood 
Plasma,  Mil.  Surgeon,  Vol.  88,  No.  2.  February,  1941. 

Discussion 

Dr.  J.  M.  Feder,  Anderson:  Mr.  President  and  mem- 
bers of  the  Tri-State  Medical  Association:  I  would  ask 
your  indulgence  to  permit  me  to  step  out  of  character  for 
a  moment  and  extend  to  this  organization  an  invitation 
issued  by  the  Anderson  County  Medical  Society  to  make 
Anderson,  South  Carolina,  the  meeting  place  for  the  next 
Annual  Convention.  I  have  filed  a  written  imitation  with 
your  Secretary,  and  letters  from  other  officials,  confirming 
this  invitation,  are  in  the  mail.  A  warm  welcome  awaits 
you. 

To  proceed  with  my  discussion,  a  year  and  a  half  ago, 
it  was  my  good  fortune  to  be  commissioned  by  the  staff 
of  the  Anderson  County  Hospital  to  conduct  an  investi- 
gation into  blood  plasma  and  blood  banking  in  general, 
and  their  adaptability  to  an  instituttion  of  the  type  of 
ours  in  particular.  During  the  course  of  this  survey,  I 
made  trips  to  several  transfusion  centers  and  wrote  many 
letters  and  received  sufficient  replies  to  form  a  rather  vol- 
uminous compilation.  The  men  at  Memorial  Hospital  in 
New  York  were  kind  enough  to  place  their  data  at  my 
disposal,  and  Dr.  Ravdin  of  the  Department  of  Research 
Surgery  of  the  University  of  Pennsylvania  and  one  of  his 
associates,  Dr.  Flosdorf,  have  been  generous  in  furnishing 
me  with  the  results  of  their  extensive  experience  with 
whole-blood  transfusions,  with  plasma  transfusions,  and 
with  drying  and  preserving  plasma  in  powdered  form. 
Quite  naturally,  I  have  discussed  this  matter  a  number  of 
times  with  my  good  friend,  Dr.  John  Elliott.  After  eval- 
uating all  available  data,  I  rendered  a  report  of  my  find- 
ings in  an  editorial  in  the  February  Bulletin  of  the  An- 
derson County  Hospital.  Copies  of  this  editorial  will  be 
distributed  to  those  interested  at  the  close  of  this  discus- 
sion. 

At  this  point,  I  want  to  say  a  few  words  about  Dr. 
Elliott.  You  will  recall  that  Fulton  developed  a  boat  that 
went  up  the  river  without  oars  or  sails. 

On  that  memorable  hot  August  day  in  1S07  when  the 
Claremont  successfully  negotiated  its  first  trip,  several 
who  had  dreamed  of  such  an  accomplishment  said,  "Well, 
I  thought  of  that  before,  Fulton  stole  my  idea."  But 
Fulton  made  the  first  successful  trip  by  steamboat.  Both 
Dr.  Elliott  and  I  grant  you  that  other  men  had  thought 
of  separating  plasma  from  the  cells,  and  administrating 
this  plasma  to  a  patient.    That,  we  do  not  deny,  nor  do 


May  1941 


BLOOD   PLASMA— Elliott 


255 


we  question  the  claims  of  those  who  make  them.  But 
these  facts  are  self-evident,  confirmed  beyond  question  or 
doubt  by  the  investigation  just  completed,  and  this  I  want 
read  into  the  records  being  inscribed  here  today:  Dr.  John 
Elliott  deserves  absolute  and  undisputed  priority  in  mak- 
ing blood  plasma  available  on  a  nationwide  basis  and  in 
carrying  out  research  that  that  end  might  be  achieved. 

Able  speakers  have  amply  elaborated  upon  the  physi- 
ology and  indications  for  plasma  transfusion.  The  only 
point  that  I  desire  to  stress  is  that  we  must  do  something 
about  making  it  more  generally  available. 

We  are  all  keenly  aware  of  the  fact  that  the  greatest 
need  for  available  plasma  in  emergencies  is  in  rural  areas, 
remote  from  hospital  facilities.  Here,  plasma  could  be 
used  on  the  spot  without  the  loss  of  time  and  in  the  ab- 
sence of  the  technical  skill  required  to  match  donors. 

In  the  beginning  of  the  preparation  of  blood  plasma 
some  was  processed  by  qualified  men  working  under  ideal 
conditions;  in  other  instances,  this  important  task  was 
relegated  to  ill-trained  technical  helpers.  The  effects  of 
some  plasma  were  good,  while  its  administration  in  other 
instances  proved  disastrous.  A  common  fault  was  exces- 
sive handling  of  the  blood  and  finished  product  by  an 
open  method.  My  own  organization  tried  this  and  found 
it  utterly  impossible  to  prepare  a  suitable  product  in  the 
atmosphere  of  the  general  laboratory.  It  is  possible  that 
this  work  could  be  done  in  a  specially  prepared  room. 
That  is  the  Memorial  Hospital's  approach  in  preparing 
the  substance  for  shipment  to  England.  We  have  been  in- 
formed that  even  under  these  near-ideal  conditions  con- 
taminations are  not  unknown. 

Dr.  Elliott  has  given  us  a  method  of  procedure  in 
which  the  blood  and  processed  plasma  are  not  exposed  to 
air-bone  contaminants.  He  has  blazed  the  trail  toward 
simplicity  and  if  we  follow  in  his  footsteps  and  approach 
the  subject  from  a  wholesale  standpoint,  in  only  a  very 
short  time,  plasma  will  be  available  to  all  who  require  it. 
Dr.  Elliott  once  made  the  statement  that  the  problem  is 
one  for  the  pathologists  of  the  nation,  and  that  in  many 
instances  they  have  shown  but  little  enthusiasm  in  meet- 
ing it.  I  grant  that  this  is  true.  I  possess  enthusiasm  to 
a  high  degree  for  the  carrying  on  of  this  work,  but  I  am 
an  extremely  busy  man  with  a  myriad  of  duties.  I  sup- 
pose my  case  is  typical,  the  day  just  does  not  have  enough 
hours.  I  positively  do  not  have  time  to  supervise  every 
step  required  in  the  successful  processing  of  plasma.  I  do 
not  feel  that  the  average  overworked  pathologist  in  the 
average  general  laboratory  is  in  a  position  to  successfully 
meet  the  situation. 

What  is  the  answer?  You  have  given  a  practical  reply 
right  here  in  North  Carolina  in  the  form  of  your  Plasma 
Center.  You  are  approaching  it  as  it  should  be  approach- 
ed: on  a  statewide  basis.  It  is  my  hope  that  other  states 
will  follow  your  excellent  example  until  there  is  at  least 
one  Plasma  Center  in  every  state  in  the  natiton.  It  was 
my  impression  from  the  investigation  just  completed  that 
the  proper  approach  must  be  on  a  statewide  or  even  .1 
nationwide  basis,  using  voluntary  donors,  the  entire  setup 
under  the  direct  supervision  of  one  dynamic  executive 
supported  by  some  philanthropic  organization,  such  as  the 
Red  Cross,  and  sponsored  by  some  interested  commercial 
agency.  I  hope  that  the  representatives  of  the  several 
states  meeting  here  today  will  go  to  their  respective  med- 
ical societies  and  say:  The  time  is  rope  to  act,  we  want  a 
State  Plasma  Center. 

The  policy  employed  by  the  North  Carolina  Center 
appears  to  me  to  be  quite  fair  and  one  that  all  could 
profit  by  copying. 

In  closing.  I  want  to  reiterate  the  single  point  that 
ample    transfusion   and    plasma   facilities   are   available   in 


the  large  medical  centers.  This  same  availability  must  be 
made  applicable  to  the  most  remotely  situated  practitioner 
of  medicine.  Then,  and  only  then,  can  we  truthfully  say 
that  plasma  transfusion  has  come  into  its  own. 

Gentlemen,  I  thank  you  for  the  opportunity  that  you 
have  granted  me  to  appear  before  you. 

Dr.  Lewellys  F.  Barker,  Baltimore:  It  has  been  a 
great  privilege  to  listen  to  this  paper  of  Dr.  White  and 
his  associates,  to  hear  Dr.  Elliott  and  also  to  hear  the 
discussion  of  Dr.  Feder.  I  would  like  to  say  that  if  no 
other  papers  are  heard  at  this  meeting,  these  have  been 
well  worth  the  journey  to  Greensboro.  It  deals  with  one 
of  the  most  important  subjects  affecting  medicine  today. 
Of  course  we  have  all  felt  the  difficulties  of  dealing  ade- 
quately with  shock  and  toxemia,  but  this  plasma  therapy 
meets  the  situation  better  than  anything  that  we  have 
ever  had  before.  We  have  used  whole  blood  transfusions 
for  a  long  time  for  shock  and  anemia.  Blood  transfusions 
are  very  valuable  and  we  have  all  used  them.  There  is 
still  value  in  blood  transfusions.  The  Red  Cross  is  is  en- 
couraging the  making  of  blood  banks  to  send  to  England 
and  other  parts  of  Europe.  It  seems  to  me  these  blood 
banks  are  likely  to  be  replaced  by  plasma  banks  to  the 
advantage  of  everybody  because  so  often  what  is  needed 
is  the  constituents  of  the  plasma.  Moreover,  the  typing 
of  blood  is  a  tedious  process  and  may  delay  therapy.  If 
we  have  plasma  prepared  in  the  careful  way  described 
here  today  we  will  have  what  we  need  in  the  treatment 
of  these  conditions. 

Now  as  Dr.  Feder  has  pointed  out  and  as  you  gather 
from  Dr.  Elliott's  paper,  preparation  of  plasma  is  not 
every  man's  job.  Very  few  of  us  are  prepared  to  under- 
take the  preparation  of  plasma.  Very  few  of  the  small 
laboratories  or  even  larger  laboratories  are  prepared  to 
undertake  it.  But  I  do  think  it  should  be  prepared  and 
should  be  stored,  and  it  seems  to  me  the  example  of  the 
State  of  North  Carolina  in  establishing  a  state  plasma 
center  ought  to  be  followed  by  every  state  in  the  country. 
I  hope  it  will  be  and  I  believe  it  is  likely  to  be. 

Dr.  Elliott  spoke  of  dried  plasma  and  the  difficulties  of 
its  manufacture  and  use.  It  is  an  expensive  process.  In 
Philadelphia  I  believe  two  apparatuses  have  been  con- 
structed, one  smaller  one  and  another  now  available  or 
will  be  soon — a  very  large  one — 'and  it  is  likely  that  dried 
plasma  soon  can  be  obtained  at  a  much  lower  price  than 
now.  I  hope  that  that  will  be  possible  because  I  believe 
there  is  a  future  for  dried  plasma  as  well  as  for  stored 
liquid  plasma,  for  when  you  think  of  it,  in  the  army 
camps  it  might  not  be  an  easy  matter  to  carry  sufficient 
liquid  plasma  to  meet  emergencies,  whereas  dried  plasma 
could  be  easily  transported  and  be  ready  for  use  in  a 
moment.  I  think  the  United  States  Army  and  Navy  might 
consider  seriously  the  advisability  of  favoring  the  prepara- 
tion of  dried  plasma  so  that  it  may  be  available  for  our 
forces  if  they  should  be  drawn  into  this  iniquitous  war. 

Dr.  Charles  S.  White:  Dr.  Northington's  reference 
to  the  first  transfusion  of  the  Pope  in  1492  always  was  a 
mystery  to  me.  The  old  Pontiff  died  although  they  used 
three  young  men.  Circulation  of  the  blood  was  not  dis- 
covered until   100  years  later. 

I  think  wherever  plasma  is  used  Dr.  Elliott's  name 
certainly  should  go  with  it.  He  is  not  only  the  father, 
but  probably  the  mother,  too,  of  transfusion.  He  is  the 
whole  family.  He  knows  more  about  plasma  than  any- 
body in  the  United  Stales  and  I  believe  North  Carolina 
appreciates  that.  We  are  beginning  to  put  emphasis  on 
plasma  at  the  Gallingcr  Hospital.  We  have  been  using  the 
blood  haul,  there  and  now  the  staff  is  getting  around  to 
using  plasma. 


256 


SOUTHERN  MEDICINE  &  SURGERY 


The  Present  Status  of  Prostatic  Surgery 
Analysis  of  Our  Last  Hundred  Cases* 

Raymond  Thompson,  M.D.,  F.A.C.S.,  Charlotte 
Thompson- Daniel  Clinic 

ADVANCES  in  surgery  of  the  prostate  con-  1938,  says  that  in  early  cases  transurethral  opera- 

stitute  the  chief  contribution  of  urology  to  tions   have  largely   replaced   non-operative   proce- 

the  healing  art  in  the  past  twenty  years,  dures,  that  modern  resectoscopes  permit   removal 

Transurethral   prostatic   resection   was    introduced  of  large  amounts  of  tissue  and  that   there  is  no 

and  its  technic  perfected,  not  by  one  man  but  by  question  of  the  relative  safety  and  immediate  ef- 

several  men,  each  of  whom  contributed  his  large  fectiveness  of  resection,  not  only  of  minor  lesions 

part.    In  my  opinion    Dr.  T  heodore    M.    Davis,  but  also  of  certain  enucleable  tumors, 

through  his  work  in  Greenville  and  in  Charlotte.  Incidence  of  Carcinoma  of  the  Prostate  Gland 

made    the    largest    single    contribution.     In    this  A  review  of  794  cases  by  Drs.  Harrv  C.  Rolnich 

twenty-year   period    transurethral   prostatic   resec-  and  Lester  A   Rjskjn(j  0f  Chicago,  published  in  the 

tion  has  largely  replaced  the  older  prostatic  oper-  joumai  0j  Urology,  January,   1937,  studied  clini- 

ations.  cally  and  pathologically,  reported   600  as  benign 

A  good  deal  of  this  report  is  repetition.    This  and  194  (24.3%)  malignant.    Of  the  194  cases  of 

must  be  the  case  in  bringing  up  to  date  a  report  of  carcinoma,  162  were  diagnosed  clinically.    The  27 

continuing  work.  (13.9%)  which  were  proven  later  to  be  carcinoma 

In    1939    the    Urologkal  &  Cutaneous   Review  had  been  diagnosed  clinically  as  benign  hvpertro- 

sent  a  questionnaire  to  55  hospital  services  listed  phy.    The  high  incidence  of  occult  carcinoma  of 

in  the  American  Medical  Directory  as  having  ap-  the  prostate  gland  should  cause  us  to  investigate 

proved  urologic  residencies.    The  purpose  of  this  carefully  any  suspicious  infiltration,  induration  or 

questionnaire  was  to  obtain  an  idea  of  the  status  nodule.'  It  should  be  needless  to  state  that  all  tis- 

of  prostatic  surgery  throughout  the  United  States  sue  removed  should  be  sent  to  the  laboratory. 

in  1938.   Twenty-six  complete  replies  were  receiv-  Following  is  an  analysis  of  100  consecutive  oper- 

ed.    In  that  year  there  were   1,410  transurethral  ati0ns  on  patients  of  the  Thompson-Dan:?!  Clinic: 
prostatic  resections  done  with  88  deaths  within  the 

,                                    .                    .      ,                               ...  TRANSURETHRAL                                 PERINEAL 

two-week  postoperative  period — a  mortality  of  ap-  94                                 6 

proximately  6  per  cent.    There  were   701   supra-  Age                                                        No.  of  Patients 

pubic  prostatectomies   (one-  and  two-stage  opera-       s°-55    6 

tions)  with  65  deaths — a  mortality  of  11  per  cent;       *5~™   7 

and  98  perineal  prostatectomies  with  4  deaths — a  65_70                                                                   23 

mortality  rate  of  4  per  cent.    In  these  26  hospitals       70-75    ...  26 

from  which  replies  were  received  there  were  ap-      7S-80 8 

proximately  twice  as  many  transurethral  prostatic      S0"8S    7 

resections   as   there   were   suprapubic   prostatecto-  Z 

mies  and  perineal  prostatectomies  combined.    On  Total loo 

many  services  the  transurethral  operation  was  done  Pre-operative  Treatment 
exclusively,  while  on  one  service  only  three  pa-  The  number  of  cases  in  which  it  was  necessary 
tients  had  resections.  On  only  three  services  were  t0  have  bladder  drainage  was  58;  there  was  com- 
as many  as  100  transurethral  operations  done  in  plete  retention  of  urine  in  49  cases.  In  cases  of 
1938.  Dr.  T.  M.  Davis,  in  the  Southern  Medical  complete  retention  or  a  larse  amount  of  residual 
Journal  for  August,  1935,  reported  748  patients  urine,  we  instituted  bladder  drainage  bv  Keyes' 
operated  on  by  prostatic  resection  with  6  deaths—  decompression  catheter  method.  In  42  cases  re- 
a  mortality  of  0.8  of  1  per  cent.  sidual  urine  was  less  than  10  ounces    and  in  ibese 

In   1938,   Raymond  Thompson   reported   to  the  bladder  drainage  was    not    necessary.    The    well 

Medical  Society  of  the  State  of  North  Carolina  established  plan  of  preliminary  treatment   should 

and  published  in  Southern  Medicine  &  Surgery's  be  continued  until  the  renal  function  has  become 

June   issue  a   series   of    108   consecutive   cases   in  stabilized   as    determined    by    renal    function    and 

which  transurethral  resection  was  done  with  two  blood  chemistry  tests.  Every  effort  should  be  made 

deaths— a  mortality  rate  of  less  than  2  per  cent.  t0  have  the  patient  in  as  good  physical  condition 

Herman's    Practice    of    Urology,    published    in  as  possible  before  operation. 

•Presented   to  the   meeting  of  the   Tri-State   Medical   Association    of    the    Carolinas   and    Virginia,    held   at    Greensboro,    February 
24th  and  25th. 


May  1941 


PROSTATIC    SURGERY— Thompson 


Postoperative  Care 
The  most  important  measure  is  thorough  drain- 
age of  the  bladder  through  a  catheter.  Hemostatic 
bags  serve  an  important  purpose  in  controlling 
bleeding:  however,  we  do  not  employ  them  rou- 
tinely. The  bladder  should  be  irrigated  at  frequent 
intervals  if  necessary  to  remove  small  blood  clots 
or  to  insure  constant  drainage. 

Postoperative  Complications 

Hemorrhage:  In  this  series  we  had  only  five 
instances  of  severe  bleeding — two  on  the  second 
day,  two  on  the  eighth  and  ninth  days,  and  the 
fifth  three  weeks  after  operation.  In  all  cases 
bleeding  was  controlled  by  insertion  of  a  catheter 
and  removal  of  blood  clots  from  the  bladder. 

Epididymitis:  Developed  postoperatively  in 
seven  cases.  The  intervals  between  operation  and 
epididymitis  were:  in  two  cases,  five  days;  in 
three  cases,  eight  days;  in  one  case,  ten  days;  in 
one  case,  three  weeks.  In  no  case  was  epididymitis 
so  severe  that  it  did  not  clear  up  within  ten  days 
to  two  weeks  under  ordinary  treatment. 

Vasectomy  was  not  performed  in  any  case  in 
this  series. 

Diverticulum:  One  case  with  a  large  stone  in 
diverticulum.  A  suprapubic  incision  was  made  for 
removal  of  the  stone,  while  the  prostatic  obstruc- 
tion was  removed  by  transurethral  resection. 

Vesical  Calculi:  One  case,  large  stone  in  a  diver- 
ticulum; three  cases,  small  stones  in  the  bladder; 
one  case,  one  large  stone  in  bladder  and  supra- 
pubic cystotomy,  later  prostatic  resection. 

Prostatic  Calculi:  Four  cases.  In  three  of  these 
cases  the  stones  were  removed  by  resection  and,  in 
one  by  perineal  prostatectomy. 

Reoperation:  In  this  series  only  one  patient 
with  benign  hypertrophy  required  a  second  opera- 
tion. This  was  done  two  weeks  after  first  resec- 
tion. However,  three  patients  with  carcinoma  of 
the  prostate  gland  had  had  resection  twelve  to 
eighteen  months  previously. 

Incidence  of  Malignancy:  There  were  sixteen 
cases  of  carcinoma  of  the  prostate  gland,  16  per 
cent. 

Time  in  Hospital 

Many  patients  could  leave  the  hospital  in  a 
week  or  ten  days,  but  as  the  8th  or  10th  day  is  the 
time  when  bleeding  is  most  likely  to  occur,  we 
advise  all  patients  to  remain  in  the  hospital  for 
two  weeks.  Many  patients  promise  to  be  quiet  at 
home,  but  usually  do  not.  Rarely  is  it  necessary 
to  remain  in  the  hospital  more  than  two  weeks. 

Mortality 
In   this  series  we  had   three  deaths.    The  first 
was  a  patient  aged   74,  who  had  complete  reten- 
tion of  urine  for  which  bladder  drainage  was  con- 
tinued  for  seven   days  after  which   twelve  grams 


of  prostatic  tissue  was  removed.  Blood  pressure, 
renal  function  tests  and  chemical  constituents  of 
the  blood  were  within  normal  limits.  Death  came 
30  hours  after  operation  from  a  cardiac  accident. 
The  second  was  a  66-year-old  man  with  moderate 
hypertension,  renal  function  and  blood  tests  nor- 
mal. Two  weeks  after  operation  the  patient  had  a 
cerebral  hemorrhage  and  died  seven  days  later. 
The  third  was  a  ptaient,  aged  70,  with  carcinoma 
of  the  prostate  gland,  who  had  had  urethral  resec- 
tion eighteen  months  previously.  His  general  con- 
dition was  fairly  good,  non-protein  nitrogen  reten- 
tion moderate,  renal  function  poor.  He  developed 
bronchial  pneumonia  and  died  nine  days  after 
operation. 

Conclusions 

1.  We  are  impressed  with  the  high  mortality 
reported  in  prostatic  surgery. 

2.  Careful  pre-  and  postoperative  attention  is  a 
large  factor  in  yielding  a  low  mortality.  The  use 
of  small  urethral  catheters  is  advised. 

3.  We  are  operating  in  a  much  larger  number 
of  cases  without  preliminary  bladder  drainage  now 
than  in  the  past.  In  cases  which  need  preoperative 
bladder  drainage  the  simple  decompression  method 
by  catheter  drainage  first  suggested  by  Dr.  Keyes 
of  New  York  is  much  preferable  to  cystotomy. 

4.  In  all  cases  of  carcinoma  of  the  prostate 
gland  transurethral  resection  is  the  operation  of 
choice. 

5.  Some  very  large  adenomatous  prostates 
should  be  removed  by  open  operation. 

6.  Thorough  resection  of  the  obstructing  pros- 
tatic tissue  should  be  done.  In  40  to  50  per  cent 
of  the  cases  20  to  25  grams  of  tissue  should  be 
removed. 

7.  All  patients  who  have  prostatic  surgery 
should  be  examined  later  and  treated  for  any 
residual  infection. 

8.  Transurethral  resection  of  the  prostate  gland 
has  been  the  greatest  factor  in  lowering  the  mor- 
tality in  prostatic  surgery  and  is  the  operation  of 
choice  in  the  great  majority  of  cases. 

Discussion 

Dr.  D.  S.  Daniels,  Richmond:  It  is  mighty  early  to  get 
up  this  time  of  morning,  but  I  was  awarded  by  this  de- 
lightful paper.  My  experience  in  transurethral  resections 
is  rather  limited.  I  am  of  the  older  school  but  I  am  fast 
being  converted.  I  feel  that  the  greatest  of  landmarks  or 
milestones  has  been  reached  in  prostatic  surgery — that  is, 
transurethral  resections.  I  feel  like  Dr.  Thompson  that 
the  great  majority  of  these  prostates  should  be  treated  by 
transurethral  resection.  Some  clinics,  as  you  know,  are 
doing  virtually  one  hundred  per  cent  transurethral.  From 
this  series  a  man  should  no  longer  fear  approaching  old 
age  and  prostatism. 

I  enjoyed  the  paper  very  much. 

Dr.  TnoMPSON,  closing:  Dr.  Daniels'  comments  are  very 
encouraging.  We  will  go  forward  in  this  work  with  added 
confidence. 


SOUTHERN  MEDICINE  &  SURGERY 


May  1941 


Hand  Injuries* 

James  W.  Davis,  M.D.,  F.A.C.S.,  Statesville 


MORE  THAN  one-third  of  all  industrial 
accidents  in  North  Carolina  during  the 
past  year  were  hand  injuries.  That  hand 
injuries  is  an  extremely  important  subject  is  evi- 
denced by  the  fact  that  the  total  cost  to  insurance 
companies  for  medical  care,  compensation  ar.d 
other  expenses  due  to  hand  injuries  last  year  was 
almost  half  a  million  dollars.  This,  however,  does 
not  tell  all  the  story.  It  does  not  tell  of  the  men 
who  have  had  serious  injuries  of  the  hands,  many 
of  whom  have  suffered  irreparable  injuries,  and 
some  of  whom  have  had  to  change  their  occupa- 
tion on  account  of  these  injuries.  Out  of  this 
group,  only  eight  lost  the  entire  hand,  but  372  lost 
part — either  all  or  some  of  the  fingers — and  381 
lost  use  of  a  hand.  The  total  number  of  all  com- 
pensation cases  recorded  by  the  Industrial  Commis- 
sion was  48,230.  This  gives  the  hand  injuries  37 
per  cent  of  the  total  number  of  all  cases — more 
than  one-third  of  all  compensation  cases.  The 
total  number  of  days  lost  because  of  hand  injuries 
was  92,285,  which  amounts  to  the  equivalent  of  a 
little  more  than  250  years  of  one  man's  time. 

These  figures  are  not  guesses.  They  are  exact 
statistics  from  the  files  of  the  North  Carolina  In- 
dustrial Commission,  records  of  accidents  which 
have  occurred  here  in  the  various  industries  in 
North  Carolina  during  the  past  year,  and  deserve 
the  thoughtful  consideration  of  every  doctor  who 
handles  industrial  or  any  kind  of  accident  cases. 

The  first  twenty-four  hours  of  treatment  governs, 
to  a  great  extent,  the  outcome  of  any  hand  injury. 
I  might  even  go  further  and  say  that  the  treat- 
ment given  to  hand  injuries  during  the  first  sixty 
minutes,  or  the  first  hour,  governs  the  outcome  to 
a  great  extent. 

I  wish  to  say  here,  though,  that  the  treatment 
given  hand  injuries  in  North  Carolina  has  been 
exceptionally  fine,  because,  out  of  all  the  hand  in- 
juries which  occurred,  there  were  2,388  which  re- 
sulted in  temporary  disability  and,  of  these,  onlv 
28.8  per  cent  became  infected.  Of  the  739  result- 
ing in  permanent  disability,  only  37,  or  4.7  per 
cent,  became  infected.  Seventeen  per  cent  of  all 
injuries  to  the  hand  were  infected  injuries.  This 
certainly  does  show  up  well  for  the  doctors  and 
hospitals  in  North  Carolina. 

In  discussing  this  subject,  we  will  detail  the 
treatment  of  a  typical,  severe  hand  injury,  consist- 
ing of  a  contused,  lacerated  and  incised  wound, 
involving  the  superficial  and  deep  tissues,  with 
possible  injury  to  the  basic  structures  and  further 
complicated  by  soiling  with  dirt  and  other  infec- 

24t*hPanr^h.t0   U'e   meeting  °f  thC   Tri-State   M'd^  Associate 


tious  material,  as  often  occurs  at  time  of  these  in- 
juries. 

It  is  extremely  important  that  the  proper  treat- 
ment be  begun  immediately. 

As  soon  as  the  patient  is  seen,  careful  inspection 
of  the  hand  should  be  made  and  then  a  general 
plan  of  treatment  should  be  formulated,  to  be 
changed  from  time  to  time  as  the  indications  may 
require. 

X-ray  examinations  should  be  made  if  there  has 
been  any  possible  injury  to  bone.  Also  a  color 
photograph  of  the  hand,  or  two  or  three  color 
photographs,  should  be  made  if  color  photographic 
equipment  be  available.  This  measure  is  becoming 
more  and  more  important  each  year,  as  such  pho- 
tographs constitute  important  medicolegal  evi- 
dence. 

We  usually  have  a  patient  who  is  suffering  in- 
tense pain,  and  this  should  be  relieved  by  a  hypo- 
dermic, if  the  patient  has  no  idiosyncrasy  to  the 
use  of  pantopon  or  dilaudid.  Where  it  is  safe  to 
do  so,  we  find  it  advisable  to  block  the  nerves  at 
site  of  injury  by  injections  of  procaine.  This  gives 
immediate  relief  from  the  intense  pain  and  enables 
us  to  make  a  more  thorough  and  more  careful  ex- 
amination of  the  hand,  and  to  test  out  the  muscle 
and  tendon  action  of  each  of  the  fingers  and  the 
hand  generally. 

While  the  hand  is  thoroughly  anesthetized,  a 
complete  debridement  and  cleansing  of  the  soiled 
tissues  can  be  done  without  causing  the  patient 
any  pain. 

Where  the  hand  is  badly  contaminated  with  dirt 
or  glass  or  other  material,  it  is  well  to  pack  the 
deeper  tissues  with  gauze,  washing  with  sterile 
mineral  oil,  so  as  to  prevent  entrance  of  dirt  into 
the  deeper  tissues  as  the  skin  of  the  hand  and  the 
the  tissues  surrounding  the  injury  are  being 
cleansed. 

With  brush  and  tincture  of  green  soap  and  run- 
ning water  is  usually  an  effective  method  of  re- 
moving the  dirt  and  other  infectious  material  from 
the  hand,  although  we  find  plain  gasoline  to  be 
very  effective.  After  the  hand  is  carefully  cleans- 
ed, it  is  dried  and  the  paraffin  gauze  removed 
from  the  deeper  tissues.  The  deeper  tissues  are 
then  painted  carefully  with  a  3  per  cent  solution 
of  tincture  of  iodine,  which  gives  a  maximum  of 
germicidal  action  with  a  minimum  of  injury  to  the 
tissues.  Some  use  a  colloidal  iodine,  which  is  all 
right. 

While  the  hand  is  still  anesthetized  and  the  pa- 
tient is  suffering  no  pain,  it  is  placed  upon  a  sterile 

.    of    the    Carolinas    and    Virpnia,    held    at    Greensboro,    February 


HAND   INJURIES— Davis 


259 


cloth,  and  here  the  surgeon  should  change  to  an- 
other pair  of  sterile  gloves  and  again  inspect  the 
hand  very  carefully.  It  is  important  that  a  good 
light  be  available  so  that  the  inspection  can  be 
thoroughly  accurate;  otherwise,  it  might  be  possi- 
ble to  overlook  certain  foreign  bodies  in  the  deep 
spaces,  especially  glass. 

It  is  advisable  to  have  a  bloodless  field  in 
which  to  work,  and,  for  this  reason,  we  can  apply 
a  blood-pressure  cuff,  after  elevating  the  hand  for 
a  minute  or  so,  and  then  pump  this  up  to  200 
mms.  of  mercury  to  stop  bleeding.  It  will  be  all 
right  to  leave  this  cuff  on  for  twenty  minutes, 
which  is  usually  more  time  than  is  necessary  for 
the  final  cleansing  and  debridement  and  any  local 
treatment  that  is  advisable  at  that  time. 

Whenever  possible,  injuries  to  the  nerves  should 
be  repaired  at  once.  Tendon  repair  is,  in  itself,  an 
important  matter,  and  too  lengthy  to  be  taken  up 
in  detail  at  this  time,  except  to  state  that  in  some 
cases  immediate  repair  of  the  tendons  is  possible 
and  in  others  this  must  be  deferred  for  some  time. 

For  example,  in  some  cases  where  the  flexor 
sublimis  only  is  cut,  it  may  be  advisable  to  re- 
move both  ends  of  the  severed  tendon  and  suture 
the  proximal  end  of  the  sublimis  in  the  palm  to 
the  profundus  tendon.  It  is  necessary,  however, 
to  get  the  tendons  repaired  or  replaced  at  some 
time  so  that  good  motion  of  the  fingers  may  be 
obtained. 

The  vast  majority  of  hand  injuries  should  be 
hospitalized  at  once,  following  the  first  treatment 
of  cleansing,  debridement  and  primary  repairs.  I 
might  add  that  I  feel  that  all  hand  injuries,  espe- 
cially where  there  is  to  be  nerve-  and  tendon- 
suturing,  should  be  done  in  a  well-organized  oper- 
ating room,  under  every  possible  aseptic  precau- 
tion. The  hand  should  be  put  up  in  position  of 
semiflexion,  and  not  on  a  splint  with  the  fingers 
extended,  as  this  may  result  in  stiffness. 

When  the  first  treatment  is  completed,  we  find 
it  advisable  to  expose  the  hand  sometimes  to  ultra- 
violet light,  or  to  x-rays,  or  to  both.  Eighty  to  100 
r  is  usually  sufficient  for  the  first  treatment.  X- 
ray-treatment  is  an  aid  to  the  prevention  of  devel- 
opment of  gas-bacillus  infection.  Combined  tetanus 
and  gas  gangrene  antitoxin  should  be  given  in 
these  cases.  The  hand  should  be  put  up  with  a 
light  dressing,  using  a  light  tent,  which  is  also 
important  in  preventing  development  of  infection. 
The  most  destructive  infection  in  hand  injuries 
is  that  by  the  streptococcus,  which  causes  slough- 
ing of  the  tendons,  lymphangitis,  prolonged  dis- 
ability, septicemia  and  even  death.  We  believe 
that  sulfanilamide,  or  one  of  its  derivatives,  given 
internally  would  be  of  great  help.    In  some  in- 


stances, sulfathiazole  powder  applied  in  the  wound 
might  be  of  help,  but  I  feel  that  the  best  and 
most  effective  aid  is  given  when  these  drugs  are 
taken  internally.  If  the  patient  is  not  able  to  take 
medicine  by  mouth,  neoprontozol  may  be  given 
intramuscularly. 

Frequent  inspection  of  the  hand  should  be  made 
for  the  first  day  or  so,  and  any  complications  that 
develop  may  be  taken  care  of  promptly. 

To  attempt  to  discuss  at  length  the  various  de- 
tails of  treatment  of  hand  injuries  is  not  within 
the  scope  of  this  paper,  as  these  things  are  taken 
up  from  time  to  time  as  the  surgeon,  in  his  judg- 
ment, may  find  necessary. 

Conclusions 

There  are  a  great  many  things  that  can  be  done 
for  hand  injuries,  even  the  most  severe  injuries 
that  seem  hopeless  at  first.  But  the  first  hour,  or 
few  hours,  of  treatment  is  what  counts  most  in  the 
end  and  governs,  to  a  large  extent,  the  outcome. 
Massage,  baking,  passive  and  active  motion,  and 
inductotherm  treatment  are  all  useful  and  should 
be  used  when  advisable. 

It  should  be  kept  in  mind  that  restoration  of 
anatomical  and  physiological  function  is  the  main 
consideration  in  the  treatment  of  hand  injuries 
and,  in  order  to  get  the  maximum  of  improvement 
and  the  minimum  of  disability,  treatment  must 
sometimes  be  kept  up  over  a  long  period  of  time. 
Weeks,  or  even  months,  of  treatment  may  be  nec- 
essary, until  the  point  is  reached  where  no  further 
improvement  can  be  obtained.  Only  then  should 
we  discharge  the  patient  from  treatment. 

Patient,  persistent  and  well  directed  treatment 
will  often  give  results  far  beyond  our  expectation 
and  much  better  than  even  the  patient  hoped  for. 

Color  photographs,  made  along  from  the  first 
to  the  last  treatment,  are  invaluable  as  records 
and  are  very  convincing  to  lawyers  and  jurors. 

A  careful,  written  record,  with  diagnosis  and 
details  of  treatment  of  hand  injuries,  should  be 
made  at  time  of  injury  and  added  to  from  time  to 
time  as  the  progress  of  the  patient  requires. 

First-aid  treatment  should  be  restricted  to  a 
minimum  of  interference  on  the  part  of  lay  first- 
aiders. 

Claim  men  should  be  impressed  with  the  eco- 
nomic, as  well  as  the  humanitarian,  objectives 
gained  by  painstaking  treatment  of  hand  injuries. 
They  should  never  underestimate  the  importance 
of  hand  injuries. 

Dr.  Davis:    I  have  some  pictures  of  these  hands. 

Dr.  L.  A.  Crowell,  Lincolnton:  I  would  like  to  see 
those  pictures  and  I  am  sure  some  of  the  other  men  would. 

Dr.  E.  R.  Hipp,  Charlotte:  It  might  be  well  to  leave 
off  the  discussion  and  have  the  pictures  instead  of  discus- 


SOUTHERN  MEDICINE  &  SURGERY 


May  1941 


DEPARTMENTS 


HUMAN  BEHAVIOUR 

James   K.   Hall,  M.  D.,  Editor,   Richmond,   Va. 


HEROISM 

DR.  RICHARD  MAURICE  BUCKE 

of 


CANADA 
1837—1902 


In  this  column  a  month  ago  I  talked  of  the 
American  Psychiatric  Association.  The  ninety- 
seventh  annual  meeting  of  that  organization  has 
just  been  concluded  in  Richmond  under  the  presi- 
dency of  Dr.  George  H.  Stevenson,  of  Canada.  A 
copy  of  the  address  of  Dr.  Stevenson  before  the 
Section  of  Historical  Medicine  of  the  Canadian 
Medical  Association  in  its  seventy-first  annual 
meeting  in  Toronto,  June,  1940,  has  lately  come 
into  my  hands.  In  it  I  am  enabled  to  renew  my 
acquaintance  with  two  of  the  mighty  contributions 
of  this  continent  to  medicine  and  to  mankind — Dr. 
Richard  Maurice  Bucke  and  Dr.  William  Osier. 
My  good  and  unique  and  large-hearted  friend, 
Dr.  John  Sasser  McKee,  of  Raleigh,  a  veteran  of 
that  other  World  War,  once  told  me  of  the  numer- 
ous reprimands  he  received  during  his  war-time 
days  because  he  habitually  addressed  his  fellow- 
physician  in  the  Service  as  Doctor  rather  than  by 
military  titles.  Someone  else  told  me  that  Dr. 
McKee  was  finally  let  alone,  after  he  had  replied 
to  his  corrective  superior  officer  with  the  emphatic 
expression  of  his  opinion  that  Doctor  was  the 
highest  title  he  could  think  of  and  that  he  had  no 
notion  of  addressing  a  doctor  otherwise  than  as 
Doctor,  even  if  he  were  to  be  put  in  the  guard- 
house and  kept  there  till  doomsday!  Dr.  William 
Osier  has  been  and  will  be  Dr.  Osier  to  me.  I 
saw  Dr.  Osier  only  two  or  three  times,  and  I  met 
him  only  once. 

Dr.  Richard  Maurice  Bucke  I  know  only  through 
the  medium  of  the  printed  page.  The  reprint  of 
the  address  of  Dr.  Stevenson  affords  a  study  in 
contrast  of  those  two  distinguished  physicians: 
Bucke  and  Osier:  A  Personality  Study,  by  Dr. 
George  H.  Stevenson,  Superintendent  of  the  Ontario 
Hospital,  London,  Ontario,  Canada.  Here,  we  would 
call  Dr.  Stevenson's  Hospital  a  state  hospital  for 
the  insane.  Of  that  Hospital  Dr.  Bucke  was  Super- 
intendent from  1877  until  his  death  in  1902. 

Dr.  Osier  understood  and  properly  practiced  the 
graceful  art  of  self-revealment,  and,  by  his  numer- 
ous autobiographies,  and  especially  through  the 
Life  of  Osier  by  Dr.  Harvey  Cusliing,  the  great 
diagnostician  is  probably  more  widely  known  than 


any  other  physician  who  has  lived  in  the  United 
States.  Because  of  that  fact,  I  shall  speak  only  in- 
cidentally of  Dr.  Osier.  I  am  interested  in  our 
knowing  more  about  Dr.  Bucke.  In  uniqueness  of 
personality,  in  character,  in  courage,  in  intellect, 
in  achievement  he  is  one  of  the  most  remarkable 
men  of  all  time.  I  wish  that  every  physician  who 
admires  those  qualities  would  request  a  copy  of 
the  reprint  of  Dr.  Stevenson.  In  these  troubled 
times  we  need  to  read  of  courage.  That  high  attri- 
bute, more  than  any  other,  relates  man  closely  to 
divinity. 

In  1838  the  Reverend  Horatio  Walpole  Bucke, 
a  clergyman  of  the  Church  of  England,  gave  up 
his  comfortable  charge  at  Methwold,  in  England, 
and  came  with  his  family  to  Canada.  He  established 
a  pioneer  home.  He  did  not  continue  in  the  mini- 
stry, but  he  engaged  in  farming.  He  brought  with 
him  his  wife,  his  children,  one  of  them  the  one- 
year-old  Richard,  the  subject  of  this  sketch.  And 
the  minister  brought  with  him,  too,  several  thous- 
and books;  for  he  was  a  scholarly  man,  and  he  was 
able  to  read  and  to  speak  at  least  seven  languages. 
What  a  radical  change  in  environment  and  in  activ- 
ities for  a  man  so  learned!  One  wonders  what 
changes  took  place  in  his  emotions,  in  his  thoughts, 
in  his  purposes  that  preceded  his  immigration 
into  the  wilderness. 

Little  Richard  Maurice  Bucke,  though  the  son 
of  a  scholarly,  bookish  Anglican  clergyman,  did 
not  during  his  boyhood  go  to  school  at  all.  He 
worked  on  the  farm.  But  he  learned  to  read  and 
in  his  father's  large  library  he  read  voraciously — 
in  history,  in  science,  in  religion,  in  philosophy.  The 
little  frontier  boy's  mother,  about  whom  we  seem 
to  know  little,  died  when  he  was  seven.  Soon  his 
father  married  again.  When  the  boy  was  sixteen 
his  stepmother  died.  Then  he  left  home.  There  is 
no  evidence  that  he  ran  away  or  that  his  father 
disapproved  of  his  going. 

Young  Richard  Bucke,  a  boy  of  sixteen,  who  had 
never  attended  any  school,  came  from  Canada 
down  into  our  United  States.  He  was  not  grown, 
he  was  without  special  training,  he  could  do  only 
manual  labor,  such  as  he  had  done  on  his  father's 
farm.  He  reached  the  valley  of  the  Ohio  and  later 
of  the  Mississippi,  and  he  did  hard  work  with 
his  hands — on  the  farm,  on  railroads  and  on  steam- 
boats, as  deck  hand  and  as  fireman;  and  in  the 
swamps  of  Louisiana  he  rived  shingles  out  of  the 
cypress  trees.  He  became  the  member  of  a  cara- 
van that  travelled  by  covered  wagons  to  Salt  Lake 
City.  Soon  he  found  a  fellow-adventurer  with  whom 
he  prospected  in  the  Sierras.  A  blizzard  and  associa- 
ted starvation  killed  his  companion.  Bucke  himself 
was  almost  dead  when  finally  found,  and  his  frozen 


SOUTHERN  MEDICINE  &  SURGERY 


feet  had  to  be  amputated,  well  above  the  ankles, 
probably  in  a  mining  camp.  After  months  of  con- 
valescence, the  twenty-year-old,  footless,  wholly 
unschooled  boy  returned  to  his  father's  home.  His 
geographic  Odyssey  had  been  finished.  His  adoles- 
cent adventures  had  deprived  him  of  his  feet  and 
almost  of  his  life. 

He  came  back  to  his  father's  home  and  at  McGill 
University  he  entered  upon  the  study  of  medicine. 
In  1862,  at  the  age  of  25,  he  was  graduated. 
Though  he  had  been  without  prescribed  and  for- 
mal schooling,  his  graduating  thesis  won  the  prize. 
The  subject  of  it  was:  The  Correlation  of  the 
Vital  and  Physical  Forces. 

He  went  abroad  for  a  year's  post-graduate  study 
in  medicine.  He  returned  to  his  home  in  Canada, 
married,  and  for  four  or  five  years  he  attended  to 
a  general  practice.  Inasmuch  as  there  are  no  clini- 
cal references  to  his  footlessness  I  do  not  know  to 
what  degree,  if  indeed,  at  all,  he  felt  handicapped 
by  his  physical  deprivation. 

The  superintendency  of  an  insane  asylum  in 
the  distant  eighties  was  wholly  unrelated  to  a 
sinecure.  Such  a  superintendent  may  have  even  as 
little  leisure  today.  But  during  the  years  of  Dr. 
Bucke's  superintendency  there  were  few,  if  any, 
trained  nurses,  an  inadequate  number  of  assist- 
ant physicians,  and  today's  mechanical  aids  in 
diagnosis  were  almost  wholly  lacking.  Dr.  Bucke 
busily  engaged  himself  in  improving  the  medical 
study  of  his  patients  and  in  humanizing  the  care  of 
them.  He  liberated  them  from  mechanical  re- 
straints, and  he  provided  as  many  of  them  as 
possible  with  congenial  employment.  His  tireless 
energy  and  his  resourceful  mind  lent  themselves 
to  unceasing  efforts  to  transform  a  custodial  insti- 
tution into  a  modern  hospital.  In  consequence  of 
his  labours  he  became  one  of  the  pioneer  psychi- 
atrists of  this  continent  and  one  of  the  great 
physicians  of  his  day. 

Dr.  Bucke's  career  is  illustrative  of  the  truth 
that  the  great  man  is  always  larger  than  his  pro- 
fessional self.  The  Royal  Society  of  Canada  made 
him  a  member;  the  British  Medical  Association 
made  him  president  of  its  psychological  section; 
and  he  was  elected  president  of  the  American 
Psychiatric  Association  under  its  former  name — the 
American  Medico-Psychological  Association.  But 
Dr.  Bucke's  increase  in  stature  was  never  added  to 
by  his  occupancy  of  high  position.  His  greatness 
was  due  to  his  own  cultivation  of  his  own  innate 
qualities.  In  spite  of  the  multiplicity  of  his  duties 
as  Superintendent  he  gave  a  course  in  nervous 
and  mental  diseases  in  a  medical  college;  he  con- 
tributed to  psychiatric  literature,  and  he  did  much 
medical  work.  In  the  early  days  of  his  superintend- 


ency he  brought  forth  a  book:  Man's  Moral 
Sature;  later  he  published  a  study  of  Walt  Whit- 
man, wnile  that  poet  was  still  alive;  and  shortly 
betore  his  death  his  philosophy  of  life  was  expressed 
in  a  volume,  the  preparation  of  which  must  have 
involved  voracious  reading  of  infinite  scope  and 
depth:  Cosmic  Consciousness. 

Always  a  student,  always  deeply  religious, 
always  an  individualist,  Dr.  Bucke  experienced 
throughout  his  earlier  years  discomfort  resulting 
from  religious  conflicts.  He  told  of  the  final  disso- 
lution of  those  doubts.  He  and  two  friends  spent 
an  evening  in  reading  Wordsworth,  Shelley,  Keats, 
Browning  and,  especially,  Walt  Whitman.  In 
driving  home  in  a  cab,  still  under  the  influence  of 
the  evening's  associations,  he  found  himself 
wrapped  'round,  as  it  were,  by  a  flame-colored 
cloud,  and  he  became  almost  ecstatically  happy. 
Within  those  few  seconds  he  claimed  that  he 
learned  more  than  in  all  his  previous  life,  and  he 
liad  a  foretaste  of  Heaven  that  dominated  the 
remainder  of  his  days.  He  became  a  devoted  dis- 
ciple of  Whitman,  and  he  asserted  that  Whitman 
was  the  greatest  religious  prophet  the  world  had 
ever  known.  His  idolization  of  Whitman  was  some- 
times too  much  for  his  more  orthodox  and  con- 
formist friends.  In  his  Life  of  Osier  the  story  is 
told  by  Cushing  of  an  evening  at  the  Rittenhouse 
Club  in  which  Osier  brought  together  Dr.  Bucke 
and  Dr.  Chapin  and  Dr.  Tyson  and  Dr.  J.  K. 
Mitchell  and  others.  Dr.  Bucke  was  already  old, 
and  the  group  must  have  marveled  at  the  complete- 
ness of  his  acceptance  of  the  religious  philosophy 
of  the  erratic  and  unkempt-looking  and  wholly 
nonconforming  old  poet  across  the  river  in  Camden. 
It  is  unlikely  that  Walt  Whitman  was  ever  a  guest 
of  the  Rittenhouse  Club  or  of  the  University  Club, 
or  in  the  homes  of  any  of  the  University's  pro- 
fessors. Educationally  and  medically  and  philoso- 
phically and  religiously,  if  not  always  politically, 
Philadelphia  is  a  proper  city.  Walt  Whitman  did 
not  belong  within  it,  nor  did  Dr.  Richard  Maurice 
Bucke. 

Dr.  Stevenson's  reprint  publishes  for  the  first 
time  five  or  six  Osier  letters — or  notes — all  written 
to  Dr.  Bucke.  Osier  and  Bucke  was  each  the  son  of 
a  minister  who  came  from  England  into  frontier 
Canada.  Each  must  have  been  largely  the  product 
of  heredity — Bucke  of  his  father  and  Osier  of  his 
mother.  But  Osier's  conformity  began  early  in  his 
life  and  he  soon  became  the  cultured  man  of  the 
world.  Bucke's  mind  was  innately  perhaps  the  more 
profound,  but  he  was  a  mystic  and  his  subjective 
self  was  always  to  him  the  most  interesting  phe- 
nomenon in  life.  Bucke  and  Osier  was  each  shaken 
and  probably  slowly  killed  by  the  tragic  death  of 


SOUTHERN  MEDICINE  &  SURGERY 


May  1941 


a  son — Dr.  Bucke's  by  accident,  young  Osier  on 
the  field  of  battle.  Dr.  Osier,  twelve  years  younger 
than  Dr.  Bucke,  lived  after  him  until  1919. 

Dr.  Bucke  had  none  of  the  usual  boyhood  school- 
ing. He  probably  did  not  attend  school  until  he 
entered  McGill  to  study  medicine.  But  he  was  a 
scholar,  even  as  a  boy.  Reckless  adventure  took 
both  his  feet  from  him  in  boyhood.  He  had  to  wear 
artificial  feet.  In  that  physical  condition  he  began 
the  study  of  medicine.  Many  a  boy,  perhaps  most 
boys,  would  have  become  invalids  as  cripples,  and 
would  have  remained  recipients  of  care.  The  loss  of 
his  feet  apparently  brought  young  Bucke  to  his 
feet,  and  fixed  him  on  his  course.  His  whole  life 
constitutes  a  magnificent  example  of  unceasing 
courage,  of  high  devotion  to  his  better  parts,  and  of 
broad  and  deep  love  of  mankind.  All  of  us  who 
must  live  with  ourselves  and  who  must  often  deal 
with  other  intolerables  in  our  professional  minis- 
trations should  make  a  study  of  the  life  of  Dr. 
Bucke.  His  character  and  his  career  exhibit  man 
at  man's  highest  level. 

In  the  midst  of  this  writing,  on  a  lovely  spring- 
time Sunday  afternoon,  I  put  down  my  pencil  to 
listen  by  radio  to  the  British  Prime  Minister, 
Winston  Churchill.  Bucke  and  Churchill!  What 
mighty  figures  English  blood  sometimes  produces! 


GENERAL  PRACTICE 

Walter  J.  Lackey,  M.D.  Editor,  fallston,  N.  C. 


HEMORRHAGE   FOLLOWING   TONSILLEC- 
TOMY 

Not  so  many  tonsils  are  being  removed  as  was 
the  case  a  few  years  back.  A  larger  fraction  of 
this  reduced  total  is  being  done  by  general  practi- 
tioners. Lives  have  been  lost  from  this  operation 
at  the  hands  of  specialist  and  at  the  hands  of  gen- 
eralist,  most  of  these  from  bleeding. 

An  article  on  this  subject  by  one  who  knows,1 
and  knows  how  to  impart  what  he  knows,  is  here 
given  in  brief: — 

Dangerous  hemorrhage  following  tonsillectomy 
is  uncommon  in  children,  frequent  in  adults.  The 
gravest  danger  in  these  cases  arises  from  inexperi- 
ence and  procrastination.  The  patient  may  bleed 
almost  to  death  with  very  little  bright-red  blood 
showing,  but  with  a  dilated  stomach  full  of  clots. 
The  bleeding  and  clotting  time  should  be  deter- 
mined beforehand  in  all  cases. 

Tonsils  must  not  be  removed  while  there  is  any 
infection  or  sore  throat.  High  blood  pressure  is  a 
contraindication. 

Do  not  allow  a  patient  to  leave  the  table  with 
the  throat  still  bleeding.    Fibrogen  should  always 

1.  P.  W.  Bailey,  Fort  Wayne,  Ind.,  in  Clin.  Med.,  April. 


be  given  as  an  initial  measure.  In  my  own  experi- 
ence it  has  seemed  that  thromboplastin  did  no 
good  at  all.  Ice  collars  and  cracked  ice  may  re- 
lieve. Gargling  with  5  per  cent  tannic  acid  solution 
sometimes  works. 

If  we  take  the  same  syringe  that  is  used  for 
local  anesthetic  operations,  and  inject  1  per  cent 
novocain,  with  1:40,000  adrenalin,  in  the  same 
amount  and  by  the  same  method  used  preliminary 
to  operation,  in  60  per  cent  of  cases  the  bleeding 
will  stop;  it  may  recur  in  an  hour.  If  it  was  al- 
most stopped,  but  there  was  still  a  little  bright- 
red  blood  in  the  saliva,  the  bleeding  will  certainly 
recur. 

Injection  should  always  be  tried  in  a  conscious 
and  cooperative  patient;  though  it  fail  as  a  com- 
plete cure,  it  will  relieve  the  anesthetist  of  the  dif- 
ficulty caused  by  the  blood  in  the  patient's  throat. 

Suture  of  the  pillars  is  the  treatment  for  bleed- 
ing in  amount.  Do  not  stand  by,  losing  time  with 
ice  chips  and  fibrogen;  get  the  patient  to  sleep  and 
stop  the  bleeding.  Sponge  pressure  alone  would 
probably  get  the  situation  under  control,  but  su- 
ture is  better.  An  artist  might  be  able  to  suture 
the  pillars  under  a  local  anesthetic.  It  is  better 
to  have  him  asleep.  Long-handled  instruments  are 
absolutely  requisite,  and  half-curved,  round-point 
needles  of  several  sizes,  No.  1  plain  catgut:  special 
pillar-suturing  needles  are  unnecessary. 

Anesthesia  must  be  deep  enough  to  relax  the 
jaw.  As  the  patient  first  goes  to  sleep,  the  anes- 
thetist must  beware  of  the  sudden  vomiting  of  a 
quantity  of  blood.  With  the  patient  relaxed,  the 
jaw  is  opened  wide  with  the  mouth  gag ;  the  tongue 
is  depressed;  and  any  blood  clots  are  removed 
from  the  fossa.  Then  apply  sponge  pressure  until 
the  bleeding  is  checked. 

Grasp  the  posterior  pillar  with  an  Allis  forceps 
and  draw  it  up  against  the  anterior  pillar.  With 
a  second  Allis,  clamp  both  pillars  together,  and  re- 
lease the  forceps  first  applied.  The  pillars  are  now 
in  good  position  for  sewing. 

Suture  with  interrupted  stitches,  entering  the 
needle  from  below  and  seizing  the  point  with  a 
Munson  cystic-duct  forceps,  or  some  similar  long- 
handled  instrument.  Knots  should  be  tied  square, 
with  three  throws.  The  stitches  should  bt  about  a 
quarter  inch  apart.  The  throat  should  be  dry  be- 
fore the  mouth  gag  is  released.  An  intravenous 
infusion  of  1,000  c.c.  of  S  per  cent  dextrose  in  phy- 
siologic saline  solution  is  advisable.  Watch  for  re- 
currence of  the  bleeding  about  the  third  day. 


Fecal  Impaction. — Think  of  it  and  examine  for  it  be- 
fore opening  the  belly  under  the  silly  diagnosis  of  "acute 
abdomen." 


May  1941 


SOUTHERN   MEDICINE   &   SURGERY 


■  THE  CAUSE  OF  STAMMERING 

The  theory  that  stammering  results  from  a 
faulty  action  of  the  larynx  in  producing  voice,  may 
be  of  real  importance,  but  it  has  never  been  com- 
pletely worked  out. 

A  writer  in  the  Illinois  Medical  Journal's  last 
issue  shows  the  incompetence  of  those  recent  the- 
ories that  find  the  explanation  of  stammering  in 
psychologic  abnormality. 

Evidence  is  presented  indicating  the  psycholo- 
gic normality  of  a  very  large  proportion  of  stam- 
merers, and  this  evidence  strongly  opposes  the 
conception  that  the  universal  explanation  of  stam- 
mering lies  in  "neuroticism,"  or  "disorders  of  per- 
sonality." 

The  author's  belief  is  that  the  impediment  is 
caused  by  a  specific  psychophysiologic  disordered 
action  of  the  larynx  in  producing  voice,  that  the 
attitudes  of  the  stammerer  are  caused  by  the  em- 
barrassment brought  about  in  large  part  through 
the  constant  and  serious  uncertainty  of  his  ability 
to  talk  normally. 

A  new  method  of  treatment  based  upon  this 
new  conception  has  been  attended  with  no  failure 
to  bring  about  complete  and  permanent  eradica- 
tion of  the  disorder  at  ages  9  to  12  in  the  six-year 
period  in  which  it  has  been  used. 

1.  E    L.  Kenyon,  Chicago,  in  III.  Med.  JI-,  April. 


TUBERCULOSIS 

J.  Donnelly,  M.  D.,  Editor,  Charlotte,  N.  C. 


INTESTINAL  TUBERCULOSIS 
Intestinal  complications  of  pulmonary  tuber- 
culosis oftentimes  receives  too  little  attention.  It 
has  been  claimed  that  a  large  proportion  of  active 
tuberculous  cases  at  some  time  in  their  course 
have  some  degree  of  intestinal  involvement  which, 
in  most  instances,  heals  without  ever  having  been 
recognized.  There  are  two  types:  the  primary  or 
hypertrophic,  and  the  secondary  or  ulcerative.  The 
latter  is  the  more  common  form,  and  the  more 
important.  There  is  still  considerable  argument  as 
to  whether  intestinal  tuberculosis  is  enterogenous 
or  hematogenous,  the  majority  agreeing  that  the 
avenue  of  infection  in  most  cases  is  the  alimentary 
tract,  and  that  the  swallowing  of  tubercle  bacilli 
laden  sputum  over  a  fairly  long  period  of  time  is 
the  activating  cause.  Healing  is  rarely  possible 
until  the  sputum  becomes  negative. 

In  the  April  issue  of  Diseases  of  the  Chest,  W. 
R.  Hewitt  has  a  discussion  of  this  subject,  and 
the  following  is  a  synopsis  of  his  observations  on 
the   pathology,    symptoms   and   treatment   of    the 


condition.  Owing  to  the  fact,  he  states,  that  tu- 
berculosis has  an  affinity  for  lymphoid  tissue,  the 
earliest  site  of  infection  is  in  the  ileocecal  region 
since  lymphoid  tissue  is  present  more  abundantly 
in  that  region.  Any  other  part  of  the  gastrointest- 
inal tract  may  be  involved,  including  the  stomach, 
but  when  such  involvement  is  found  the  condition 
is  likely  to  be  extensive.  Newest  infections  are 
found  in  the  Peyer's  patches,  which  later  go  on  to 
ulceration.  Ulceration  is  slow,  which  gives  adhesions 
time  to  form,  a  process  which  as  a  rule  prevents 
perforation.  There  is  caseation,  endothelial  and 
lymphocytic  cell  infiltration  and  giant-cell  forma- 
tion, with  narrowing  of  the  lumens  of  the  arteries 
often  to  obligation — which  may  explain  the  infre- 
quent occurrence  of  hemorrhage.  The  mesenteric 
lymph  nodes  are  always  involved.  Healing  and 
breaking  down  occur  simultaneously  in  the  bowel, 
scar-tissue  is  formed  and  narrows  the  lumen  of  the 
bowel.  Bands  of  adhesions  from  perforating  lesions 
add  to  the  obstruction.  Peritonitis  is  common  in  late 
disease,  and  fistulas  frequently  follow  surgical 
procedures. 

In  regard  to  the  symptomatology  of  intestinal 
tuberculosis,  the  author  states  that  it  is  impossible 
to  single  out  any  one  diagnostic  train  of  symptoms 
follow  each  other  in  great  variety.  Pain  is  in- 
constant and  is  not  proportionate  to  the  degree  of 
involvement  in  the  bowel.  It  is  usually  present  in 
the  lower-right  or  mid-abdomen,  and  may  be  severe 
and  cramplike,  although  it  is  usually  dull  and 
aching.  Palpation  over  the  area  frequently  elicits 
pain  when  it  is  not  otherwise  present.  Pain  in- 
volvement is  very  suggestive  of  intestinal  disease. 

Diarrhea  has  previously  been  supposed  to  be  an 
important  symptom  of  this  disease,  but  the  author 
says  that  it  is  found  present  in  only  30  per  cent  of 
the  cases,  and  that  it  is  no  more  a  symptom  of 
ulceration  that  constipation  is  of  absence  of  ulcera- 
tion. An  occasional  loose  stool,  or  recurrent  attacks 
of  diarrhea  are  signs  of  disease,  but  food  allergies 
and  functional  disorders  must  be  ruled  out.  Ulcer- 
action  is  usually  extensive  when  the  diarrhea  is  pre- 
sent continually.  Massive  hemorrhage  in  this  con- 
dition is  rarely  seen. 

In  discussing  other  symptoms,  it  is  noted  that  an 
irregular  temperature  is  characteristic  of  the 
disease,  while  uncomplicated  pulmonary  tubercu- 
losis has  a  rather  regular  temperature  curve.  With 
intestinal  tuberculosis  as  a  complication  the  earlv 
morning  subnormal  temperature  may  remain 
through  the  forenoon,  or  there  may  be  no  fever  for 
several  days  when  a  sudden  rise  may  occur.  Fre- 
quent intestinal  upsets  with  a  rise  of  temperature 
are  suspicious  indications,  but  the  temperature 
curve  may  remain  normal.  Loss  of  appetite  and 


SOUTHERN  MEDICINE   &   SURGERY 


consequent  lowered  food  intake  causes  loss  of 
weight,  not  only  because  of  lowered  food  intake, 
but  also  because  of  lessened  absorption.  Other 
symptoms  are  gaseous  eructation,  distention  after 
eating,  nausea,  vomiting  and  constipation,  either 
occasional  or  more  or  less  continuous. 

In  making  the  diagnosis  laboratory  methods 
with  the  exception  of  x-ray  examination,  are  of 
practically  no  value.  The  x-rays  must  be  relied 
on  to  a  large  extent,  and  this  examination  should 
be  made  much  oftener  in  cases  with  spu- 
tum positive  for  tubercle  bacilli  over  a  period  of 
months.  Diagnosis  by  x-rays  depends  on  filling 
defects,  changes  in  the  motility  of  the  bowel  and 
spasticity.  X-ray  films  should  be  made  from  the  6th 
or  7th  hour  through  the  9th  hour,  and  a  24-hour 
film  should  also  be  made.  The  colon  enema  is  not 
always  necessary  for  the  diagnosis.  Dilatation  and 
segmentation  are  considered  evidence  of  small  in- 
testinal involvement.  From  the  Sth  to  the  9th  hour 
after  giving  barium  by  mouth  it  should  be  passing 
through  the  ileocecal  area  into  the  right  colon,  and 
at  this  time  fluoroscopic  examination  is  of  aid  in 
locating  fixation,  thickening  and  tenderness.  The 
writer  also  favors  a  film  made  after  expulsion  of 
the  barium.  Filling  defects  are  caused  by  either 
scarring  or  spasm  at  the  site  of  the  mucosal  injury. 
Stasis  in  the  ileum  with  little  or  no  barium  remain- 
ing in  the  terminal  ileum  after  9  hours  also  indi- 
cates disease  in  the  same  area.  The  cecum  should 
remain  well  filled  from  the  6th  through  the  10th 
to  12th  hours,  and  if  barium  remains  in  the  ileum, 
while  the  ascending  colon  is  well-filled  and  the 
cecum  is  poorly  filled,  the  indications  are  that 
disease  is  present  in  the  cecum. 

The  author  considers  prophylactic  treatment  as 
the  first  line  of  defense  in  intestinal  tuberculosis, 
i.  e.,  well  planned  active  treatment  in  order  to 
render  the  sputum  negative  for  tubercle  bacilli  as 
quickly  as  possible  The  various  modern  methods 
of  chest  surgery  are  recommended  as  effectual  in 
achieving  this  result. 

Maintenance  of  good  digestive  ability  and, 
hence,  the  best  possible  state  of  nutrition  is  neces- 
sary, remembering  that  a  high  state  of  nutrition  is 
not  necssarily  synonymous  with  a  rapid  gain  in 
weight.  Proper  nutrition  is  produced  by  supplying 
all  food  elements,  vitamins  and  minerals,  and 
causing  them  to  be  properly  and  fully  absorbed. 
The  diet  should  be  bland  and  with  a  minimum  of 
residue,  but  a  highly  restricted  diet  should  not  be 
continued  for  any  considerable  length  of  time. 
When  blood  findings  are  below  normal,  iron  in 
some  form  should  be  added.  Powdered  opium  or  the 
deoderized  tincture  should  be  used  for  pain  or 
looseness    of    the    stools.    Constipation    should    be 


handled  in  the  simplest  way,  as  laxatives  should  be 
avoided,  and  mineral  oil  should  not  be  used  for  any 
considerable  length  of  time. 

The  author  considers  artificial  heliotherapy  as 
essential  in  the  treatment,  and  considers  it  per- 
ferable  to  sunshine  as  the  dose  can  be  accurately 
measured  and  does  not  harm  the  lung  condition, 
as  sunshine  often  does.  The  mercury  vapor  ultra- 
violet lamp  is  used  over  the  whole  body,  except 
the  chest  and  eyes,  both  of  which  should  be 
covered.  Exposure  is  begun  with  one-half  minute 
daily  over  front  and  back  with  the  burner  at  a 
36  inch  distance,  the  time  to  be  increased  by  not 
over  one-half  minute  a  day.  When  the  exposure 
reaches  30  minutes  daily  to  back  and  front  the  lamp 
may  be  gradually  lowered  to  30  inches.  The  writer 
recommends  that  irradiation  be  continued  in  this 
way  over  a  period  of  from  one  to  two  years.  He 
concludes  the  article  by  saying  that  the  prognosis 
in  intestinal  tuberculosis  is  very  favorable  provided 
the  lung  involvement  can  be  satisfactorily  con- 
trolled, and  the  local  treatment  of  the  condition 
itself  carefully  carried  out. 


RHINO-OTO-LARYNGOLOGY 

Clay  W.  Evatt,  M.  D.,  Editor,  Charleston.  S.  C. 


OTITIS  HEMORRHAGICA 
During  and  following  the  influenza  epidemic  I 
saw  quite  a  few  cases  of  otitis  hemorrhagica.  In 
most  of  these  the  hemorrhage  was  petechial  from 
a  generally  engorged  external  canal,  and  accom- 
panied by  a  similar  engorgement  of  the  mucous 
membrane  of  the  nose  and  pharynx,  and  in  some 
cases  the  conjunctiva  also.  The  appearance  of  the 
auditory  canal  and  drum  was  not  unlike  that  fre- 
quently seen  in  measles.  In  four  cases,  all  chil- 
dren, the  canal  was  clear,  the  drum  purplish  red 
and  shiny.  On  myringotomy  a  small  to  moderate 
amount  of  whole  blood  was  released  from  pressure. 
In  one  case  a  definite  fluid  level  was  seen  before 
opening.  In  no  case  was  there  involvement  of  the 
inner  ear.  Cultures  from  these  ears  showed  no 
growth  in  some,  hemolyzing  and  non-hemolyzing 
staphylococcus  aureus  in  others,  non-hemolyzing 
streptococcus  (strep,  viridans)  in  still  others,  and 
only  one  Beta  hemolyzing  streptococcus.  Irriga- 
tion and  drops  were  used  as  indicated  and  sulfath- 
iazole  according  to  body  weight  were  given,  except 
in  the  Beta  streptococcus  case  where  neosulfonyl 
was  used.  Recovery  was  uneventful  and  prompt  I 
in  all  cases. 

It  is  noteworthy  that  in  some  cases  there  was 
no  bacterial  growth,  using  the  same  technique  and 
the  same  culture  medium  in  all  cases;  also  that, 
of  those  cases  cultured  only  about  one  in  fifteen 


SOUTHERN   MEDICINE   &   SURGERY 


showed  Beta  streptococcus,  emphasizing  the  futil- 
ity of  giving  sulfanilamide  to  all  comers  with 
otitis  media  (pharyngitis,  bad  colds,  etc.)  A  num- 
ber of  the  cases  made  immediate  recovery  after 
myringotomy  without  any  chemotherapy.  In  those 
cases  showing  no  bacterial  growth,  one  is  led  to 
wonder  if  the  virus  of  influenza  is  not  responsible 
for  the  otitis  media  even  without  bacteria. 

In  the  epidemic  of  1918  all  the  cases  which 
came  to  autopsy  showed  an  invasion  by  bacteria; 
in  other  words,  death  was  caused  by  these  bac- 
teria. Also,  cases  of  pneumonia  following  measles 
which  came  to  autopsy  all  showed  a  secondary  in- 
vasion with  bacteria. 

From  the  recent  epidemic  of  influenza,  Stokes 
and  Wolman1  report  a  fatal  case  which  came  to 
necropsy.  A  blood  culture  taken  before  death 
demonstrated  a  pure  culture  of  Staphylococcus 
aureus.  The  same  bacterium  was  recovered  from 
the  trachea  and  lungs.  During  the  last  hour  of  th<j 
patient's  life  there  was  an  increasing  amount  of 
hemorrhagic  fluid  choking  her  nose  and  throat, 
amounting  terminally  to  over  1000  c.c.  Two  rao- 
idly  fatal  cases  of  influenza,  not  yet  reported, 
showed  an  overwhelming  secondary  infection  with 
Staphylococcus  aureus. 

Influenza,  common  colds,  and  rheumatic  fever 
seem  to  be  due  to  a  virus  paving  the  wav  for  a 
bacterium.  Fatal  cases  of  measles  are  not  due  to 
the  virus  of  measles,  but  to  the  secondary  bacte- 
rial invaders. 

Hemorrhagic  otitis  media  could  be  due  to  the 
Staphvlococcus  toxins  which  weaken  the  blood- 
vessel walls  and  produce  the  hemorrhagic  tendency 
seen  in  many  cases  of  influenza. 

The  treatment  of  these  cases  of  influenza  should 
be  started  earlv.  Chemotherapy  should  not  be 
used  indiscriminately,  but  where  it  is  to  be  used, 
sulfathiazole  is  the  drue  of  choice  until  bacteri- 
ologic  report  is  known,  then  if  necessarv  sulfapyri- 
dine  or  sulfanilamide  may  be  substituted. 


PUBLIC  HEALTH 

N.  TrfOMAS  Ennett,  M.D..  Editor,  Greenville,  N.  C. 
Health   Officer  Pitt   County. 


IMMUNIZATION  CERTIFICATION 
It  appears  that  many  physicians  are  not  famil- 
iar with  the  North  Carolina  law  in  the  matter  of 
certification  of  diphtheria  immunization.  For  the 
information  of  such  physicians  and  in  the  interest 
of  parents  and  school  principals,  as  well  as  the 
health  officer,  we  here  quote  two  sections  of  the 
diphtheria  law: 


"Section  4:  A  certificate  giving  the  name  and 
address  of  the  parent,  parents  or  guardian,  the 
name  and  age  of  the  child  and  the  date  of  the  ad- 
ministration of  the  prophylactic  agent,  shall  be 
submitted  by  the  physician  rendering  this  profes- 
sional service  to  the  local  Health  Officer,  and  in 
instances  where  there  is  no  Health  Officer,  said  cer- 
tificate shall  be  submitted  to  the  County  Physi- 
cian. Such  certificate  shall  be  kept  on  file  as  a 
permanent  record  by  the  *local  County  Registrar 
for  births.  Furthermore,  such  certificate  of  im- 
munization shall  be  presented  to  school  authorities 
upon  admission  to  any  public,  private  or  parochial 
school  in  North  Carolina. 

Section  Sl/2:  Provided  this  Act  shall  not  apply 
to  children  whose  parent  or  parents  or  guardians 
?re  bona  fide  members  of  a  religious  organization 
whose  teachings  are  contrary  to  the  practices  here- 
in required." 

It  appears  to  us  that  the  certificate  made  out  by 
the  practicing  physician  should  be  made  out  in 
triplicate,  one  for  the  parent  to  be  passed  to  the 
principal  of  the  school,  one  to  the  registrar,  and 
one  to  the  Health  Officer. 

*We  interpret  the  expression  "local"  to  mean  city  or  township 
registrar. 


OPHTHALMOLOGY 

Herbert  C.  Neblett,  M.  D.,  Editor,  Charlotte.  N.  C. 


HEADACHE  NOT  OF  OCULAR  ORIGIN 

Two  impressive  problems  pre  presented  by  the 
majority  of  patients  who  seek  an  eye  examination. 
The  one,  the  history  of  headache  as  a  common 
symptom;  the  other,  the  belief  that  the  eyes  must 
be  at  fault,  and  that  glasses  will  be  a  panacea  for 
any  and  all  types  of  headache. 

It  has  been  taught  that  the  great  majority  of 
headaches  are  functional  in  origin  and  that  the 
majority  of  these  have  an  ocular  basis.  The  for- 
mer viewpoint  is  readily  subscribed  to,  but  the 
latter  is  not  so  acceptable.  For  years  the  writer 
has  made  a  careful  study  of  this  problem  in  an 
effort  to  prove  to  his  own  satisfaction  and  that  of 
the  patient  that  headache,  not  of  organic  origin, 
oftener  than  not  has  its  etiology  elsewhere  than  in 
the  eye. 

Proof  of  this  are  the  facts  that  many  persons 
with  defects  of  vision  based  upon  high  refractive 
errors  of  any  type  rarely,  if  ever,  experience  head- 
ache worthy  of  note  and  present  themselves  for 
examination  because  of  defective  sight;  and  that 
the  majority  of  headache  victims  have  neither  vis- 
ual deficiency,  accommodative  anomaly,  muscle 
imbalance,  ocular  pathology,  nor  refractive  error 
— or  at  most  one  of  minor  consequence  and  of  a 


SOUTHERN  MEDICINE  &  SURGERY 


simple  type.  To  say  that  an  optical  lens  relieves 
the  majority  of  these  patients  is  not  based  on  fact. 
If  perchance  it  does  relieve  the  headache  the  relief 
is  in  psychic  response  to  the  wearing  of  the  glasses. 
Cases  of  this  type  are  frequently  encountered,  pa- 
tients wearing  a  plus  or  minus  0.12  diopter  sphere 
or  cylinder  who  claim  they  are  lost  without  these 
glasses  and  headache  is  more  marked  without 
them.  Further  proof  in  this  particular  is  had  by 
the  fact  that  in  the  absence  of  an  ocular  problem 
patience,  perseverance  and  a  careful  analysis  by 
the  oculist  will  prove  to  the  patient  that  glasses 
are  not  indicated,  that  his  headache  will  not  be 
benefited  by  them  and  that  the  cause  of  the  head- 
aches is  outside  the  sight  organs.  By  so  doing  he 
may  accomplish  three  things:  he  may  dispel  the 
belief  prevalent  among  the  laity  that  glasses  are 
the  panacea  for  headaches;  he  may  temporarily 
lose  the  patient  and  glasses  prescribed  elsewhere 
be  found  by  the  patient  to  give  no  relief,  and  he 
will  return  poorer  but  wiser  and  grateful;  or  he 
may  be  able  to  convince  the  patient  that  the  head- 
aches are  based  upon  incorrect  habits  of  living  or 
upon  general  physical  factors,  etc.,  and  be  the 
means  of  having  the  patient  obtain  nlief  by  means 
directed  against  the  real  cause. 

What  are  some  of  the  other  factors  at  fault 
which  produce  functional  headaches  not  of  ocular 
origin?  Chronic  fatigue,  physical  and  nervous, 
from  whatever  cause — prevalent  among  all  classes 
of  people  because  of  the  speed  at  which  we  live — 
chronic  constipation  in  80  per  cent  of  women  and 
25  per  cent  of  men.  a  hurried  breakfast  of  some 
fruit  juice  and  a  cup  of  coffee  or  coffee  alone  to 
begin  the  day's  work  and  supplemented,  beginning 
at  9  a.  m.,  with  some  caffeine  drink  and  continued 
throughout  the  day  so  that  a  proper  and  nourish- 
ing dietary  is  neither  ingested  nor  desired,  dietary 
fads  for  weight-reducing  principally  among  women, 
habitual  and  excessive  smoking  bv  all  classes 
which  in  many  produces  a  baneful  effect,  allergic 
states  producing  congestion  of  the  mucous  mem- 
brane of  the  nose  and  accessory  sinuses,  lack  of 
outdoor  exercise  and  healthful  diversion,  too  much 
competition  in  life  for  the  child  and  adult  pos- 
sessed of  a  highly  nervous  mechanism.  Add  to 
these  the  regimentation  of  all  classes  of  people  in 
their  economic,  social,  religious  and  domestic  life, 
and  a  physical  and  mental  status  will  result  which 
will  produce  many  functional  problems  of  the  body 
of  which  headache  is  not  the  least. 

In  summary — we,  as  oculists,  are  physicians, 
and  we  can  best  serve  our  patients  and  ourselves 
by  a  broader,  more  comprehensive  application  of 
our  knowledge  of  the  practice  of  medicine  in  each 
individual  case,  rather  than  lose  our  identity  by 


confining  ourselves  too  technically  to  the  eye  as  an 
organ  apart  from  the  rest  of  the  human  anatomy. 


HOSPITALS 

R.  B.  Davis,  M.D..  Editor,  Greensboro.  X.  C. 


THERE  ARE  TWO  SIDES 
In  a  meeting  of  a  board  of  directors  of  a 
hospital  the  purchase  of  new  equipment  is  fre- 
quently discussed.  All  kinds  of  questions  are  asked: 
who  requisitioned  the  purchase?  how  long  has  it 
been  since  that  department  asked  for  a  similar  pur- 
chase? how  much  did  that  department  spend  last 
"ear  for  new  equipment?  what  is  the  cost  of  the 
desired  items?  The  most  important  questions  are 
often  left  out.  They  are:  Will  the  present  equip- 
ment render  trustworthy  service  if  properly  used 
by  a  careful  and  painstaking  personnel?  If  it  will 
not,  can  it  be  economically  repaired  so  that  it 
will  render  such  service? 

The  other  side  of  the  question  is  supported  by 
the  head  of  the  department  requesting  the 
equipment.  This  is  usually  the  argument:  A 
certain  piece  of  equipment  is  so  many  years  old. 
It  is  entirely  out  of  date.  To  use  it  requires  too 
much  time  and  effort.  Other  departments  in  the 
hospital  have  had  new  equipment  since  thev  had 
anything.  Their  department  would  be  up-to-date  if 
it  had  this  particular  equipment.  It  is  seldom  that 
they  will  come  out  and  make  the  point-blank 
statement  that  the  present  equipment  is  not  capa- 
ble of  doing  the  work.  Often  they  will  admit  that 
it  is  possible  to  repair  the  old  equipment  so  that  it 
will  be  satisfactory. 

Now  from  the  board  of  directors  viewpoint  it  is 
hard  to  see  from  any  other  angle  than  that  of 
black  and  red  figures  unless  thev  happen  to  be 
nhvsicians  themselves.  Unfortunately,  this  is  not 
usually  the  case.  The  group  appointed  to  run  a 
hospital  are  most  often  selected  for  one  of  three 
reasons:  First,  because  thev  are  wealthy  and  there- 
by influential;  second,  because  they  are  very 
popular;  third,  because  they  have  succeeded  in 
some  kind  of  business.  None  of  them  is  appointed 
because  he  knows  the  difference  between  a  Bausch 
&  Lomb  and  a  Spencer  Microscope,  or  a  Kny- 
^cheerer  operating  room  table  and  one  of  some 
cheaper  type.  The  only  wav  for  these  individuals 
to  intelligently  supervise  the  purchasing  of  new 
equipment  is  for  them  to  consult  someone  who 
knows  and  who  is  capable  of  giving  an  unbaised 
opinion.  Also,  thev  should  learn  to  ask  intelligent 
questions.  A  direct  and  correct  answer  to  an  in- 
telligent question  will  help  a  lot.  The  first  and  last 
question  should  be:  Will  this  new  equipment  facil- 
itate  the  recovery  of  our  patients?   In  between. 


SOUTHERN  MEDICINE  &  SURGERY 


however,  they  should  ask  how  much  the  new 
equipment  costs,  how  durable  it  is  and  if  it  is  a 
time-saving  device. 

We  shall  all  have  to  admit  that  propaganda 
is  an  effective  method  of  persuasion.  No  one 
realizes  this  better  than  the  commercial  houses 
selling  equipment.  Their  representatives  are  ex- 
perts at  propagandizing  department  heads.  By  the 
time  a  representative  gets  through  with  an  interview 
the  dietitian,  the  operating  room  supervisor,  the- 
laboratory  technician — any  department  head — is 
convinced  that  his  or  her  department  is  the  scape- 
goat of  the  hospital  family,  and  that  he  or  she 
should  be  ashamed  to  admit  being  connected  with 
an  institution  that  will  not  replace  such  obsolete 
equipment. 

Before  the  visit  of  the  representative  of  the 
commercial  house  they  had  considered  themselves 
getting  along  all  right,  but  now  they  are  very 
certain  that  their  setup  is  bevond  redemption  un- 
less drastic  changes  are  made.  Maybe  one  has 
recently  visited  a  similar  department  in  another 
hospital  where  new  equipment  has  been  installed. 
This  has  stimulated  enthusiasm  and'coveteousness. 
Vanity  demands  "the  best,"  or  "as  good  as  others 
have"'  anyway.  With  that  frame  of  mind  they  are 
prepared  for  the  thought  that  it  is  not  money 
out  of  their  pocket  and  why  should  they  have 
their  pride  trampled  on  in  the  interest  of  the 
financiers  of  some  institution. 

The  heads  of  many  of  the  departments  in  the 
hospitals  nearly  always  refer  to  the  hospital  as 
"my  hospital";  strangely  they  sometimes  forget 
that  relationship  when  they  want  something  which 
costs  time  and  labor  or  money.  Also  when  some 
other  institution  offers  them  a  position  with  a  raise 
in  salary  or  shorter  hours. 

So  we  can  see  that  there  are  two  sides  to  this 
as  well  as  to  other  questions.  Neither  side  should 
be  dogmatic  or  inconsiderate  of  the  other's  position. 
The  best  solution  is  for  the  hospital  directors  to 
employ  a  businesss  manager  or  superintendent 
who  is  intelligent,  trained  and  fair-minded.  Such 
an  individual  should  know  whether  or  not  the 
equipment  is  obsolete,  whether  it  is  being  properly 
used,  whether  the  results  are  satisfactory,  whether 
it  is  capable  of  being  repaired:  and  if  new  equip- 
ment is  necessary,  when  the  proper  price  has  been 
submitted.  The  one  thing  which  is  necessary  for 
all  parties  to  consider  is  that  all  hospitals  are  built, 
maintained  and  operated  for  the  benefit  of  the 
sick  man  who  is  unable  to  work  and  therefore 
unable  to  earn  a  livelihood  for  himself  and  fur  his 
family:  Those  who  make  their  livlihood  out  of 
such  institutions  will  have  to  learn  to  live  and 
enjoy  the  services  they  are  rendering  to  mankind, 


rather   than   the   remuneration   they  are  receiving 
for  their  labors. 


INSURANCE  MEDICINE 

H.  F.  Starr,  M.D.,  Editor,  Greensboro,  N.  C. 

In  establishing  a  Department  of  Insurance 
Medicine.  Southern  Medicine  &  Surgery  has  taken 
a  forward  step  from  which  a  large  number  of  its 
leaders  will  benefit. 

The  amount  of  insurance  work  done  by  physi- 
cians in  the  United  States  and  the  extent  to  which 
insurance  fees  contribute  to  the  total  income  of 
physicians  in  this  country  is  truly  astounding.  The 
Medical  Examiners'  Committee  of  the  American 
Life  Convention  collected  data  and  reported  that 
Life  Insurance  Companies  alone  paid  to  physicians 
$70,504,361.42  in  medical  fees  in  the  year  1936 
(the  latest  year  in  which  the  figures  were  compil- 
ed). This  does  not  include  the  amount  paid  by 
self-carriers,  state  insurance  plans,  contract  prac- 
tice, group  and  industrial  payments,  automobile 
liability  payments,  nor  fees  paid  as  provided  in 
accident  policies.  The  committee  estimated  con- 
servatively that  these  excluded  groups  paid  an  ad- 
ditional $50,000,000  to  physicians.  The  average 
practitioner  receives  practically  one-fourth  of  his 
income  from  insurance  work.  So,  for  this  reason 
alone,  a  department  in  this  journal  dealing  with 
insurance  medicine  should  meet  a  very  definite 
need,  particularly  in  view  of  the  fact  that  there  is 
little  material  on  the  subject  available  to  practic- 
ing physicians.  Almost  every  physician  at  some 
time  or  other  engages  in  insurance  work  to  a  great- 
er or  less  extent. 

Insurance  Medicine  is  a  specialty  and  it  has 
built  up  quite  an  extensive  literature  of  its  own 
which  is  almost  entirely  unknown  to  Clinical  Med- 
icine. Yet  there  is  much  information  that  insur- 
ance medicine  has  accumulated  which  should  inter- 
est clinicians  and  can  be  utilized  to  a  very  decided 
advantage  in  clinical  medicine.  It  will  be  the  pur- 
pose of  this  Department  to  present  from  time  lo 
time  various  phases  of  insurance  medicine  which 
it  is  hoped  will  prove  useful  to  the  readers,  in  their 
clinical  as  well  as  their  insurance  work. 

Eminent  authorities  in  the  field  of  insur- 
ance medicine  will  contribute  articles  to  this  De- 
partment frequently.  We  are  happy  to  announce 
that  next  month  there  will  appear  an  article  by 
Dr.  Harry  W.  Dingman,  Medical  Director  and 
Vice-President  of  the  Continental  Life  Insurance 
Company  of  Chicago,  a  recognized  authority  and 
author  of  Insurability  Prognosis  &  Selection,  Se- 
lection of  Risks  and  numerous  papers  on  various 
phases  of  insurance  medicine. 


SOUTHERN  MEDICINE  &  SURGERY 


May  1941 


Comments  and  criticisms  from  readers  or  sug- 
gestions as  to  topics  for  discussion  will  be  grate- 
fully received. 


THERAPEUTICS 

J.  F.  Nash,  M.  D„  Editor,  Saint  Pauls,  N.  C. 


THE  GLUCOSE-INSULIN  TREATMENT  OF 
ADVANCED  CIRRHOSIS 

That  something  may  be  done  for  a  patient  in 
advanced  cirrhosis  of  the  liver,  even  to  returning 
the  individual  practcially  to  normal,  is  news  in- 
deed.   This  news1  is  passed  on  for  wide  use. 

The  liver  with  portal  cirrhosis  of  the  most  ad- 
vanced type  is  capable  of  a  reversion  to  a  func- 
tionally adequate  liver.  It  is  probable  that  alcohol 
plus  the  dietary  deficiency  factor  "X"  is  responsi- 
ble for  most  of  the  Laennec's  cirrhosis  that  we  see. 

In  the  treatment  the  essential  points  are  that  1) 
whisky  and  all  other  forms  of  alcohol  be  stopped. 
2)  the  missing  elements  in  the  diet  be  supplied  in 
excess,  and  3)  the  secondary  therapeutic  measures 
be  designed  to  be  helpful  rather  than  fatal. 

Salyrgan,  mercupurin  and  other  diuretics  do  lit- 
tle if  anything  for  the  ascites;  they  may  do  harm 
by  causing  a  serious  dehydration  in  the  extraportal 
circulatorv  system.  The  ascites  requires  paracente- 
sis, repeated  as  often  as  necessary,  provided  one 
bears  in  mind  what  is  happening  physiologically  a« 
one  continues  to  draw  off  fluid;  unless  these 
changes  are  compensated,  repeated  paracentesis 
can  kill  the  patient. 

Along  with  paracentesis,  the  customary  low- 
fluid,  low-protein  and  low-salt  diet  is  like  a  drink 
of  wormwood.  How  much  water  the  patient  is  to 
have  can  best  be  judged  bv  his  thirst.  Salt  can  be 
replaced  with  ease  in  the  food,  or  in  saline  solution 
bv  vein.  For  replacement  of  the  protein  transfu- 
sions of  blood  serum  or  of  whole  blood  are  usuallv 
necessary. 

After  the  ascites,  the  next  concern  is  measures 
beneficial  to  the  liver  itself — liver  extract  parenter- 
al^- to  supply  the  blond-building  factor  and  sodium 
zanthine,  vitamin  B>  in  excess  along  with  the  rest 
of  the  vitamin  B  complex.  Brewer's  yeast  does 
good,  not  only  because  of  the  vitamin  B  complex  it 
contains,  but  also  because  it  contains  a  factor  "X"; 
also  a  pancreatic  extract,  known  as  hoocaic  (active 
ingredient  appears  to  be  choline).  Our  most  bene- 
ficial substance  in  treating  liver  dise^co  in  general 
is  glucose.  In  advanced  cirrhosis  400  to  600  c.c.  of 
carbohydrate  a  day.  either  orally  or  intravenously. 
is  essential. 

On  the  regimen  outlined,  the  patient  with  ad- 
vanced  cirrhosis  will   get  along  for  an  indefinite 


period.  If  the  liver  damage  is  not  too  severe  he 
may  even  cease  to  have  ascites  and  return  to  a  fair 
degree  of  activity. 

In  obstinate  cas'<=  an  additional  measure  has 
been  found  to  "turn  the  trick."  It  was  noted  that 
considerable  amounts  of  glucose  came  through  in 
the  urine.  Thinking  to  obviate  this  waste  of  car- 
bohydrate, insulin  was  given  sufficient  to  render 
the  urine  sugar-free.  In  a  patient  who  had  been 
•  tapped  28  times  in  30  weeks  the  ascites  disap- 
peared two  weeks  after  starting  insulin,  the  patient 
remaining  otherwise  on  the  original  treatment. 
After  two  months,  the  insulin  was  withdrawn  and 
in  a  fortnight  paracentesis  became  necessary.  In- 
sulin was  resumed  and  again  withdrawn  on  three 
subsequent  occasions  so  that  thr  relation  of  the 
insulin  to  the  disappearance  of  the  ascites  seemed 
established  in  one  patient.  Then  the  same  proce- 
dure was  repeated  in  two  additional  patients  with 
far-advanced  Laennec's  cirrhosis  with  similar  re- 
sults. After  insulin  had  been  given  for  periods  of 
nine,  six,  and  six  months,  respectively,  in  the  three 
cases,  the  liver  had  recovered  so  as  to  do  its  work 
without  insulin.  All  three  patients  have  returned 
to  a  fair  degree  of  activity  and  have  normal  liver 
functions  as  measured  by  the  hippuric  acid  syn- 
thesis and  other  tests. 

When  repeated  paracentesis  is  necessary  in 
Laennec's  cirrhosis,  a  diet  containing  adequate 
fluid,  protein  and  salt  is  essential;  also  transfu- 
sions, liver  extract,  thiamine  chloride.  Brewer's 
yeast,  a  carbohydrate  intake  of  400  to  600  gm. 
daily  and  insulin  in  amounts  sufficient  to  prevent 
glycosuria. 


1.  J.  A    Schindler.   Monroe.  Wii 


Wise.   Med.   J!..   Ma 


LESSONS  FROM   INFLUENZA   EPIDEMIC 

The  recent  epidemic  of  influenza  was  very  gen- 
eral and  of  a  milder  type  than  the  1918  pandemic: 
complications  were  as  frequent,  but  mortality  was 
much  lessened. 

Research  has  been  constant  for  a  vaccine  or 
preventative.  Quite  recently  it  was  noticed  that 
ferrets  during  the  course  of  their  distemper  could 
not  be  infected  with  influenza.  Both  distemper 
and  influenza  germs  (virus?)  are  grown  on  incu- 
bated eggs.  The  work  and  experimentation  with 
vaccines  made  in  this  manner  have  given  encour- 
aging results. 

Chemotherapy  is  of  inestimable  value  in  influ- 
enzal complications.  Before  the  advent  of  the  sul- 
fonamides pneumonia  took  a  toll  up  to  40  per 
cent.  Since  their  use  has  become  general  the  mor- 
tality is  virtually  nil  for  respiratory  diseases.  No 
untoward  reactions  have  been  noted  in  the  use  of 


Mav  1941 


SOUTHERN  MEDICINE  &  SURGERY 


this  drug.  The  thiazole  derivative  has  been  most 
satisfactory  and  the  cost  is  a  third  of  that  of  the 
other  derivatives.  There  has  been  no  cyanosis, 
only  slight  nausea,  and  large  doses  could  be  ad- 
ministered for  a  shorter  period  of  time.  No  uri- 
narv  calculi  have  been  noticed  following  its  usage. 
Xo  blood  dyscrasias  have  exhibited  themselves — 
Drs.  Holmes  and  Martin  have  recovered  from  the 
bone-marrow  alcohols  which  will  prevent  agranulo- 
cytosis. 

Promin.  one  of  the  newer  sulfone  drugs,  has 
been  found  efficacious  in  streptococcal  infections, 
especially  those  of  the  upper  respiratory  tract  and 
erysipelas. 

"Grain  for  grain  it  was  less  toxic  than  sulfanila- 
mide and  was  tolerated  better  than  either  sulfan- 
ilamide or  sulfapvridine.  It  was  injecttd  slowly 
in  amounts  of  S  Gm.  three  times  a  day  in  all  pa- 
tier  ts.  regardless  of  age  or  weight.  It  did  not 
cause  destruction  of  red  blood  cells  nor  irritate  the 
kidneys.  There  was  no  evidence  of  formation  of 
crystalline  deposits  in  the  urinary  tract.  Orally 
the  drug  was  erratically  absorbed."1 

It  might  be  thought  that  a  combination  of  sero- 
and  chemotherapy  in  the  treatment  of  pneumonia 
would  be  most  effective,  but  on  account  of  the  in- 
accessibility of  laboratories  and  of  sera,  and  the 
high  cost  of  sera,  this  combination  use  is  rarely 
practicable.  However,  the  sulfones  have  a  happy 
use  in  preventing  and  curing  pneumonias,  sinus 
infections  and  other  complications  of  influenza. 


cases  thyroid  extract  produced  results  which  were  almost 
miraculous. 


PSEUDO  SINUSITIS 

(Eugene  Orr,  Nashville,  in  Jl.   Tain.  Stale  Med.  Assn..   Mar.) 

The  term  "sinus  disease"  is  loosely  used.  It  has  sup- 
planted the  "catarrh"  of  yesteryear.  The  headache  patient 
is  too  often  the  victim  of  a  loosely- made  diagnosis  of 
sinus  disease  or  eyestrain.  It  does  not  take  any  sort  of 
special  examination  to  find  that  many  of  these  patients 
do  not  have  sinus  disease.  Often  a  history  together  with  a 
general  examination  will  suffice. 

To  operate  on  the  x-ray  findings  alone  is  to  do  unnec- 
essary surgery.  The  antrum  is  diseased  oftcner  than  any 
other  sinus  and  here,  as  a  rule,  it  is  comparatively  easy 
to  make  an  accurate  diagnosis. 

A  review  was  made  of  310  cases,  all  of  them  sure  they 
had  sinus  disease.  (Post-nasal  discharge  does  not  neces- 
sarily mean  sinus  disease.)  We  began  with  everybody  who 
claimed  to  have  sinus  disease  and  sifted  out  310  cases  in 
which  we  suspected  sinus  disease;  further  sifted  these  310 
cases  and  have  158  cases  of  proved  or  suspected  sinus 
disease;  152  had  definite  symptoms  of  sinus  disease,  but 
were  not  sinus  cases  in  any  respect.  Chief  causes:  over- 
treatment,  allergic  and  nutritional  disturbances  and  endo- 
crine dysfunction,  and  diagnosis  from  x-ray  shadows 
alone.  In  prescribing  nasal  medication  for  an  acute  con- 
dition, instruct  the  individual  to  discontinue  the  medica- 
tion after  the  acute  symptoms  have  subsided,  and  to  use 
boiled  tap  water  instead  of  distilled  water. 

Allergy  perhaps  offers  the  most  difficult  problem  in  this 
whole  group. 

Endocrine  dysfunction  plays  important  role.    In  a  few 


GENERAL  PRACTICE 

James    L.    Hamner,    M.  D.,    Editor,    Mannboro,    Va. 


MINOR  DISCOMFORTS  OF  PREGNANCY1 

Minor  discomforts  are  present  in  every  preg- 
nancy. Recognition  of  the  existence  of  these  dis- 
comforts and  their  correction  will  pay  dividends. 

Nausea  and  vomiting  occur  during  the  first  tri- 
mester in  SO  per  cent  of  all  pregnancies — usually 
in  the  morning  but  may  be  at  any  time.  Some 
disturbance  of  carbohydrate  metabolism  is  involv- 
ed. Aggravating  factors  are  worry,  loss  of  sleep, 
fear  of  labor,  or  even  the  financial  aspects.  Con- 
stipation is  common.  Gossip  is  often  responsible. 
The  author's  best  success  has  been  obtained  with  a 
high-carbohydrate  diet,  in  small  feedings,  at  1-  to 
3-hour  intervals.  Fluid  is  not  taken  with  solid 
food  but  an  hour  afterward.  After-dinner  mints 
provide  the  stimulating  effect  of  peppermint  plus 
the  dextrose.  Frequent  feedings  produce  results  by 
keeping  food  in  the  stomach.  Constipation  must 
be  corrected.  Apprehension  should  be  relieved. 
Sedation  is  rarely  necessary;  then  phenobarbital 
Yi  gr.  Active  focal  infection  should  be  removed. 
A  craving  for  certain  foods  is  not  harmful  unless 
these  are  coarse  or  spicy. 

Heartburn  is  common  during  the  latter  months 
due  to  interference  with  peristalsis  of  the  stomach 
and  intestine.  Fermentation  takes  place  in  retain- 
ed food.  Avoid  acid  drinks  and  rich  or  spiced 
foods.  Alkali,  such  as  calcium  carbonate,  is  used 
as  required. 

Constipation  is  frequent  and  causes  extra  work 
for  the  kidneys.  The  diet  should  be  high  in  rough- 
age with  adequate  fluids.  Pears,  rhubarb,  prunes 
and  sauer-kraut  are  efficient  laxatives.  Agar-agar 
or  psyllium  should  be  used  in  the  dry  form.  Min- 
eral oil  interferes  with  digestion  and  absorption 
of  food.  If  a  laxative  is  necessary,  milk  of  magne- 
sia alone  or  combined  with  a  small  amount  of  cas- 
cara  sagrada  may  be  useful. 

In  the  breast  first  a  prickly,  tingling  sensation, 
then  a  feeling  of  fullness  or  tightness  and  later 
discomfort  in  the  pectoral  muscles  due  to  weight 
occurs.  A  snugly-fitting  and  supporting  brassiere 
transfers  the  weight  to  the  shoulders.  Cocoa  butter 
applied  to  the  abdominal  wall,  the  breasts  and 
thighs  will  not  prevent  the  occurrence  of  striae. 
This  massage,  however,  relieves  the  discomfort  of 
stretching. 

Urgency  and  frequency  appear  during  the  latter 


1.  F.  W.    Davis,   Columbus,  in  Ohio  State  Medical  Journal  via 
Digest  of  Treatment.  January. 


SOUTH ER.X  MEDICINE  &  SURGERY 


May  1941 


part  of  the  first  and  last  trimesters.  Marked  ante- 
version  of  the  fundus  in  early  pregnancy  throws 
the  cervix  toward  the  hollow  of  the  sacrum  which 
in  turn  stretches  the  base  of  the  bladder.  Later  on 
the  large  uterus  usurps  the  space  into  which  the 
bladder  expands  as  it  fills.  Usually  the  complaint 
is  most  at  night.  Since  we  do  not  wish  to  cut  down 
the  fluid  intake,  fluids  are  restricted  only  during 
the  4  hours  before  retiring.  In  the  last  trimester 
an  abdominal  girdle  may  assist. 

Vaginal  discharge,  usually  dating  from  the  end 
of  the  first  month,  is  a  frequent  complaint.  In  the 
absence  of  a  demonstrable  specific  organism,  it  re- 
sults from  the  congestive  changes  In  the  pelvis.  A 
daily  sodium  bicarbonate  douche  is  immediately 
effective. 

Hemorrhoids  are  more  prevalent  and  painful 
during  the  last  trimester  especially  in  constipated 
patients.  If  correction  of  bowel  function  does  not 
relieve  them,  astringent  suppositories  -containing  a 
local  anesthetic  are  indicated.  Cold  witch  hazel 
compresses  may  be  applied  with  pressure  over  the 
anus  immediately  after  a  bowel  movement.  Scleros- 
ing injections  should  be  postponed  until  after  de- 
livery if  possible. 

Swelling  of  the  feet  is  common  in  the  latter 
weeks  of  pregnancy  in  the  evening.  In  the  absence 
of  anv  pathology,  the  patient's  mind  is  usually  re- 
lieved by  the  mechanical  explanation.  If  edema  is 
marked,  recumbency  with  elevation  of  the  feet  will 
be  necessary  during  the  day. 

Pain.  After  sitting  for  a  period  of  time,  it  may 
be  difficult  to  arise  and  walk;  walking  may  be 
painful  for  a  short  time.  Pain  is  in  the  lower  abdo- 
men, over  the  symphysis  pubis,  over  the  sacro-iliac 
joints,  the  coccyx  or  hip.  Cramping  of  the  muscles 
of  the  feet  or  calves  may  arise  due  to  venous  stasis. 
Massage  and  heat  are  used  for  the  immediate  re- 
lief of  cramps.  Properly  fitting,  low-heeled  shoes 
aid  in  maintaining  body  balance  as  the  abdomen 
enlarges  forward.  A  well-fitted  girdle,  snug  over 
the  pubic  bones,  a  sort  of  half  hammock  effect, 
holds  the  tumor  of  pregnancy  well  in  and  up  out 
of  the  brim  of  the  pelvis.  Very  good  results  have 
been  obtained  in  cases  of  pubic  or  low-back  pain 
by  pushing  calcium  and  vitamin  D  orallv.  A  few 
have  not  needed  the  girdle  after  2  to  3  weeks. 

PRACTICAL  POIXTS  IX  THE  EYE.  EAR. 

NOSE  AXD  THROAT  FIELD1 
Eye:  Acute  iritis  is  rather  common  and  must 
be  differentiated  from  acute  glaucoma.  Proper 
diagnosis  is  essential,  for  atropine,  indispensable 
in  iritis,  is  contraindicated  in  glaucoma  and  its  use 
may  lead  to  blindness. 

1.  D.    B.    Staton.    in    Mississippi  Doctor,   via   Digest   of    Treat- 
ment, January,    1941 


Insist  on  routine  blood  YVassermanns  for  all 
pregnant  women.  Proper  treatment  for  maternal 
syphilis  may  prevent  interstitial  keratitis  in  the 
infant. 

Prostatitis  may  c?use  lesions  of  the  fundus. 

Ear:  In  anv  acute  infection  in  childhood  don't 
forget  the  ears.  Middle-ear  infections  are  com- 
mon, and  early  myringotomy  with  wide  incision 
may  save  much  distress. 

Xose:  Do  not  lance  or  open  a  boil,  pimple  or 
furuncle  about  the  nose  or  inside  the  nose. 

In  lesions  of  the  nasal  sinuses  fungus  infection 
should  be  recalled.  Massive  doses  of  iodides  are 
therapeutically  valuable  here. 

Throat:  Do  not  forget  that  tic  douloureux 
(trigeminal  neuralgia)  may  be  caused  by  infected 
tonsils.  Also  bear  in  mind  that  a  persistent  cough 
may  be  caused  by  an  extremely  long  uvula. 

Any  patient  with  hoarseness  lingering  longer 
than  3  weeks  should  have  a  thorough  examination 
of  the  larynx.  Cough  or  choking,  otherwise  unex- 
plained, in  small  children,  should  arouse  suspicion 
of  a  foreign  body  in  the  trachea  or  larynx. 

Infected  tonsils  or  adenoids,  unless  acutely  in- 
flamed, should  be  removed  whether  in  child  or 
adult.  If  acutely  inflamed  remove  as  soon  as  acute 
local  symptoms  and  fever  subside.  Weight  gain, 
mental  improvement  and  cessation  of  postnasal 
discharge  may  result. 


DENTISTRY 


DOMESTIC  WATER  AXD  DEXTAL  CARIES 

J.   H.    GtrtON,   D.  D.  S.,   Editor,   Charlotte.   N.   C. 

Recent  studies1  have  disclosed  marked  differ- 
ences in  the  prevalence  of  dental  caries  in  com- 
munities often  in  close  proximity  to  one  another. 
Considering  the  apparent  similarity  of  the  popula- 
tion groups  and  the  methods  followed  in  the  selec- 
tion of  the  samples,  it  is  difficult  to  ascribe  these 
differences  to  any  cause  other  than  the  mineral 
composition  of  the  common  water  supply.  At  the 
present  time  both  epidemiological  and  experimen- 
tal evidence  points  to  fluoride  as  the  factor  par- 
tially inhibiting  dental  caries. 

A  study  of  eight  suburban  Chicago  communities 
discloses  marked  differences  in  the  amount  of  den- 
tal caries.  The  rates  in  Elmhurst,  Maywood,  Au- 
rora and  Joliet,  whose  public  water  supplies  con- 
tain 1.8,  1.2,  1.2  and  1.3  parts  per  million  of  flu- 
ride,  respectively,  were  252,  258,  281  and  323, 
respectively.  At  Evanston,  Oak  Park  and  Wauke- 
gan,  using  fluoride-free  water,  the  dental  caries 
experience  rates  were  673,  722  and  810,  respect- 
ively. 


1     H.  T.   Dean,  et  a\,  in  Pub.  Health  Reports,  April    11th. 


May  1941 


SOUTHERN  MEDICINE  &  SURGERY 


271 


Using  the  proximal  surfaces  of  the  four  supe- 
rior incisors  as  a  basis  of  measurement,  there  was 
14.3  times  as  much  of  this  type  of  dental  caries  in 
the  1,009  children  from  Evanston,  Oak  Park  and 
Waukegan  as  in  the  1,421  children  from  Elmhurst, 
Mavwood,  Aurora  and  Joliet. 

The  differences  in  the  counts  of  acidophilus  ba- 
cillus in  the  saliva  corresponded  to  the  differences 
in  the  dental  caries  experience  in  the  groups  of 
communities  studied. 

Considering  the  relative  sameness  of  these  ur- 
ban populations  and  the  sampling  method  follow- 
ed, it  is  difficult  to  ascribe  these  differences  to  any 
cause  other  than  the  common  water  supply. 

The  caries-inhibitory  factor,  presumably  fluo- 
ride, was  operative  at  such  low  concentration  that 
mottled  enamel  as  an  esthetic  problem  was  not 
encountered. 


SURGERY 

Geo.  H.  Bunch,  M.  D.,  Editor,  Columbia,   S.   C. 


THE  TREATMENT  OF  ASCITES  COMPLI- 
CATING CIRRHOSIS  OF  THE  LIVER 

Atrophic  cirrhosis  of  the  liver  is  a  fairly 
common  condition  resulting  in  progressive  des- 
truction of  liver  cells  and  their  replacement  by  scar 
tissue.  The  disease  is  caused  by  the  prolonged 
action  of  an  unknown  poison  or  toxin  upon  the 
liver  cells.  This  may  come  from  faulty  metabolism 
or  it  may  be  of  chemical  or  bacterial  origin. 
Treatment  should  be  preventive;  for  by  the  time 
symptoms  become  manifest,  although  the  liver  has 
considerable  regenerative  power,  usually  irrepara- 
bly damage  has  been  done. 

In  advanced  cirrhosis  ascites  from  obstruction 
to  the  portal  circulation  is  of  frequent  and  distress- 
ing symptom.  For  many  years  symptoms  of  pressure 
of  the  accumulating  fluid  upon  the  heart  and  the 
lungs  have  been  relieved  by  removal  of  the  excess 
fluid  by  paracentesis.  Relief  has  been  only  tempor- 
ary, however,  and  repeated  tappings  have  been 
necessary  for  removal  of  the  recurrent  ascites.  In 
some  of  these  cases  after  many  tappings  at  length- 
ening intervals  the  ascites  has  not  returned. 

This  result  is  thought  to  be  due  to  the  relief  of 
portal  obstruction  by  the  establishment  of  a  collat- 
eral blood  supply  to  the  liver  through  the  many 
omental  adhesions  caused  by  the  trauma  and  the 
localized  peritonitis  of  repeated  paracentesis.  The 
Talma-Morrison  operation  of  omentopexy  and 
visceropexy  has  been  designed  to  bring  about  the 
Same  effect  more  quickly  and  more  surely  by 
laparotomy.  Although  perhaps  based  upon  sound 
physiological  principles,  the  results  of  the  operation 


have  been  disappointing  in  our  very  limited  ex- 
perience with  it.  Admittedly  used  only  in  advanced 
cases  it  has  not  prevented  the  recurrence  of  ascites 
nor  has  it  appreciably  prolonged  life. 

The  chronic  peritonitis  of  portal  cirrhosis  thickens 
the  peritoneum  and  causes  it  to  lose  its  power  of 
absorbing  ascitic  fluid,  and  may  actually  aid  in 
its  elaboration.  Hughson,  in  1927,  advocated  as  a 
possible  form  of  treatment  for  cirrhosis  the  removal 
of  large  areas  of  parietal  peritoneum.  Otto  has 
recently  reported  three  cases  of  cirrhosis  with  as- 
cites in  which  he  has  excised  the  parietal  periton- 
eum of  the  entire  anterior  abdominal  wall.  The 
operation  in  each  case  was  successful  in  relieving 
the  ascites.  Two  of  the  three  patients  have  returned 
to  their  normal  activities.  In  no  case  has  there  been 
shock,  secondary  hemorrhage  or  postoperative  in- 
testinal obstruction.  He  thinks  that  obstruction 
does  not  develop  because  the  overlieing  omentum 
becomes  adherent  to  the  abdominal  wall.  It  pro- 
tects the  viscera  by  preventing  their  coming  in 
contact  with  the  denuded  surface. 

"Postoperative  paracentesis  has  been  necessary 
but  two  or  three  times  in  this  brief  series  of  cases. 
This  has  been  performed  at  weekly  intervals  and 
collateral  circulation  has  been  found  to  be  estab- 
lished in  three  weeks,  and  ascites  has  not  recurred." 

In  conclusion,  it  may  be  said  that  it  will  take 
time  and  experience  to  evaluate  the  Otto  operation. 
It  can  never  hope  to  restore  liver  cells  that  have 
been  replaced  by  scar  tissue. 


A  CASE  OF  INSULIN  ALLERGY  SIMULATING 
CORONARY  OCCLUSION 

(H.  F.  Wechsler,  ct  al,  New  York,  in  //.  Lub.  &  CUn  Med., 
April) 
The  injection  of  20  units,  and  later  of  3  units,  of  Iletin 
(Lilly)  in  a  65-year-old  arteriosclerotic  hypertensive  dia- 
betic patient  gave  rise  to  a  syndrome  strongly  simulating 
coronary  occlusion.  Reviewing  the  case  from  the  view- 
point of  a  possible  allergy,  it  is  clear  that  we  are  dealing 
with  the  symptoms  of  anaphylactic  shock.  Skin  tests  cor- 
roborated this  assumption. 


Sulfanilamide  has  proved  curative  in  most  cases  of 
pyelonephritis  in  which  there  was  no  obstruclion  to  the 
urinary  flow. 


FOUR-WEEKS  COURSES  IN  OBSTETRICS 
The  Illinois  State  Department  of  Public  Health  and  the 
Children's  Bureau,  U.  S.  Department  of  Labor,  are  spon- 
soring ten  4-weeks  courses  in  obstetrics  at  the  Chicago 
Lying-in  Hospital  during  the  fiscal  year  1941-1942.  Only 
a  limited  number  of  physicians  will  be  accepted  for  each 
course.  The  only  cost  to  the  individual  is  for  room  and 
board  and  $25.00  ($10.00  of  which  is  refunded  at  the 
completion  of  the  course).  Applications  and  inquiries 
should  be  addressed  to: 

Post-graduatr    Course,    Department    of    Obstetrics    and 
Gynecology,  5848  Drexel  Avenue,  Chicago. 


SOCTHERX  MEPICI.XE  St  SURGERY 


May  1941 


CLINIC 


Conducted  By 
Frederick    R.    Taylor,   B.S.,    M.D.,   F.A.C.P. 


A  20-YR.-OLD  school-teacher  consulted  me  on 
Jan.  12th,  1917,  complaining  of  pain  in  the  back 
of  her  neck  and  a  general  eruption.  Three  days 
previously  4  lumps  had  appeared  in  the  back  of 
her  neck,  and  a  Sth  one  appeared  the  night  before 
coming  to  me.  Her  neck  had  been  stiff  and  sore 
from  the  beginning  of  her  trouble,  her  appetite 
and  sleep  poor.  She  had  slight  sore  throat,  and 
slight  photophobia.  She  had  a  very  severe  attack 
of  measles  about  a  year  previously,  in  which  I  at- 
tended her.  Nothing  in  her  history  threw  further 
light  on  her  trouble  except  that  she  had  been  in 
contact  with  at  least  5  persons  who  had  just  re- 
covered from  German  measles. 

The  patient  appeared  comfortable.  She  showed 
slight  lacrimation  and  congestion  of  the  eyes,  but 
her  eyes  are  especially  susceptible  to  all  influences. 
No  Koplik's  spots.  There  was  very  marked  en- 
largement of  the  posterior  cervical  lymph  nodes. 
They  did  not  fluctuate.  There  was  a  pale  rose- 
pink  rather  morbilliform  general  eruption.  No 
fever.    Pulse  94.    Respiratory  rate  20. 

Diagnosis:  German  measles.  No  treatment  was 
required.  Recovery  was  uneventful. 

Discussion:  German  measles  is  unusual  in  our 
part  of  the  country  in  endemic  form.  It  appears, 
in  epidemics,  and  then  disappears  entirely  from 
the  community,  often  for  several  years.  When  it 
first  reappears,  the  diagnosis  may  be  missed 
through  failure  to  think  of  it.  Of  course,  in  a  case 
like  this,  with  a  history  of  having  had  measles  and 
of  exposure  to  German  measles,  the  diagnosis  is 
obvious.  The  sensitiveness  of  the  patient's  eyes, 
however,  suggested  measles,  but  the  past  history. 
absence  of  Koplik's  spots,  of  fever  and  of  acute 
respiratory  symptoms,  and  the  general  well-being 
of  the  patient,  excluded  that  diagnosis. 

On  Oct.  24th,  1927.  a  24-yr.-old  school-teacher 
complained  of  sudden  transitory  dimness  of  vision. 
A  week  previously  she  had  such  an  attack  for  the 
first  time.  In  this  she  got  dizzy  and  couldn't  see 
much,  though  she  had  light  perception.  This  was 
followed  at  once  by  nausea,  but  no  vomiting.  She 
has  not  fainted  or  lost  consciousness.  The  1st  at- 
tack lasted  10  or  15  minutes.  She  had  a  slight  at- 
tack the  next  day.  Two  days  before  consulting 
me,  while  in  a  stand  at  a  football  game  ,facing  the 
sun,  she  had  2  short  attacks,  one  right  after  the 
other.  She  goes  through  these  attacks  sitting  up, 
and  never  falls.  She  ate  a  honey-dew  melon  before 
her  first  attack,  but  nothing  unusual  before   the 


other  attacks.  She  had  been  told,  not  long  before, 
when  she  had  her  tonsils  and  adenoids  removed, 
that  she  was  somewhat  near-sighted,  but  did  not 
need  glasses.  She  had  very  recently,  however,  had 
unusual  eye-strain  in  grading  poorly-written  4th- 
grade  papers.  Her  sister*  noted  that  her  eyes  were 
puffy  two  days  before  coming  to  me.  She  had 
conjunctivitis  2  years  previously.  There  was  noth- 
ing else  of  significance  in  her  history. 

Examination  showed  nothing  of  significance  as 
recorded.  The  urine,  voided  just  at  the  end  of  a 
menstrual  period,  contained  considerable  pus,  and, 
naturally,  a  trace  of  albumin. 

I  did  not  make  any  diagnosis,  but  referred  her 
to  an  ophthalmologist.  Dr.  O.  B.  Bonner,  who  re- 
ported that  she  had  a  slight  increase  of  intraocular 
tension  in  her  left  eye,  though  no  cupping  of  the 
disc.  He  kept  her  out  of  school  for  a  week  under 
a  miotic.  Her  urine  cleared  up  in  a  few  days  with- 
out treatment. 

Diagnosis:    Acute  glaucoma. 

Discussion:  This  was  a  mild  case.  Severe  cases 
are  true  ophthalmic  emergencies,  as  the  sight  may 
be  destroyed  very  quickly.  No  mention  is  made  in 
my  record  of  any  attempt  on  my  part  to  estimate 
the  intraocular  tension.  This  was  an  error  of  omis- 
sion. In  such  a  mild  case,  I  might  not  have  discov- 
ered it  anyway,  but  I  should  have  palpated  the 
eyes.  Incidentally,  we  really  should  routinely  pal- 
pate the  eyes  of  our  patients,  in  order  to  get  a  | 
"tactus  eruditus"  with  reference  to  intraocular  ten- 
sion, if  we  hope  to  be  able  to  detect  any  but  the 
most  severe  degrees  of  increased  intraocular  ten- 
sion. In  any  case  of  doubt,  the  patient  should  be 
promptly  referred  to  an  ophthalmologist. 

Another  case  of  a  very  different  type  in  which 
I  made  a  ridiculous  error  comes  to  mind.  I  had 
just  returned  from  New  Orleans  and  found  a  man  ] 
waiting  on  my  front  porch  holding  his  hand  over 
one  eye  and  apparently  crying  out  with  pain.  He 
told  me  he  had  been  to  a  Charlotte  ophthalmolo- 
gist, whom  I  knew,  who  told  him  he  had  glaucoma 
and  had  given  him  some  drops  to  use.  Palpation 
showed  that  the  affected  eye  was  almost  as  hard 
as  a  rock.  (No,  it  was  not  a  glass  eye — nothing 
quite  that  ridiculous!).  I  warned  him  of  the  dan- 
gerous nature  of  his  condition  and  told  him  he  must 
go  back  to  the  ophthalmologist  at  once.  He  said 
he  couldn't  go  to  Charlotte  that  day,  and  might 
not  find  the  doctor,  anyway,  as  it  was  Sunday.  I 
then  told  him  he  must  go  to  a  local  man,  at  least 
as  a  temporary  measure  in  his  emergency,  and 
called  Dr.  Bonner  and  made  an  appointment  fori 
him,  and  (this  was  my  chief  error)  gave  him  a 
hypodermic  of  morphine  to  relieve  his  apparently 
great  pain.   I  later  learned  that  he  never  consulted 


SOUTHERN  MEDICINE  &  SURGERY 


273 


Dr.  Bonner,  who  went  specially  to  his  office  that 
Sunday  morning  and  waited  about  an  hour  for 
him.  A  few  days  after,  I  happened  to  mention  the 
case  to  my  friend,  Dr.  E.  T.  Harrison,  who  broke 
out  into  a  big  laugh  and  said,  "Why,  don't  you 
know  who    that    was?"    That    is    the    notorious 

.    He  has  glaucoma,  all  right,  but  it 

is  chronic  glaucoma,  and  he  has  been  totally  blind 
in  that  eye  for  10  years.  He  has  been  advised  to 
have  it  out,  for  fear  of  sympathetic  ophthalmia 
destroying  the  other  eye,  but  he  won't  do  this,  as 
that  glaucomatous  eye  is  his  best  asset  to  get  mor- 
phine from  doctors." 

Discussion:  Not  being  an  ophthalmologist,  the 
error  may  have  been  pardonable,  but  all  such 
cases,  once  thev  have  deceived  a  physician,  should 
be  reported  at  the  next  meeting  of  the  county 
medical  society,  even  though  it  may  mean  a  mild 
discomfiture  of  the  physician  reporting  his  error. 

I  well  recall  another  case  which  I  did  so  report, 
that  got  me  much  laughed  at,  or  with,  because  a 
number  of  others  were  in  the  same  boat.  I  had 
just  returned  to  practice,  late  in  1929,  after  l^j 
years'  absence  working  for  the  State  Board  of 
Health.  A  woman,  dressed  handsomely  and  paint- 
ed like  a  clown,  came  to  my  office  and  told  me  she 
was  a  Mrs.  Thompson  of  Thompson's  dairy  farm, 
out  in  the  Deep  River  section.  I  thought  I  knew 
the  Deep  River  section  pretty  well,  and  did  not 
know  of  any  Thompson's  dairy  farm  there,  but 
reflected  that  changes  had,  no  doubt,  occurred  in 
that  community  during  my  absence.  So,  I  listened 
to  her  story.  It  seemed  that  she  had  a  poor  old 
mother  dying  of  cancer,  who  had  just  been  to  Dr. 
Howard  Kelly,  who  had  told  her  that  nothing 
could  be  done  but  to  give  her  enough  morphine  to 
make  her  comfortable.  I  told  "Mrs.  Thompson" 
that  I  would  be  ready  to  go  see  her  mother  in 
about  15  minutes.  Then  she  began  to  demur,  say- 
ing that  the  road  was  so  bad  that  she  feared  I 
could  not  get  out  there  with  my  car.  However,  she 
admitted  that  she  had  driven  a  car  in,  and  I  made 
the  obvious  reply  that  I  could  take  a  car  anywhere 
she  could.  Then  she  asked  why  I  should  go  out 
there — why  not  just  give  her  a  prescription  for 
some  morphine  for  her  mother  and  save  all  that 
trouble.  I  replied  that  I  never  gave  a  prescription 
for  anything  for  a  patient  T  never  saw,  let  alone 
a  narcotic  prescription!  She  then  gave  me  direc- 
tions how  to  get  out  there.  I  followed  the  direc- 
tions, and  drove  around  the  Deep  River  section 
for  an  hour  or  so,  trying  to  find  Thompson's  dairy 
farm,  only  to  be  assured  by  all  of  the  many  people 
I  knew  out  there  that  there  was  no  such  place. 
The  whole  set-up — the  type  of  clothing  and  make- 
up worn  by  the  woman,  the  story  she  told,  her  ob- 
jection to  my  going  out  to  see  her  mother,  and  the 


fact  that  I  knew  of  no  such  family  in  the  Deep 
River  section  made  me  suspicious  from  the  start; 
but  I  determined  to  run  the  matter  down  and  find 
out  what  it  was  all  about,  if  possible.  The  next 
morning  I  found  a  note  on  my  desk  to  call  a  med- 
ical friend,  did  so,  and  he  asked,  "What  were  you 
doing  looking  for  Thompson's  dairy  farm  in  the 
Deep  River  section  yesterday  afternoon?"  I  re- 
plied, "How  did  you  know  I  was  out  there?"  He 
then  told  me  he  had  done  the  same  thing  an  hour 
or  so  after  I  had  gflne  out  there.  It  seemed  that 
the  woman  had  gone  to  several  doctors  in  one 
afternoon,  hoping  to  get  a  prescription  for  mor- 
phine. The  old  mother  and  the  farm  were,  of 
course,  pure  fiction.  On  reporting  the  incident  at 
the  next  meeting  of  the  Guilford  County  Medical 
Society,  such  an  outburst  of  horse-laughs  deveU 
oped  that  I  wondered  why,  till  I  learned  that  a 
number  of  Greensboro  men  had  spent  the  next  day 
(Sunday)  after  my  episode,  looking  for  a  Thomp- 
son's dairy  farm  around  Greensboro!  It  seemed 
that  there  was  a  gang  working  from  Charlotte  to 
Durham,  trying  to  get  morphine  in  this  way.  I 
informed  the  police,  but  if  the  woman  was  ever 
caught  I  do  not  know  it. 


THE  THERAPEUTICS  OF  INTERNAL  DISEASES: 
Volume  III,  Supervising  Editor,  George  Blumer,  MA. 
(Yale),  M.D.,  David  P.  Smith  Clinical  Professor  of  Med- 
icine, Yale  University  School  of  Medicine;  Associate  Ed- 
itor, Albert  J.  Sullivan,  M.D.,  Adjunct  Clinical  Profes- 
sor of  Medicine,  George  Washington  and  Georgetown 
Medical  Schools.  1941.  $40.00  per  set   (of  4  volumes). 

This  volume,  just  made  available,  covers  dis- 
eases due  to  fungi,  metazoan  diseases,  protozoan 
diseases,  intoxications,  diseases  due  to  physical 
agents;  the  treatment  of  edema,  dehydration,  acid- 
osis and  alkalosis;  pre-  and  postoperative  treat- 
ment; treatment  of  diseases  of  the  lower  respira- 
tory tract;  treatment  of  heart  diseases  and  diseases 
of  the  blood  and  lymph  vessels. 

Our  own  Dr.  David  T.  Smith  writes  the  excel- 
lent chapter  on  Diseases  Due  to  Fungi. 

Some  confusion  exists  in  the  medical  world  as 
to  the  relative  value  of  the  different  agents  used 
against  malaria.  Here  is  a  dependable  statement 
of  the  case. 

The  treatment  of  edema  is  given  in  great  detail. 
Sodium  lactate  is  recommended  instead  of  sodium 
bicarbonate  in  the  treatment  of  acidosis.  Digitalis 
retains  its  place  as  chief  heart  drug. 

Not  only  what  to  give,  but  what  not  to  give,  is 
included  in  this  comprehensive  work. 

These  few  samples  attest  the  value  of  a  set  of 
books  which  may  be  depended  upon  to  "grade  to 
sample"  as  we  say  of  cotton  or  tobacco. 

Allercy  to  liver  extract  is  not  unknown. 


SOUTHERN  MEDICINE  &  SURGERY 


May  1941 


SURGICAL  OBSERVATIONS 


OF  THE  STATF 

DAVIS  HOSPITAL 

Statesville 


PELVIC  EXAMINATION 

A  proper  pelvic  examination  will  enable  a  doc- 
tor to  diagnose  accurately  practically  all  the  ordi- 
nary pelvic  conditions  that  are  likely  to  be  pres- 
ent in  a  multipara.  There  is  no  field  of  diagnosis 
more  neglected  than  that  of  the  pelvic  examina- 
tion. 

Evaluation  of  the  findings,  so  necessary  for  in- 
stitution of  proper  treatment,  including  time  for 
and  choice  of  operation,  involves  often  a  great 
many  difficulties.  First  have  a  history,  especially 
that  pertaining  to  the  pelvis.  Among  other  things, 
this  should  include  previous  diseases  and  injuries, 
childbirth,  miscarriages  and  any  history  of  dis- 
charge, flooding  or  pelvic  inflammatory  disease. 
Unless  a  very  accurate  history  is  obtained  the  ex- 
amination will  not  be  as  complete  as  it  would  be 
otherwise.  For  example,  the  only  way  in  which  a 
weakness  of  the  vesical  sphincter  muscle  can  be 
determined  is  by  asking  the  patient.  Unfortunate- 
ly many  a  woman,  on  being  asked  if  the  bladder 
leaks  will  say  "no";  but  on  closer  questioning  or 
repeated  questions,  and  if  you  ask  "when  the 
bladder  is  full  and  you  strain,  lift,  sneeze,  cough 
or  laugh  does  some  urine  leak  out?",  in  many  cases 
you  will  get  a  prompt  answer  of  "yes."  This  estab- 
lishes the  fact  that  there  is  some  leakage  from  the 
bladder  under  certain  circumstances  and  is  the 
only  means  by  which  we  can  tell  whether  or  not 
the  vesical  sphincter  muscle  is  competent. 

A  history  of  backache,  pain  in  the  pelvis,  bear- 
ing-down sensation  as  if  everything  in  the  abdo- 
men were  coming  down,  constipation,  leucorrhea, 
menorrhagia  and  metrorrhagia  should  be  carefully 
inquired  into  before  the  examination  is  made. 

The  examination  should  be  done  with  the  pa- 
tient in  the  proper  position  on  the  table  for  pelvic 
examination.  A  good  speculum  should  be  available 
and  also  a  good  light  which  will  enable  the  exam- 
iner to  see  plainly  the  external  parts,  the  vaginal 
area  and  the  cervix.  In  addition,  there  should  be 
two  cotton  applicators  for  collection  of  smears, 
one  for  trichomonas  and  the  other  for  gram-neg- 
ative organisms.  Lugol's  solution  should  be  avail- 
able. An  elaborate  array  of  instruments  is  not 
necessary. 

Examine  the  external  genitalia,  noting  any  ab- 
normalities, large  veins,  growths,  ulcers,  or  other 
pathology.  The  clitoris  should  be  examined  for 
adhesions.  The  presence  or  absence  of  discharge 
should  be  noted.  Next  the  speculum  is  inserted 
gently  and  the  cervix  inspected.  At  this  time  se- 
cretions may  be  obtained  on  the  cotton  applicators 


for  examination.  If  there  are  any  suspicious  areas 
paint  the  cervix  with  Lugol's  solution  and  it  will 
aid  greatly  in  differentiating  between  cancer  and 
ordinary  cervical  erosion. 

The  presence  or  absence  of  rectocele  or  cystocele 
should  be  noted;  the  external  urethra  examined  for 
prolapse,  caruncle  or  other  abnormalities.  The 
speculum  is  withdrawn  and  by  bimanual  examina- 
tion the  condition,  size,  shape  and  position  of  the, 
womb,  cystic  or  enlarged  ovaries,  pelvic  inflamma- 
tory disease,  infiltration  of  the  broad  ligaments  or 
other  pathological  conditions  investigated.  The) 
patient  should  be  told  to  strain  a  little  and  this 
will  enable  the  examiner  to  determine  whether  or 
not  there  is  any  marked  cystocele  or  if  the  uterus 
tends  to  prolapse.  Now  lubricate  the  finger,  after 
changing  gloves,  and  make  a  rectal  examination 
for  growths,  hemorrhoids,  fissures,  or  ringworm; 
for  tears  of  the  sphincter  ani  muscle,  excess  of 
fibrous  tissue  etc. 

If  there  is  any  enlargement  of  the  uterus  sug- 
gesting a  tumor  or  pregnancy,  an  x-ray  examina- 
tion may  be  advisable  and  will  often  aid  in  clear- 
ing up  the  diagnosis. 

The  specimen  of  the  discharge  removed  fori 
the  examination  of  trichomonas  infection  should 
be  immediately  immersed  in  a  small  amount  of 
normal  salt  solution.  This  simplifies  the  examina- 
tion a  great  deal. 

At  the  same  time,  the  lower  abdomen  should  be 
examined  for  the  presence  of  scars,  diastasis  or  any 
other  abnormality. 

After  the  examination  is  completed,  if  there  are] 
any  points  about  which  you  are  in  doubt  these  j 
should  be  rechecked.  A  careful  record  should  be 
made,  including  diagnosis  and  treatment  recom- 
mended. These  should  be  written  down  so  that 
they  can  be  discussed  in  detail  with  the  patient 
that  day  or  later  on. 

The  patient  should  be  informed  of  any  trouble 
that  may  be  found  and  the  treatment  carefully 
outlined.  It  is  important  to  make  the  plan  of 
treatment  clear  to  the  patient.  Unless  the  proper 
treatment  is  gi  "en,  the  examination  will  not  be  of] 
much  use. 

Where  there  is  to  be  some  delay  about  institut- 
ing surgical  treatment,  the  patient  should  be  given 
appropriate  treatment  in  anticipation  of  operation. 
For  example,  leucorrhea  should  be  treated  and 
also  cystitis.  Chronic  constipation  is  another  cause 
of  trouble  and  should  be  relieved. 

Bv  giving  every  patient  a  thorough  and  careful 
examination,  many  lives  will  be  saved,  early  ma-j 
lignancies  will  be  noted  and  many  pelvic  condi- 
tions resulting  from  childbirth  will  be  noted  and 
properly  corrected,  bringing  relief  and  comfort  tO' 
the  patient. 


SOUTHERN  MEDICINE  &  SURGERY 


IN  MEMORIAM 

TRI-STATE  MEDICAL  ASSOCIATION 

1941 
(To  be  concluded  in  our  next  issue) 


DR.  CHARLES  OLIVER  DeLANEY 
Dr.  G.  Carlyle  Cooke,  Winston-Salem 

Charles  Oliver  DeLaney  was  born  in  Union 
County,  North  Carolina,  January  15  th,  1895.  He 
died  in  Winston-Salem  at  his  home  December 
15th,  1940. 

He  received  his  education  in  the  Union  County 
schools,  finished  his  first  two  years  of  Medicine 
at  the  University  of  North  Carolina  in  1917,  and 
was  graduated  from  Jefferson  Medical  College  in 
1919.  In  his  final  years  at  Jefferson  he  was  in  the 
S.  A.  T.  C.  of  the  Medical  Reserve  of  the  Army. 
He  had  his  internship  in  the  Sacramento  County 
Hospital  in  California  where  he  was  Medical  Di- 
rector for  one  year. 

He  took  up  his  practice  of  urology  in  Gastonia, 
N.  C,  and  moved  to  Winston-Salem  in  1924. 

He  was  a  past  president  of  the  North  Carolina 
Urological  Society,  and  was  president  of  the 
North  Carolina  Baptist  Hospital  Staff  at  the  time 
of  his  death. 

Dr.  DeLaney  was  a  pioneer  in  urology  in  the 
State;  he  was  satisfied  with  nothing  less  than  the 
best.  No  better  example  of  his  taste  for  the 
esthetic,  as  well  as  the  superlatives  of  life,  can  be 
found  than  in  the  luxurious  offices  which  he  main- 
tained as  his  workshop. 

In  his  social  activities  as  well  as  with  his  pa- 
tients, he  always  had  an  attractive  and  winsome 
portion  of  life's  humor  to  dispense. 

He  is  greatly  missed  by  the  profession  of  Win- 
ston-Salem and  by  all  who  knew  him. 

DOCTOR   HARRY    ERNEST    HEINITSH, 
JUNIOR 

Dr.  W.  B.  Lyles,  Spartanburg 

H.  E.  Heinitsh,  Jr.,  was  born  in  Spartanburg, 
November  16th,  1894,  the  son  of  Dr.  H.  E. 
Heinitsh  and  the  late  Bessie  Means  Heinitsh. 
Graduating  from  Wofford  College  he  took  his  pro- 
fessional training  at  Jefferson  Medical  College, 
and  his  internship  and  residency  were  served  in  the 
University  of  Pennsylvania  Hospital.  For  a  period 
of  the  World  War  Dr.  Heinitsh  was  stationed  in 
Philadelphia  as  a  member  of  the  United  States 
Army  Medical  Corps. 

Returning  to  his  home  town  he  practiced  his 
profession  among  those  who  had  known  him  and 


his  forebears  for  generations.  A  fine,  well-trained 
mind  and  a  thorough  knowledge  of  medicine  were 
not  the  only  assets  of  this  young  physician,  for 
with  these  he  was  endowed  with  a  gentle  sympa- 
thetic heart,  an  unselfish  devotion  to  duty  and  the 
highest  integrity.  These  attributes  naturally  drew 
to  him  a  large  practice  from  all  walks  of  life,  yet 
neither  purse  nor  position  governed  Dr.  Heinitsh's 
zeal  and  interest  in  his  patients.  The  poorest  and 
humblest  received  alike  the  same  devoted  atten- 
tion and  care  as  did  those  of  means  and  power. 
Never  sparing  himself,  putting  his  patients  first 
and  forgetting  self,  contributed  to  the  rapidity  with 
with  which  he  succumbed  when  attacked  in  his  last 
illness. 

In  1934  Dr.  Heinitsh  married  Annette  Blake 
Franklin.  She  with  his  son  and  an  adopted  daugh- 
ter survive  him. 

The  untimely  death  of  Dr.  Heinitsh  on  June 
20th,  1940,  left  a  stunned  and  bereaved  people.  A 
useful  and  a  beloved  life  was  taken,  leaving  his 
family,  friends,  patients  and  colleagues  to  sustain 
an  irreparable  loss. 

DOCTOR  EMORY  HILL 

Dr.  Walter  J.  Rein,  Richmond 

On  December  4th,  1940,  Dr.  Emory  Hill  step- 
ped through  a  door  in  an  old  wall.  He  was  born 
on  September  8th,  1883,  at  Scottsville,  Virginia. 
He  received  the  A.B.  degree  at  Columbia  Univer- 
sity and  then  pursued  his  professional  studies  at 
the  Medical  College  of  Virginia,  where  he  was 
graduated  in  the  class  of  1907.  Thereafter,  he 
spent  a  year  under  S.  Weir  Mitchell  at  the  Ortho- 
pedic Hospital  and  Infirmary  for  Nervous  Diseases 
in  Philadelphia.  He  later  interned  for  a  year  at 
the  Wills  Eye  Hospital,  also  in  Philadelphia.  He 
started  the  practice  of  his  profession  in  Chicago  in 
1910.  While  there  he  took  advanced  graduate 
work  at  the  University  of  Chicago  and  later  was 
on  the  faculty  of  Rush  Medical  College.  In  1919 
he  returned  to  Virginia  to  open  offices  in  Rich- 
mond, where  he  was  accorded  recognition  as  one 
among  the  ablest  eye  specialists  in  this  section  of 
the  country.  In  1929  he  succeeded  the  late  Dr. 
Jos.  A.  White  as  Professor  of  Ophthalmology  in 
the  Medical  College  of  Virginia,  a  position  he  held 
until  about  two  years  ago. 

Dr.  Hill  was  a  Fellow  of  the  American  Medical 
Association;  a  member  of  the  College  of  Physi- 
cians of  Philadelphia;  a  member  of  the  American 
Ophthalmological  Society,  of  which  organization 
he  was  secretary  from  1925  through  1932.  He  also 
served  in  various  capacities  in  state  and  local  med- 
ical societies.  He  was  chosen  to  a  place  in  "Who's 
Who  in  America"  in  1937. 


SOUTHERN  MEDICINE  &  SURGERY 


Though  he  was  not  a  prolific  writer  he  did 
write,  and  with  clearness,  conciseness  and  practica- 
bility. Much  of  his  work  has  been  published  in  the 
leading  journals.  All  these  honors  he  carried  with 
extreme  modesty. 

Dr.  Hill  was  the  first  in  Virginia  to  limit  his 
practice  to  ophthalmology.  It  may  be  said  that  he 
was  the  pioneer  of  ophthalmology  in  this  section 
of  the  country. 

Richmond  owes  its  eminence  as  a  medical  center 
in  part  to  the  fact  that  during  the  past  quarter 
century  several  men  who  have  ranked  with  the  best 
in  their  field  in  America  labored  here.  Dr.  Hill 
was  one  of  them  and  as  a  member  of  the  faculty 
of  the  Medical  College  of  Virginia  did  his  part  to 
bequeath  his  skill  and  his  art  to  the  next  genera- 
tion of  physicians  of  his  State  and  Section.  He 
served  that  institution  with  true  devotion  in  all 
capacities,  to  a  degree  far  greater  than  is  generally 
known.  He  desired  his  students  to  acquire  a  sound, 
practical  knowledge.  He  had  perseverance  and  de- 
termination. His  work  was  never  perfunctory  but 
painstaking  and  thorough  and  always  properly  ag- 
gressive. His  tireless  energy,  wise  counsel  and 
genuine  sincerity  made  him  an  ideal  leader.  Among 
others  of  his  creative  plans  was  the  development, 
beginning  in  Richmond,  of  an  of  an  increasingly 
active,  now  State-wide  system  of  "Sight-Saving" 
classes  in  the  schools.  By  reason  of  his  great 
knowledge  and  experience  he  spoke  authoritatively 
on  all  phases  of  ophthalmology.  His  inquisitive 
mind  spurred  him  on  to  learn  everything  possible 
from  every  case.  He  was  a  keen  diagnostician, 
whose  sound  judgment  and  practical  suggestions 
made  him  the  ideal  consultant.  The  patient  who 
went  to  Dr.  Emory  Hill  recognized  immediately 
the  sureness,  the  certain  touch,  which  distinguishes 
the  born  physician;  the  embryonic  ophthalmologist 
privileged  to  come  under  his  tutelage  was  indeed 
fortunate. 

A  few  more  words  about  the  man.  Duty  was  for 
him  the  superior  law.  An  honest  mind  and  relia- 
bility were  to  him  indispensable;  he  despised  an 
untruth.  He  seemed  often  to  be  cold  and  not  easily 
approachable,  but  this  was  only  the  expression  of 
an  efficiency.  His  concentration  on  efficiency  in 
his  work  and  his  unwillingness  to  divert  his  atten- 
tion by  needless  talk  seemed  to  some  people 
abrupt,  on  first  acquaintance;  but  as  they  knew 
him  better  they  realized  his  personal  interest. 
Rather  than  a  multitude  of  lukewarm  friends,  he 
enjoyed  some  very  close  ones,  and  not  many  knew 
the  man  of  subtle  humor,  quick  repartee  and  care- 
free disposition.  When  released  from  the  pressure 
of  work  he  could  relax  into  a  boyish  gaity;  he  was 
a  charming  companion.   His  family,  his  science,  his 


ample   diversified   library,   and  his  love  of  music 
provided  him  with  richness  in  life. 

In  his  death  ophthalmology  lost  one  of  its  truly 
great  men,  a  highly  successful  practitioner  and 
dexterous  surgeon,  a  generous  teacher  and  a  true 
friend;  all  lost  a  fearless,  inspiring  leader,  a  great 
teacher,  a  wise  counsellor,  and  a  just  man. 

DOCTOR  EDGAR  ALPHONSO  HINES 

Dr.  Robert  Wilson,  Charleston 

In  the  death  of  Edgar  A.  Hines  the  most  con- 
spicuous figure  in  organized  medicine  in  South 
Carolina  passed  from  among  us. 

Graduating  from  the  Medical  College  of  the 
State  of  South  Carolina  fifty  years  ago  he  devoted 
himself  from  the  beginning  of  his  career  with  sin- 
gleness of  purpose  to  the  advancement  of  his  cho- 
sen profession:  and  from  the  time  he  assumed  the 
secretaryship  of  the  State  Medical  Association, 
more  than  thirty  years  ago,  he  played  a  large  part 
in  every  movement  affecting  medical  organization 
in  the  State  of  his  adoption. 

His  public  activities  have  been  set  forth  abund- 
antly in  the  memorials  which  have  been  published 
since  his  death.  Here  let  me  speak  a  word  of  the 
man  whose  loval  friendship  I  have  enjoyed  for 
half  a  century. 

Living  always  at  the  highest  level  of  profes- 
sional attainment,  a  few  years  ago  in  spite  of  his 
advanced  age  he  successfully  passed  the  qualify- 
ing examination  in  pediatrics,  the  branch  of  med- 
icine in  which  he  was  most  deeply  interested.  In 
practice  as  in  public  health  and  in  medical  educa- 
tion he  was  content  with  nothing  less  than  the 
best. 

Courteous,  genial  and  considerate  of  others,  he 
never  incurred  the  ill  will  of  his  confreres  and  none 
was  ever  known  to  speak  evil  of  him.  He  was 
loved  by  those  who  knew  him  and  admired  by  al! 
for  his  unfailing  energy  and  ceaseless  industry. 

Aware  of  his  fatal  malady,  he  refused  to  rest  or 
to  lay  aside  any  of  his  activities,  preferring  to  die 
as  he  had  lived  in  useful  service,  and  in  the  early 
morning  of  January  27th,  1940,  after  returning 
home  from  a  medical  meeting  in  a  neighboring 
city  at  which  he  had  delivered  an  address  on  the 
medical   preparedness  program, 

"God's  finger  touched  him  and  he  slept." 

DOCTOR  HENRY  GRADY  LASSITER 

Dr.  W.  G.  Suiter,  Weldon 

Henry  Grady  Lassiter,  a  beloved  physician  of 
Weldon,  and  an  active  member  of  this  society, 
died  August  1st,.  1940,  following  an  illness  of 
thirty-six  hours.  Henry  Lassiter  was  born  in 
Northampton    County.    N.    C,    September    13th, 


SOUTHERN  MEDICINE  &  SURGERY 


1891.  He  spent  the  early  years  of  his  life  under 
the  influence  and  guidance  of  the  late  Doctors  M. 
Bolton  of  Rich  Square,  N.  C,  and  R.  P.  More- 
head  of  Weldon.  He  entered  the  University  of 
North  Carolina  in  1911  and  completed  his  medical 
course  at  Jefferson  in  the  class  of  1917.  He  volun- 
tered  his  services  to  the  government  for  the  dura- 
tion of  the  World  War  and  was  assigned  to  an  in- 
ternship in  the  Camden  Hospital,  Camden,  New 
Jersey.  In  1918  he  located  in  Weldon  where  he 
spent  a  useful  and  unselfish  life.  His  widow,  Mrs. 
Willie  Musgrove  Lassiter,  and  two  children,  Alex, 
aged  16;  and  Jane,  aged  12,  survive  him. 

Dr.  Lassiter  was  a  trustee  in  the  Weldon  Meth- 
odist Church,  past  president  of  the  Halifax  County 
Medical  Society;  and  a  Fellow  of  the  Medical  So- 
ciety of  the  State  of  North  Carolina,  of  the  Tri- 
State  Medical  Association  of  the  Carolinas  and 
Virginia,  and  the  American  Medical  Association. 

"Dr.  Grady,"  as  he  was  affectionately  called, 
began  and  continued  his  practice  in  a  strictly  eth- 
ical but  quiet  and  unassuming  manner.  Although 
deeply  interested  in  civic,  religious  and  other 
worthwhile  activities,  he  left  it  to  others  to  take 
the  leadership  in  those  fields  that  he  might  spend 
all  of  his  time  and  energy  with  his  patients  whom 
he  loved  and  served  faithfully  all  through  the 
years.  Particularly  considerate  and  patient  was  he 
in  his  service  in  the  chronic  and  nervous  cases,  that 
so  often  tax  the  patience  of  physicians.  He  always 
had  the  time  to  listen  to  their  problems  and  to 
guide  them  in  a  helpful  way.  In  this  present-day 
busy  world  of  scientific  precision  and  diagnostic 
accuracy  we  here  may  well  emulate  this  virtue  of 
his,  and  not  forget  the  patient  in  our  search  for  a 
diagnosis. 

The  following  tribute  was  paid  him  in  our  town 
paper:  The  call  of  human  suffering  was  the  beacon 
which  he  followed  without  regard  to  race  or  color, 
to  financial  or  social  standing.  He  ministered  to 
both  the  bodies  and  the  spirits  of  the  people  he 
served.  The  old,  young,  white,  colored — more  and 
less  prominent — who  came  to  his  home  for  a  last 
look  at  the  remains;  the  many  whom  he  had  served 
The  old,  young,  white,  colored — more  and  less 
prominent — who  came  to  his  home  for  a  last  look 
at  the  remains;  the  many  whom  he  had  served, 
even  supplying  medicine  and  other  necessities  with- 
out thought  or  hope  of  financial  reward,  all  bear 
silent  testimony  to  the  genuine  affection  which  was 
universally  his.  His  memory  is  inscribed  in  letters 
of  his  own  life's  blood  on  the  hearts  of  the  many 
he  served  so  faithfully  and  well. 

"Whosoever  will  be  great  among  you,  let  him 
be  your  minister;  whosoever  will  be  chief  among 
you,  let  him  be  your  servant." 


DOCTOR  JOSEPH  AUGUSTUS  WHITE 
Dr.  Nielson  H.  Turner,  Richmond 

After  a  lingering  illness,  Dr.  Joseph  A.  White 
passed  away  on  February  the  fifteenth,  1941. 

He  was  born  on  April  the  nineteenth,  1848,  of 
an  old  Catholic  family,  in  Baltimore,  Maryland. 
His  father,  Ambrose  A.  White,  was  a  prominent 
merchant  of  that  city.  His  mother  was  Mary  Hur- 
ley White.  Abraham  White,  his  great-grandfather, 
was  a  Major  of  Artillery  in  the  Revolutionary  War, 
and  was  present  at  the  surrender  of  Cornwallis  at 
York  town. 

His  preliminary  education  was  received  at  Rock 
Hill  Academy  at  Ellicott  City,  at  Loyola  College 
in  Baltimore,  and  at  Mount  Saint  Mary's  College, 
at  Emmittsburg,  Maryland,  from  which  institution 
he  obtained  the  following  degrees:  A.B.  in  1867, 
A.M.  in  1809,  and  LL.D.  in  1929. 

He  began  the  study  of  Medicine  at  the  Univer- 
sity of  Maryland  in  1867,  and  the  M.D.  degree 
was  bestowed  upon  him  in  April,  1869.  During 
one  year  of  this  time  he  served  as  an  interne  in 
the  University  Hospital.  He  began  postgraduate 
studies  at  the  College  of  Physicians  and  Surgeons 
in  New  York,  where  he  remained  until  September, 
1869.  For  the  next  three  years,  he  remained  in 
Europe  continuing  his  preparation,  spending  time 
at  the  following  places  in  the  order  named:  in 
England,  in  Paris  and  in  Germany — at  Freiberg, 
Heidelberg  and  Berlin — returning  to  America  in 
1872. 

This  same  year  he  began  the  practice  of  the 
specialty  of  ophthalmology,  otology,  rhinology  and 
laryngology  in  Baltimore,  when  he  was  appointed 
Professor  of  Ophthalmology  at  Washington  Uni- 
versity Medical  School. 

In  1879,  on  invitation  from  a  group  of  promi- 
nent physicians,  he  located  in  Richmond,  where  he 
soon  became  prominent  socially  and  professional- 
ly, and  because  of  his  accomplishments  his  renown 
quickly  extended  throughout  the  South. 

He  was  one  of  the  founders  of  the  University 
College  of  Medicine  in  Richmond.  The  first  free 
clinic  in  Richmond  for  the  treatment  of  disease  of 
the  eye,  ear,  nose  and  throat,  was  established  by 
him,  and  for  many  years  he  contributed  to  it  in 
service  and  in  donations. 

He  was  Professor  of  Ophthalmology  and  Oto- 
Laryngology  in  the  University  College  of  Medi- 
cine, later  Professor  of  Ophthalmology  in  the  Med- 
ical College  of  Virginia,  and  at  a  subsequent  date 
in  this  same  institution  he  received  in  addition  an 
appointment  as  Professor  of  Oto-Laryngology,  and 
he  continued    to    hold    these    positions    until    his 


SOUTHERN  MEDICINE  &  SURGERY 


Mav  1941 


eighty-second  year,  when  he  became  Professor 
Emeritus.  He  has  been  President  of  the  Richmond 
Academy  of  Medicine  and  Surgery;  of  the  Medi- 
cal Society  of  Virginia;  of  the  Tri-State  Medical 
Association  of  the  Carolinas  and  Virginia;  of  the 
Virginia  Society  of  Ophthalmology  and  Oto-Laryn- 
gology;  of  the  Richmond  Eye,  Ear,  Nose  and 
Throat  Society;  of  the  American  L.  R.  and  O. 
Society,  and  of  the  Virginia  Society  of  the  Sons  of 
the  American  Revolution;  and  Chairman  of  the 
Section  on  Ophthalmology  of  the  American  Med- 
ical Association. 

Among  the  additional  Clubs  and  Societies  in 
which  he  held  membership  are  the  American  Oph- 
thalmological  Society,  the  American  Otological 
Society,  the  West  Virginia  Medical  Society,  the 
Westmoreland  Club,  the  Commonwealth  Club,  the 
Richmond  German  Club,  the  Deep  Run  Hunt 
Club  and  the  Country  Club  of  Virginia. 

Over  two  hundred  articles  and  addresses  before 
Societies  and  in  papers  pertaining  to  his  specialty 
were  contributed  by  him.  Several  useful  instru- 
ments, including  a  palate  retractor  and  a  tonsil 
forceps,  were  invented  by  him,  and  the  widely  used 
White's  ophthalmic  ointment  was  devised  by  him. 

Many  gentlemen  successful  in  this  specialty  re- 
ceived their  training  in  association  with  him,  and 
he  was  always  eager  to  and  took  a  delight  in  help- 
ing them,  giving  the  benefit  of  his  many  years  of 
experience. 

In  1877  he  married  Miss  Sophie  Berney,  the 
daughter  of  Dr.  Jas.  Berney  of  Montgomery,  Ala- 
bama. His  wife  died  in  1901.  He  was  devoted  to 
his  family,  and  because  of  his  consideration  and 
love  for  his  children  he  never  remarried.  His 
daughter,  Mrs.  R.  A.  P.  Walker;  and  grand-daugh- 
ters, Mrs.  Jno.  M.  Taylor,  Jr.,  and  Mrs.  W.  Gar- 
land Richardson,  survive  him. 

That  he  remained  among  the  distinguished  in 
his  chosen  field  is  no  surprise,  when  it  is  known 
that  he  was  constantly  on  the  alert  in  attending 
society  meetings  and  perusing  the  literature  in 
search  of  information  for  the  benefit  of  his  pa- 
tients. From  time  to  time  he  did  experimental  in- 
vestigating, but  as  he  told  me  on  several  occasions, 
he  always  tried  it  on  himself  first  in  each  instance. 

His  ready  wit  and  keen  sense  of  humor,  along 


with  his  loyalty,  his  sincerity,  his  unselfishness,  his 
punctuality,  his  love  for  the  truth,  resulting  nat- 
urally in  frankness,  and  his  many  other  fine  quali- 
ties endeared  him  to  his  numerous  friends  and  as- 
sociates. 

With  him  it  was  a  question  of  service,  and  the 
question  of  compensation  was  of  secondary  im- 
portance. He  received  and  treated  gratis  in  his 
office  a  great  number  of  patients  whose  pride  for- 
bade them  to  go  to  the  dispensary. 

He  was  a  devoted  communicant  of  the  Roman 
Catholic  Church,  and  as  the  officiating  priest  said 
of  him  in  his  funeral  oration,  "He  Kept  the 
Faith."  Late  in  his  life  when  he  became  incapaci- 
tated, he  arranged  to  have  the  priest  visit  him 
weekly  so  that  he  could  continue  to  worship  his 
Maker  according  to  the  dictates  of  his  own  con- 
science. 

His  death  has  resulted  in  a  great  loss  to  his 
family  to  his  friends,  and  to  the  whole  of  the 
med'cal  profession. 

DOCTOR  JAMES   THRUSTON   WOLFE 

Dr.  Charles  S.  White,  Washington 

Dr.  James  Thruston  Wolfe  was  born  at 
Front  Royal,  Virginia,  on  July  1st,  1881.  He 
graduated  in  medicine  from  the  George  Washing- 
ton University  in  1908  and  served  his  internship 
at  Providence  Hospital,  Washington,  D.  C.  After 
entering  private  practice,  Dr.  Wolf  attracted  a 
large  number  of  patients  by  his  untiring  efforts  in 
their  behalf  and  by  his  enthusiasm  and  kindness. 
He  was  a  frequent  attendant  at  medical  societies, 
where  he  expressed  his  views  without  restraint, 
even  though  they  were  at  variance  with  commonly 
accepted  principles.  Dr.  Wolfe  contributed  many 
articles  to  medical  journals  and  enjoyed  a  large 
circle  of  friends  both  in  and  out  of  the  profession. 
Surviving  are  his  wife,  Mrs.  Elizabeth  Young 
Wolfe,  a  sister,  Selina  Wolfe,  and  a  brother,  Scott 
A.  Wolfe.  He  was  a  member  of  the  Tri-State 
Medical  Association  from  1935  until  his  death, 
Dec.  8th,  1940,  and  few,  indeed,  have  been  the 
members  who  have  put  forth  more  energetic  ef- 
fort in  that  length  of  time.  We  missed  him  in  this 
meeting  and  we  shall  miss  him  as  the  vears  go  bv. 


May  1941 


SOUTHERN  MEDICINE  &  SURGERY 


TRI-STATE  MEDICAL  ASSO- 
CIATION OF  THE  CARO- 
LINAS  AND  VIRGINIA 


MONDAY  MORNING  SESSION 
February  24th,  1941 

The  opening  meeting  of  the  Forty- third  Annual 
Session  of  the  Tri-State  Medical  Association  of 
the  Carolinas  and  Virginia,  held  at  the  O.  Henry 
Hotel,  Greensboro,  convened  at  10  a.  m.  Monday, 
February  24th,  1941.  The  meeting  was  called  to 
order  by  Dr.  Clyde  M.  Gilmore,  Chairman  of 
Committee  of  Arrangements. 

Dr.  Gilmore:  I  want  to  introduce  to  you  our 
fellow  townsman,  the  President  of  the  Guilford 
County  Medical  Society,  who  will  welcome  you. 
Dr.  Fred  Patterson.     (Applause.) 

Dr.  Patterson:  Mr.  Chairman,  Dr.  Gilmore, 
Dr.  Andrews,  Fellows  of  the  Tri-State  Medical 
Association:  The  Guilford  County  Medical  So- 
ciety extends  to  each  member,  guest  and  visitor 
the  right  hand  of  fellowship.  We  are  pleased  to 
have  you  and  hope  your  stay  here  will  be  very 
pleasant.   Thank  for  coming.    (Applause.) 

Dr.  Gilmore:    Thank  you,  Dr.  Patterson. 

Our  response  will  be  made  by  Dr.  C.  J.  An- 
drews, of  Norfolk,  Virginia,  President  of  the  As- 
sociation.   Dr.  Andrews. 

President  Andrews:  Mr.  Chairman,  Fellows  of 
the  Association:  It  is  with  a  great  deal  of  pleasure 
that  I  express  the  appreciation  of  the  Tri-State 
Medical  Association  for  the  hearty  welcome  which 
Dr.  Patterson  has  extended  to  us.  The  reputation 
of  Greensboro  and  its  profession  and  people  is 
well  known.  So  far  as  the  Tri-State  is  concerned, 
we  have  unusual  evidence  of  it.  The  Tri-State's 
meeting  in  Gneensboro  in  1929,  I  am  told  by  Dr. 
Hall,  was  the  first  occasion  on  which  the  plan 
which  will  be  put  on  here  this  time  of  clinics  was 
instituted.  Incidentally,  Dr.  Hall  tells  me  that 
that  was  the  best  meeting  the  Tri-State  has  ever 
had.  Of  course,  I  don't  know  how  much  was  due 
to  Dr.  Hall  and  how  much  to  Greensboro,  but  I 
am  going  to  give  most  of  that  to  Greensboro.  We 
thank  you.    (Applause.) 

Dr.  Gilmore:  Our  President,  Dr.  Andrews,  will 
now  take  charge  of  the  meeting  and  we  will  go 
ahead  with  the  program. 

MONDAY  EVENING  SESSION 

Banquet  at  6:30  p.  m.  in  the  Main  Dining 
Room  of  the  O.  Henry  Hotel  to  First-Meeting 
(1899)  members,  guest  speakers,  ex-presidents,  of- 
ficers and  their  ladies.  Dr.  J.  M.  Northington 
master  of  ceremonies. 


Dr.  Northington:  Ladies  and  Gentlemen:  The 
honor  guests  of  this  occasion  are  those  who  partic- 
ipated in  the  first  meeting  of  this  Association 
forty-two  years  ago.  That  is  not  a  long  time  for 
a  man  to  live  but  it  is  a  long  time  for  him  to  en- 
dure what  he  has  to  enduce  as  a  practitioner  of 
medicine. 

First  I  want  to  present  to  you  Dr.  Buckner  of 
the  City  of  Roanoke,  Virginia,  which  when  he  first 
started  practicing  medicine  was  called  Mud  Lick. 
Dr.  Buckner. 

Dr.  Leigh  Buckner:  Dr.  Northington,  Ladies 
and  Gentlemen:  I  correct  the  gentleman,  to  begin 
with.  He  has  slandered  by  home.  It  was  Big 
Lick.    (Laughter.) 

I  am  very  grateful  to  this  Society  for  inviting 
me  here.  While  it  has  been  embarrassing  to  be 
held  up  as  an  antique,  still  I  feel  that  I  have  the 
keys  of  the  house.  The  grinders  haven't  ceased 
and  even  the  grasshopper  is  not  a  burden.  I  ap- 
preciate the  fact  that  the  apple  tree  has  flourished 
and  most  of  the  petals  have  dropped  and  when  I 
look  around  at  you  younger  men  here,  I  realize 
that  you  are  following  along  that  road,  too. 

I  want  to  thank  you  very  heartily  in  the  name 
of  all  the  old  founders  of  this  organization  for  the 
splendid  job  you  have  done  in  bringing  it  to  its 
present  state  of  efficiency.  I  know  I  express  their 
wishes  when  I  say  that  they  hope  that  you  will 
make  every  year  a  milepost  in  the  further  and 
splendid  development  of  the  Society.  (Applause.) 

Dr.  Northington:  Another  distinguished  mem- 
ber of  this  venerable  group  we  delight  to  honor 
ourselves  in  honoring  is  Dr.  Robert  Gibbon,  of 
Charlotte. 

Dr.  Gibbon:  This  is  quite  a  surprise.  I  can 
only  congratulate  myself  on  being  in  such  good 
company    (Applause.) 

Dr.  Northington:  Another  in  this  group  of  dis- 
tinguished gentlemen  who  have  been  distinguished 
in  former  times,  and  more  distinguished  in  later 
times,  is  Dr.  Hubert  Royster.  (Applause.) 

Dr.  Royster:  Ladies  and  Gentlemen:  The  in- 
gredients of  an  afterdinner  speech  consist  of  a 
joke,  a  platitude  and  a  quotation.  The  joke  is 
before  you.  (Laughter.)  The  platitude  is— I  re- 
gret, ladies  and  gentlemen,  that  you  called  upon 
me  for  this  impromptu  speech,  as  I  am  totally  un- 
prepared. (The  fact  is  that  I  have  known  for  two 
weeks  that  I  was  going  to  make  this  speech.)  So, 
that  is  a  lie.   The  quotation  is, 

"Of  all  sad  words  of  tongue  or  pen, 
The  saddest  are  these — it  might  have  been." 

In  190S  I  was  elected  President  of  this  Asso- 
ciation here  in  Greensboro.  Of  course  I  was  a  very 
young  man,  and  through  the  years  I  have  con- 
tinued to  reserve  the  niche,  which  was  preserved 
for  me   from   time  immemorial.    It   was  discussed 


SOUTHERN  MEDICINE  &  SURGERY 


May  1941 


and  voted  to  make  retiring  presidents  honorary 
members,  so  that  after  my  retirement  I  was  made 
an  honorary  member.  Along  about  twenty  years 
afterward  I  thought  it  better  for  me  to  resign  and 
get  other  men  in.  Hon.  J.  K.  Hall,  sitting  here  at 
my  right,  said  when  I  handed  in  my  resignation 
that  it  was  impossible  for  an  honorary  member  to 
resign,  so  here  I  am  thirty-six  years  after  my  elec- 
tron. I  believe  I  am  the  oldest  in  seniority  if  not 
in  years.  I  went  to  Edinburgh — in  1913  I  believe. 
I  had  a  friend  on  my  hands  and  somebody  had 
him  on  his  hands.  We  got  together  in  that  Scotch 
town  where  the  carts  stop  running  during  church 
hours.  I  thing  he  is  older  than  I  am  in  years  at 
least. 

I  have  done  my  duty.  Mr.  Toastmaster.  It  is 
the  duty  of  every  speaker  called  upon  to  stand  up, 
speak  up  and  shut  up.    (Applause.) 

Dr.  Northington:  I  have  been  requested.  La- 
dies and  Gentlemen,  to  add  to  this  list  of  distin- 
guished speakers  some  others  equally  distinguish- 
ed.  Dr.  Robert  Wilson,  of  Charleston.  (Applause.) 

Dr.  Wilson:  (Applause.)  I  was  not  one  of  the 
founders. 

Dr.  Northington:  I  beg  your  pardon,  but  you 
are  cited  for  other  services,  by  reason  of  -your 
other  distinguished  attainments. 

Dr.  Wilson:  Well.  I  feel  very  much  like  Dr. 
Royster.  The  joke  is  before  you.  I  can  only  say, 
my  friends,  that  I  am  very  grateful  to  be  here 
with  you  this  evening.  Xot  like  Dr.  Royster,  I 
was  not  informed  two  weeks  ahead  that  I  would 
be  expected  to  make  a  speech,  therefore  these  few 
remarks  are  absolutely  impromptu.  Dr.  Royster 
was  able  in  advance  to  prepare  something  that  was 
really  worth  while.  Unfortunately  I  didn't  know 
until  the  moment  Dr.  Northington  asked  me  to  get 
up.  so  I  have  nothing  more  to  say  than  to  express 
my  appreciation  for  being  here,  for  being  singled 
out  to  say  a  word  and  for  having  had  the  distin- 
guished honor  of  being  your  President  one  year. 
(Applause.) 

Dr.  Northington:  Dr.  Wilson,  whether  or  not 
he  be  prepared  in  his  own  sense  of  being  prepared, 
is  always  prepared,  and  we  can  always  count  on 
hearing  from  him  words  fitly  spoken,  which  a  wise 
man  has  likened  to  apples  of  gold  in  pictures  of 
silver.    Dr.  James  K.  Hall. 

Dr.  Hall:  Ladies  and  Gentlemen:  I  feel  dis- 
parity, both  socially  and  intellectually.  I  have 
been  seated  for  the  last  hour  before  a  very  good 
meal  and  between  a  Dean  and  a  former  Dean. 
You  can  imagine  why  I  feel  so  with  a  Dean  on  my 
right  and  a  former  Dean  on  my  left. 

This  has  been  a  night  of  memories  with  me. 
Dr.  Robert  Wilson  presided  over  this  meeting  at 


Virginia  Beach  in  1928  and  I  here  in  this  hotel, 
perhaps  in  this  room,  in  February,  1929.  Someone 
told  me  afterwards  that  here,  at  that  meeting  in 
1929,  was  held  the  first  psychiatric  clinic  in  this 
State.  We  had  a  good  many  other  clinics.  It  is  a 
night  of  memories  with  me.  I  attended  the  meet- 
ing of  this  organization  the  first  time  in  the  Jef- 
ferson Hotel  in  Richmond  in  1910  and  did  not 
miss  a  meeting  for  a  good  many  years.  I  never 
missed  one  when  I  could  help  it.  I  am  sorry  I 
couldn't  get  here  early  this  morning.  This  is  a 
splendid  Association.  The  best  medical  men  in 
the  Carolinas  and  Virginia  have  been  members 
for — how  many  years — forty-two.  I  attended  a 
few  weeks  ago  at  the  University  of  Virginia  the 
funeral  of  Paul  Brandon  Barringer.  Wasn't  he 
one  of  the  founders? 

Dr.  Northington:  He  was.  There  were  seven- 
teen of  these  founders-survivors  and  three  of 
them  have  died  in  the  last  month,  after  the  invita- 
tions were  extended,  which  leaves  fourteen. 

Dr.  Hall:  Well,  I  am  happy  to  be  here  and  I 
am  happy  that  you  are  all  well  and  that  you  are 
all  here  together  and  I  expect  this  organization  to 
continue  its  good  work  year  after  year.  (Ap- 
plause.) 

Dr.  Northington:  Is  Dr.  W  C.  Davison  pres- 
ent? 

Dr.  Davison:  Ladies  and  Gentlemen:  I  can't 
possibly  have  been  a  member  for  forty-two  years 
but  I  have  been  a  member  for  one-third  of  that, 
fourteen  years.  Like  the  other  gentlemen  who 
have  spoken,  I  have  greatly  enjoyed  being  here 
and  attending  this  meeting. 

Dr.  Northington:    Dr.  C.  C.  Carpenter. 

Dr.  Carpenter:  I  can't  boast  of  the  number  of 
years  I  have  been  a  member  of  this  organization, 
but  I  will  say  that  I  expect  to  be  a  member  for 
the  next  forty  "years. 

Dr.  Northington:  President  Andrews  will  take 
charge  of  the  program  from  here. 

President  Andrews:  Fellows  of  the  Tri-State 
Medical  Association.  Ladies  and  Gentlemen:  I 
first  want  to  take  advantage  of  this  occasion  to  ex- 
press my  appreciation  of  the  honor  which  you 
done  me  in  making  me  your  President.  I  think  it 
is  an  honor  of  which  anyone  might  justly  be 
proud,  but  particularly  when  I  see  the  distinguish- 
ed group  which  I  will  join  at  the  end  of  this  meet- 
ing as  Past  President. 

Dr.  Northington  wrote  me  some  time  ago  to 
know  what  would  be  the  subject  of  my  address.  I 
told  him,  "Medical  Problems  and  Projects."  He 
wrote  me  a  week  or  two  afterward  to  know  what 
it  was  and  I  told  him  the  same  thing.  However, 
he  has  given  me  a  better  title,  "Problems  and 
Progress,"  and  the  thought  occurs  to  me  that  this 


SOUTHERN  MEDICINE  &  SURGERY 


is  not  necessarily  medical  problems.  I  think  that 
we  have  been  taking  too  much  to  ourselves.  The 
problems  we  call  ours  are  problems  of  the  people 
more  than  they  are  of  us  doctors,  and  the  prob- 
lems which  the  medical  fraternity  has  been  trying 
to  work  out  are  still  those  of  the  people,  as  we 
shall  try  to  point  out  as  we  go  along. 

Dr.  Andrews  reads  his  formal  address.  (Ap- 
plause.) 

Dr.  Andrews:  The  next  part  of  the  program  is 
an  address  bv  the  President-Elect,  Dr.  Brenizer. 
Is  Dr.  Brenizer  present? 

Dr.  Northington:  I  speak  for  the  President- 
Elect  who  was  to  have  given  me  his  address  to  be 
read  bv  a  proxy.  I  don't  know  what  happened  to 
Dr.  Brenizer.  but  I  do  know  that  the  outline  or 
what  he  would  have  covered  would  have  given  an 
account  of  the  organization  in  the  great  first 
World-War.  of  the  organization,  the  transport,  and 
ihe  services  of  Hospital  Unit  0  and  Base  Hospital 
65.  Unit  O  was  aggregated  largely  at  Charlotte, 
and  brought  into  effective  organization  very  early 
in  the  war.  They  did  their  bit  for  the  cause  of 
Democracy.  They  were  amalgamated  with  Har- 
vard Unit  which  had  preceded  them  to  Bordeaux 
and  there  they  worked  in  close  harmony  in  this 
integrated  Unit  and  performed  one  of  the  most 
distinguished  services  of  any  Hospital  Unit  that 
functioned  in  World  War  Number  One. 

Base  Hospital  65  was  organized  in  this  city 
and  Winston-Salem.  The  moving  influences 
were  Dr.  John  Wesley  Long,  of  Greensboro,  and 
Dr.  Frederic  M.  Hanes,  of  Winston-Salem.  Dr. 
Long,  as  we  all  know,  was  a  human  dynamo. 
Dr.  Long  organized  this  Unit  and,  after  training 
at  Fort  McPherson,  Georgia,  we  went  across  the 
ocean  to  the  seat  of  war,  and  wound  up  that  little 
ball  of  yarn.  Base  Hospital  65  was  organized 
originally  as  a  Surgical  Unit.  It  functioned  largely 
as  a  Medical  Unit,  and  it  was  so  rumored,  and 
most  likely  but  for  the  early  and  unanticipated 
termination  of  the  war,  that  for  its  functioning 
as  a  Medical  Unit,  each  member  of  the  organiza- 
tion would  have  had  conferred  upon  him  or  her  a 
distinguished  service  cross — rather  a  Croix  de 
Guerre.  I  speak  reverently  as  a  member  of  this 
organization  and  in  the  city  in  which  Dr.  Long 
discharged  his  great  service  to  ailing  humanity.  I 
pause  to  pay  tribute  to  Dr.  John  Wesley  Long,  a 
man  who  was  known  to  most  of  you  and  by  every 
one  to  whom  he  was  known  was  held  in  the  highest 
regard  as  a  man  of  ability  and  integrity  and  of 
zealous  purposes. 

If  I  had  Dr.  Brenizer's  manuscript,  I'd  read  it 
to  you.  but  it  will  appear  in  the  Journal  of  this 
Association.    CApplause.) 


President  Andrews:  In  agreement  with  the 
time-honored  custom,  the  best  is  for  the  last.  Dr. 
Barker  of  Baltimore  and  Dr.  Orr  of  Nebraska  will 
address  you  in  just  a  few  minutes. 

We  will  pause  for  just  a  moment  while  equip- 
ment is  being  set  up. 

Brief  recess. 

President  Andrews:  Next  on  the  program  is 
"The  General  Problems  of  Old  Age"  by  Dr.  Lew- 
ellys  F.  Barker,  of  Baltimore. 

Dr.  Barker  read  his  address.  (Carried  in  March 
issue  of  this  journal.) 

Dr.  Northington:  Mr.  President,  I  would  vio- 
late the  tradition  of  this  Association  to  say  a  few 
words  in  appreciation  of  this  wonderful  address 
and  I  say  it  largely  in  quotation  marks.  I  speak 
as  a  voice  from  the  grave.  Dr.  John  Peter  Munroe 
taught  more  men  in  medicine  in  North  Carolina 
than  any  other  human  did  and  taught  them  well. 
One  of  the  last  things  that  he  said  to  me,  when, 
after  several  strokes,  he  spoke  in  a  faltering;  voice 
which  could  be  interpreted  only  by  one  who  was 
used  to  his  now-stumbling  speech,  when  I  men- 
tioned to  him  the  name  of  this  great  doctor,  this 
great  teacher  of  medicine,  Dr.  Barker,  his  brown 
eyes  lit  up  with  pleasure  and  he  said,  "Barker 
always  tells  you  something  to  do  for  sick  folks." 
And  here  is  Dr.  Barker  to  verify  this  statement  of 
this  dying  patriarch  of  medicine  in  North  Caro- 
lina, this  Past  President  of  this  Association,  gone 
to  his  reward  within  the  past  year. 

Dr.  Barker,  we  rejoice  to  have  you  here.  (Ap- 
plause.) 

President  Andrews:  At  this  time  I  take  pleas- 
ure in  introducing  Dr.  W.  A.  Boyd,  of  Columbia, 
who  will  introduce  our  next  invited  and  distin- 
guished guest.    Dr.  Boyd. 

Dr.  W.  A.  Boyd:  Mr.  President,  Gentlemen  of 
the  Association,  Our  Guests:  In  the  last  few  years 
many  drugs  have  been  brought  forward  and  pre- 
sented to  the  medical  profession  as  curative  agents 
for  the  various  infections  that  afflict  mankind. 
Some  of  our  confreres  have  been  extravagant  in 
their  claims  for  the  benefits  to  be  derived  from 
these  drugs.  Others  have  been  more  conservative. 
All  of  us,  I  think,  are  agreed  that  under  certain 
conditions  they  are  of  benefit  and  helpful. 

We  are  peculiarly  fortunate  tonight  in  having 
with  us  a  man  who  has  not  sought  publicity,  a 
man  who  has  taught  us  how  to  care  for  the  acute 
and  chronic  infections  of  bone  and  joint,  a  man 
who  has  been  recognized  and  honored  by  his  col- 
leagues everywhere,  one  who  is  not  radical,  one 
who  is  not  conservative,  one  who  gained  his  expe- 
rience from  careful  analysis  of  his  work,  who  will 
(To  Page  287) 


SOUTHERN  MEDICINE  &  SURGERY 


May  1941 


SOUTHERN  MEDICINE  &  SURGERY 

Official  Organ 

TRI-STATE    MEDICAL    ASSOCIATION    OF    THE 

CAROLINAS  AND  VIRGINIA 

James  M.  Northlngton,  M.D.,  Editor 


Department  Editors 
Human  Behavior 

James    K.    Hall,   M.D Richmond,   Va. 

Orthopedic   Surgery 
Oscar  Lee  Miller,  M.  D  | 
John  Stuart  Gaul,  M.D.f Charlotte,  N.  C. 

Urology 

Hamilton  W.  McKay,  M.D.\  Charlotte,  N.  C. 

Robert  W.  McKay,  M.D ) 

Surgery 

Geo.  H.  Bunch,  M.D Columbia,  S.  C 

Obstetrics 

Henry  J.  Langston,  M.D Danville,  Va. 

Ivan  M.  Procter,  M.D Raleigh,  N.  C. 

Gynecology 

Chas.  R.  Robins,  M.D Richmond,  Va. 

G.  Carlyle  Cooke,  M.D Winston-Salem,  N.  C. 

Pediatrics 

G.  W.  Kutscher,  Jr.,  M.D Asheville,  N.  C. 

General  Practice 

J.   L.   Hamner,  M.D Mannboro,   Va. 

W.  J.  Lackey,  M.D Fallston,  N.   C. 

Clinical  Chemistry  and  Microscopy 

C.  C.  Carpenter,  M.D I 

~    „    ,,  „„„»,,,»    X  Wake  Forest,  N.  C. 

R.  P.  Morehead,  B.S.,  M.A.,  M.D..  | 

Hospitals 
R.   B.   Davis,  M.D Greensboro,  N.   C. 

Cardiology 
Clyde  M.  Gllmore,  A.B.,  M.D Greensboro.  N.  C. 

Public  Health 
S.  Thos.  Ennett,  M.D Greenville,  N.  C 

Radiology 
Wright  Clarkson,  M.D.,  and  Associates.. ..Petersburg,  Va. 
R.  H.  Lafferty,  M.  D.,  and  Associates,     Charlotte,  N.  C. 

Therapeutics 
J.  F.  Nash,  M.  D., Saint  Pauls.  N.  C. 

Tuberculosis 
John    Donnelly,   M.D Charlotte,   N.    C. 

Dentistry 
J.  H.   Guion,  D.  D.  S Charlotte,  N.   C 

Internal  Medicine 
George  R.  Wilkinson,  M.  D Greenvil'e,  S.  C. 

Ophthalmology 
Herbert  C.  Neblett,  M.  D., Charlotte,  N.  C. 

Rhino-Oto-Laryngology 
Clay  W.  Evatt,  M.  D.,  .'...Charleston,  S.  C. 


Offerings  for  the  pages  of  this  Journal  are  requested  and 
given  careful  consideration  in  each  case.  Manuscripts  not 
found  suitable  for  our  use  will  not  be  returned  unless 
author  encloses  postage. 

As  is  true  of  most  Medical  Journals,  all  costs  of  cuts, 
etc.,  for  illustrating  an  article  must  be  borne  by  the  author. 


AN  EDITORIAL 

BY 

Clarence  C.  Little,  Sc.D. 

Managing  Director,  American  Society  for  the  Control  of 

Cancer 

All  over  the  country  today  there  is  a  new 
spirit  of  determination  and  resolution.  We  have 
watched  overseas  the  clash  of  a  cruel  and  coldly 
impersonal  type  of  social  order  with  the  less  effi- 
cient but  far  more  human  organization  called  De- 
mocracy. From  the  very  outset  we  knew  in  our 
hearts  which  was  right  and  which  was  wrong.  Be- 
cause of  the  very  kindness  and  consideration  on 
which  our  sort  of  civilization  was  founded  we  were 
at  first  unable  to  grasp  the  full  menace  of  the 
forces  arrayed  against  it.  Now,  however,  we  are 
awake,  alert  and  active.  We  have  taken  up  our 
position  and  we  cannot  relinquish  it  until  final 
and  complete  victory.  What  a  close  parallel  there 
is  between  this  situation  and  that  of  the  problem 
of  cancer  control. 

For  decades  we  have  known  that  cancer  is  a 
cruel  and  ruthless  killer,  an  enemy  of  homes  and 
of  human  happiness.  It  has  taken  men  and  women 
in  their  prime — leaders  in  art,  in  science  and  in 
industry.  It  has  broken  up  families  and  robbed 
children  of  their  parents.  For  years  it  has  been  a 
menace  breeding  fear  and  discouragement. 

Because  other  diseases  were  less  vigorous  and 
menacing,  and  because  they  provided  us  with  less 
opposition  in  diagnosis  and  treatment,  we  have 
attacked  them  first  and  with  more  optimism.  One 
after  another  they  have  been  checked  or  beaten. 
Now,  however,  we  are  finally  aroused  as  a  people 
and  have  taken  our  stand  as  regards  cancer.  No 
longer  can  it  be  suffered  to  move  unchecked  and 
terrible.  We  know  that  it  is  vulnerable.  It  is  no 
mystical  being  that  can  defy  the  assault  of  knowl- 
edge and  science  activated  by  courage  and  ideal- 
ism. Some  with  special  training  knew  this  for  some 
time,  however,  before  it  was  possible  to  enlist  and 
use  the  will  of  the  general  public  in  the  fight. 
What  has  made  the  difference?  Why  can  we  today 
move  forward  with  faith  and  hope? 

It  is  the  women  of  America  who  have  made  this 
possible.  Rising  as  volunteers  to  participate  in  the 
nrganization  of  the  Women's  Field  Army  Against 
Cancer  (a  part  of  the  work  of  the  American  So- 
ciety for  the  Control  of  Cancer)  they  have  done 
wonders.  Thev  have  spread  knowledge  of  the  signs 
and  symptoms  that  may  mean  cancer.  Millions 
upon  millions  of  people  have  received  this  infor- 
mation without  cost.  They  have  organized  meet- 
ngs  which  have  been  addressed  by  selected  med- 
;cal  speakers.  Under  proper  medical  supervision, 
they  have  aided  indigent  patients  to  obtain  diag- 


SOUTHERN  MEDICINE  &  SURGERY 


nosis  and  treatment.  They  have  removed  much  of 
the  paralvzing  fear  of  cancer  that  held  the  people 
powerless;  they  have  transformed  the  whole  bat- 
tlefront  against  cancer  from  one  where  isolated 
raids  were  being  made  to  a  general  and  inspiring 
advance.  They  have  brought  courage  and  peace 
to  thousands.  They  have  begun  to  cheat  Death  of 
his  prey. 

This  is  good  training  for  any  sort  of  struggle,  a 
type  of  preparedness  for  organized  effort  against 
tremendous  evil.  It  is  the  logical  and  reasonable 
school  for  those  qualities  that  Democracy  must  de- 
velop in  order  to  survive.  That  is  why  it  is  not 
only  your  duty  but  your  privilege  to  take  part  in 
the  fight  against  cancer.  To  shirk  that  task  is  a 
poor  prospect  for  your  ability  to  meet  the  sort  of 
challenge  that  Life  will  force  upon  all  of  us  in  the 
immediate  future.  To  meet  the  call  cheerfully  and 
intelligently  will  help  you  to  win  other  battles  to 
come.  The  need  is  clear.  Humanity  calls.  Enlist 
and  Serve! 


THE  ADMINISTRATION  OF  ANESTHETICS 
BY  THE  NON-SPECIALIST 

There  is  a  popular  idea  that,  in  order  to  do 
anything  passably  well,  one  must  not  be  able  to  do 
anything  else.  Only  recently  it  came  to  my  know- 
ledge that  neither  the  carpenter  not  the  plasterer 
any  longer  nails  on  the  laths  to  hold  the  plastei . 
For  that  work  the  employment  of  a  lather  is  re- 
quired. 

Along  this  same  line  of  reasoning — or  unreason- 
ing, as  you  may  choose — i<  has  com-i  to  pass  that 
many  hospital  authorities  and  others  demand  that 
all  anesthetic  aministration  be  done  by  those 
carried  in  the  American  Directory  as  specialists  in 
Anesthesiology;  and  this  despite  the  fact  that 
most  of  these  specialists  do  all  the  general  practice 
that  comes  their  way. 

A  nice  question  might  be  raised  and  debated: 
Is  the  anesthesiologist  any  better  qualified  to 
practice  general  medicine  and  surgery  than  is  the 
practitioner  of  general  medicine  and  surgerv  to  give 
anesthetics?  And  some  intelligent  doctnrs  might 
even  prefer  a  general  practitioner  who  has  kept 
abreast  with  the  advancing  knowledge  of  anesthe- 
tics, rather  than  a  specialist,  when  the  doctor  him- 
self, a  member  of  his  family,  or  one  of  his  natients 
is  to  be  put  to  sleep.  Some  doctors  believe  that 
broad  familiarity  with  the  health  vagaries  of  human- 
kind qualifies  for  correct  evaluation  of  the  new 
offerings  in  this  as  in  other  fields. 

Whether  or  not  one  agree  with  this  reasoning, 
in   the   vast   majority   of  instances   the  anesthetic 


1.   H.    S.    Ruth.    Mer 


Bull.   Am.   Col.  Surgs.,  Jan. 


must  be  administered  by  some  person  not  a  fellow 
of  the  College  of  Anesthesiology:  so  the  idea  of 
the  author  whose  article  here  is  abstracted — that 
general  practitioners  should  be  cheerfully 
accepted  for  this  service  and  given  whatever  help 
they  may  need — is  sound  and  sensible. 

The  great  number  of  anesthetic  agents  being 
added  and  the  complexities  of  the  mechanisms  for 
administration  tend  to  confuse  those  of  us  whose 
intern  days  are  some  distance  behind  us.  A  brief 
of  a  specialist1  in  anesthesia  who  realizes  that  one 
must  cut  his  garment  according  to  his  cloth  is  pre- 
sented. 

The  inexperienced  anesthetist,  in  an  emergency, 
is  prone  to  do  the  wrong  thing  or  to  overtreat  the 
patient.  Adrenalin  is  injected  into  the  heart  on  the 
appearance  of  temporary  apnea  ,  rather  than  sim- 
ole  inflation  of  the  lungs  with  pure  oxygen.  Inex- 
perienced individuals  do  not  accurately  record  the 
details  of  anesthesia.  Consequently,  it  is  possible 
to  make  the  chart  of  a  stormy,  unsatisfactory  and 
even  dangerous  anesthesia  appear  uneventful. 

The  Philadelphia  County  Medical  Society  for 
the  past  14  months,  through  its  Anesthesia  Study 
Commission,  has  studied  deaths  during  or  within 
24  hours  of  the  administration  of  an  anesthetic 
agent.  During  this  period  28  deaths  were  consid- 
ered preventable.  A  pathetic  picture  is  painted 
especially  by  the  number  of  instances  when  a 
direct  overdose  of  a  spinal  anesthetic  agent  was 
administered  (50  plus  per  cent).  The  selection  of 
a  dose  of  200  mgm.  of  procaine  for  an  appendec- 
tomy or  20  mgm.  of  pontocaine  for  the  reduction 
of  a  fractured  leg,  is  not  reasonable.  Particularly 
discouraging  were  the  findings  that  when  respira- 
tory function  ceased,  through  any  cause  other  than 
circulatory  collapse,  in  over  50%  of  instances  car- 
diovascular stimulants  or  intracardiac  injections 
were  prescribed,  instead  of  the  comparatively  sim- 
ple but  urgent  remedy  of  administering  oxygen 
into  the  lungs.  In  some  instances  the  Anesthesia 
Study  Commission  believes  that  fatalities  probably 
were  initiated  by  some  of  the  attempted  resuscita- 
tive  measures. 

The  inadequately  trained  physician  usually  will 
have  a  general  practice  which,  at  times,  is  used  to 
obtain  calls  for  anesthesia.  A  trade,  open  or  im- 
plied, is  consummated,  whereby  his  surgerv  is  re- 
ferred to  a  given  surgeon  in  order  to  obtain  the 
privilege  of  administering  an  anesthetic  agent  to 
his  patient. 

When  it  is  necessary  for  untrained  individuals 
to  administer  anesthetic  agents,  it  is  advisable  thai 
they  adhere  to  the  more  simple  techniques  and 
better-known  agents.    Tt  may  be  highly  beneficial 


SOUTHERN  MEDICINE  &  SURGERY 


May  1941 


to  flow  oxygen  under  the  mask  employed  for  drop 
ether  anesthesia.  Complicated  equipment  should 
be  left  to  the  specially  trained.  Spinal  anesthesia 
should  probably  be  reserved  for  the  robust  patient. 
Procaine  in  single  or  multiple  doses  is  one  of  the 
best  agents. 

Until  such  time  as  a  sufficient  number  of  ade- 
quately trained  anesthetists  are  available,  other 
alternative  measures  should  be  given  consideration. 
In  smaller  communities,  younger  men  should  be 
encouraged  to  study  the  ltierature  and  visit  cen- 
ters of  anesthesiology,  and  for  them  the  adminis- 
tration of  anesthetic  agents  should  be  made  more 
attractive  and  compensating.  In  larger  institu- 
tions, much  progress  may  be  made  by  the  addition 
of  a  well-trained  anesthesiologist  to  supervise  the 
remainder  of  the  department,  to  attend  the  criti- 
cally ill,  to  apply  the  more  specialized  techniques, 
and  to  share  in  the  responsibility  for  the  choice 
of  anesthetics  in  cases  of  emergency.  In  any  com- 
munity, opportunity  should  be  given  by  the  or- 
ganized medical  profession  to  nearby  anesthesiolo- 
gists, so  that  interested  physicians  may  institute 
educational  campaigns  in  this  field  by  conferen- 
ces, study  groups,  and  the  presentation  of  papers. 

YVe  would  amplify  the  suggestion  thus:  That 
this  be  made  an  exchange  of  knowledge,  between 
the  specialist  and  the  general  practitioner,  each 
supplementing  the  knowledge  of  the  other.  A 
fair  exchange  is  no  robbery. 


A  POINT  AS  TO  MAKING  A  LIVING  BY 
PRACTICING  MEDICINE 

Many  doctors  are  getting  a  very  precarious  live- 
lihood out  of  their  practice.  We  could  get  a  valua- 
ble lesson  from  considering  all  the  implications  of: 
It  is  not  the  high  cost  of  living  that  bothers  me, 
but  the  high  cost  of  high  living. 

In  a  pediatric  meeting  some  time  ago  a  promi- 
nent specialist  in  this  field  made  this  frank,  honest 
and  intelligent  statement: 

This  problem  of  income  is  a  very  serious  one. 
I,  very  probably,  have  a  little  different  situation 
in  my  office  from  most  of  the  pediatricians  practic- 
ing in  the  State  in  that  I  try  to  keep  all  of  my 
patients  that  I  can  out  of  the  hospital. 

Whenever  you  hospitalize  the  patient,  the  hos- 
pital gets  the  bulk  of  the  income  and  you  don't  get 
anything  at  all.  I  do  all  my  own  transfusions  right 
in  ray  office,  my  matching  and  everything  else,  and 
I  charge  those  patients  a  flat  fee.  Sometimes  I  do 
3  or  4  transfusions  in  a  day,  and  I  find  it  a  very 
substantial  source  of  income.  My  empyema  cases 
I  do  not  allow  to  go  into  the  hands  of  a  surgeon. 
I  haven't  in  the  past  10  years  hospitalized  a  pa- 


tient with  empyema.    I  do  that  work  right  in  my 
office. 

It  is  admitted  generally  that  the  no-child  to 
three-children  families  of  today  have  made  it 
pretty  hard  on  the  pediatricians.  Another  promi- 
nent baby  doctor  has  put  himself  on  record  as 
favoring  extension  of  the  age  at  which  a  boy  or 
girl  is  to  pass  from  the  care  of  the  pediatrician. 

When  the  editor  was  in  college  it  was  the  general 
teaching  that  after  seven  years  of  life,  for  purposes 
of  medical  and  surgical  care,  a  human  being  par- 
took more  of  the  properties  of  those  older  than  of 
those  younger.  The  passing  age  has  been  much 
beyond  that  for  a  long  time.  Some  years  ago  a 
good  doctor  who  had  for  years  been  prominent  as 
a  pediatrician  reported  in  a  medical  meeting  the 
case  of  a  patient,  aged  78,  whom  he  had  treated  a 
few  weeks  before.  Where  the  age  limit  will  go  to  is 
anybody's  guess. 

Back  from  the  digression,  we  commend  strongly 
the  idea  that  pediatricians  and  all  others  who  have 
to  make  a  living  out  of  the  practice  of  medicine 
will  do  well  to  use  discrimination  as  to  sending 
patients  into  hospitals.  Hospitals  are  a  boon  to 
the  race — in  certain  cases.  But  there  is  no  more 
reason  for  sending  every  patient  to  a  hospital  than 
for  taking  out  every  patient's  tonsils  or  appendix. 

Unnecessary  hospitalization  is  responsible  for 
much  of  the  agitation  about  the  cost  of  medical 
care.  It  always  puts  an  unfair  financial  burden  on 
the  patient.  Often  it  destroys  all  chance  of  the 
doctor  being  paid. 

If  you  would  put  yourself,  vour  wife  or  your 
child,  sick  the  same  way  as  is  a  certain  patient, 
into  the  hospital:  and  if  it  were  as  hard  for  you  to 
get  hold  of  a  few  dollars  as  it  is  for  the  patient  or 
the  one  who  has  to  pay  the  patient's  bills — by  all 
means  send  to  the  hospital:  otherwise  do  not. 

Be  considerate  of  your  patients'  health  first;  but 
be  intelligently  considerate  also  of  their  financial 
welfare,  and  of  vour  own. 


A    RIGHT    DIAGNOSIS    "EPILEPSY"    IS    A 

TERRIBLE  THING:   A  WRONG  DIAGNOSIS 

"EPILEPSY"  IS  A  HORRIBLE  THING 

There  are  over  500,000  cases  of  ordinary  epilep- 
sy in  this  country — more  cases  than  there  are  of 
advanced  tuberculosis,  more  than  there  are  of 
diabetes1.  There  is  no  chronic  disease  that  carries 
more  stigma  than  does  epilepsy.  There  are  so 
many  correctable  conditions  that  have  been  and 
are  still  being  so  labeled  and  so  stigmatized  as  to 
make  it  appropriate  that  attention  be  called  to 
them. 


1.  T.  F.  Frist,  Nashville,  in  //.  Tenn.  State  Med.  Assn.,  April. 


SOUTHERN  MEDICINE  &  SURGERY 


Convulsions  may  be  caused  by  fevers  of  child- 
hood, cerebral  injuries,  advanced  arteriosclerosis  or 
dehydration;  but  these  conditions  being  self-limit- 
ed proper  diagnoses  are  soon  made.  Seven  condi- 
tions are  described  as  almost  entirely  simulating 
either  petit  mal,  or  grand  mal  seizures,  and  going 
for  years  with  such  a  diagnosis,  many  having  "epi- 
lepsy" written  on  their  death  certificates,  and  the 
stigma  is  passed  on  to  subsequent  generations. 

The  most  common  of  the  seven  is  the  hypersen- 
sitive carotid  plexus.  The  carotid  sinus  is  the  dila- 
tation at  the  bifurcation  of  the  common  carotid 
artery.  Just  to  its  outer  side  is  a  nerve  plexus 
which  is  apt  to  become  hypersensitive,  and  its  irri- 
tation to  cause  syncope,  convulsions,  urinary  and 
fecal  incontinence,  and  other  symptoms  of  epilepsy. 
The  diagnosis  can  usually  be  made  by  making 
rather  quick,  firm  pressure  on  the  carotid  bulb. 
The  carotid  bulb  is  usually  easily  felt  just  under 
the  angle  of  the  jaw.  The  pressure  maintained 
with  slow  massage  for  30  to  45  seconds  will  bring 
on  the  symptoms.  A  case  is  reported  of  a  man 
who  had  such  attacks  from  wearing  a  very  high, 
tight,  stiff  collar.  He  was  advised  to  get  a  size 
larger,  soft,  low  collar.  His  attacks  became  much 
less  frequent  and  subsided  completely  when  he 
was  given  belladonna  to  inhibit  the  vagal  effect. 
Xo  attack  during  the  past  two  years  except  on  one 
occasion  when  he  left  off  belladonna  for  two  weeks. 
Xearly  all  these  cases  can  be  relieved  in  one  of 
four  ways:  with  atropine,  which  inhibits  the  vagus 
nerve:  with  ephedrine,  which  relieves  the  depressor 
type  by  boosting  the  blood  pressure;  with  vitamin 
B,  which  decreases  the  sensitivity  of  the  carotid 
plexus;  or  by  denervation. 

The  second  condition,  and  the  one  which  per- 
haps most  nearly  simulates  epilepsy,  is  hypopara- 
thyroidism, or  chronic  tetany.  Tetany  may  come 
from  the  taking  of  an  excess  of  alkali,  or  from 
prolonged  vomiting.  A  history  would  always  clear 
up  this  diagnosis,  but  a  diagnosis  of  a  true  spon- 
taneous hypoparathyroidism  is  difficult  unless  we 
consider  it,  and  then  it  becomes  simple.  In  such  a 
case  one  is  apt  to  have  attacks  of  dizziness  with 
falls,  rigidity,  cramping  in  the  arms  and  calves, 
aura,  lethargy,  tongue-biting,  cyanosis,  clonic  con- 
tractions. Then  if  he  have  too  little  blood  calcium, 
a  positive  Chvostek  and  Trousseau's  sign,  a  diet 
high  in  calcium,  perhaps  supplemented  with  cal- 
cium and  phosphorous  medication,  will  relieve. 

The  third  condition  is  orthostatic  hypotension- - 
weakness,  dizziness,  syncope  and  sometimes  con- 
vulsions when  the  patient  assumes  an  erect  posi- 
tion, deficient  sweating,  local  or  general,  failure  of 
pulse  rate  to  increase  when  the  patient  stands  up, 
aggravation  of  symptoms  during  hot  weather,  and 
secretion    of    more    urine    when    recumbent    than 


when  erect.  In  a  case  reported,  on  two  occasions 
the  patient  had  severe  attacks  while  working  and 
was  told  he  had  sunstroke.  Examination  disclosed 
that  the  blood  pressure  recumbent  was  60  to  80 
points  higher  than  when  erect.  Three-eighths  grain 
of  ephedrine  sulphate  three  times  a  day  and  elastic 
bandages  to  both  legs  for  eight  months  brought 
almost  complete  relief. 

The  fourth  condition  to  be  considered  is  hyper- 
insulinism  or  hypoglycemia.  To  suspect  it  is  to 
diagnose  it;  and,  once  diagnosed,  the  management 
is  simple. 

The  fifth  condition  is  that  in  which  we  see  con- 
vulsive seizures  as  manifestations  of  brain  tumor, 
a  condition  in  which  it  is  urgent  that  not  a  day 
be  wasted  if  we  are  to  obtain  best  results. 

The  sixth  condition  is  congenital  heart  block. 
A  girl  aged  four  years  fainted  while  playing  in  the 
yard  and  had  a  convulsive  seizure;  during  the  next 
three  weeks  she  had  a  number  of  convulsions  un- 
accompanied with  fever,  vomiting  or  other  symp- 
toms usual  with  childhood  convulsions.  The  only 
abnormal  finding  was  a  pulse  rate  40  to  48,  during 
the  attack  as  low  as  36.  Electrocardiogram  indi- 
cated a  bundle-branch  block.  Relief  was  given  by 
atropine  and  ephedrine,  and  the  child  has  gotten 
along  well  for  several  years  with  little  trouble,  and 
not  labeled  ''epileptic." 

The  seventh  condition  the  author  quoted  consid- 
ers is  convulsive  seizures  as  a  result  of  involve- 
ment of  the  central  nervous  system  in  secondary 
or  tertiary  syphilis.  He  cites  a  recent  study  at  the 
University  of  Iowa  Hospital  of  100  cases  of  "epi- 
lepsy" of  which  15  per  cent  were  due  to  syphilis 
of  the  central  nervous  system.  In  the  early  sec- 
ondary stage  a  mild  meningeal  reaction  is  not  un- 
common, and  it  may  manifest  itself  by  a  general- 
ized convulsion.  In  the  late  secondaries  the  men- 
ingovascular type  of  syphilis  occasionally  causes 
"epileptic"  seizures.  Tertiary  lesions,  particularly 
gummata,  frequently  cause  convulsions,  and  they 
are  common  symptoms  of  dementia  paralytica. 

In  the  next  case  of  vertigo,  syncope,  or  petit  mal 
or  grand  mal  convulsions,  we  see  we  are  well  ad- 
vised to  consider  carefully  the  following  conditions 
and  procedures: 

Carotid  sinus  syndrome — pressure  on  carotid 
bulb. 

Hypoparathyroidism — blood  calcium  determina- 
1  ion . 

Orthostatic  hypotension — blood  pressure,  recum- 
bent and  erect. 

Hypoglycemia — blood-sugar  determination. 

Central  nervous  system  syphilis — blood  and  spi- 
nal fluid  Wassermann  reaction. 

Brain  tumor — x-ray  examination,  ventriculo- 
gram. 


SOITHER.X  MED1C1SE  &  SURGERY 


May  194! 


Congenital  heart  block — pulse  rate  and  electro- 
cardiogram. 

How  many  of  vour  patients  have  you  wrongly 
labelled  "epilepsy,"  and  thus  done  them  an  irreme- 
diable wrong?  How  many  have  you  assumed  to  be 
epileptics,  considered  their  cases  closed,  and  by 
this  negligence  lost  for  them  their  chance  of  cure5 


Two  Excellent  Postgraduate  Courses  Offered 
Near  Home 

At  different  times  in  the  summer  that  is  upon  us 
two  of  our  own  medical  schools  are  offering  for 
merely  nominal  fees  to  make  better  doctors  out  of 
good  doctors. 

Duke  University  Medical  School  has  arranged 
a  practical  course  of  instruction  in  Obstetrics  with 
some  incidental  Gynecology — just  the  kind  of  in- 
struction the  men  doing  the  bulk  of  this  kind  of 
work  need.  A  clever  idea  is  that  of  refunding  a 
portion — nearlv  half — of  the  small  fee  to  all  those 
who  complete  the  course.  It's  new  to  us  and  has 
our  hearty  approval.  One  who  could  evolve  such 
an  idea  from  his  inner  consciousness  may  be  de- 
pended on  to  provide  a  course  made  up  entirely  of 
meat.  (It  turns  out  that  it  was  another  similar 
course  which  offered  this  feature,  but  Duke  has 
something  just  as  good.) 

Write  the  Dean  promptly.  The  course  will  soon 
begin. 

The  Medical  School  of  the  University  of  Vir- 
ginia offers  a  Postgraduate  Course  in  Medicine,  for 
June  16th-2 1st.  Final  reservations  must  be  made 
by  June  10th.  Those  interested  are  requested  to 
write  the  Chairman  on  Postgraduate  Clinics 
promply.  Each  applicant  is  sent  a  printed  list  of 
67  subjects,  with  request  that  25  preferences  be 
checked  and  the  list  returned. 

Each  of  the  courses  will  include  clinics,  ward 
rounds  and  laboratory  studies. 

It's  impossible  to  think  of  any  place  that  so 
much  is  offered  for  so  little.  This  is  of  the  essence 
of  progressive,  practical  medicine. 

Our  Department  of  Life  Insurance  Medicine 
With  this  issue  begins  the  conduct  of  a  depart- 
ment having  to  do  with  the  part  of  the  practice  of 
medicine  of  special  concern  to  life  insurance  exam- 
iners. This  is  a  large  part,  and  much  of  this  large 
body  of  knowledge  is  of  daily  usefulness  in  all 
other  medical  and  surgical  diagnosis. 

The  journal  is  fortunate  in  having  procured  the 
services  of  Dr.  H.  F.  Starr,  Medical  Director  of 
the  Pilot  Life  Insurance  Company,  for  employment 
in  the  editorship.  Dr.  Starr  will  write  about  and 
get  contributions  from  other  doctors  high  up  in 
Insurance  Medicine. 


A  large  fraction  of  the  income  of  a  good  many 
of  us  comes  in  the  form  of  checks  from  life  insur- 
ance companies.  Some  of  the  work  for  which  such 
checks  are  sent  is  not  done  as  carefully  as  it  should 
be  done.  Indeed,  some  life  insurance  companies 
have  had  such  disappointing  results,  have  got  so 
little  for  the  money  so  spent,  that  thev  dispensed 
with  the  services  of  local  medical  examiners  and 
began  issuing  policies  on  general  appearance  and 
what  the  agents  could  learn  of  the  health  historv. 

Dr.  Starr  will  also  request  contributions  for  his 
department  from  local  medical  examiners,  and 
others  he  thinks  should  be  able  to  give  us  all  infor- 
mation of  value. 

There  can  be  no  reasonable  doubt  that  the  De- 
partment of  Life  Insurance  Medicine,  under  such 
editorship,  will  serve  an  excellent  purpose  and 
prove  of  all-round  helpfulness. 


Doctor  George  William  Kutscher,  Jr. 

We  learn  from  the  Bulletin  of  the  Buncombe 
County  Medical  Society  that  Dr.  Kutscher  is  dead. 
A  good  many  months  ago  a  letter  from  his  secre- 
tary expressed  for  him  regret  that  he  was  not  able 
to  supplv  material  for  his  Department  of  Pediatrics 
in  this  Journal.  Later  came  news  of  a  surgical 
operation  in  Philadelphia,  still  later  of  the  belief 
that  he  was  on  his  way  to  complete  recovery.  Xow 
he  is  dead. 

For  the  past  ten  vears  Dr.  Kutscher  conducted 
the  department  in  this  journal  devoted  to  the  pro- 
motion and  diffusion  of  knowledge  of  pediatrics. 
Except  on  the  few  occasions  when  he  was  too  ill  to 
write,  his  contributions  came  in  on  time:  and  thev 
were  alwavs  worth  printing.  They  were  never  just 
fill-ins. 

For  the  past  six  years  he  served  as  secretarv  of 
his  countv  medical  society,  and  served  so  faithfully 
and  efficiently  as  to  earn  the  gratitude  and  esteem 
of  every  member.  He  tended  many  children,  sick 
and  well.  He  was  active  in  every  movement  for 
the  promotion  of  children's  phvsical,  mental  and 
moral  health. 

Too  young  is  he  cut  down;  yet — 

"it  matters  not  where,  when. 
Nor  how.  so  we  die  well;  and  can  that  man  that  does  so 
Need  lamentation   for  him?" 


PROLOXGED  LABOR 

Prolongation  of  labor,  the  author'  pertinentlv 
says,  has  been  confused  with  difficult  labor  to  such 
an  extent  as  to  lead  relatives  into  insisting  upon 
ill-advised  interference. 

Dystocia  is  encountered  1 )  where  the  expul- 
sive forces  are  subnormal  and  unable  to  overcome 


1.  E,    F,    Bpchner,   Jr.,    Chattanooga, 
Feb. 


/.    Taut.   Med,   Assn.. 


SOVTHERX  MEDICINE  &  SURGERY 


the  natural  resistance  to  delivery;  2)  where  the 
resistance  of  the  birth  canal  offers  a  serious  me- 
chanical obstacle;  3)  where  faulty  presentation  or 
excessive  development  of  the  fetus  retards  or  pre- 
vents delivery;  4)  where  accidental  complications 
interfere  with  the  normal  progress  of  labor,  and 
5)  we  are  most  likelv  to  encounter  dvstocia  as  the 
result  of  several  contributing  factors. 

Labor  should  be  induced  for  assured  postmatur- 
ity. Fluids,  glucose,  supportive  treatment,  hypnot- 
ics and  sedatives  are  valuable  for  inertia  and  ex- 
haustion. Manual  manipulations  to  correct  faulty 
presentations  are  indicated  before  any  attempts  at 
instrumentation.  Forceps  delivery,  with  the  occiput 
remaining  posterior  in  the  narrow  pelvis,  perform- 
ed gentlv  on  proper  grounds,  will  also  solve  a  large 
fraction  of  these  problems. 

The  majority  of  instances  of  dystocia  can  be  in- 
telligently and  adequately  handled  in  the  home  or 
isolated  place. 

A  small  fraction  of  the  more  severe  grades  of 
dystocia  need  hospitalization  for  abdominal  deliv- 
ery. 

Classical  section,  if  used  at  all,  should  be  reserv- 
ed for  the  elective  case  before  the  onset  of  labor. 

Low  cervical  section  or  laparotrachelotomy  may 
be  used  after  a  good  test  of  labor,  but  should  not 
be  relied  upon  to  protect  the  neglected  dystocia 
from  peritonitis. 

The  difficulties  and  poor  results  of  destructive 
operations  on  the  fetus  often  make  the  radical 
Porro  section  the  procedure  of  choice  for  the  neg- 
lected case. 


NEWS 


TRI-STATE—From    Page    281 

give  us  the  benefit  of  his  knowledge  and  his  ex- 
perience. This  man  has  been  honored  bv  all  of  his 
colleagues  in  the  American  Medical  Association 
and  elsewhere  and  he  comes  to  us  tonight  to  give 
us  a  real  message,  from  a  real  American,  a  genial 
Irishman,  a  competent  and  finished  surgeon.  It  is 
my  great  pleasure  to  present  to  you  Dr.  H.  Win- 
nett  Orr.  who  will  speak  to  us  on  "The  Present 
Status  of  Chemotherapy  in  the  Treatment  of  In- 
fected Wounds  and  Septicemia."  Members  of  the 
Association,  it  is  my  pleasure  and  privilege  to  pre- 
sent Dr.  Orr,  of  Lincoln,  Nebraska.  (Applause.) 
(Dr.  Orr's  address  appears  in  this  issue  of  the 
Association's  journal.) 


Anthrax — Three    cases    in    Wisconsin     (Wis.    Med.    Jl., 
Feb.)    all   contracted   from   handling   diseased   carcasses. 


Intractable  Paln.— When  the  cause  can  not  be  remov 
ed.  think  of  cobra  venom. 


Encephalitis  may  occur  as  a  complication  o/  mumps. 


University  of  Virginia 

On  March  21st,  Dr.  John  M.  Meredith  participated  in 
the  Post-Graduate  Course  in  Medicine  and  Surgery  for 
the  Elizabeth  City  County  Medical  Society  conducted  un- 
der the  auspices  of  the  Department  of  Clinical  and  Med- 
ical Education  of  the  Medical  Society  of  Virginia.  His 
subject  was  Surgical  Aspects  of  Sciatica.  On  April  4th, 
Dr.  Robert  V.  Funsten  presented  a  lecture  before  this  So- 
ciety on  Simplified  Treatment  of  Certain  Fractures,  and 
on  April  11th,  Dr.  William  H.  Parker  spoke  on  Carcinoma 
of  the  Cervix. 

On  March  22nd,  Dr.  Fletcher  D.  Woodward  addressed 
the  Faculty  and  Medical  Students  of  the  University  of 
Texas  Medical  College  in  Galveston.  His  subject  was  Dis- 
eases of  the  Esophagus. 

The  Phi  Lambda  Kappa  Lecture  was  given  on  March 
31st  by  Dr.  Samuel  Loewenberg,  Professor  of  Medicine  at 
the  Jefferson  Medical  College  of  Philadelphia.  He  dis- 
cussed Endocrinopathies. 

At  the  meeting  of  the  Alleghany-Bath  and  Greenbrier 
Valley  Medical  Society  at  White  Sulphur  Springs  on  April 
3rd,  Dr.  Henry  B.  Mulholland  spoke  on  The  Modern  Con- 
ception of  the  Treatment  of  Diabetes. 

On  April  3rd.  the  Southern  Society  of  Clinical  Surgeons 
spent  the  first  day  of  their  three-day  annual  meeting  at 
the  University  of  Virginia.  After  the  operative  clinic  the 
following  dry  clinic  was  presented  in  the  forenoon: 
Thrombophlebitis  in  a  Sympathectomized  Limb  by  Dr. 
Edwin  P.  Lehman;  Total  Gastrectomy— Three  Successful 
Cases  by  Dr.  C.  B.  Morton;  Chest  Tumor  by  Dr.  E.  C. 
Drash;  Appendix  Abscess— Conservative  Treatment  by 
Dr.  W.  H.  Parker;  Multiple  Stones  in  Common  Bile  Duct 
by  Dr.  W.  R.  Hill;  Annular  Pancreas  by  Dr.  E.  P.  Leh- 
man; Non-Rotation  of  Colon— Operative  Rotation  by  Dr. 
C.  B.  Morton;  Actinomycosis  of  the  Stomach  by  Dr.  W. 
H.  Parker;  and  Developmental  Anomalies  by  Dr.  H.  E. 
Jordan.  The  morning  program  included  also  a  paper  by 
Drs.  E.  P.  Lehman  and  Floyd  Boys  on  Experiments  with 
Heparin  and  one  by  Dr.  S.  W.  Britton  on  The  Influence 
of  Extracts  of  the  Pituitary  Gland  and  Adrenal  Cortex 
on  Water  Balance.  At  the  afternoon  session  the  following 
program  was  presented:  Dr.  Alfred  Chanutin  spoke  on 
Studies  on  Calcium  Metabolism  with  the  Aid  of  the  Ultra- 
centrifuge;  Drs.  G.  M.  Lawson  and  E.  P.  Lehman  pre- 
sented a  paper  on  Clinical  Experience  with  Sulfanilylguan- 
idine;  Dr.  E.  M.  Landis  discussed  Pressor  Activity  of  Ex- 
tracts of  Human  Kidney  in  Relationship  to  Hvpertension ; 
Dr.  W.  W.  Waddell,  Jr.,  spoke  on  Clinical  Studies  on  Vit- 
amin K;  and  Dr.  G.  C.  Ham  discussed  Studies  on  Anti- 
diuretic Substances  in  the  Urine  of  Patients  with  Toxe- 
mias of  Pregnancy.  The  mee'ing  was  continued  at  the 
Medical  College  of  Virginia  in  Richmond  on  April  4th 
and  Sth. 

The  twenty-seventh  Post-Graduate  Clinic  sponsored  by 
the  University  of  Virginia  Medical  School  and  the  Division 
of  Extension  was  held  on  April  11th.  The  following  pro- 
gram was  presented:  Sulfonamide  Compounds  in  Medi- 
cine by  Dr.  J.  E.  Beckwith ;  Sulfonamide  Compounds  in 
Surgery  by  Dr.  W.  H.  Parker;  Fluid  Balance  by  Dr. 
Staige  D.  Blackford;  Administration  of  Fluids  by  Dr.  W. 
R.  Hill;  Digitalis  Therapy  by  Dr.  J.  Edwin  Wood,  Jr., 
and  Dr.  John  Hortenstine.  Diuretics  by  Dr.  E.  M.  Lan- 
dis; Treatment  of  Deficiency  States  by  Dr.  H.  B.  Mul- 
holland ;  Treatment  of  Anemia^  by  Dr.  Byrd  Leavell ;  The 
Female  Sex  Hormones  by  Dr.  Tiffany  J.  Wi'liams;  and 
The  Male  Sex  Hormones  by  Dr.  Samuel  Vest.  Eighty-two 
physicians  attended  the  Clinic. 

The    third   Alpha   Omega   Alpha   Lecture   was   presented 


288 


SOUTHERN  MEDICINE  &  SURGERY 


May  1941 


on  April  11th  by  Dr.  Homer  W.  Smith,  Professor  of  Phy- 
siology at  the  New  York  University  College  of  Medicine. 
Dr.  Smith  spoke  on  The  Quantitative  Study  of  Renal 
Function. 


MEDAL  FOR  MacXIDER 
(Chapel   Hill   II  eckly) 

The  Kober  Medal,  one  of  the  most  coveted  of  all  the 
distinctions  to  be  won  in  the  domain  of  medical  science, 
has  been  awarded  to  Dr.  William  deB.  MacNider. 

Dr.  Alfred  Newton  Richards,  vice-president  for  medical 
affairs  of  the  University  of  Pennsylvania,  made  the  presen- 
tation at  a  session  of  the  recent  convention  of  the  Associa- 
tion of  American  Physicians  at  Atlantic  City.  Dr.  Richards 
is  an  old  friend  of  Dr.  MacNider's  and  has  come  here  to 
visit  him  several  times. 

The  late  Dr.  Kober.  an  eminent  physician  and  medical 
investigator  long  associated  with  George  Washington  Uni- 
versity, established  the  medal  by  a  bequest  to  the  Ameri- 
can College  of  Physicians.  Under  the  terms  of  the  bequest, 
the  award  was  to  be  made,  from  time  to  time,  for  a  i 
important  achievement  in  medical  research.  It  was  awarded 
to  Dr.  MacNider  for  his  researches  in  Bright's  disease  and 
in  tissue  resistance. 

Dr.  C.  L.  Walton,  Glen  Alpine,  was  elected  President 
of  the  Burke  County  Medical  Society  at  its  meeting  at 
Morganton  on  April  15th.  Dr.  John  S.  McKee,  of  the 
staff  of  the  State  Hospital,  was  elected  Vice-President  and 
Dr.  Edith  Goodwin  Barbour,  Secretary-Treasurer.  Dr. 
James  W.  Vernon  was  named  delegate  to  the  State  Med- 
ical Society. 


Dr.  George  W.  Morse,  for  more  than  a  year  a  member 
of  the  Staff  of  the  Davis  Hospital,  Statesville,  has  gone 
to   Pensacola.   Florida,   to   engage  in   private   practice. 


Medical  College  of  Virginia 

The  annual  Stuart  McGuire  Lectures  and  spring  post- 
graduate clinics  were  held  April  24th  and  25th.  Dr.  Al- 
fred Blalock  of  Vanderbilt  University  gave  the  McGuire 
lectures,  the  first  on  Pathogenesis  of  Shock  and  the  second 
on  Prevention  and  Treatment  of  Shock.  Speakers  on  the 
postgraduate  clinic  program  were:  Dr.  L.  R.  Broster. 
Senior  Surgeon  to  Charing  Cross  Hospital.  London,  speak- 
ing on  Recent  Developments  in  the  Treatment  of  War 
Wounds;  Lieutenant  Colonel  David  N.  W.  Grant,  Chief 
Medical  Division,  United  States  Army  Air  Corps,  Medical 
Division,  Occupational  Fatigue  as  Manifested  in  Flying 
Personnel;  Dr.  Henry  K.  Beecher.  Chief,  Department  of 
Anesthesia,  Massachusetts  General  Hospital,  Clinical  As- 
pects of  Anesthesia  and  Shock;  Dr.  C.  C.  Coleman,  Pro- 
fessor of  Neurological  Surgery  of  the  college,  Penetrating 
Wounds  of  the  Brain,  and  Dr.  Harry  J.  Warthen,  Asso- 
ciate Professor  of  Surgery,  Gas  Bacillus  Infection. 

Mr.  George  W.  Bakeman,  who  has  been  in  charge  of 
the  Paris  office  of  the  Rockefeller  Foundation  for  a  num- 
ber of  years,  has  been  appointed  Assistant  to  President 
Sanger. 

The  annual  lectureship  sponsored  by  Psi  Omega  dental 
fraternity  was  given  at  the  Simon  Baruch  Auditorium  on 
May  5th  by  Dr.  William  J.  Gies.  Doctor  Gies'  topic  was 
Medicine  and   Dentistry  in   Health  Service. 

Dr.  Alton  D.  Brashear,  Assistant  Professor  of  Anatomy, 
has  been  made  a  member  of  the  supreme  council  of  Psi 
Omega   fraternity. 

"The  ex-internes  of  the  Hospital  Division  of  the  college- 
held  their  annual  reunion  on  April  23rd.  The  program 
for  the  reunion  included  clinical-pathological  conferences 
as  well  as  the  postgraduate  clinics  and  the  McGuire  Lec- 
ture program.  A  tour  of  the  new  hospital,  a  smoker,  and 
a  banquet  concluded  the  day's   activities. 

Alpha    Epsilon   Iota,   woman's   medical    fraternity,   spon- 


Rx  0  L  I  0  D  I  N     2  oz.  For  Head  Colds, 

( lodinized  Oil  Compound )  Nose  and  Throat 

Its  action  produces  a  mild  hyperemia  with  an  exudate  of  scrum.  thus  depleting  the  tissues.  Oliodin 
improves  breathing,  soothes  nose  and  throat.  Try  it  after  nasal  tamponage,  suction  irrigation, 
etc.,  and  note  improved  results. 


FOR  THE  EYES 


Rx  OPHTHALMIC  SOL  No.  2 


Use  it  as  an  antiseptic  collyrium ;  to  relieve  catarrhal  affections 
of  the  eye;  before  and  after  operations;  for  routine  treatment 
after  eye  injuries;  to  relieve  irritation  caused  by  wind,  dust, 
bright  lights,  etc. 

Rx   DeLEOTON 

NASAL  DOUCHE  POWDER 


!/2  oz.  or  15  c.  c. 

With   Mercury 
Oxycyanide  and 
Zinc   Sulfate 


8  oz. 


Action:  Cleansing — Deodorant — Astringent.  Uses:  In  solution  removes  most  of  the  germ-laden 
secretion  and  fetid  crusts  which  collect  in  the  ncse.  Prescribe  it  for  relief  in  head  colds  and  also 
sinus  irrigations.  [Follow  by  the  use  of  OLIODIN  Nasal  Oil.]  Contains:  Zinc  Phenolsulphonate, 
SorM'im  Benzoate,  Methenamine,  Amaranth,  Menthol,  Methvl  Salicvlate,  Dextrose  (Base). 

W/ 

Samples  from:        The    De    LEOTON    COMPANY     Capitol  Station,  Albany.  N.  Y. 


COOPER  CREME 

ONE  SPERMICIDAL  CREME  GIVEN   HIGHEST  RATING  BY  THE  PROFESSION 

TESTED    BY    TIME  PROVED    BY    EXPEDIENCE 

WHITTAKER     LABORATORIES,     INC.  250    WEST    S7lh     STREET  HEW    YORK,     N.    Y. 


SOUTHERN  MEDICINE  &  SURGERY 


CONSCIENTIOUS 
OBJECTOR 


Little  patients  do  object,  sometimes  rather  vigorously,  to  any  suggestion  of  medication,  but 
they  eagerly  accept  the  delicious  5-vitamin  nutritive  tonic,  Cal-C-Tose.  Added  to  milk, 
Cal-C-Tose  makes  a  rich,  appetizing,  chocolate-flavored  drink  that  tickles  the  palate  of  the 
most  finicky  child.  It  is  delicious  served  either  as  a  "hot  chocolate"  or  as  a  cold,  refreshing 
milkshake.  In  addition  to  its  full  protective  complement  of  the  essential  vitamins  A,  Bi,  B2,  C, 
and  D,  Cal-C-Tose  also  contains  skimmed  milk  protein,  dibasic  calcium  phosphate, 
as  well  as  other  valuable  minerals.  Cal-C-Tose  is  packaged  in  12-ounce  and  5-pound 
containers.  HOFFMANN -LA  ROCHE,  INC.  •  ROCHE  PARK  •  NUTLEY,  NEW  JERSEY 
Patronage  of  our  Advertisers  is  a  Mark  of  Friednship  to  the  Journal 


?9C 


SOUTHERN  MEDICINE  &  SURGERY 


May  1941 


sored  a  lectureship  on  April  ISth  by  Dr.  Josephine  Neal, 
Clinical  Professor  of  Neurology  of  the  College  of  Physi- 
cians and  Surgeons,  Columbia  University.  Doctor  Neal 
spoke  on  Acute  Encephalitis  with  Special  Reference  to 
Infectious  Diseases. 

On  April  3rd  the  college  was  host  to  the  Fifteenth  An- 
nual Convention  of  the  Southern  Society  of  Clinical  Sur- 
geons. Following  operative  clinics  in  the  morning  the 
group  made  a  trip  to  Williamsburg  in  the  afternoon.  Dr. 
Randolph  H.  Hoge,  Assistant  Professor  of  Anatomy  and 
Surgery  at  the  college,  was  elected  to  membership  in  the 
Society  at  its  meeting  here. 

Dr.  H.  Hudnall  Ware,  Jr.,  Associate  Professor  of  Ob- 
stetrics, recently  addressed  the  Fredericksburg  Medical 
Society  on  Ectopic   Pregnancy. 

The  college  was  host  to  the  Virginia  Academy  of  Science 
May  lst-3rd  for  its  annual  meeting.  A  splendid  program 
was  rendered. 

The  Society  of  Neurological  Surgeons  also  met  at  the 
college  May  lst-3rd  for  operative  clinics  and  program  of 
lectures. 


MARRIED 

Howard  McDowell  McCue  and  Carolyn  Moore,  of 
Richmond,  were  married  on  April  5.  Both  are  members 
of  the  graduating  class  in  medicine  of  the  Medical  College 
of  Virginia. 

Dr.  Charles  Russell  Robins,  Jr.,  and  Miss  Susan  Clay, 
both  of  Richmond,  were  married  on  April  19th. 

DEATHS 

Dr.  Harry  Barton  Hinchman,  (Medical  College  of 
of  Virginia,  1916)   died  April  5th.  of  an  acute  heart  attack 


at  his  home  at  Richmond.  During  his  young  manhood 
Dr.  Hinchman  was  prominent  in  Richmond  athletic  circles 
and  at  one  time  was  a  pitcher  on  the  old  Church  Hill 
baseball  team.  He  was  a  member  of  the  Richmond  Gun 
Club.  He  was  a  staff  physician  at  the  Virginia  Hospital 
here  during  and  immediately  after  the  World  War.  He 
was  a  member  of  the  Richmond  Academy  of  medicine,  the 
Richmond  Kiwanis  Club,  the  Country  Club  of  Virginia 
and  of  the  Knights  of  Columbus. 

Dr.  Aurelius  R.  Shands,  died  April  2  7th  at  his  home 
at  Washington  of  heart  trouble. 

He  was  born  at  Petersburg,  Va.,  November  5th.  1886, 
graduated  from  University  School  there  in  1880,  and  re- 
ceived a  Doctor  of  Medicine  degree  from  the  University 
of  Maryland  in  1884.  He  became  Professor  of  Orthopedic 
Surgery  at  Columbian  University,  now  George  Washing- 
ton University,  in  1894,  and  later  was  professor  emeritus. 

Dr.  Shands  was  a  member  of  the  American  Orthopedic 
Association,  of  which  he  was  president  in  1912,  the  South- 
ern Surgical  Association,  the  Virginia  State  Medical 
Society  and  the  Washington  Academy  of  Science. 

Among  the  survivors  is  a  son,  Dr.  A.  R.  Shands,  Jr.. 
who  was  the  first  Professor  of  Orthopedic  Surgery  in  the 
Duke  University,  Medical  Schoo],  and  is  now  the  head  of 
the  Orthopedic  Foundation  established  by  the  DuPonts  at 
Wilmington,  Delaware. 

Dr.  Charles  K.  Kernan,  one-time  physician  to  the 
Southwestern  State  Hospital,  Marion.  Va..  died  at  a  Ma- 
rion hospital  April  18th,  at  the  age  of  73.  He  had  prac- 
ticed many  years  in  Pulaski  County  and  the  City  of  Bris- 
tol. 


ASAC 

15%,  by  volume  Alcohol 
Each   fl.   oz.   contains: 

Sodium  Salicylate,  U.  S.  P.  Powder 40  grains 

Sodium  Bromide,  U.  S.  P.  Granular 20  grains 

Caffeine,    U.    S.   P 4  grains 

ANALGESIC,    ANTIPYRETIC 
AND    SEDATIVE. 

Average    Dosage 

Two  to  four  teaspoonfuls  in  one  to  three  ounces  of 
water   as   prescribed   by   the   physician. 

How   Supplied 
In  Pints,  Five  Pints  and  Gallons  to  Physicians  and 
Druggists. 

Burwell  &  Dunn  Company 

Manufacturing    ^S§^     Pharmacists 
i  hed     Dl^J      in    7887 

CHARLOTTE,  N.  C. 


Sample   sent   to    any    physici; 
request 


the    U.   S.    on 


SOUTHERN  MEDICINE  &  SURGERY 


291 


We  could  quote  you  paragraph  upon  para- 
graph regarding  the  superb  efficiency  of 
Coraniine,  "Ciba"  as  a  circulatory  and 
respiratory  stimulant.  We  could  cite 
numerous  passages  regarding  speedy  ac- 
tion, high  tolerance  and  wide  margin  of 
safety  from  the  vast  bibliography  pub- 
lished on  Coramine.*  But  it  is  our  belief 
that  only  actual  use  can  convince  you  of 
the  great  potentialities  of  this  useful  drug. 


"Trade  Mark  Reg.  U.  S.  Pat.  Off.  Word  "Cora- 
mine"  identifies  the  product  as  the  diethyl 
amide  of  nicotinic  acid  of  Ciba's  manufacture. 


CORAMINE 

(diethyl  amide  of  nicotinic  acid),  is  the 
original,  genuine  product  manufactured  ex- 
clusively by  Ciba,  and  easily  identified  by 
its  crystal-white  clearness.  It  has  proven  its 
stimulating  ability  in  .  .  .  accident  cases, 
pneumonia,  asphyxia,  surgical  shock, 
selected  cases  of  cardiac  involvement  and 
other  collapse  states.  .  .  .  Large  doses  arc  ad- 
visable in  severe  poisonings.  Why  not 
request  literature? 


o 


o 


o 


CIBA    PHARMACEUTICAL    PRODUCTS,  Inc.,  SUMMIT,   IM.  J. 


SOUTHERN  MEDICINE  &  SURGERY 


May  1941 


BOOKS 


ir-m 

HEALTH  AND  LONGEVITY,  by  Charles  M.  Baird. 
Christopher  Publishing  House,  Boston.  1941.  $1.75. 

On  one  side  of  a  flyleaf  is  a  passage  of  scripture 
which  says  man's  days  shall  be  a  hundred  and 
twenty  years.  On  the  other  is  the  statement  that 
most  deaths  in  the  United  States  are  preventable. 
Plain  nonsense.  Mr.  Baird  might  have  found  an- 
other passage  of  scripture  which  says  the  days  of 
a  man's  years  are  three-score  years  and  ten.  Mr. 
Baird  ought  to  be  able  to  find  employment  under 
Bernaar  Macfadven. 


HEALTH:  Mental,  Moral  and  Physical,  by  Horace 
Wendell  Soper,  M.D.,  F.A.C.P.  The  Christopher  Publish- 
ing House,  Boston.   1941.  $1.50. 

Chapter  heads  are:  St.  Louis;  Exercise;  Sleep; 
Tobacco;  Alcohol;  The  Prevention  of  Colds, 
Grippe  and  Flu;  Constipation  and  Diarrhea;  Mai-' 
nutrition;  Milk;  Shaving;  First  Aid  in  Emergen- 
cies; The  Weather;  The  Old  and  the  New  Deal; 
Degeneration;  Uncle  Sam — Sentimentalist;  Rob- 
ert G.  Ingersoll,  1833-99;  Dr.  R.  Walter  Mills, 
1877-1924;  Longevity;  Immortality;  Health  Par- 
agraphs. 

The  anecdotes  in  the  first  chapter  bring  to  mind 
the  saying  that  the  old  ones  are  the  best.  If  the 
Georgia  doctor  who  moved  to  Saint  Louis  said 
"You  all"  in  referring  to  one  person  he  learned  to 
do  so  after  he  left  Georgia. 

The  dealing  with  exercise,  sleep  and  tobacco  is 
rational.  That  the  distillation  of  pure  whiskey  is  a 
complicated  process  is  news,  indeed.  On  catching 
cold,  constipation,  diet,  especially  milk-consump- 
tion, and  first-aid  the  author  has  things  to  say  that 
provoke  thought.  The  author  drags  in  by  a  hind 
leg  his  idea  that  Uncle  Sam  should  "have  sense 
enough"  to  stay  out  of  the  present  war.  The 
health  paragraphs  are  largely  homilies  generally 
accepted. 


PHYSICAL  MEDICINE:  The  Employment  of  Physi- 
cal Agents  for  Diagnosis  and  Therapy,  by  Frank  H.  Kru- 
sen,  M.D.,  F.A.C.P.,  Associate  Professor  of  Physical  Med- 
icine, the  Mayo  Foundation,  University  of  Minnesota. 
With  351  illustrations.  W.  B.  Saunders  Co.,  Philadelphia 
and  London.    1941.    $10.00. 

The  plan  of  the  book  is  to  deal  with  each  physi- 
cal agent  made  use  of  under  these  headings:  In- 
troduction —  definition  —  development  —  present 
status;  Physics;  Source,  device  or  method  of  pro- 
duction; Physiologic  effects;  Technic  of  applica- 
tion; Indications — Contraindications:  dangers  and 
limitations;  Conclusions. 


History  of  physical  therapy  is  outlined.  Heat 
and  cold,  locallv  and  generally;  light;  electricity 
of  various  forms;  water,  hot  and  cold;  massage, 
exercise,  with  and  without  mechanical  devices; 
rest  and  relaxation;  special  applications  of  physi- 
cal therapy  to  certain  disease  conditions — all  these 
matters  are  covered  thoroughly. 

A  much-needed  book  on  a  subject  neglected 
now  because  it  was  over-enthusiastically  advocat- 
ed a  few  years  ago.  This  authoritative  exposition 
of  the  value  of  physical  agents  and  of  the  tech- 
niques of  their  exhibition  will  go  far  toward  gain- 
ing for  these  agents  the  place  to  which  their  merits 
entitle  them. 


A  FAMILY  DOCTOR'S  NOTEBOOK,  by  I.  J.  Wolf, 
M.D.,  Professor  of  Medicine,  Emeritus,  The  University  of 
Kansas  School  of  Medicine.  Fortuny's,  New  York  City. 
1940. 

The  author  is  a  product  of  the  German  univer- 
sities at  their  best.  The  contrast  between  the  Kan- 
sas City  of  1888  and  the  old  university  cities  of 
Germany  was  such  as  to  prove  discouraging. 

The  author  says  he  has  written  this  book  as  a 
family  physician  who  after  fifty  years  of  practice, 
still  counts  among  his  patients  and  intimate  friends 
a  great  many  who  sought  his  help  fifty  years  ago. 
He  says  to  point  out  advantages  and  disadvantages 
crept  into  the  practice  of  medicine,  and  to  suggest 
of  specialism  and  the  many  abuses  which  have 
a  remedy  for  them  will  be  a  part  of  his  story. 

His  account  of  how  he  was  educated;  how  he 
established  a  practice;  what  happened  to  his  in- 
vestments; his  writings,  lav  and  professional;  his 
ideas  on  medical  ethics,  various  types  of  physicians 
and  patients,  modern  trends,  high  cost  of  doctor- 
ing, birth  control,  fads  and  fallacies,  family  physi- 
cian and  specialist,  the  physician  and  religion — all 
these  and  other  matters  make  this  book  one  well 
worth  attentive  reading. 

Few  doctors  will  agree  with  all  that  Dr.  Wolf 
thinks  and  says.  Any  doctor  will  find  in  his  book 
much  of  instruction  and  entertainment. 


The  peddler  knocked  at  the  door  and  started  his  sales 
talk  with  the  statement.  "I'm  out  scratching  for  a  living." 

"Sorry,  but  I  don't  ich,"  vowed  the  woman  of  the  house 
as  she  slammed  the  door. 


SOUTHERN  MEDICINE  &  SURGERY 


•      1941      • 

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Radio  and  Fan  in  Every  Room.  Golf  Links.  Artesian  Swimming 
Pool  with  Sand  Beach.  Tennis,  Badminton.  Ping  Pong.  Croquet, 
Horseshoe  and  Shuffleboard  Courts.  Ballroom  and  Convention 
Hall.    Banquet  Facilities.    Spacious  Grounds. 

COOLEST  SPOT  IN  ALL  FLORIDA.  AT  THE  BIRTHPLACE  OF 
THE  TRADE  WINDS.  Where  the  Labrador  (Arctic)  Current 
meets  the  Gulf  Stream,  and  Summer  Bathing  and  Fishing  are 
Superb. 

Write  tor  Special  Summer  Rates.  April  to  December. 

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PRODUCTS    OF 
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Glenview,  III.,  College  Pi..  N.Y.,  Acton,  Ont„  London,  Eur. 
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DON  BAXTER,  INC.,   Glcndulc,   Cal. 

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Hospital  Supply 

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SOUTHERN  MEDICINE  &  SURGERY 


May  1941 


PHYSICIANS' 

REQUIREMENTS 


EYE,  EAR,  NOSE  and  throat  instruments.  Suction  and 
pressure  pumps.  Physicians'  equipment.  Cabinets.  Oper- 
ating tables.  Examining  chairs.  Sphygmomanometers. 
Trial  lenses.  New-Used.  HARRY  WREGG,  INC.  384 
Second  Ave.,  New  York  City. 

KARA'S  NEW  OTOSCOPE— Finest  in  quality.  Excep- 
tional low  cost:  complete  with  3  specula  and  medium  bat- 
tery: handle  and  extra  lamp  in  modern  walnut  case.  Ask 
your  dealer  or  write  to  KARA  SURGICAL  SUPPLY  CO. 
5  E.  Gun  Hill  Rd.,  New  York  City. 

USED  MEDICAL  HOSPITAL  AND  LABORATORY 
equipment  bought  and  sold;  estates  purchased:  sterilizers, 
microscopes,  lamps,  cystoscopes,  etc.,  always  on  hand. 
Harry  Wells,  304  E.  59th  St.  New  York  City. 

SULFOR-ALBA— A  strictly  ethical  product  for  the  con- 
trol of  acne,  acne  rosacea  and  similar  skin  affections.  1 
lb.  jar  for  $3.00  Professional  supply  for  clinical  test  sent 
on  request  to  physicians.  ALBOLAC  COMPANY,  Room 
1208  at  333  West  52nd  Street,  New  York  City. 

LUBR'IOAINE— Anesthetic  Jelly  Water-Soluble,  Non- 
Toxic,  Non-Irritating.  A  valuable  aid  for  the  painless 
examination  of  mucous  membranes.  Marked  surface  an- 
esthesia develops  within  one  minute.  F"or  use  in  Rectum, 
Urethra,  Ear,  Nose,  Throat.  Sample  to  Physicians. 
AKATOS,  INC.,  55  Van  Dam  Street,  New  York  City. 

ASTHMA— Prompt  Symptomatic  Relief.  Count  on 
ASTHMALENE  to  check  paroxysms  of  asthma  quickly 
and  effectively.  Combination  antispasmodic  and  expector- 
ant. Clinical  samples  on  request  to  physicians.  Complete 
literature.  Est.  1868.  Address  B.  S.  McKEAN  INC., 
Dept.  SS  Mamaroneck,  New  York. 

PRESCRIPTION  FORMS— bound  like  a  pocket  check 
book— looseleaf  with  a  stub  for  complete  records  of  each 
case.  Your  name  or  other  information  imprinted  at  no 
additional  cost;  1000  forms  for  $2.50;  Genuine  leather 
binder  free  with  first  order.  Send  check  with  order  to 
Box  83,  Medical  Statistics,  125  West  40th  Street,  New 
York  City. 

"GONOCOCCAL  INFECTION  IN  THE  MALE"  by 
A.  L.  Wolbarst,  M.  D.,  Fellow,  American  Urological  As- 
sociation; Second  edition,  completely  revised  and  enlarged. 
140  illustrations.  7  colored  plates.  Published  at  $5.50  by 
C.  V.  Mosby  Co.;  remainder  copies  at  $1.00  each  while 
they  last.  Send  no  money.  Pay  Postman  on  delivery. 
MEDICAL  BOOKS,  ROOM  1808,  at  1440  Broadway, 
New  York  City. 

ARE  YOU  VISITING  NEW  YORK  CITY?  If  so  stop 
at  the  Hotel  Park  Chambers.  Modern,  yet  retaining  the 
old  fashioned  hospitality  of  yesterday's  inns.  5  minutes 
from  Radio  City;  One  block  from  Central  Park.  Lux- 
urious rooms  from  $3.  single,  $4.  double,  suites  from  $5. 
Excellent  Food.  May  we  send  you  a  Guide-Map  of 
New  York  City?  A.  D'Arcy,  Manager.  HOTEL  PARK 
CHAMBERS.     68  West  58th  Street,  New  York  City. 


Now  EVERY  Doctor  Can 
Fit  a  Pessary 

with  the  use  of  Bach  Pessalator  and  Bach 
Soft  Rubber  Pessary 


Instruction   circular  on   request 
The  key-note  of  the  Bach  Pessalator  and  Bach 
Cervical  Cap  Pessary — all  soft  rubber,  no  metal 
spring  in  the  rim — is  simplicity. 
By    means   of   the   Pessalator.    the    Bach    Pessary 
can   be   applied   quickly,   easily   and   gently. 
There  are  three  sizes — regular,  medium  and  large, 
but  the  regular  size  will  usually  fit  the  average, 
normal  cervix. 

Price:     Pessalator  and   Pessary   SI. 50  each. 
Physician's  Samples   (limited)    60c  each. 

Distributed   by 
THE  SANITUBE  COMPANY 

Dept.  G 
NEWPORT,   R.    I. 


May  1941  SOUTHERN  MEDICINE  &  SURGERY 


Southern  Railway's 

SO  UTHERNER 


This  month  appears  Southern  Railway's  THE  SOUTHERNER,  to  serve  the 
territory  between  New  York  and  New  Orleans. 

Built  of  high-tensile  steel,  with  sheathing  of  stainless  steel,  THE  SOUTHERN- 
ER which  will  operate  as  three  Diesel-powered  trains,  includes  all  the  latest  refine- 
ments for  the  ultimate  in  safety,  speed  and  comfort.  Each  train  will  consist  of 
Straight,  Partition  and  Baggage-Dormitory  Chair  Cars,  Dining  Car  and  Lounge- 
Tavern-Observation  Unit,  all  reflecting  the  latest  ideas  in  structural  development 
and  modern  styling  and  beauty. 

Passenger  units  have  thermostatically  controlled  heating  and  air  conditioning, 
are  insulated  throughout.  Judicious  use  is  made  of  a  number  of  advancements  favor- 
ing gracious  living.  A  good  part  of  the  luxury  picture  appears  in  the  comfortable 
seating  arrangement  in  all  cars,  the  commodious  and  up-to-date  dining  car  arrange- 
ments and  the  facilities  for  en  route  enjoyment  offered  in  lounge,  tavern  and  obser- 
vation rooms. 

Diesel  locomotives  for  the  trains  are  built  by  the  Electro-Motive  Corporation, 
a  subsidiary  of  General  Motors. 

Particularly  interesting  from  the  standpoint  of  detailed  comfort  planning  is  the 
fact  that  chair  cars  have  twin-rotating,  reclining-type  seats,  cushioned  and  attrac- 
tively finished.  The  dining  car  has  accommodations  for  48  persons  in  satin  metal 
framed  chairs  with  rubber  seats  and  back  cushions.  Settees,  lounge  chairs,  writing 
desk,  card  section  and  refreshment  facilities  have  been  planned  to  fit  the  comfort 
and  utility  requirements  of  passengers  in  the  Lounge-Tavern-Observation  unit. 

A  rich  decorative  treatment  has  been  designated  for  all  units  of  THE  SOUTH- 
ERNER the  basic  colors  being  blue,  green  and  beige  in  light,  medium  and  dark 
tones.  Blue  and  beige  are  distributed  in  straight  chair  car  planning,  each  car  carry- 
ing out  variations  of  the  same  color  treatment  throughout .  Partition  chair  cars  em- 
phasize beige  and  the  Baggage-Dormitory-Chair  Cars  are  done  in  tones  of  blue. 
Green  is  the  predominating  scheme  in  dining  car  and  Lounge-Tavern-Observation 
units. 

The  whole  scene  is  enriched  with  an  attractive  arrangement  of  photo-murals 
which  have  been  especially  planned  to  heighten  the  atmosphere  of  luxury  and  beauty 
in  THE  SOUTHERNER. 


SOUTHERN  MEDICINE  &■  SURGERY 


May  1941 


THEY  CAN'T  WAIT  MUCH  LONGER 
Stricken  Civilians  in  England 
and  Allied  Countries 
Need  Your  Help  TODAY! 


fW 


,||  i|  pp a 


Both  the  first  aid  kits  and  opera- 
ting sets  have  been  approved  as  to 
contents  and  containers  by  physicians 
on  the  Medical  and  Surgical  Supply 
Committee  of  America.  Send  in  your 
contribution  toward  purchasing  a 
unit  today.  Please  make  checks  payable 
to  Arthur  Kunzinger,  treasurer  and 
mail  with  coupon  below. 


MEDICAL  AND  SURGICAL 
SUPPLY  COMMITTEE         OF 

AMERICA,  420  LEXINGTON 
AVENUE,  NEW  YORK.  CITY. 
LExington    2-3970 

Name    

Address    

City     State     

Amount  of   Contribution  $ 


0?ERA;  overs  insurance 


EMERGENCY   FIRST   AID   KIT 
Cost   S70    (covers   insurance   and  ship- 
ment  to   England  and  Allied  Countries.) 


Patronage  of  our  Advertisers  is  a  Mark  o)  Friednship  to  the  Journal 


SOUTH ERN  MEDICINE  &  SURGERY 


297 


ESiiili*1"*1^^^^  Help  the  American 


s£si----:-r!  TUP  control  of  cwc 


the  Am*'  ~~  jfciropoKW*  «rca,—  se„t  to  you  J-  , 


PROFESSIONAL   CARDS 


GENERAL 

Nalle  Clinic  Building                                                                                   412  North   Church   Street,  Charlotte 

THE  NALLE  CLINIC 

Telephone— 3-2141    (//  no  answer,  call  3-2621) 

General  Surgery                                              General  Medicine 

BRODIE   C.   NALLE,   M.D. 
Gynecology   &   Obstetrics.. 
EDWARD    R.   HIPP,    MD 

Traumatic   Surgery 

PRESTON   NOWLIN.   M  D 

Urolocy 

LUCIUS   G.    GAGE,   M.D. 
Diagnosis 

LUTHER   W.   KELLY,   M.D. 
Caroio-Respiratory    Diseases 

Consulting   Staff 

DRS.   LAFFERTY,   BAXTER   &   PARSONS 
Radiology 
BARRET   LABORATORY 
Pathology 

J.  R.  ADAMS,  M.D. 
Diseases  of  Infants  &  Children 

W.  B    MAYER,  M.   D. 
Dermatology  &  Syphtlology 

C— H— M   MEDICAL   OFFICES 

D1A  GNOSIS— SURGER  Y 

X-RAY— RADIUM 

Dr.   G   Carlyle  Cooke — Abdominal  Surgery 

&  Gynecology 
Dr.  Geo.  W.  Holmes — Orthopedics 
Dr.  C.  H.  McCants — General  Surgery 
222-226  Nissen  Bid.                      Winston-Salem 

WADE   CLINIC 

Wade  Building 
Hot  Springs  National  Park,  Arkansas 

H.  King  Wade,  M.  D                              Urology 
Charles  S.  Moss,  M.D             General  Surgery 
Jack  Ellis,  M.D.                     General  Medicine 
Frank  M.  Adams,  M.D          General  Medicine 
N.  B.  Burch,  M.D.    Eye,  Ear,  Nose  &  Throal 
Raymond  C.  Turk,  D.D.S.       Denial  Surgerv 
A.  W.  Scheer                           X-ray  Technician 
Etta  Wade                              Clinical  Pathology 
Martorte  Wade                                 Bacteriology 

INTERNAL  MEDICINE 

ARCHIE   A.   BARRON,   M.  D.,   F.A.  C.P. 
INTERNA  L    MEDICINE— NEUROLOG  Y 
Professional   Bldg.                                 Charlotte 

JOHN  DONNELLY,  M.D. 

DISEASES  OF  THE  LUNGS 

324^  N.  Tryon  St.                              Charlotte 

CLYDE    M.    GILMOixE,    A.  B.,    M.  D. 
CARDIOLOG Y— INTERNAL    MEDICINE 
Dixie  Building                                    Greensboro 

JAMES   M.  NORTHINGTON,  M.D. 
INTERNAL    MEDICINE— GERIATRICS 
Medical  Building                                   Charlotte 

ORTHOPEDICS 

HERBERT   F.   MUNT,   M.D. 

ACCIDENT  SURGERY  &  ORTHOPEDICS 

FRACTURES 

Nissen  Building                          Winston-Salem, 

Mav  1941 


PROFESSIONAL   CARDS 


NEUROLOGY  and  PSYCHIATRY 


J.   FRED   MERRITT,   M.  D. 

NERVOUS  and  MILD  MENTAL 
DISEASES 

ALCOHOL  and  DRUG  ADDICTIONS 

Glenwood   Park   Sanitarium  Greensboro 


EYE,  EAR,  NOSE  AND  THROAT 


H.  C.  NEBLETT,  M.D. 

OCULIST 

Phone  3-5852 

Professional  Bldg.  Charlotte 


AMZI  J.  ELLINGTON,  M.D. 

DISEASES  of  the 
EYE,  EAR,  NOSE  and  THROAT 

Phones:  Office  992 — Residence  761 

Burlington  North   Carolina 


UROLOGY,   DERMATOLOGY  and   PROCTOLOGY 

THE  CROWELL   CLINIC   of   UROLOGY   and   UROLOGICAL   SURGERY 
Hours — Nine  to  Five  Telephones — 3-7101 — 3-7102 

STAFF 

Andrew  J.  Crowell,  M.  D. 

(1911-1938) 

Angus  M.  McDonald,  M.  D.  Claude  B.  Squires,  M.  D. 

Suite  700-711  Professional  Building  Charlotte 


Dr.  Hamilton  W.  McKay 


Dr.  Robert  W.  McKay 


DOCTORS  McKAY  and  McKAY 

Practice  Limited  to  UROLOGY  and  GENITO-UR1NARY  SURGERY 

Hours  by  Appointment 

Occupying  2nd  Flood  Medical  Arts  Bldg.  Charlotte 


Raymond  Thompson,  M.  D.,  F.  A.  C.  S.  Walter  E.   Daniel,  A.  B.,  M.  D. 

THE  THOMPSON  -  DANIEL  CLINIC 

of 
UROLOGY  &  UROLOGICAL  SURGERY 

Fifth  Floor  Professional  Bldg.  Charlotte 


C.  C.  MASSEY.  M.  D. 

PRACTICE  LIMITED 

TO 

DISEASES   OF    THE   RECTUM 


Professional   Bldg. 


Charlotte 


L.  D.  McPHAIL,  M.D. 
RECTAL  DISEASES 


Professional   Bldg. 


Charlotte 


WYETT    F.   SIMPSON,    M.D. 

GENITO-URlNA?,Y   DISEASES 

Phone    1234 

Hot  Springs  National  Park  Arkansas 


PROFESSIONAL   CARDS 


SURGERY 


R.   S.   ANDERSON,   M.  D. 

GENERAL  SURGERY 

144  Coast  Line  Street  Rocky  Mount 


R.    B.    DAVIS,    M.D.,    M.  M.  S.,    F.  A.  C.P. 
GENERAL  SURGERY 

WILLIAM    FRANCIS    MARTIN,    M.D. 

AND 
RADIUM   THERAPY 

GENERAL  SURGERY 

Hours  by  Appointment 
Piedmont-Memorial  Hosp.             Greensboro, 

Professional    BIdg.                                   Charlotte 

OBSTETRICS  &  GYNECOLOGY 


IVAN  M.  PROCTER,  M.D. 
OBSTETRICS   &    GYNECOLOGY 

133    Fayetteville   Street  Raleigh 


SPECIAL  NOTICES 


THE  EDITING  OF  MEDICAL  PAPERS 

This  journal  has  arranged  to  meet  the  demand  for  the  service  of  editing  and  revis- 
ing papers  on  medicine,  surgery  and  related  subjects,  for  publication  or  presentation 
to  societies.  This  service  is  rendered  on  terms  comparing  favorably  with  those  pre- 
vailing generally  in  other  Sections  of  the  Country. 

SOUTHERN  MEDICINE  &  SURGERY. 


REPRESENTATION  WANTED 
LEADING  MANUFACTURER  of  Physical  Therapy   Equipment   has  a   few 
territories  for  reliable  dealers.    Write  giving  full  details  to  "Physical  Therapy"  c/o 
Southern  Medicine  &  Surgery,  Charlotte,  N.  C. 


DO   YOU   WRITE? 

Book    Manuscripts    Wanted    —    All    subjects 
for  immediate  publication.   Booklet  sent  free. 

Meador    Publishing    Co.,    324    Newbury    St., 

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THE  JOURNAL  OF 
SOUTHERN  MEDICINE  AND  SURGERY 

306  North  Tryon  Street,  Charlotte,  N.  C. 

The  Journal  assumes  no  responsibility  for  the  authenticity  of  opinion  or  statements  made  by  authors  or  in  communica 
tions  submitted  to   this  Journal  for  publication. 


JAMES   M.   NORTHINGTON,   M.  D.,   Editor 


CHARLOTTE,  N.  C,  JUNE,   1941 


The  Background  and  Treatment  of  Hypertensive  Disease 

Edgar  A.  Hines,  Jr.,  M.D.,  Rochester,  Minnesota 
Division  of  Medicine,  Mayo  Clinic 


THE  PROBLEM  of  the  causation  and 
treatment  of  hypertensive  disease  should 
be  considered  as  one  of  the  major  chal- 
lenges to  the  medical  profession.  When  it  is  con- 
sidered that  four  times  as  many  deaths  result  from 
the  effects  of  hypertension  as  from  cancer  and  that 
approximately  a  fourth  of  all  deaths  of  persons 
past  fifty  years  of  age  are  due  to  the  effects  of 
hypertensive  disease,  the  importance  of  this  prob- 
lem is  evident.  Time  will  not  permit  me  to  discuss 
in  detail  all  the  various  aspects  of  the  causation 
and  pathogenesis  of  hypertensive  disease.  The 
chairman  of  your  program  committee  has  asked 
me  to  talk  about  a  phase  of  the  problem  in  which 
I  have  been  especially  interested;  that  is,  the  in- 
herent factors  concerned  in  the  development  of 
hypertension  or,  to  use  a  more  general  phrase,  the 
background  of  hypertensive  disease.  In  addition,  I 
shall  discuss  some  of  the  practical  aspects  of  the 
treatment  of  hypertensive  disease. 

Much  information  concerning  the  development 
of  hypertension  is  becoming  available  in  hospitals 
and  clinics  in  which  careful  records  are  kept,  in 
the  making  of  annual  physical  examinations  for 
insurance  purposes  and  in  the  records  of  large  or- 
ganizations in  which  annual  physical  examination 
are  required  of  personnel.  Study  of  these  records 
is  leading  to  a  better  understanding  of  the  range 
of  normal  blood  pressure  and  to  the  realization 
that  hypertensive  disease   begins  much   earlier   ir, 

•Prc«-nted    to    the   meeting   of   the    Tri-State    Medical    Associatio 
24th  and  25th. 


life  than  has  been  suspected. 

A  study  of  the  blood  pressure  and  history  of 
many  patients  for  a  period  of  ten  years  and  a 
study  of  the  records  of  many  patients  who  have 
been  followed  at  the  Mayo  Clinic  for  twenty  to 
thirty  years  have  convinced  me  that  there  is  a  defi- 
nite background  on  which  hypertension  develops 
and  that  without  this  background  the  clinical  pic- 
ture of  essential  hypertension  usually  does  not 
develop,  regardless  of  what  disease  or  pathologic 
change  the  patient  may  acquire.  I  believe  that 
such  inherent  factors  as  are  concerned  in  the  de- 
velopment of  hypertension  can  be  recognized  when 
the  condition  is  in  the  prehypertensive  stage.  Fur- 
thermore, I  believe  these  factors  must  have  some 
etiologic  relationship  to  the  hypertension  which 
eventually  develops. 

Characteristics  of  the  Background  of  Hypertensive 
Disease 
The  hereditary  factor. — There  is  little  doubt 
that  heredity  plays  an  important  role  in  the  back- 
ground of  hypertensive  disease.  Janeway1  in  1916 
expressed  the  opinion  that  "The  belief  in  an  inher- 
ited quality  of  the  arterial  tissues  with  a  tendency 
to  premature  death  from  apoplexy,  angina  pectoris, 
or  other  local  manifestation,  is  too  firmly  grounded 
in  clinical  observation  to  be  without  basis.  Hyper- 
tensive arterial  disease  must  be  looked  on  today  as 
the  type  in  which  heredity  plays  the  largest  role." 
Subsequent    investigations   have   amply   confirmed 

i    of    the    Carolinas    and    Virginia,    held    at    Greensboro,    February 


HYPERTENSIVE    DISEASE— Hints 


June,    1941 


this  opinion.  The  most  significant  data  in  regard 
to  this  problem  concern  the  incidence  of  hyperten- 
sive cardiovascular  disease  among  relatives  of  per- 
sons who  have  hypertension  as  compared  with  a 
similar  incidence  among  relatives  of  persons  who 
have  a  normal  blood  pressure.  O'Hare,  Walker  and 
Vickers2  found  that  68  per  cent  of  300  patients 
who  had  hypertension  gave  a  family  history  of 
cardiovascular  disease  as  compared  with  37  per 
cent  of  564  patients  not  suffering  from  hyperten- 
sion who  gave  such  a  history.  I  have  found  a  fam- 
ily history  of  hypertensive  cardiovascular  diseas? 
to  be  five  times  as  frequent  among  persons  who 
have  hypertension  or  who  are  hyperreactors  to  a 
standard  stimulus  test3  (cold  pressor  test)  than  it 
is  among  persons  who  react  normally  to  the  test. 
I  have  also  found,  in  a  follow-up  study  of  a  group 
of  1374  patients,  that  the  incidence  of  subsequent 
hypertension  was  approximately  six  times  greater 
among  those  with  a  family  history  of  hypertensive 
cardiovascular  disease  on  the  original  visit  as  it 
was  among  those  who  did  not  have  such  a  family 
history.4  Measurement  of  the  blood  pressure  of 
relatives  by  Weitz,5  Ayman'!  and  others  has  shown 
that  there  is  a  significantly  higher  incidence  of  ele- 
vated blood  pressure  among  relatives  of  persons 
who  had  hypertension  than  among  relatives  of  per- 
sons who  did  not  have  hypertension. 

Personality. — The  most  evident  characteristic 
of  a  person  suffering  from  essential  hypertension  is 
a  certain  type  of  personality.  The  majority  of  pa- 
tients who  have  essential  hypertension  are  dy- 
namic, hard-driving,  non-procrastinating  persons 
with  the  desire  and  ability  to  accomplish  much  in 
a  short  period.  Careful  questioning  of  the  patient 
and  his  relatives  will  reveal  the  fact  that  this  type 
of  personality  has  not  developed  since  the  patient 
acquired  hypertension,  but  that  it  represents  the 
patient's  natural  tendencies  and  has  been  charac- 
teristic of  the  patient  as  far  back  as  can  be  remem- 
bered. The  occurrence  of  migraine  in  the  historv 
of  patients  who  have  essential  hypertension  is  sig- 
nificant. Migraine,  or  a  history  of  previous  mi- 
graine, occurs  approximately  five  times  as  often 
among  patients  suffering  from  hypertension  as  it 
does  among  nonhvpertensive  persons  of  correspond- 
ing ages.  The  unusual  concurrence  of  these  two 
diseases  probably  is  due  to  inherent  factors,  partic- 
ularly those  of  personality  and  heredity  which  are 
common  to  both  diseases. 

Vascular  hyperreactivity. — The  chief  objective 
feature  of*  the  background  of  hypertensive  disease 
is  a  disturbed  physiology  which  I  have  called  vas- 
cular hyperreactivity.7  This  vascular  hyperreactiv- 
ity is  manifested  by  marked  variability  of  the 
blood  pressure  and  by  hyperreactive  response  of 
the  blood  pressure  to  a  variety  of,  or  perhaps  to 
all,  forms  of  stimulation.   Vascular  hyperreactivity 


may  be  estimated  by  determination  of  the  range 
of  blood  pressure  at  hourly  or  half-hourly  intervals 
for  twenty-four  to  forty-eight  hours,  during  periods 
in  which  the  patient  is  active  and  during  periods 
of  rest.  Another  less  time-consuming  method  is 
the  performance  of  a  test  by  which  the  reaction  of 
the  blood  pressure  to  a  standard  stimulus  is  meas- 
ured after  a  basal  level  of  blood  pressure  has  been 
obtained.  The  cold  pressor  test  is  a  satisfactory 
method  for  such  a  determination.  The  technic  of 
this  test  is  as  follows:  The  patient  is  allowed  to 
rest  in  a  supine  position  in  a  quiet  room  for  twenty 
to  sixty  minutes.  Twenty  minutes  is  a  satisfactory 
rest  period  for  persons  who  have  normal  blood 
pressure.  Several  readings  of  blood  pressure  are 
taken  until  a  basal  level  has  been  approximated. 
If  hypertension  is  present,  a  longer  period  of  rest 
may  be  necessary  to  establish  a  basal  level.  The 
blood  pressure  of  a  few  patients  who  have  severe 
essential  hypertension  will  remain  at  fixed  high 
values  and  a  basal  level  cannot  be  secured  even 
after  several  hours'  rest.  With  the  patient  still 
supine,  and  with  the  cuff  of  the  sphygmomanome- 
ter on  one  arm  the  opposite  hand  is  immersed  in 
ice  water  (4°  C.  or  39.2°  F.)  to  a  point  just  above 
the  wrist.  With  the  hand  still  in  the  water,  read- 
ings of  the  blood  pressure  are  taken  at  the  end  of 
thirty  and  of  sixty  seconds.  The  higher  of  the  two 
readings  obtained  while  the  patient's  hand  is  in  the 
ice  water  is  taken  as  an  index  of  the  response.  The 
hand  is  removed  from  the  ice  water  as  soon  as  the 
reading  made  at  the  end  of  sixty  seconds  has  been 
obtained  and  readings  are  taken  every  two  minutes 
thereafter  until  the  blood  pressure  returns  to  its 
previous  basal  level.  As  to  the  question  of  what 
constitutes  a  significant  response,  analysis  of  the 
results  of  a  large  number  of  tests  has  determined 
that  an  elevation  above  the  basal  level  of  more 
than  20  mm.  of  mercury  in  the  systolic  pressure 
and  of  more  than  IS  mm.  of  mercury  in  the  dias- 
tolic pressure  indicate  a  hyperreactive  type  of  re- 
sponse to  the  test.  If  the  maximal  value  obtained 
is  more  than  140  mm.  of  mercury,  systolic,  and  90 
mm.  of  mercury,  diastolic,  the  patient  is  even  more 
certain  to  have  a  hyperreactive  vasoconstrictor 
mechanism. 

Vascular  hyperreactivity,  as  measured  by  the 
cold  pressor  test,  is  present  to  some  degree  in  all 
cases  of  essential  hypertension.  Vascular  hyper- 
reactivity is  present  in  some  persons  who  do  not 
have  hypertension.  In  studying  a  group  of  control 
persons  I  was  surprised  to  find  that  approximately 
IS  to  20  per  cent  of  young  persons,  who  did  not 
have  hypertensive  disease,  gave  hyperreactive  re- 
sponses to  the  cold  pressor  test.  Furthermore,  as 
already  stated,  it  was  found  that  among  these 
hyperreacting  normal  persons  there  was  a  higher 
incidence  of  family  histories  of  hypertension  than 


June,    1941 


II YPERTEXSIVE    DISEASE— Hines 


30.5 


there  was  among  the  hvporeacting  persons.  Fur- 
ther study  of  the  blood  pressure  reactions  of  a 
large  number  of  families  leads  to  the  conclusion 
that  the  degree  of  vascular  hyperreactivity  prob- 
ably is  governed  by  genetic  factors.  These  obser- 
vations indicate  that  vascular  hyperreactivity 
among  persons  who  do  not  have  hypertension  rep- 
resents an  antecedent  or  latent  phase  of  essential 
hvpertension.  In  further  support  of  this  theory 
there  is  evidence  that  hvpertension  is  more  likelv 
to  develop  among  persons  with  a  usually  normal 
blood  pressure  who  hvperreact  to  the  cold  pressor 
test  than  it  is  to  develop  among  persons  who  hypo- 
react  to  such  a  test." 

Persons  who  hyperreact  to  the  cold  pressor  test 
also  hvperreact  to  other  forms  of  stimuli;  for  in-' 
stance,  thev  hvperreact  to  the  experience  of  com- 
ing into  the  physician's  office  for  the  first  time  to 
have  their  blood  pressure  taken.  Sometimes  this 
first  reading  of  blood  pressure,  if  it  is  slightly  ele- 
vated, is  discarded  by  the  examining  physician. 
The  possible  significance  of  the  fact  that  only  cer- 
tain patients  will  have  an  elevation  of  the  blood 
pressure  under  such  circumstances  has  been  largely 
overlooked.  Actually,  this  particular  reading  of 
blood  pressure  represents  a  kind  of  psvchic  pressor1 
test.  I  have  made  use  of  this  psychic  reaction  in 
obtaining  additional  information  as  to  the  possible 
significance  of  vascular  hyperreactivity  among 
persons  who  have  usually  normal  blood  pressure 
by  studying  the  records  of  patients  who  had  re- 
turned to  the  Mayo  Clinic  ten  to  twenty  years 
after  an  original  examination  and  by  correlating 
data  concerning  the  subsequent  development  of 
hypertension  with  the  original  readings  of  blood 
pressure  of  such  patients.  In  this  study  it  was 
found  that  the  majority  (70.4  per  cent)  of  the 
patients  who  as  a  result  of  nervous  stress  had  an 
original  elevation  in  systolic  and  diastolic  blood 
pressure  into  the  upper  ranges  of  normal  (140  to 
ISO  mm.  of  mercury,  systolic,  and  85  to  100  mm. 
of  mercury,  diastolic)  had  hypertension  ten  or 
twenty  years  later,  whereas  only  a  small  number 
(3.4  per  cent)  for  whom  the  original  reading  of 
blood  pressure  had  been  in  the  lower  ranges  of 
normal  had  hypertension  ten  or  twenty  years  later. 
To  state  this  in  a  different  way,  of  206  patients 
who  recently  had  hypertension,  86  per  cent  had 
?iven  evidence  of  vascular  hyperreactivity  ten  or 
twenty  years  previously,  although  they  did  not 
have  hypertension  at  that  time  and  although  the 
majority  did  not  have  hypertension  until  a  number 
of  years  had  elapsed  since  the  original  examina- 
tion. 

The  renal  factor. — I  have  not  time  to  discuss  in 
detail  the  possible  significance  and  clinical  appli- 
cation of  the  important  contributions  of  Goldblatt8 
and  others  who  have  produced  hypertension  exper- 


imentally bv  constriction  of  the  renal  circulation. 
I  would,  however,  urge  caution  in  acceptance  of 
the  theory  that  renal  ischemia  is  the  solution  to 
the  causation  of  hypertension  in  the  majority  of 
cases.  Particularly  should  caution  be  exercised  in 
attributing  a  primary  etiologic  role  to  a  renal 
lesion  solely  because  it  is  found  to  be  present  in  a 
patient  who  has  hypertension.  Because  of  the  re- 
vival of  interest  in  a  possible  renal  mechanism  in 
essential  hvpertension,  Lander  and  I  have  made  a 
follow-up  study"  in  regard  to  heredity  and  vascu- 
lar hyperreactivity  in  a  group  of  264  patients  suf- 
fering from  various  renal  and  urologic  diseises 
who  did  not  have  hypertension  on  their  original 
visit  to  the  Mayo  Clinic  and  who  had  returned  to 
the  clinic  for  examination  fifteen  to  twenty  years 
after  their  original  visits.  The  results  of  this  study 
show  that  those  patients  who  had  a  high  normal 
blood  pressure  (evidence  of  vascular  hyperreactiv- 
ity) on  their  original  visits  and  those  who  had  a 
family  history  of  hypertension  were  four  to  five 
times  as  likely  to  have  hvpertension  subsequently 
as  were  those  who  had  a  low  normal  blood  pressure 
or  no  family  history  of  hypertension,  regardless  of 
the  type  or  extent  of  the  urologic  or  renal  lesion 
and  regardless  of  whether  the  onset  of  symptoms 
of  the  disease  of  the  urinary  tract  occurred  before 
or  after  the  original  reading  of  blood  pressure. 
Results  of  this  study  indicated  that  factors  con- 
cerning the  development  of  hypertension  which 
are  inherent  in  each  person  may  be  of  equal  im- 
portance in  the  development  of  hypertension  re- 
gardless of  whether  renal  disease  is  present  or  is 
not  present.  It  is  probable  that  in  those  cases  in 
which  a  renal  pressor  mechanism  may  be  operat- 
ing this  mechanism  is  initiated  by  vascular  changes 
resulting  from  the  inherent  vascular  hyperreactiv- 
ity. 

Treatment 

There  is  no  specific  treatment  for  hypertensive 
disease.  It  is  a  mistake  to  speak  at  present  of  curing 
a  patient  of  essential  hypertension.  Some  procedures 
and  treatments  may  relieve  and  lower  blood  pres- 
sure, but  it  is  doubtful  whether  anything  done  at 
present  cures  any  patient  of  his  inherent  hyperten- 
sive tendency.  The  treatment  of  hypertensive  dis- 
ease should  begin  in  the  prehypertensive  stage, 
when  regulation  of  the  patient's  methods  of  living 
so  as  to  conserve  the  vascular  system  from  strain 
may  pay  large  future  dividends.  However,  most 
patients  suffering  from  hypertensive  disease  do  not 
come  to  the  physician  for  treatment  until  the  dis- 
ease is  moderately  advanced.  When  the  physician 
is  faced  with  a  patient  suffering  from  hypertensive 
disease,  it  is  obligatory  that  he  first  make  a  reason- 
able effort  to  rule  out  secondary  factors  which  mav 
contribute  to  the  hypertension  before  deciding  on 
a  program  of  treatment.   If  such  factors  are  found, 


HYPERTESSIYE    DISEASE— Hines 


June.    1941 


they  should  be  removed  or  treated  whenever  there 
is  a  reasonable  expectation  of  benefit  to  the  patient 
to  be  derived  from  such  a  course.  This  rarely  can 
be  accomplished  to  any  spectacular  extent,  except 
in  cases  of  pheochromocytoma  and  in  rare  cases 
of  unilateral  renal  disease.  During  the  past  three 
years  there  have  been  several  reports  in  the  liter- 
ature concerning  patients  who  had  unilateral  renal 
disease  and  hypertension  and  who,  after  surgical 
removal  of  a  diseased  kidney,  experienced  a  return 
of  the  blood  pressure  to  normal.1"  However,  all 
patients  have  not  experienced  relief  of  hypertension 
after  removal  of  a  diseased  kidney.  At  present  the 
evidence  suggests  that  only  those  patients  who  suf- 
fer from  unilateral  atrophic  pyelonephritis  can  rea- 
sonably expect  regression  of  their  hypertension  to 
follow  nephrectomy.  In  spite  of  a  careful  search 
for  significant  secondary  factors,  the  majority  of 
instances  of  hypertension  will  be  found  to  be  of  the, 
essential  type.  If  the  possibility  is  borne  in  mind 
of  a  specific  cause  for  elevation  of  the  blood  pres- 
sure, it  is  not  likely  that  any  important  secondary 
factors  will  be  overlooked. 

The  medical  treatment  of  hypertension  is  not 
satisfactory.  The  spontaneous  variability  of  the 
blood  pressure  makes  estimation  of  the  real  value 
of  various  types  of  therapy  extremely  difficult.  In 
the  planning  of  a  logical  program  of  treatment  the 
background  of  hypertensive  disease  should  not  be 
ignored.  The  hereditary  factor  cannot  be  elimi- 
nated, although  it  may  be  conjectured  that  the 
breeding  of  a  race  of  hyporeactors,  so  to  speak, 
might  eliminate  hypertensive  disease.  An  effort 
can  be  made  to  reduce  the  strain  on  the  vascular 
system  bv  teaching  the  patient  to  relax.  This  must 
be  approached  first  bv  helping  the  patient  to  un- 
derstand his  problem  and  by  doing  whatever  is 
possible  to  relieve  undue  anxiety.  Most  patients 
suffering  from  hypertension  have  an  undue  fear 
that  some  disaster  is  about  to  overtake  them,  an 
attitude  which  unfortunately  in  some  instances  has 
been  caused  by  unwise  remarks  on  the  part  of 
some  physician.  The  patient  suffering  from  hyper- 
tension should  have  a  regulated  program  which  is 
conducive  to  relaxation,  consisting  of  regular  pe- 
riods for  rest  during  the  day,  regular  vacation? 
and,  above  all,  a  hobby  of  a  noncompetitive  type. 
Tobacco  should  be  used  sparingly,  or,  better  still, 
avoided  entirely.  Sedative  drugs  frequently  are  of 
value  in  the  allaying  of  undue  nervous  tension. 
The  hyperreactive  nature  of  the  person  who  has 
hypertension  usually  necessitates  relatively  larger 
doses  of  sedative  drugs  to  produce  the  desired  ef- 
fects. Better  results  than  those  formerly  obtained 
have  been  reported  to  follow  the  use  of  thiocya 
nates,  and  the  administration  of  thiocyanates  has 
been  made  safer  since  a  method  has  become  avail- 
able  for   determination   of   their   concentration   in 


the  blood.  As  Barker"  has  pointed  out,  the  im- 
portant feature  of  this  type  of  therapy  is  estab- 
lishment of  a  definite  concentration — between  6 
and  12  mg.  per  100  ex. — in  the  blood.  If  it  is  less 
than  6  mg.,  very  little  effect  is  noticeable,  and  if 
it  is  greater  than  14  mg.,  there  is  danger  of  the 
occurrence  of  serious  toxic  effects.  There  is  a  wide 
individual  variation  in  a  patient's  tolerance  of  thio- 
cyanates and  elimination  of  thiocyanates  from  the 
blood  stream;  consequently,  the  dosage  must  be 
determined  individually.  A  test  of  the  content  of 
thiocyanates  in  the  blood  should  be  made  at  least 
once  a  week  until  a  stable  dosage  has  been  deter- 
mined, after  which  once  a  month  usually  is  often 
enough.  Headache,  nervous  tension  and  insomnia 
may  be  relieved  by  thiocvanate  therapy.  In  some 
instances  weakness  and  fatigue  may  be  increased 
temporarily  and  in  an  occasional  instance  enlarge- 
ment of  the  thyroid  gland  may  occur.  Symptoms 
of  intoxication,  such  as  increasing  nervousness, 
dermatitis,  nausea  and  vomiting  and  mental  con- 
fusion, should  be  watched  for  carefully,  but  they 
are  unlikely  to  occur  if  the  thiocvanate  content  of 
the  blood  is  kept  below  15  mg. 

There  is  little  evidence  that  special  diets  are  of 
much  value  in  reducing  blood  pressure.  Restriction 
of  the  intake  of  sodium  chloride  has  been  advocat- 
ed by  Allen12  and  others.  In  my  experience,  there 
has  been  little  difference  noted  between  the  effect 
of  a  salt-free  diet  on  the  blood  pressure  and  the 
effect  of  a  diet  in  which  the  sodium  chloride  is 
only  moderately  restricted.  Certainly,  patients  suf- 
fering from  hypertensive  disease  should  not  be 
maintained  for  an  indefinite  time  on  a  diet  in 
which  salt  or  protein  is  greatly  restricted,  unless 
an  adequately  controlled  period  of  observation  has 
demonstrated  significant  lowering  of  blood  pres- 
sure while  the  patient  followed  such  a  program  of 
treatment.  The  use  of  special  diets  in  the  manage- 
ment of  hypertensive  disease  has  been  abandoned 
by  most  students  of  hypertension,  except  for  pa- 
tients who  are  obese  or  who  have  renal  failure. 

Various  tvpes  of  operations  on  the  sympathetic 
nervous  svstem  have  been  devised  for  the  treat- 
ment of  essential  hypertension.  At  the  Mayo 
Clinic  the  operation  of  choice  is  section  of  the 
major,  minor  and  lesser  splanchnic  nerves,  with 
partial  resection  of  the  celiac,  and  resection  of  the 
upper  lumbar  sympathetic,  ganglions.  Approxi- 
mately 450  patients  have  been  subjected  to  this 
operation  at  the  Mayo  Clinic  during  the  six  years 
prior  to  the  time  of  this  report  without  a  post- 
operative death.  According  to  a  recent  summary 
by  Allen  and  Adson,13  excellent  results  in  reduction 
of  blood  pressure  have  been  obtained  by  this  oper- 
ative procedure  in  approximately  13  per  cent  of 
cases  and  results  have  been  fair  in  18  per  cent.  In 
30  per  cent  of  cases  the  blood  pressure  was  not 


MYPERTE.XSIVE    DISEASE— Hinc 


affected,  and  in  39  per  cent  good  immediate  results 
were  obtained  which  lasted  for  weeks  or  months, 
but  return  of  blood  pressure  to  preoperative  levels 
occurred.  The  symptoms  had  been  relieved  in  ap- 
proximately 80  per  cent  of  cases,  regardless  of  the 
effect  on  the  blood  pressure.  Sympathectomy  is 
not  the  answer  to  the  quest  for  a  specific  treatment 
for  hypertension,  but  because  of  the  small  risk,  in- 
volved and  the  number  of  excellent  results  ob- 
tained by  the  operation,  it  is  a  worthwhile  proce- 
dure in  certain  carefully  selected  cases.  At  present, 
patients  are  selected  for  sympathectomy  at  the 
Mavo  Clinic  according  to  the  following  criteria: 
Operation  is  advised  only  for  patients  whose  blood 
pressure  responds  satisfactorily  before  operation  to 
the  following  standard  tests:  (1)  slow  and  inter- 
mittent intravenous  injection  of  a  S  per  cent  solu- 
tion of  pentothal  sodium  to  a  stage  at  which  de- 
crease in  the  blood  pressure  no  longer  occurs 
(ordinarily  500  mg.  to  1  gm.  is  injected),  (2)  ad- 
ministration of  3  grains  (0.2  gm.)  of  sodium  amy- 
tal  each  hour  for  three  successive  hours;  (3)  ad- 
ministration of  l/2  grain  (0.032  gm.)  of  sodium 
nitrite  at  half-hour  intervals  until  six  doses  have 
been  given,  and  (4)  hourly  determination  of  blood 
pressure  during  rest  and  sleep  for  a  minimum  of 
twenty-four  consecutive  hours. 

If  the  blood  pressure  decreases  to  normal  or  to 
■nearly  normal  as  a  result  of  all  these  measures,  the 
patient  may  be  considered  a  satisfactory  candidate 
for  operation.  If  the  response  of  the  blo^d  pres- 
sure to  these  measures  is  inadequate,  the  results 
of  operation  are  almost  certain  to  be  unsatisfac- 
tory: and  even  when  the  response  is  adequate  the 
benefit  from  operation  may  not  be  all  that  was 
hoped  for.  The  problem  of  the  selection  of  pa- 
tients for  operation  is  further  complicated  by  the 
neurosurgeon's  desire  to  perform  the  opera'ion  be- 
fore the  blood  pressure  becomes  relatively  fixed  at 
high  values,  also  by  his  desire  not  to  operate  on 
persons  who  have  a  relatively  mild  and  mnpro- 
gressive  form  of  hypertensive  disease.  In  addition 
to  the  unfavorable  response  of  the  blood  pressure, 
contraindications  for  cperation  are  as  follows:  age 
greater  than  fifty  years,  congestive  heart  failure, 
angina  pectoris  marled  renal  insufficiency  and  ad- 
vanced arteriosclerosis.  Spasm  and  apparent  scle- 
rosis of  the  retinal  arteries,  retinitis,  moderate  en- 
largement of  the  heart,  inversion  of  T  waves  in 
the  electrocardr'Tam,  albuminuria  and  slight  re- 
duction in  renal  funct'on  or  a  cerebrovascular  acci- 
dent from  which  recovery  has  been  satisfactory 
are  not  in  themselves  contraindications  to  opera- 
tion. 

The  use  of  renal  extracts  in  the  treatment  of 
hypertension  aroused  considerable  interest  after 
the  reports  of  Grollman.  Williams  and  Harrison" 
and  of  Page'"'  and  his  co-workers.   It  is  to  be  hoped 


that  future  developments  in  this  field  of  therapy 
may  provide  the  long-desired  specific  remedy  for 
the  control  of  hypertensive  disease.  However,  at. 
present  this  work  must  be  considered  to  be  in  an 
experimental  stage.  Apparently,  the  extract  is  dif- 
ficult to  prepare  in  uniform  potency  and  the  ex- 
pense involved  in  the  obtaining  of  even  a  small 
amount  of  it  precludes  its  use  in  any  general  way. 

Summary  and  Conclusions 

Hypertensive  forebears,  a  dynamic  personality, 
a  tendency  to  migraine,  and  vascular  hyperreactiv- 
ity are  the  characteristic  features  of  the  back- 
ground of  hypertensive  disease.  Vascular  hyperre- 
activity is  characteristic  of  the  prehypertensive 
stage  of  essential  hypertension  and  it  may  be  the 
genetic  defect  which  is  inherited.  To  this  prehy- 
pertensive background  of  vascular  hyperreactivity 
may  be  added  secondary  or  accelerating  factors,  or 
the  vascular  hyperreactivity  may  of  itself  produce 
changes  in  certain  organs  (the  kidneys  for  in- 
stance), which  bring  into  play  a  secondary  pressor 
mechanism,  still  further  elevating  the  blood  pres- 
sure. 

The  mechanism  of  the  production  of  vascular 
hyperreactivity  is  not  well  understood.  It  is  prob- 
ably related  to  an  inherited  hyperreactive  vaso- 
motor center,  although  peripheral  mechanisms  for 
the  production  of  vasoconstriction  may  play  a 
part. 

There  is  no  specific  treatment  for  hypertensive 
disease.  Whenever  possible,  attempts  at  control 
should  be  started  in  the  prehypertensive  stage  of 
the  disease.  A  reasonable  effort  shou'd  be  made  to 
recognize  significant  secondary  and  contributing 
factors  affecting  the  blood  pressure  before  a  pro- 
gram of  treatment  is  decided  on.  Regulation  of 
methods  of  work  and  recreation  should  receive 
considerable  attention  and  undue  emphasis  on 
readings  of  blood  pressure  should  be  avoided. 
Drug  therapy  usually  is  entirely  ineffective  in  low- 
ering blood  pressure  significantly.  In  certain  cases 
t^e  sedative  drugs  and  thiocyanate  therapy  under 
properly  controlled  usage  may  be  effective  in  re- 
lieving symptoms  and  lowering  blood  pre-sure. 
Special  dietary  measures  are  of  limited  va'ue. 
Sympathectomy  is  a  worthwhile  procedure  in  cer- 
tain carefully  selected  cases.  The  possible  effec- 
tiveness of  renal  extracts  in  the  control  of  hyper- 
tension has  aroused  considerable  interest  but  such 
treatment  is  as  yet  in  an  experimental  stage. 

References 

1.  Janewav,  T.  C:  The  etiology  of  disease,  of  the  cir- 
culatory system.    Boston  M.  &  S.  J.,  174:925-938,  1916. 

2.  O'Hare,  J.  P..  Walker,  W.  G..  and  Vickers,  M.  C: 
Heredity  and  hypertension.  J.  .1.  M.  A.,  S3-.27-2&,  July 
5,    1924. 

3.  Hlnes,  E.  A.,  Ju.:  The  hereditary  faclor  in  essential 
hypertension.    Ann.  Int.  Med.,  //:593-601,  Oct.,  1937. 


(06 


HYPER TESS1VE    DISEA SE—Hine 


June,    1941 


4.  Hikes,  E.  A.,  Jr.:  The  hereditary  factor  and  subse- 
quent development  of  hypertension.  Proc.  Staff  Meet., 
Mayo  Clin.,  .75:145-146,  March  6,  1940. 

5.  Weitz,  Wilhelm:  Zur  Atiologie  der  genuinen  oder 
vascularen  Hypertension.  Ztschr.  f.  klin.  Med.,  9(5:151- 
181,  1923. 

6.  Ayman,  David:  Heredity  in  arteriolar  (essential)  hy- 
pertension; a  clinical  study  of  the  blood  pressure  of 
1,524  members  of  277  families.  Arch.  Int.  Med.,  53: 
792-802,  May,  1934. 

7.  Hines,  E.  A.,  Jr.:  The  significance  of  vascular  hyper- 
reaction  as  measured  by  the  cold  pressor  test.  Am. 
Heart  J.,  74:408-416,  April,   1940. 

8.  Goldblatt,  H.:  Studies  on  experimental  hypertension. 
V.  The  pathogenesis  of  experimental  hypertension  due 
to  renal  ischemia.  Ann.  Int.  Med.,  77:69-103,  July, 
1937. 

9.  Hines,  E.  A.,  Jr.,  and  Lander,  H.  H.:  Factors  con- 
tributing to  the  development  of  hypertension  in  patients 
suffering  from  renal  disease.  /.  A.  M.  A.,  77(5:1050-1052, 
March  15,  1940. 

10.  Barker,  N.  W.,  and  Walters,  Waltman:    Hyperten- 
sion and  chronic  atrophic  pyelonephritis.   J.  A.  M.  A,. 

775:912-916,  Sept.   14,   1940. 

11.  Barker,  M.  H.:  The  blood  cyanates  in  the  treatment 
of  hypertension.  J.  A.  M.  A.,  70(5:762-765,  March  7, 
1936. 

12.  Allen,  F.  M.:  Treatment  of  kidney  disease  and  high 
blood  pressure.  Part  I.  Morristown,  New  Jersey,  The 
rhysiatric   Institute,   1925,  210  pp. 

13.  Allen,  E.  V.,  and  Adson,  A.  W.:  The  treatment  of 
hypertension;  medical  versus  surgical.  Ann.  Int.  Med., 
74:288-307,  Aug.,   1940. 

14.  Grollman,  Arthur,  Williams,  J.  R„  Jr.,  and  Harri- 
son, T.  R.:  Reduction  of  elevated  blood  pressure  by 
administration  of  renal  extracts.  J.  A.  M.  A.,  775:1169- 
1176,  Oct.  5.  1940. 

15.  Page,  I.  H.,  Helmer,  O.  M.,  Kohlstaedt,  K.  G.. 
Fouts,  P.  J.,  and  Kempf,  G.  F.:  Reduction  of  arterial 
blood  pressure  of  hypertensive  patients  and  animals 
with  extracts  of  kidneys.  J.  Exper.  Med.,  73:7-41,  Jan., 
1941. 


DR.  EDWARD  A.  BABER,  A  POWER  IN  GEORGIA, 
AND  HIS  TRAGIC  END 

(J.   D.    Baxemore.  in  //.   Med.   Ass».   Co.,    April) 

Edward  Ambrose  Baber,  Macon's  first  doctor,  was  born 
in  Buckingham  County,  Virginia,  Sept.  12th,  1793.  Forced 
to  seek  a  milder  climate  after  being  injured  in  the  Battle 
of  Bladensburg  during  the  War  of  1812,  he  removed  to 
Georgia. 

Just  as  he  had  established  himself  General  Jackson 
asked  that  he  join  his  staff  as  surgeon  on  his  invasion  of 
Spanish  territory  in  Florida.  After  the  Seminole  campaign 
he  returned  to  Georgia.  Soon  he  was  asked  to  give  his 
advice  to  a  group  of  commissioners  who  wanted  to  lay 
out  a  new  town  to  be  named  for  Nathaniel  Macon.  He 
admonished  the  commissioners  not  to  lay  the  town  off 
near  the  river,  but  as  far  from  the  swamps  as  was  possible. 

Dr.  Baber  founded  the  Masonic  Lodge,  the  Academy, 
was  first  president  of  the  first  bank,  organized  the  first 
Church,  made  plans  for  first  court  house  (in  1827).  He 
conceived  the  idea  ef  a  railroad  to  connect  Macon  with 
the  sea,  and  thereafter  was  known  as  the  "Father  of  the 
Central  Railroad  of  Georgia."  He  started  the  first  library, 
organized  the  first  military  company  and  was  commissioned 
its  first  captain.  Now.  a  member  of  the  Legislature,  he 
introduced  a  bill  authorizing  the  Governor  to  appoint 
"three  suitable  persons  to  form  a  system  of  academic  and 
free  school  education  throughout  the  State.'' 


On  the  day  of  his  marriage  to  Miss  Mary  Sweet.  June 
16th,  1829,  she  was  pronounced  in  the  last  stages  of  tuber- 
culosis. He  believed  he  could  cure  his  bride  with  proper 
diet,  rest,  fresh  air,  travel  and  life  in  the  open  in  a  favor- 
able climate.  She  outlived  him  by  48  years.  As  Mrs.  Baber 
often  said,  "He  married  me  only  to  turn  me  out  of  doors." 

On  Sunday,  March  8th,  1846,  when  only  49  years  of  age, 
in  the  sick  room  of  a  patient,  a  dose  of  cyanide  of  potas- 
sium compounded  by  Majendie's  recipe,  as  published  in  the 
Seventh  Edition  of  Ellis'  Formulary,  swallowed  to  con- 
vince the  patient  (whose  suspicions  of  its  improper  strength 
had  been  aroused  by  the  apothecary)  that  it  might  be 
taken  with  impunity,  terminated  the  life  of  Dr.  Baber." 
The  day  was  officially  recorded  as  Macon's  Dark  Sunday. 
The  formulary  contained  a  typographical  error  and  that 
whole  edition,  as  soon  as  possible,  was  recalled  by  the 
government  and  burned. 


ACUTE   PORPHYRIA 


<\V.    II.    Ford   &   H.    L.    Ulrich,    Minneapolis,    in    Minn.    Med., 
April) 

Porphyria  is  not  an  extremely  rare  disease,  but  the  diag- 
nosis may  be  missed  even  after  careful  study  and  autopsy. 
Three  cases  have  been  found  in  Minneapolis  in  the  last 
five  months.  The  diagnosis  in  our  case  was  made  only 
because  of  the  red  urine,  which  showed  the  typical  spec- 
troscopic bands  of  porphyrin. 

Waldenstrom  has  reviewed  the  chemical  and  clinical 
studies  of  100  cases  of  porphyria. 

The  condition  must  be  differentiated  from  neuroses, 
psychoses,  encephalitis,  multiple  neuritis.  Landry's  paraly- 
sis, periarteritis  nodosum.  The  commonest  confusion  occurs 
in  acute  abdominal  symptoms,  particularly  where  there  is 
pain,  fever,  constipation,  vomiting  and  leukocytosis.  He 
records  29  patients  undergoing  abdominal  operation,  the 
mistaken  diagnosis  being  appendicitis  in  16,  ileus  in  7,  pel- 
vic conditions  in  4,  cholecystitis  in  2.  Gastric  or  duodenal 
ulcers  have  also  been  erroneously  diagnosed.  He  has  never 
been  able  to  find  porphyrin  in  the  urine  in  any  other  dis- 
ease. 

The  therapy,  which  is  more  or  less  futile,  consists  of 
diuretics,  alkalis,  morphine  or  papaverine  in  the  vein,  cal- 
cium and  heat.  Sedatives,  particularly  bromides,  should  be 
avoided. 

In  full-blown  cases.  80%  are  fatal.  The  recurrent  ab- 
dominal type  is  much  less  dangerous. 

Of  100  caes,  20  died  within  one  year  from  the  appear- 
ance of  the  symptoms  of  the  disease.  Only  two  lived  eight 
years.  Of  12  known  living  cases,  one  has  gone  on  for  2  7 
years. 

In  all  cases  with  acute  abdominal  symptoms,  and  in 
cases  which  present  puzzling  neurological  data,  think  oj 
porphyria. 


IMMUNIZATION  AGAINST  TETANUS 

(H.  J.  Parish,  in  Proc.  Royal  Soc.  of  Med.  (Engl.  Mar.) 
The  incidence  of  tetanus  in  this  war  has  been  negligible. 
In  no  case  has  tetanus  been  reported  in  wounded  soldiers 
who  had  received  protective  inoculations  of  toxoid.  Al- 
though active  immunization  may  be  indicated  for  A.  R.  P. 
workers,  members  of  the  Land  Army,  and  others  specially 
exposed  to  risk,  mass  immunization  of  the  civilian  popula- 
tion is  not  advised.  This  omission  is  not  likely  to  have 
serious  consequences  provided  that  antitoxic  serum  can  be 
given  early  to  all  wounded  persons. 

Many  sore  arms  which  are  ascribed  to  the  prophylactic 
are  really  due  to  bacterial  infection;  sterilize  syringes  and 
needles  by  heat.  Far  too  many  rely  on  alcohol  as  a  dis- 
infectant, although  its  unreliability  is  well-known. 


June.    1941 


SOUTHERN  MEDICINE  &■  SURGERY 


Obesity:     A  Clinical  Point  of  View 
Frank  A.  Evans,  M.D.,  Pittsburgh 

Western  Pennsylvania  Hospital 


OBESITY,  an  unwholesome  physical  state, 
must  be  accepted  by  physicians  as  a  clinical 
condition  which  merits  their  serious  atten- 
tion. Its  menace  to  continued  good  health  while 
one  is  passing  through  successive  decades  of  life 
has  been  demonstrated.  Tht  realization  of  this  fact 
by  an  ever-increasing  number  of  people  is  giving  a 
greater  opportunity  for  treatment. 

Understanding  of  obesity  as  a  clinical  problem 
has  been  clouded  by  inaccurate  thinking  and  un- 
proven  hypotheses.  A  correct  attitude  toward  obe- 
sity and  its  treatment  will  result  from  the 
acceptance  of  the  following  facts. 

1.  Obesity  can  result  only  from  a  plus  energy 
balace,  from  the  ingestion  of  more  energy  units 
than  are  expended,  from  overeating.  All  obesity 
is,  therefore,  alimentary. 

2.  The  cure  of  obesity  can  be  accomplished  only 
by  the  establishment  of  a  negative  energy  balance, 
from  expending  more  energy  units  than  are  taken 
in,  thus  oxidizing  the  stored  fat. 

3.  The  only  practical  way  in  which  a  negative 
energy  balance  can  be  created  is  by  limitation  of 
intake,  by  dieting. 

4.  The  limited  diet  prescribed  for  the  correction 
of  obesity  must  contain  an  adequate  amount  of  all 
the  known  essential  foodstuffs.  There  need  be  no 
calories  in  the  diet  in  addition  to  those  afforded 
by  the  articles  necessary  to  supply  the  essential 
foodstuffs. 

5.  Continued  success  with  menus  so  limited  de- 
mands from  the  patient  a  high  grade  of  cooperation 
in  accurate  dieting.  This  is  obtained  only  when 
he  recognizes  that  the  sensual  delights  of  eating 
must  be  given  up  for  the  period  of  treatment. 

I 
An  automatic  regulation  of  energy  intake  to 
energy  output  is  operative  in  most  people  much  of 
the  time.  Its  mechan'sm  is  not  understood  but  >t 
is  surprizingly  accurate.  The  wonder  is  that  obesity 
is  not  more  prevalent,  since  eating  is  such  a  pleasant 
occupation  and  delectable  dishes  are  everywhere 
and  at  all  times  available.  When  the  automatic  reg- 
ulation breaks  down  an  abnormal  state  of  nutrition 
results  unless  conscious  attention  is  given  the 
matter.  Obesity  follows  if  the  breakdown  yields  a 
plus  energy  balance,  because  all  intake  in  excess 
of  needs  is  converted  into  and  laid  down  as  fat. 
Recovery  from  undernutrition  is  accompanied  by 
the  building  up  of  vital  tissues.  There  is,  among 
other  things,  a  storing  of  nitrogen '  until  normal 


weight  has  been  attained.  In  fully-developed 
normal  adults,  with  the  single  exception  of  preg- 
nancy, excess  weight  is  never  due  to  increased 
weight  of  vital  tissues.  The  excess  weight  is  all  fat 
and  its  extent  is  a  measure  of  the  amount  of  food 
eaten  in  excess  of  needs. 

Considerations  of  the  causes  of  obesity  are 
studies  of  the  manner  of,  and  reason  for,  the 
breakdown  of  the  mechanism  regulating  energy  in- 
take and  output.  The  breakdown  can  occur  in  two 
ways:  lowered  energy  expenditure  without  a  corre- 
sponding limitation  of  food  intake;  and  increased 
food  intake  without  a  counterbalancing  greater 
energy  expenditure. 

The  milder  grades  of  obesity  insidiously  develop- 
ing as  one  grows  older  probably  result  from  a 
breakdown  in  both  directions.  People  as  they  grow 
older  should,  and  most  do,  take  less  exercise  and 
so  need  less  energy-producing  food.  More  spare 
time,  and  greater  contentment  lead  to  more  eating. 
One  must  recognize,  in  addition  to  this,  an  en- 
docrine factor  especially  noteworthy  in  some 
rapid  weight  increases  after  menopause.  The 
ways  in  which  various  changes  in  endocrine 
function  break  down  the  energy  intake-output 
balancing  mechanism  have  not  been  explained. 
Certainly  no  metabolic  anomaly  has  been  shown 
such  an  increased  tendency  to  convert  glucose  into 
fat,  a  diminished  ability  to  burn  either  glucose  or 
fat,  or  an  altered  specific  dynamic  action  of  the 
food  eaten.2 

When  endocrine  dysfunction  and  obesity  are 
seen  together  the  endocrine  disorder  suspected  of 
causing  disturbance  of  energy  balance  is  not 
always  primary.  Irregularities  of  menstruation, 
often  dependent  upon  endocrine  imbalance,  are  very 
common  in  obese  young  women.  The  majority  of 
these  patients  are  relieved  of  their  menstrual  diffi- 
culties after  attaining  a  normal  weight  by  careful 
dieting.  This  suggests  that  overeating  is  the  pri- 
mary factor,  that  the  endocrine  dysfunction 
causing  the  dysmenorrhea  results  from  the  ingest- 
ion of  a  diet  faulty  as  to  metabolic  requirements. 
This  observation  supplies  a  practical  suggestion  for 
direction    of   treatment. 

The  obesity  sometimes  seen  in  hypothyroid 
states  is  brought  about  probably  by  lowered  energy 
expenditure;  however,  regardless  of  how  low  the 
energy  output  may  be,  or  from  whatever  cause,  a 
wholesome  menu  which  does  not  exceed  the 
caloric  needs  is  available.  Failure  to  adopt  such  a 


OBESITY— Evans 


June,    1941 


menu,  in  other  words  overeating,  is  therefore  the 
cause  of  the  obesity  in  cases  such  as  these,  as 
it  is  under  all  other  circumstances. 

The  more  severe  grades  of  obesity,  especially  in 
young  people,  are  almost  always  initiated  by  an 
abnormally  high  level  of  energy  intake.  Later,  when 
the  excess  weight  has  become  burdensome  and 
much  activity  is  difficult  or  impossible,  the  factor 
of  lowered  energy  output  also  enters.  Several 
reasons  may  be  presented  for  the  breakdown  in 
young  people  of  the  energy  intake-output  balanc- 
ing mechanism  which  results  in  overeating.  Each 
factor  probably  is  responsible  for  its  share  of 
cases.  Then  some  fat  people  with  good-humored 
enthusiasm  consciously  overindulge  in  gustatory 
sensualism.  Others  lack  understanding  or  are 
simply  careless.  How  often  one  sees  persons  eat 
heedlessly  food  which  they  neither  need  nor  very 
much  enjoy.  Family  habits  of  eating  vary.  Some 
families  set  a  "groaning  board"  which  constitutes 
a  constant  temptation  to  overeating.  Once  this 
habit  has  been  established  it  takes  more  food  to  give 
a  feeling  of  satisfaction  and  thus  a  vicious  circle  is 
initiated-'.  The  members  of  such  a  family  ingest 
many  more  calories  than  those  in  a  household  who 
prefer  thin  soups,  salads  and  fruits.  Wilder3  sug- 
gested faulty  functioning  of  a  center  in  the  dience- 
phalon  which  regulated  the  sensation  of  hunger  for 
the  failure  of  the  energy-balancing  mechanism  in 
some  of  the  obese.  This  does  not,  however,  mean 
that  a  metabolic  anomaly  is  operative.  The  primary 
demand  for  energy  requirements  is  always  met  in 
all  people.  Attentive  control  of  the  food  intake 
to  this  level  will  mean  that  no  energy  in  excess 
of  needs  will  be  available  for  conversion  into  fat 
and  obesity  will  be  avoided. 

It  must  be  recognized  that  obesity  can  result 
from  an  excess  energy  intake  only,  whatever  may 
have  been  the  background  of  the  overeating. 

II 

Acceptance  of  the  fact  that  all  obesitv  is  alimen- 
tary makes  it  clear  that  the  cure  of  obesity  can 
be  accomplished  by  no  other  means  than  a  reversal 
of  the  situation  bringing  it  about,  the  creation  of 
a  negative  energy  balance.  Massages  and  hot  baths 
do  not  lower  energy  intake  or  increase  energy-out- 
put appreciably,  so  they  are  of  no  value  in  the 
correction  of  obesity.  Indeed,  they  may,  by  in- 
creasing the  appetite,  lead  to  a  greater  plus  energy 
balance.  Any  weight  losses  noticed  after  physio- 
therapeutic procedures  result  from  loss  of  water, 
will  be  of  no  more  than  a  few  hours  duration, 
and  will  contribute  nothing  to  the  removal  of  the 
excess  fat.  The  appreciable  weight  losses  shown 
by  the  scales  after  purging  are  likewise  dependent 
upon  loss  of  water.  When  this  is  pointed  out,  some 


patients  interested  in  scale  readings  only  attempt  to 
maintain  the  weight  loss  by  limitation  of  fluid  in- 
take. This  is,  of  course,  unwholesome  and  never 
successful,  because  the  body  will  establish  its 
water-balance  bv  tenaciously  retaining  the  water 
in  the  food  eaten  and  any  little  that  is  taken  to 
quench  thirst.  The  reduction  in  weight  by  removal 
of  fat  can  be  accomplished  only  by  a  negative 
energy  balance. 

Ill 
A  move  in   the  direction  of  a  negative  energv 
balance   can   be   made   by   increase   of   output.   A 
larger  energy  expenditure  can  be  brought  about  by 
drugs,  and  by  exercise. 

Pharmacological  Products 

The  administration  of  thyroid  preparations  in- 
creases energy  expenditure;  but  it  is  prone  to  cause 
tremor,  tachycardia  and  emotional  instability. 
These  by-effects  are  unpleasant.  Furthermore,  thy- 
roid medication  is  unwholesome  and  definitely  con- 
traindicated.  The  basal  metabolic  rate  in  the  obese 
is  normal.4  ■"•  It  is  noteworthy  that  in  the  obese  the 
two  factors,  surface  area  and  level  of  oxygen  ex- 
change, which  are  related  to  each  other  to  obtain 
the  metabolic  rate  are  proportionally  increased.  But 
the  increased  surface  area  of  these  patients  results 
from  laying  on  of  fat,  a  tissue  physiologically  inert. 
The  true  basal  metabolic  rate  should  be  determined 
by  relating  the  level  of  oxygen  exchange  to  the 
actively  functioning,  vital  tissues  alone.  This  means 
that  the  factor,  surface  area,  employed  in  the  cal- 
culation should  not  be  the  actual  surface  area  in 
the  obese  patient,  but  his  surface  area  at  his  normal 
weight.  When  this  is  done  it  is  seen  that  the  obese 
have  a  plus  basal  metabolic  rate  of  from  25  to  30 
per  cent  in  relation  to  their  actively  functioning 
tissues.  One  series  of  patients  may  be  cited  in 
illustration  :fi  Five  obese  patients  who  averaged  94 
pounds  overweight  showed  an  average  energy  ex- 
change of  71  calories  per  hour.  This  gave  an  average 
basal  metabolic  rate  of  minus  3  per  cent,  a  normal 
figure.  Fifty-eight  calories  per  hour  would  have 
given  a  normal  rate  for  these  patients  if  they  had 
been  of  normal  weight.  The  71  calories  per  hour 
observed  gave  an  average  basal  rate  of  plus  23 
per  cent  as  related  to  the  ideal  weight.  One  should 
not,  of  course,  elevate  further  such  a  high  basal 
metabolic  rate. 

Thyroid  medication  is  relatively  ineffective.  A 
daily  deficit  of  no  more  than  1000  calories  a  day 
can  be  accomplished — if  no  increased  intake  occurs. 
A  caloric  deficit  much  greater  than  that  often 
can  be  accomplished  by  diet.  Furthermore,  thyroid 
preparations  can  not  be  taken  indefinitely  and 
any  reduction  resulting  from  their  use  alone  will, 
therefore,  be  temporary. 


June.   1941 


OBESITY— Evans 


The  same  objections  apply  to  any  other  drug 
used  to  increase  energy  output.  Dinitrophenol  has 
the  additional  danger  of  possible  cataract  for- 
mation. 

Exercise 

Increased  energy  expenditure  can,  of  course,  be 
brought  about  by  exercise.  An  increase  effective 
in  the  treatment  of  obesity  results  only  from  much 
exercise,  hours  long.  Morning  and  evening  calis- 
thenics are  of  no  avail.  The  necessary  amount  of 
exercise  is  contraindicated  in  many  obese  persons 
because  of  elevated  levels  of  oxygen  exchange, 
cardiovascular  systems  already  under  strain, 
broken  arches,  and  easy  fatigability.  Exercise  in 
persons  young  and  vigorous  enough  to  take  it 
without  damage  will  invariably  increase  appetite. 
Unless  rigid  control  of  food  intake  is  also  practiced 
no  negative  caloric  balance  will  result.  Even  so,  the 
negative  energy  balance  which  can  be  accomplished 
by  amounts  of  exercise  possible  for  only  a  few  is, 
as  with  drugs,  relatively  ineffective  when  compared 
to  that  possible  by  careful  dieting. 

Diet 
Dieting  can  bring  about  caloric  deficits  twice 
as  large  as  those  possible  by  any  other  means; 
and  dieting  can  be  continued  for  as  long  as  neces- 
sary to  cure  the  obesity.  It  teaches  the  patients 
the  principles  of  wholesome  nutrition  so  that  when 
reduced  they  know  how  to  eat  properly.  It  often 
makes  control  of  appetite  after  reduction  easy 
so  that  relapses  are  less  likely  to  occur.  The  long 
period  of  control  of  gustatory  overindulgence  will 
in  most  patients  correct  abnormal  tastes  and  culti- 
vated habits  of  overeating.  When  this  bad  habit 
is  corrected  it  takes  less  food  to  satisfy,  so  that 
as  much  comfort  and  pleasure  results  from  whole- 
some kinds  and  quantities  of  food  as  was  afforded, 
when  obese,  only  by  an  excessive  caloric  intake. 
The  best,  indeed  the  only  practicable,  way  for  any 
patient  to  attain  a  caloric  deficit  effective  for 
the  cure  of  obesity  is  by  limitation  of  food  intake. 

IV 

The  creation  of  a  negative  energy  balance  for 
the  correction  of  obesity  has  been  accomplished  by 
several  dietary  regimens.  Folin  and  Denis  ' 
employed  repeated  periods  of  fasting  and  found 
this  method  moderately  effective  and  safe.  Harrop  " 
suggested  diets  limited  to  milk  and  bananas  ex- 
clusively, or  for  two  meals  a  day.  The  first  strict 
regimen  afforded  900  to  1000  calories  and  most 
essential  foodstuffs  in  nearly  adequate  amounts. 
The  second  permitted  a  more  general  but  carefully 
planned  meal  in  the  evening  with  somewhat  less 
severe  restriction  of  calories.  These  diets  resulted 
in  satisfactory  weight  losses  if  continued  long 
enough.  They  had  the  real  advantage  of  simplicity 


and  inexpensiveness.  There  was  little  or  no  dis- 
comfort from  hunger  because  of  the  hunger-satisfy- 
ing value  of  milk  and  bananas.  Gordon  and  Nissler" 
keeping  in  mind  a  theoretically  possible  hypogly- 
cemia with  restricted  food  intake,  devised  a 
dietary  regimen  called  "dextrose  moderately  low 
calory  intake."  The  meals  were  compiled  carefully 
and  the  calories  reduced  to  a  final  minimum  from 
day  to  day.  Dextrose  candy  was  given  at  the 
periods  of  greatest  hunger  and  presumably  of  low- 
est blood  sugar  levels.  Satisfactory  reductions 
resulted. 

General  diets  moderately  limited  in  caloric  con- 
tent have  been  widely  employed.  Usually  they 
afford  1200  to  1400  calories.  This  results  in  a 
moderate  caloric  deficit  leading  to  a  gradual  weight 
loss  of  one  to  two  pounds  a  week.  Such  a  slow 
weight  loss,  especially  in  those  who  are  much  over- 
weight, is  often  so  discouraging  that  patients  do  not 
persist.  Oddly  enough  there  is  usually  more  dis- 
comfort from  hunger  with  moderately  limited  diets 
than  with  those  more  severely  restricted. 

Evans  and  Strang  10  treated  a  number  of  obese 
patients  with  diets  supplying  all  the  known  essen- 
tial foodstuffs  by  preparations  and  edibles  of  the 
lowest  possible  energy  values.  The  menus  contained 
from  400  to  600  calories  permitting  large  daily 
caloric  deficits,  sometimes  of  2000  or  more.  This 
deficit  made  up  from  oxidation  of  the  stored  fat 
resulted  in  weight  losses  of  3  to  4  pounds  a  week. 
The  patients  regularly  displayed  an  increased  feel- 
ing of  well-being  and  less  fatigability.  This  indi- 
cated that  no  vital  tissues  were  being  wasted  and 
only  the  stored  fat  was  being  burned. 

Evidence  that  no  vital  tissues  were  being  wasted 
was  given  by  several  physiological  considerations. 
The  patients  remained  in  nitrogen  equilibrium 
throughout  the  period  of  treatment,  often  of 
months'  duration  ".  The  menus  affording  adequate 
protein  for  the  ideal  weight  often  supplied  but  5 
calories  per  kilogram  of  actual  weight.  The  index 
of  creatinin  excretion  remained  the  same  at  the 
beginning,  throughout  the  course  of  treatment,  and 
at  the  end,  and  was  normal  as  related  to  the  ideal 
weight.12  The  oxygen  exchange,  higher  in  the 
obese  than  in  people  of  normal  weight,  came  down 
proportionally,  except  for  minor  variations,  with 
the  weight  and  surface  area,  but  never  to  a  level 
below  that  normal  for  them  if  of  ideal  weight".  The 
basal  metabolic  rate  based  on  the  actual  surface 
area  when  obese,  when  partly  reduced,  and  when  a 
normal  weight  had  been  attained,  was  always 
normal.  This  was  in  sharp  contrast  to  the  depressed 
levels  of  oxygen  exchange  caused  by  starvation. 

The  supply  of  so  much  of  the  energy  needs 
from  stored  fat,  with  the  severely  limited  caloric 
intakes  of  Strang  and  Evans,  compelled  the  body 


OBESITY— Evans 


June.    1941 


to  utilize  metabolic  mixtures  of  high  ketogenic- 
antiketogenic  ratios.  There  was  ketonuria  fre- 
quently but  never  ketosis.  The  ketonuria,  often 
pronounced  at  the  beginning,  always  cleared  up 
during  the  first  few  weeks  of  dieting  as  it  did  with 
the  successive  periods  of  fasting  employed  by  Folin 
and  Denis '.  These  authors  suggested  that  the 
ability  of  the  body  to  burn  high-fat  mixtures 
increased  with  practice. 

Many  minor  annoyances  were  relieved.  With 
these  diets  so  strictly  limited  in  caloric  content, 
as  with  others  properly  planned  but  more  generous, 
elevated  blood  pressures  were  brought  down  with 
the  weight  loss  in  a  gratifying  percentage  of  cases. 
Cardiovascular  insufficiency  and  glycosuria  were 
improved  and  cleared  up  entirely  in  many  who 
dieted  until  a  near  normal  weight  was  attained. 
Few  contraindications  to  these  limited  diets  were 
recognized  by  Evans  and  Strang.  They  have  never 
been  employed  in  a  tuberculous  patient,  chiefly, 
perhaps,  because  no  tuberculous  patient  who  was 
appreciably  obese  has  been  encountered.  Should 
an  obese  person  acquire  tuberculosis  it  is  at  least 
possible  that  the  improvement  in  physiological 
function  resulting  from  a  carefully  balanced  food 
intake  leading  to  weight  reduction  would  be  bene- 
ficial. The  diets  were  not  employed  during  preg- 
nancy lest  some  as  yet  unknown  essential  food- 
stuff necessary  to  its  successful  completion  had 
inadvertently  been  omitted. 

Evans  and  Strang  encountered  no  misfortunes 
or  even  minor  mishaps.  When  an  adequate  supply 
of  essential  foodstuffs  is  given  no  added  calories 
are  necessary.* 

V 

Menus  supplying  all  known  essential  foodstuffs 
but  containing  no  more  than  600  calories  are  diffi- 
cult to  plan.  This  difficulty  becomes  an  impossi- 
bility if  an  effort  is  made  to  make  them  interesting. 
And  yet,  because  the  treatment  of  obesity  is  too 
prolonged  for  continuous  hospital  residence,  it  must 
be  carried  out  by  patients  supervising  their  own 
diets  at  home.  Under  these  circumstances  the  co- 
operation in  the  accurate  dieting  necessary  for 
results  is  not  easily  obtained.  The  nature  of  obesity 
and  the  principles  employed  in  its  treatment  should 
be  explained  to  the  patient.  It  must  be  emphasized 
that  the  excess  is  fat  tissue  only,  that  no  vital 
tissues  are  so  built  up.  The  idea  that  one 
or  several  endocrine  disorders  cause  obesity  should 
be  uprooted.  It  is  not  necessary  to  speculate  on 
the  suggested  possible  mechanisms  of  the 
breakdown  of  the  energy  intake-output  balancing 


•FOOTNOTE:  Sample  menus  from  all  systems  of  diet  men- 
tioned above,  suitable  for  almost  all  patients, 
appear  in  Diseases  of  Metabolism  \V.  B. 
Saunders    Co  ,    Philadelphia,     1941. 


function  occurring  in  endocrine  disorders  or  to  dis- 
cuss unproven  hypotheses  of  endocrine  activity  in 
relation  to  fat  deposition  or  distribution.  The 
patient  should  be  assured  that  however  low  his 
energy  expenditure  may  be,  and  from  whatever 
cause,  a  wholesome  menu  can  be  provided  which  will 
supply  no  excess  energy  units,  and  thereby  obesity 
can  be  avoided ;  and  that  however  great  his  appetite 
may  be,  if  he  limits  the  intake  to  the  daily  fuel 
and  replacement  requirement,  it  will  all  be  used 
for  those  purposes  and  none  can  be  laid  down  as 
fat.  He  must  be  made  to  recognize  that  all  obesity 
is  alimentary.  The  distention  of  the  skin  in  obesity 
is  not  pneumatic  or  spiritual;  it  is  caused  by  an 
increased  amount  of  tangible  material.  A  moment's 
thought  convinces  that  there  is  no  portal  other 
than  the  mouth  through  which  it  could  have  been 
introduced  under  the  skin.  All  this  excess  material 
has  been  swallowed. 

Patients  should  be  assured  that  any  negative 
energy  balance  they  maintain  will  be  translated 
with  mathematical  accuracy  into  oxidation  of  their 
stored  fat  with  a  corresponding  diminution  in  the 
amount  of  this  fat.  The  weight  loss  shown  by  the 
scales,  however,  is  not  regular,  due  to  the  varia- 
tion in  water  content  of  the  body  at  different  times. 
Patients  should  be  warned  of  this,  lest  a  period  of 
a  week  or  more  of  accurate  dieting  with  no  change 
in  the  scale  reading  lead  to  discouragement  and  in- 
terruption of  treatment.  These  plateaus  of  no 
weight  loss  and  periods  of  greater  loss  than  the 
caloric  deficit  justifies  have  been  suggested  as 
evidence  of  some  anomaly  of  metabolism.  The 
phenomenon  is  obviously  due  to  water  swings.  Irre- 
futable proof  of  this  has  been  afforded  by  the 
studies  of  Xewburgh  and  Johnston 1S. 

It  is  sometimes  wise  to  correct  the  impression  held 
by  so  many  vigorous  people  with  good  appetites 
that  hunger  is  a  sensation  to  be  avoided  and  satia- 
tion one  to  be  assiduously  sought  after.  Moderate 
hunger  is  wholesome  and  satiation  an  evidence  of 
over  indulgence.  The  pleasure  of  eating  is  sensual 
in  character,  and  if  employed  to  excess  may  be 
compared  to  the  abuse  of  alcohol.  Although  a 
proper  amount  of  food  is  necessary  and  right,  any 
amount  in  excess  may  properly  be  regarded  as 
immorality.  This  point  of  view  helps  many  pa- 
tients to  cooperate  in  dieting. 

The  difficulty  of  controlling  appetite  has  at 
times  been  exaggerated.  This,  perhaps,  would 
appear  from  the  suggestion  of  small  doses  of 
digitalis,  or  ipecac,  to  convert  the  zest  for  food  of 
those  with  healthy  appetites  into  indifference  or 
repugnance.  Many  persons  would,  no  doubt,  con- 
template with  dismay  the  idea  of  living  out  their 
lives  denied  of  the  positive  pleasure  of  eating  un- 
restrictedly   of    good    food,    rather    than   keeping 


June.   1941 


OBESITY— Evans 


311 


strictly  to  moderate  indulgence  in  this  delight. 

Evans  and  Strang  pointed  out  to  all  prospective 
patients  that  the  menus  did  not  attempt  to  pander 
to  sensuality  of  appetite.  For  success  a  patient 
must  be  willing  to  forego  temporarily  the  pleasures 
of  the  table.  Patients  who  are  unwilling  to  do  this 
cannot  be  treated  successfully,  and  the  majority  of 
those  who  accept  this  point  of  view  persevere  long 
enough  to  reduce  to  the  desired  weight. 

Patients  who  diet  with  a  correct  understanding 
of  the  subject  have  little  hunger,  certainly  no 
more  than  they  should  have  normally.  They  must, 
however,  be  taught  to  distinguish  between  hunger 
and  the  memory  of  the  joys  of  gluttony;  must 
follow  the  sage  advice  of  the  poet-philosopher — 

Make  less  thy  body  hence;  and  more  thy  grace: 
Leave  gormandizing. 

Conclusions 
Success  in  the  treatment  of  obesity  demands 
the  recognition  that:  it  is  always  alimentary;  it 
can  be  cured  by  no  means  other  than  accurate 
dieting;  and  the  necessary  accuracy  and  duration 
of  dieting  can  be  accomplished  only  by  those 
patients  who  are  willing  to  control  their  gustatory 
sensualism. 

Bibliography 

1.  Strang,  J.  M.,  McClugage,  H.  B.,  and  Brownlee, 
M.  A.  Metabolism  in  Undernutrition  Arch.  Int.  Med., 
June    193=!.   vol    55.   p.    958. 

2.  Strang.  J.  M.  and  McClugage,  H.  B.:  The  Specific 
Dynamic  Action  in  Adnormal  States  of  Nutrition, 
Am.  Jour.  Med.  Sc,  July.  1931,  vol.  182,  p.  49. 

3.  Wilder  R.  M.:  Diseases  of  Metabolism  and  Nutrition, 
Arch.  Int.  Med.,  Feb.   1938,  vol.   61,  p.   297. 

4.  Means,  J.  H.:  Basal  Metabolism  in  Obesity,  Arch. 
Int.  Med.,  1916,  vol.   17,  p.  704. 

5.  Strang,  J.  M.  and  Evans,  Frank  A.:  The  Energy  Ex- 
change in  Obesity,  Jour.  Clin.  Invest.,  Oct.  20,  1928, 
vol   VI.  p.   277. 

6.  Evans,  F.  A.  and  Strang,  J.  M.:  The  Treatment  of 
Obesity  with  Low  Caloric  Diets,  Jour.  A.  M.  A.,  Oct. 
10.   1931,   vol.   97,  p.   1063. 

7.  Folin,  O..  and  Denis,  W.:  On  Starvation  and  Obesity 
with  Special  Reference  to  Acidosis,  J.  Biol.  Chem., 
1915.   vol.   21,  p.    183. 

8.  Harrop,  G.  A.:  A  Milk  and  Banana  Diet  for  Treatment 
Obesity,  Jour.  A.  M.  A.,  vol.   102,  p.   2003. 

9.  Gordon,  B.,  and  Nissler,  C.  W.:  Dextrose  in  the 
Treatment  of  Obesity,  Med.  Clin,  of  N.  A.,  1929,  vol. 
12.  p.   1167. 

10.  Evans,  F.  A.  and  Strang,  J.  M.:  A  Departure  from  the 

Usual  Methods  in  Treating  Obesity,  Am.  Jour.  Med. 

Sc.  March    1929,  vol   177,  p.  339. 

Evans,  F.  A.:  Treatment  of  Obesity  with  Low  Calory 
Diets,    Report    of     121     Additional     Cases,    Internat'l 
Clin.,  1938,  vol.  Ill,  series  48,  p.  19. 
11.  Strang,  J.  M.,  McClucace,  H.  B.,  and  Evans,  F.  A. 

The  Nitrogen  Balance  During  Dietary  Correction  of 
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336. 


12.  McClucace,   H.    B.,   Booth,   G.,   and   Evans,    F.    A.: 
Creatinin  Excretion  in  Abnormal  States  of  Nutrition. 

Am.   Jour.   Med.  Sc,  March   1931,  vol.   181,  p.   349. 

13.  Newburgh,  L.  H.  and  Johnston,  M.  W.:  The  Nature 
of  Obesity,  Jour.  Clin.  Invest.,  1930,  vol.  8,  p.  197. 


MEDICAL  HISTORY  IN  NEWPORT 

(Editorial  in  R.  I.  Med.  JI.,  May) 

The  Pilgrim  Fathers  had  little  use  and  no  place  for  dis- 
senters from  their  ideas.  Episcopalian  Holmes  suffered 
thirty  stripes  rather  than  pay  a  fine  of  thirty  pounds; 
John  Clarke  was  put  in  gaol  and  paid  a  fine  of  twenty 
pounds;  Roger  Williams  was  banished  from  Plymouth 
Colony;  the  less  fortunate  Quakers  were  hanged  on  Boston 
Common.  In  the  spring  of  1636,  Williams  fled  into  the 
wilderness,  where,  joined  by  other  refugees,  he  attempted 
a  settlement  at  Rehoboth,  east  of  the  Seekonk  River.  But 
warned  from  this  site,  which  encroached  on  the  holdings 
of  Plymouth  Colony,  the  fugitives  crossed  the  river  to  the 
west  shore.  Williams  chose  the  place  which  he  named 
Providence  while  a  band  led  by  John  Clarke  journeyed 
southward  to  Aquidneck  Island  where  they  purchased  land 
from  the  Indians  and  founded  the  settlement  at  Newport. 

The  Puritans  enjoyed  freedom  in  Plymouth  Colony,  Bap- 
tists flourished  at  Providence;  but  Newport,  as  Cotton 
Mather  stated,  "was  occupied  by  Antimonians,  Anabaptists 
Quakers,  Ranters,  and  everything  else,  and  if  any  man  has 
lost  his  religion,  he  may  find  it  in  this  general  muster  of 
opinions."  When  Quakers  were  hanging  from  the  trees  on 
Boston  Common,  the  Governor  of  Rhode  Island  was  a 
Quaker. 

Until  1760  no  physician  settled  at  Providence;  but  the 
founder  of  Newport  had  a  medical  education,  had  signed 
his  name,  "John  Clarke,  Physician,  of  London,''  and  he 
practiced  medicine  in  Newport  and  on  Sundays  preached 
in  the  First  Baptist  Church.  For  a  hundred  years  John 
Clarke  was  followed  by  a  line  of  eminent  physicians.  The 
names  of  Hooper,  Halliburton,  John  Brett,  Isaac  Senter, 
Walter  Channing,  and  William  Hunter  are  notable  in  med- 
ical history.  Previous  to  1772,  Dr.  Jonathan  Easton  of 
Newport  was  practicing  inoculation  against  smallpox.  Dr. 
Benjamin  Waterhouse  brought  the  first  knowledge  of  vac- 
cination to  this  country  when  he  returned  from  England 
in  1800  and  first  proved  its  value  by  vaccinating  his  own 
children. 

Dr.  William  Hunter  came  to  Newport  in  1752  after 
completing  his  studies  at  the  University  of  Edinburgh 
under  the  celebrated  Munro,  Senior.  Dr.  Hunter  practiced 
at  Newport  twenty-four  years.  His  apothecary  shop,  his 
medical  library,  and  his  collection  of  surgical  instruments 
were  famous  in  their  time.  In  1755-1756,  Dr.  Hunter  gave 
lectures  on  anatomy  and  surgery  in  the  Senate  Chamber 
of  the  Old  Colony  House  at  Newport.  The  lectures  were 
advertised  in  the  Boston  Post  in  Januarv  and  February, 
1755. 

About  the  year  1730,  Dean  Berkeley  created  a  medical 
furor  at  Newport  by  his  advocacy  of  tar-water  as  a  cure 
for  most  diseases.  Reverend  George  Berkeley,  an  Irishman, 
educated  at  Oxford,  had  sailed  from  England  with  the  in- 
tent of  founding  a  school  for  the  benighted  savages  in 
Bermuda.  The  captain  of  his  ship  could  not  find  the  Is- 
land of  Bermuda  but  succeeded  in  discovering  a  land  un- 
known to  him  but  which  proved  to  be  in  the  vicinity  of 
Newport.  Here  for  some  years  Dean  Berkeley  preached  in 
Trinity  Church.  At  Middletown  he  built  a  fine  residence 
which  he  named  Whitehall  and  which  he  presented  to 
Yale  College.  In  1730  he  founded  the  Newport  Philosophi- 
cal Society,  which  sponsored  the  Redwood  Library,  oldest 
American  library  in  continuous  use.  On  his  return  to  Eng- 
land in  1732  he  was  made  Bishop  of  Cloyne.  In  1733  he 
sent   from   England  the  organ   which  is  in  Trinity   Church. 


SOl'THERX  MEDICINE  &  SURGERY 


June.    1941 


The  Potent  Drug  Iodine* 

J.  G.  Johnston,  M.  D.,  Charlotte 


IX  THESE  latter  davs  we  are  so  engrossed  in 
our  study  of  the  newer  things  and  drugs  that 
many  times  we  forget  those  that  are  older, 
some  of  which  are  as  valuable  as  some  of  the 
newer,  more  recent  drugs,  or  even  more  so.  So  lest 
we  forget,  I  desire  to  call  your  attention  for  a  few 
minutes  to  one  of  the  older  drugs  that  has  always 
held  a  great  fascination  for  me  and  has  given  me 
much  satisfaction  in  its  use  over  many  years.  That 
drug  is  Iodine. 

Iodine  is  a  peculiar,  non-metallic,  elementary 
solid  substance  with  atomic  weight  of  127.  It  ex- 
ists in  waters  of  the  ocean,  in  some  mineral  springs, 
in  some  marine  animals  and  in  seaweeds  from  the 
ashes  of  which  formerly  it  was  most  commonly 
produced.  It  exists  also  in  some  land  plants  and  in 
cod-liver  oil.  It  is  found  in  certain  minerals,  the 
water  of  certain  rivers,  and  in  the  water  supply  of 
several  towns.  The  soils  of  some  sections  have 
rather  large  quantities  of  iodine  while  others  are 
so  nearly  devoid  of  it  that  in  these  regions  goitre 
is  so  prevalent  that  the  regions  are  known  as  goitre 
belts. 

At  ordinary  atmospheric  temperature  iodine  is  a 
solid  crystalline  bodv  with  a  specific  gravity  of 
4.947  which  fuses  at  225  and  boils  at  347°  F. 
Under  the  influence  of  heat  it  gives  off  vapor  of  a 
rich  violet  color  which  is  remarkablv  dense,  having 
a  specific  gravity  of  8.782 — almost  twice  as  heavy 
as  the  solid  element.  Iodine  possesses  great  pow- 
ers of  combination  and  forms  iodides  with  pure 
metals  and  most  of  the  simple  non-metallic  ele- 
ments. It  is  sparingly  soluble  in  water  but  dis- 
solves easily  in  alcohol  and  ether,  forming  dark- 
brown  liquids.  The  characteristic  and  common 
test  for  iodine  is  that  with  starch  it  forms  a  com- 
pound of  a  deep  blue  color.  This  test  is  so  delicate 
that  it  is  said  that  a  solution  of  starch  dropped 
into  water  containing  less  than  a  millionth  part  of 
iodine  will  be  tinged  blue  by  it. 

While  iodine  is  largely  used  in  photography  and 
in  the  arts,  in  Medicine  it  is  employed  in  its  pure 
state,  but  much  more  frequently  in  the  form  of 
the  iodides,  especially  that  of  potassium,  which 
has  been  found  to  be  of  great  benefit  in  goitre, 
scofula,  diseases  of  the  liver  and  spleen,  in  syph- 
ilitic affections,  rheumatism  and  enlarged  glands 
as  well  as  in  lead  poisoning.  Potassium  iodide  is 
practically  a  specific  for  gummas  and  all  gumma- 
tous swellings.     Iodide  of  iron  is  also  valuable  in 


chlorosis  and  almost  all  of  the  anemias.  Iodine  is 
a  non-conductor  of  electricity  and  is  electronega- 
tive. About  thirty  years  ago  a  patient  who  was 
rather  obese  came  to  the  hospital  for  operation  but 
before  she  was  operated  on  her  chest  began  to  fill 
up  with  fluid.  In  spite  of  all  the  accepted  methods 
of  treatment  the  edema  became  worse  until  her 
lungs  were  almost  entirely  full.  As  a  last  resort, 
for  it  did  not  seem  possible  that  she  could  live 
twelve  hours,  iodine  was  driven  into  her  chest  with 
electricity  from  a  strong  galvanic  battery.  Next 
morning  she  was  better.  The  edema  continued  to 
subside.  She  went  home  in  a  few  days  to  recuper- 
ate, coming  back  in  a  few  months  for  her  opera- 
tion. 

I  am  sure  that  many  of  you  here  know  much 
more  of  the  effects  of  iodine  in  general  treatment 
than  I,  but  I  wish  to  call  your  attention  to  some 
things  in  other  lines  in  which  iodine  has  given  me 
excellent  results. 

Case    Reports 

A  white  man,  married.  36  years  old,  rate  clerk,  came  in 
saying  he  had  chronic  nasal  catarrh  and  had  had  it  for 
several  years.  His  breath  was  bad  and  examining  his 
nose  disclosed  each  nostril  almost  entirely  full  of  large 
green  scabs  which  obstructed  his  breathing  and  when 
cleaned  off  left  the  mucous  membrane  thickened,  with 
many  ulcerated  areas  over  it  which  bled  easily  and  rather 
copiously.  He  said  that  he  had  been  treated  by  various 
men  with  no  improvement  and  was  very  much  discour- 
aged over  his  condition.  He  put  it  squarely  up  to  me 
saying,  he  had  spent  a  good  deal  of  money  on  his  nose, 
that  if  you  can  help  it,  all  right,  however,  if  not,  he 
wanted  me  to  say  so,  and  "I  will  just  let  it  go."  My 
reply  was  something  like  this:  You  have  a  condition  that 
is  chronic  and  it  will  take  a  long  time  and  lots  of  patience 
on  your  part  as  well  as  mine  to  do  anything  with  it. 
Have  you  the  necessary  patience?  He  replied  that  if  I 
could  help  him,  he  would  stick  just  as  long  as  I  said. 

We  started  treatment  June  28th,  1939.  His  nose  was 
cleaned  out  thoroughly  with  peroxide,  dried  and  packed 
with  a  weak  solution  of  free  iodine  in  oil,  leaving  it  in 
the  nose  about  thirty  minutes  and  spraying  the  nostrils 
with  an  oily  spray  on  its  removal.  He  was  also  given 
some  of  the  iodine  solution  to  drop  in  his  nose  night  and 
morning.  At  first  he  came  almost  every  day  and  after 
three  months  twice  a  week.  September,  1940,  I  increased 
the  strength  of  the  iodine  solution,  but  in  a  short  while 
he  complained  that  the  stronger  solution  caused  so  much 
secretion  that  he  could  not  keep  the  cotton  plug  in  the 
nose  long  enough,  so  it  was  weakened  to  one-half  of  its 
original  strength.  Since  that  time  we  have  alternated  with 
this  weaker  solution  and  the  original  free  iodine  solution. 
Now  as  to  the  results:  I  cannot  say  that  he  is  cured — 
far  from  it,  but  his  nose  is  comfortable.  We  rarely  find 
one  of  the  green  scabs  now  and  when  we  do  it  is  small 
and  the  odor  has  gone.   The  scabs  we  find  now  are  small. 

linas    and    Virginia,    held    at    Greensboro,    February 


June,    1941 


IODINE— Johnston 


313 


soft  and  white,  coming  away  easily  with  no  bleeding. 
Some  days  I  do  not  find  any  scabs  and  then  generally  a 
simple  pack  is  used.  He  has  learned  to  blow  the  packs 
out  of  his  nose  when  they  have  stayed  long  enough,  so  he 
does  not  have  to  remain  in  the  office  so  long.  He  has 
been  subject  to  colds  during  both  summer  and  winter,  so 
last  fall  catarrhal  vaccine  were  started,  once  a  week,  and 
he  says  he  had  only  one  cold  this  winter  and  that  one  he 
attributes  to  dust  from  tearing  up  the  floor  of  the  office 
in  which  he  works.  It  has  taken  a  long  time  to  reach 
this  point,  but  he  is  happy  over  it  and  I  should  be,  although 
I  would  be  very  glad  to  know  how  I  could  accomplish 
the  same  results  in  less  time.  I  do  not  know  how  much 
longer  we  shall  have  to  keep  it  up,  but  I  intend  shortly 
to  limit  his  treatments  to  once  a  week,  and  if  we  even 
have  to  continue  his  treatments  indefinitely,  it  could  be 
much  worse. 

A  white,  single  woman  clerk,  consulted  me  February 
11th,  193S.  with  the  following  history:  Some  years  ago 
she  was  operated  on  for  some  sinus  condition  for  which 
an  intranasal  operation  had  been  done  and  for  the  past 
several  months  she  had  been  unable  to  breathe  through 
her  nose.  Examination  showed  both  nostrils  filled  with 
hyperplastic  material  having  somewhat  the  appearance  of 
polypoid  tissue,  but  more  solid  and  containing  much  less 
fluid  in  the  tissues.  Through  the  left  nostril  she  could 
occasionally  get  a  slight  amount  of  air,  but  the  right  was 
closed  absolutely.  She  was  miserable;  she  wanted  some- 
thing done  for  her  nose — anything  except  another  opera- 
tion. She  was  told  clearly  what  the  chances  were  for 
accomplishing  anything  by  non-surgical  methods  and  that 
it  would  be  a  long-drawn-out  procedure.  She  insisted, 
however,  and  we  began  packing  eacn  nostril  as  far  back 
as  we  could  with  cotton  saturated  with  a  weak  solution  of 
free  iodine  in  oil.  She  came  religiously  for  about  two 
months  on  an  average  of  three  times  a  week,  sometimes 
staying  as  long  as  two  hours  before  the  pack  was  removed. 
Usually  though,  it  was  removed  in  from  twenty  to  thirty 
minutes.  We  saw  no  encouraging  results  for  three  weeks 
when  we  began  to  notice  that  the  packs  went  farther  back 
into  the  nasal  cavity  than  at  first,  and  it  took  about  three 
months'  treatment  before  she  got  her  first  breath  of  air 
through  the  right  nostril.  From  then  on  we  made  con- 
tinuous, though  slow,  progress,  for  there  was  much  tissue 
to  be  absorbed. 

By  April  1st  she  began  to  come  twice  a  week  for  treat- 
ments with  an  extra  one  occasionally.  During  July,  1938, 
she  was  much  encouraged,  and  was  much  improved,  but 
continued  to  come  regularly  for  her  treatments.  October 
she  was  much  better  and  began  coming  only  once  a  week, 
usually  staying  about  two  hours  before  removing  the  pack. 
From  that  time  she  made  rapid  improvement  both  in  her 
ability  to  breathe  through  the  nose  and  also  in  its  prog- 
ress to  normality.  In  December,  1938,  she  began  coming 
only  twice  a  month  and  continued  to  improve  and  kept 
up  this  program  both  in  attendance  and  improvement 
until  dismissal. 

She  was  dismissed  April  25th,  1939,  with  a  nose  that 
functioned  perfectly.  Her  sense  of  smell  had  returned  and 
is  now  practically  as  good  as  ever.  I  have  not  seen  her  as 
a  patient  since  that  time,  but  see  her  occasionally  on  the 
street  and  she  says  that  she  has  had  no  trouble  with  her 
nose  whatever  since  that  time. 

De  Schweinitz,  in  his  Diseases  of  the  Eye,  speaks 
highly  of  iodine  in  the  treatment  of  scleritis  and 
sclerokeratoiritis.  particularly  in  those  that  may 
be  called  rheumatic  cases.  In  induration  of  the 
lacrimal  gland  iodine  is  one  of  our  most  valuable 
drugs.   Iodine  introduced  into  a  dermoid  cyst  after 


evacuating  the  contents  is  valuable  as  well  as  in 
the  lacrimal  sac  after  curetting.  He  thinks  that 
iodine  is  one  of  the  most  valuable  drugs  in  injuries 
of  the  sclera  as  a  disinfectant  before  suturing. 

Fuchs,  in  the  fifteenth  edition  of  his  book,  says 
that  iodine  is  a  valuable  drug  in  diseases  of  the 
lids  and  in  many  of  the  diseases  of  the  anterior 
part  of  the  eye.  He  uses  it  externally  and  also  in- 
ternally. Keratitis,  in  his  opinion,  is  a  very  intrac- 
table disease,  but  he  thinks  iodine  does  as  much 
or  probably  more  for  this  condition  than  any  other 
drug.  In  superficial  and  deep  scleritis  he  thinks 
well  of  both  iodine  and  potassium  iodide  in  their 
treatment. 

Iridocyclititis  and  its  sequelae  are  best  treated 
with  mercury  or  salvarsan,  followed  by  potassium 
iodide,  in  his  opinion.  Potassium  iodide  or  a 
course  of  inunctions  are  useful  in  choroiditis  for 
their  absorptive  action  and  may  be  valuable  in 
both  specific  and  nonspecific  cases.  Treatment  of 
optic  neuritis  must  of  course  be  directed  at  its 
underlying  cause,  and  in  all  cases  Fuchs  thinks  that 
absorptives,  as  mercury  and  potassium  iodide,  are 
always  indicated,  but  on  the  other  hand,  he  says 
that  acute  syphilitic  cases  of  optic  atrophy  should 
have  antiluetic  treatment,  while  in  late  syphilitic 
disease  he  avoids  mercury  and  uses  iodine  or 
strychnine  by  injection  or  galvanism.  Unfortu- 
nately all  of  these  usually  fail.  He  also  mentions 
potassium  iodide  in  the  treatment  of  early  catar- 
acts, but  that  is  also  generally  a  failure. 

There  are  new  developments  in  the  manner  in 
which  iodine  is  used  in  some  eye  cases  that  are,  to 
say  the  least,  interesting  and  sometimes  with  sur- 
prising results.  Some  of  these  have  been  known 
for  many  years,  but  under  stress  of  seemingly  more 
important  things  have  been  overlooked  and  for- 
gotten until  some  emergency,  accident,  or  stress  of 
some  kind  brings  it  back  into  memory  and  rescues 
it  from  oblivion.  In  some  of  my  cases  these  have 
been  responsible  for  their  resurrection.  I  will  take 
your  time  only  long  enough  to  report  three  cases: 
Case   Reports 

A  machinist,  thirty-six  years  old,  came  in  January  1st 
last,  with  the  history  of  having  gotten  a  piece  of  steel  in 
the  cornea  of  the  right  eye  on  December  16th.  He  said 
that  he  had  a  positive  blood  report  and  was  taking  injec- 
tions. Left  eye  normal,  with  vision  equal  to  20/15.  Right 
eye:  Cornea  hazy.  Pupil  dilated  with  ring  of  pigment  at 
former  attachment  of  pupillary  margin  to  anterior  capsule 
of  lens.  Many  fine  vitreous  opacities  with  one  large  dense 
opacity  about  opposite  entrance  of  foreign  body  in  cornea 
were  found.  Tension  normal,  but  eyeball  was  very  red 
and  tender  on  pressure.  No  distinct  view  could  be  had  of 
the  retinal  vessels,  but  their  location  could  be  surmised  by 
a  slightly  more  distinct  redness  in  their  locality.  Vision 
indistinctly  20/50.  One  c.c.  of  a  weak  solution  of  free 
iodine  was  injected  subconjunctival^  in  the  right  eye. 
Atropine  ointment  and  hot  applications  were  ordered  every 
three  to  four  hours.    Aspirin  for  relief  of  pain  if  necessary. 

January  2nd— Right  eye  feels  much  better.  Pain  re- 
lieved.    Can   see   disc    and   vessels   of   fundus   indistinctly. 


IODISE— Johnston 


June,   1941 


Atropine    ointment    continued.     Right    eye    vision    20/40. 
Left  eye  vision  20  15. 

January  4th — Right  eye  vision  20  30  plus.  One  c.c.  of 
a  weak  solution  of  free  iodine  was  injected  subconjunc- 
tivally.  Right  eye:  Ring  of  pigment  almost  entirely  ab- 
sorbed from  anterior  capsule,  only  one  spot,  lxl}<£  mm., 
and  one  pin-point  spot  remaining.  Ciliary  redness  gone, 
but  some  general  redness  of  eye  ball  remains.  Good  view 
of  fundus,  vitreous  opacities  very  much   diminished. 

January  6th — Almost  all  redness  gone  from  right  eye. 
No  pain.  One  small  spot  of  pigment  in  lens  capsule.  One 
c.c.  of  a  weak  solution  of  free  iodine  injected  subconjunc- 
tival^' and  atropine  in  eye. 

January  8th — Redness  gone.  No  pain.  One  small  spot 
of  pigment  on  the  capsule.  One  c.c.  of  a  weak  solution  of 
free  iodine  injected  subconjunctival^  and  atropine. 

January  10th — No  pain,  redness  gone.  Vision  in  right 
20  20.  Dismissed.  Has  been  working  since  and  has  had 
no  trouble. 

A  white  man,  40,  came  in  December  16th,  1940,  with 
history  of  having  been  struck  in  right  eye  four  days  be- 
fore. Eye  painful  when  touched  or  when  he  stoops  over. 
Pupil  normal  in  reaction.  Eye  red  with  deep  purplish  ap- 
pearance. Scleral  vessels  considerably  dilated.  Tension 
normal,  cornea  normal.  One  c.c.  of  a  weak  solution  free 
iodine  was  injected  subconjunctival^-  and  hot  packs  of 
epsom  salts  solution  were  ordered.  Right  eye  vision  20/ 
40.  Left  eye  vision  20  '30.  He  had  a  cold  and  was  given 
cod-liver  oil  with  creosote  and  guaiacol. 

December  19th— Tenderness  and  redness  of  eye  much 
improved.  Pain  was  entirely  gone  and  only  slight  redness 
in  upper  nasal  area.  One  c.c.  free  iodine  solution  again 
injected  subconjunctival^. 

December  23rd — Tenderness  and  redness  gone.  Right 
eye  vision  20/30.    Left  eye  vision  20  30.    Dismissed. 

White  matron,  25,  came  in  February  6th,  1937,  with 
history  of  everything  looking  hazy  for  the  past  two  weeks. 
Her  urine  was  negative.  Wassermann  negative,  hemoglobin 
50.  white  cells  6,000.  No  pain  or  headache.  Right  eye 
vision  20  30  plus.  Left  eye  vision  20  20.  Right  eye:  Tri- 
angular area  of  opaque  spots  in  central  part  of  posterior 
surface  of  the  cornea  with  base  of  triangle  at  the  lower 
part  of  the  cornea.  Could  make  out  no  opacities  of  the 
vitreus.  Left  eye:  Almost  whole  of  the  posterior  surface 
of  the  cornea  was  covered  with  the  same  kind  of  spots. 
In  addition  the  vitreus  was  filled  with  fine  dust-like  opa- 
cities. She  was  given  ten  drops  of  saturated  solution  of 
potassium  iodide  three  times  a  day  and  the  right  eye  was 
injected  subconjunctivally  with  one-half  c.c.  of  weak  free 
iodine  solution.  The  left  received  a  conjunctival  injection 
of  one-half  c.c.  of  colloidial  iodine. 

February  13th— In  both  eyes  Descemet's  membrane  had 
cleared  remarkably,  only  a  few  of  the  spots  being  seen 
on  the  posterior  surface  of  each  cornea.  Very  few  fine 
dust-like  opacities  of  the  vitreous  could  be  seen'  There  was 
more  reaction  in  the  left  eye  from  the  injection  of  colloidal 
iodine  than  in  the  right  which  was  injected  with  free 
iodine,  but  the  improvement  seemed  to  be  about  equal  in 
both  eyes.  Each  eye  was  again  injected  with  one-half  c.c 
weak  free  iodine  solution  subconjunctivally 

February   20th— Very   fine   pin   point   opacities   seen    on 

Descemet's  membrane  only  with  slit  lamp.  One-half  c.c 
free  iodine  solution  injected  subconjunctivally  below  in 
each  eye. 

February  27th— Eyes  entirely  clear.  Vision  with  correc- 
tion 20/20.  Dismissed  with  instruction  to  come  back  if 
she  had  trouble,  but  to  date  she  has  not  returned. 

Of  course  these  few  cases  are  insufficient  from 
which  to  draw  any  satisfactory  conclusion  as  to 


treatment.  However,  I  believe  the  results  in  these 
individual  cases  are  such  that  we  may  be  encour- 
aged to  further  investigate  and  study  the  effects  of 
iodine  in  these  and  other  conditions. 


HYPERTHYROIDISM  IN  ELDERLY  PATIENTS 

(D.  H.  Pner.  Atlanta,  in  Jl.  Med.  Assn.  Ala..  .May) 
Hyperthyroidism  in  its  subacute  and  less  dramatic  types 
may  be  difficult  to  recognize  at  any  age  of  life  but  partic- 
ularly in  elderly  patients.  In  the  hyperthyroidism  of  the 
elderly  the  cardiac  symptoms  frequently  so  predominate 
that  the  nature  of  the  trouble  is  not  suspected  at  once. 
Suspect  the  thyroid  in  every  cae  of  cardiac  disorder, 
particularly  in  the  latter  decades  of  life.  Stare,  moist 
palms,  slight  tremor,  or  the  quality  of  the  pulse,  may  cause 
suspicion.  Confirmation  with  basal  metabolic  studies  may 
clinch  the  diagnosis;  however,  in  some  patients  the  basal 
metabolic  rate  is  not  increased. 

Hyperthyroidism  after  middle  life  may  fail  to  show  any 
striking  cardiac  symptoms  and  present  only  the  picture  of 
extreme  exhaustion,  fatigue,  weakness  and  loss  of  weight. 
Iodine  is  to  be  administered  along  with  sedatives,  bed 
rest,  and  increased  diet,  and  subtotal  thyroidectomy  done 
in  one  or  two  stages.  There  was  in  80  patients,  one  death, 
this  due  to  secondary  hemorrhage.  Symptomatic  improve- 
ment was  obtained  in  all  cases.  Irradiation  was  used  for 
temporary  effect  while  the  patient  was  being  prepared  in 
three  cases  of  the  cardiac  group. 


THE  CURE  OF  COCCYGODYNIA 

(G    S.   King,   Bay   Shore,   N.   Y..   in   Ind.   .1/,-,/.,  Jan.) 

Pain  in  the  coccygeal  region  is  usually  constant  and  dis- 
tressing, so  that  car  riding  and  sitting  become  painful.  The 
pain  is  more  pronounced  by  pressure  even  so  slight  as  that 
resulting  from  the  weight  of  the  clothing. 

During  the  last  few  years  a  new  treatment  has  been  em- 
ployed which  has  given  satisfactory  relief  in  many  cases  of 
long  duration. 

With  the  patient  on  the  left  side  in  Sim's  position,  the 
outline  of  the  coccyx  is  carefully  noted  by  palpation ;  the 
area  directly  over  the  coccyx  and  its  tip  is  pa'.nted  with 
tincture  of  iodine.  With  one  finger  on  the  tip  of  the  coccyx 
above  the  anal  opening,  a  hypodermic  needle  fitted  to  a 
10-c.c.  syringe  filled  with  2%  novocaine  solution  is  insert- 
ed down  to  and  directly  on  to  the  bony  structure  of  the 
tip  and  3  c.c.  is  injected  into  the  tissue  around  and  anterior 
to  the  tip.  The  needle  is  partially  withdrawn  and  further 
injections  of  the  solution  are  made  over  the  dorsum  of  the 
coccyx  and  laterally  into  the  soft  tissue  on  either  side  up 
to  its  attachment  to  the  sacrum.  In  10  minutes  the  area 
is  nonsensitive.  Following  the  same  technic  10  c.c.  of  hy- 
pertonic saline  solution  are  then  introduced  into  the  same 
point  where  the  novocaine  solution  had  previously  been 
injected. 

There  is  seldom  any  reaction.  The  relief  from  the  coccy- 
codynia  is  immediate  and  usually  lasts  from  5  to  10  days. 
Usually  5  or  6  injections  at  weekly  periods  are  sufficient 
.o  give  permanent  relief. 


Sulfanilamide —  Patients  should  be  cautioned  pre- 
ferably to  stay  at  home  and  at  rest  while  taking  the 
drug  and  not  to  drive  an  automobile,  make  any  impor- 
tant decision  or  sign  any  papers  while  the  drug  is 
being  administered — Jl.  A.  M.  A. 


Digitalis  and  Atropine  in  combination  have  given 
good  results  in  a  series  of  several  thousand  cases  of  sea- 
sickness. 


June,    1941 


SOUTHERN  MEDICINE  &  SURGERY 


Progressive  Lipodystrophy — A  Case  Report 
And  Discussion  of  the  Problem    * 

George  R.  Wilkinson,  M.D.,  Greenville 


Introduction 

PROGRESSIVE  LIPODYSTROPHY  must 
be  classed  as  a  rare  disease.  Kraus1  in  the 
last  edition  of  Cecil's  Medicine  states  that 
only  some  fifty  cases  are  reported  in  the  literature, 
while  Serejski,2  quoting  Leschke,  places  the  num- 
ber of  typical  cases  on  record  at  seventy-two.  The 
pathogenesis  is  mooted.  Says  Brain:3  "Its  cause 
is  unknown,  though  endocrine  abnormalities,  dis- 
turbances of  autonomic  innervation  and  infections 
have  all  been  held  to  play  a  part  in  its  etiology. 
To  these  Pollak4  adds  fracture  of  the  base  of  the 
skull,  basal  meningitis  and  hydrocephalus.  Pro- 
gressive lipodystrophy,  the  term,  is  used  to  desig- 
nate a  disturbance  characterized  by  abnormality 
in  the  distribution  of  subcutaneous  fat;  it  occurs 
more  exclusively  in  women,  beginning  before 
puberty  with  disappearance  of  fat  in  the  face, 
neck,  arms  and  trunk;  after  puberty  with  progres- 
sive symmetrical  increase  in  the  subcutaneous  fat 
in  the  hips  above  the  genitalia  and  lower  extremi- 
ties. 

Case  Report 

History.  The  patient  is  a  54-year-old  white 
woman,  the  third  child  of  a  family  of  three  girls. 
Her  father,  when  30  vears  of  age  and  healthv,  was 
killed  in  a  railroad  accident.  The  mother  died 
mentally  deranged  at  30.  The  older  sister  died  of 
pellagra  and  gallbladder  disease  at  50.  The  young- 
er sister  survives,  is  healthv,  though  slightly  obese. 
In  the  mother's  family  there  were  seven  siblings, 
in  the  father's,  five;  all  reached  maturity.  None 
had  a  similar  disease.  One  first  cousin  has  goitre. 
Xo  other  endocrine  disorders  are  noted. 

The  patient  was  born  physiologically  at  full 
term.  Her  childhood  was  uneventful.  She  remem- 
bers being  slightly  obese  until  she  developed  ery- 
sipelas of  the  face  at  the  age  of  12.  The  erysipelas 
was  treated  with  a  lead  plaster.  During  her  con- 
valescence it  was  noticed  that  the  face,  arms,  neck 
and  trunk  began  to  get  thin.  For  a  year  she  was 
kept  out  of  school,  rested  and  overly  fed.  When 
I3y2  she  contracted  typhoid  fever,  recovering 
without  complications.  Menstruation  began  at  14. 
The  cycle  was  never  regular;  the  flow  lasted  three 
to  four  days  and  was  painful  and  scanty.  During 
her  14th  year  the  lower  extremities  began  to  en- 
large, the  enlargement  starting  just  above  the  an- 
kle on  the  right  leg.    Soon  a  similar  fat-like  mass 


appeared  on  the  other  side,  so  the  legs  looked  like 
mates  again.  At  14  she  re-entered  school.  She  did 
very  well  in  grammar  in  high  school  and  college. 
Graduating  from  college  she  taught  school  and 
married  at  the  age  of  26.  Her  first  and  only  preg- 
nancy was  interrupted  on  account  of  nephritis. 
Following  this  there  was  further  enlargement  of 
the  legs.  At  34  the  appendix  was  removed.  At 
operation  absence  of  the  fat  usually  seen  in  the 
omentum  was  noted.  At  51  she  married  a  second 
time.  Menstruation  ceased  at  52.  Following  the 
cessation  of  menstruation  the  fat  pads  around  the 
knees  became  larger.  She  now  presents  herself  for 
examination,  seeking  relief  on  account  of  the  dif- 
ficulty experienced  in  walking.  The  pads  just 
above  and  below  the  knee  compress  each  other 
when  she  stands  and  scrape  each  other  when  she 
walks  unless  she  walks  with  her  feet  far  apart. 


i 


ing   of   the   Tri-State    Medical   Association    of    the    Carolina 


PROGRESSIVE   LIPODYSTROPHY— Wilkinson 


June.   1941 


The  patient  is  happily  married  to  her  second 
husband.  She  lives  at  home,  keeps  house,  main- 
tains her  interest  in  the  adopted  children  she  has 
reared.  Her  insight  and  judgment  are  good.  De- 
spite her  physical  disabilities  she  maintains  a 
cheerful  outlook  and  has  not  permitted  her  physi- 
cal handicap  to  interfere  with  her  enjoyment  of 
life. 

Physical  Status:  Age  54,  height  61 1/2  inches, 
weight  l24l/2  pounds.  The  face,  neck,  arms  and 
upper  half  of  the  trunk  are  emaciated.  The  veins 
in  the  arms  are  prominent.  The  outlines  of  the 
underlying  muscles  are  visible.  The  cheeks  are 
particularly  hollow.  On  palpation  the  sucking  pads 
are  not  felt.  The  upper  part  of  the  body  is  sharply 
masculine  in  appearance.  There  is  some  little  fat 
over  the  lower  abdomen  and  genitalia.  Just  above 
the  knee  caps  are  large  pones  of  fat.  Large  pads 
are  seen  mesially  and  laterally  above  and  below 
the  knees.  The  pad  below  the  knees  appears  to  be 
one  solid  mass  extending  clear  across  the  front  of 
the  legs.  Below  these  pads  the  legs  are  rather 
large  to  the  ankles.  The  feet  are  relatively  thin 
and  small.  Quoting  Granzow:5  "In  the  lower  half 
of  the  body  a  Venus  of  an  exaggerated  Rubens 
type,  while  the  upper  part  of  the  body  and  the 
head  are  witch-like  in  appearance."  The  skin  is 
dry  and  rough  over  the  emaciated  portion  of  the 
body.  Over  the  lower  extremities  the  skin  is  soft, 
moist,  pink  and  elastic.  There  is  nothing  remark- 
able about  the  eyes,  ears,  nose  or  throat.  There 
is  no  general  glandular  enlargement.  The  breath- 
ing is  free  and  easy.  The  lungs  are  clear.  The 
arteries  are  just  palpable,  the  blood  pressure  not 
elevated.  There  is  a  well  healed  scar  in  the  lower 
right  abdomen.  The  kidneys,  spleen  and  liver  are 
neither  tender  nor  enlarged  on  palpation.  The 
genitalia  are  physiological.  Tendon,  plantar,  ab- 
dominal and  eye  reflexes  are  physiological  and 
Chvostek's  sign  is  negative. 

The  pilomotor  reflex  is  not  elicited  by  heat,  cold 
or  scratching  over  the  emaciated  area.  In  the 
lower  extremities  the  reaction  is  readily  obtained 
with  slight  stimulation.  The  application  of  a  hot 
test-tube  and  ice  produces  redness  which  is  slow 
to  appear  in  the  upper  extremities.  Heat  to  the 
lower  extremities  produces  redness  readily  which 
disappears  quickly.  An  ice  cube  against  the  skin 
blanches  the  skin  out  quickly  and  promptly  pro- 
duces goose-flesh  below.  Stroking  the  skin  with 
the  fingernail  produces  a  white  line  followed  by  a 
pink  flush  which  does  not  spread.  Same  scratch  to 
the  lower  extremities  produces  a  much  wider  white 
line  which  spreads  rapidly,  turns  pink  in  thirty 
seconds  and  produces  after  a  minute  a  wheal.  In 
a  room  temperature  of  74,  the  upper  extremities 
are  dry.    The  lower  extremities  are  quite  moist. 


Viewing  the  body  in  this  room  temperature  the 
upper  part  of  the  body  is  rather  pale  with  some 
acrocyanosis,  while  the  lower  part  of  the  abdomen 
and  legs  are  florid. 

Laboratory  Study:  Hemoglobin  88  per  cent; 
\Vassermann,  Kahn,  Kline  exclusion  test  negative: 
leukocytes  7,400 — pmns.  62,  small  lymphs.  36, 
monos.  2;  erythrocytes  4,500,000,  uniform  in 
shape  and  size;  numerous  platelets;  no  malarial 
parasites  found;  hematocrit  3.5  mm.;  sedimenta- 
tion 9  mm.  in  60  minutes;  blood  cholesterol  181 
mg.  per  cent;  serum  calcium  8.5  mg.  per  cent; 
blood  chloride  412  mg.  per  cent;  blood  sugar  105 
mg.,  non-protein  nitrogen  25  mg.,  per  cent.  Urine 
specific  gravity  1.011,  otherwise  negative. 

Roentgenographic  films  of  the  lower  extremities 
shows  marked  increase  in  soft  parts.  The  muscles 
are  clearly  seen  and  the  difference  in  density  be- 
tween the  muscles  and  fat  indicates  the  presence 
of  fat  deep  in  the  leg  between  the  muscles. 

Discussion  of  Pathogenesis 
Simmons  first  described  this  anomaly  in  1911. 
Considerable  speculation  has  arisen  as  to  its  prob- 
able etiology.  At  first  the  difficulty  was  classed  as 
of  endocrine  origin.  Pollak4  and  later  Serejski2 
pointed  out  the  possibility  of  the  condition  being 
due  to  difficulty  in  the  diencephalic  centers,  the 
idea  being  that  the  vegetative  center  probably  has 
some  latent  or  congenital  weakness  which  does  not 
manifest  itself  until  other  difficulties  arise — with 
the  menses,  with  gestation,  at  the  menopause,  be- 
cause of  trauma  or  infection.  Pollak  describes  a 
case  which  occurred  after  an  injury  sustained  when 
a  man  was  covered  with  stone  following  a  blasting 
mishap.  Serejski  presents  a  case  which  is  more 
classical  in  its  course.  His  case  in  many  respects 
is  quite  analogous  to  the  case  here  reported,  inso- 
far as  the  atrophy  appeared  before  puberty,  the 
hyperplasia  beginning  just  after  puberty  and  be- 
coming quiescent,  then  with  gestation  further  hy- 
perplasia took  place  as  in  Serejski's,  being  quies- 
cent for  many  years  and  then,  in  this  case,  begin- 
ning to  enlarge  after  the  menopause. 

Serejski  stresses  the  abnormal  response  of  the 
vegetative  nervous  system  to  pilocarpine,  adrenalin 
and  atropine.  In  the  case  here  reported  the  inves- 
tigation of  the  autonomic  nervous  system  shows  a 
deficient  pilomotor  reflex  over  the  emaciated  area 
with  a  marked  response  over  the  fatty  region. 

The  vasomotor  response  to  heat  over  the  ema- 
ciated area  was  slow  to  appear  and  lasted  longer — 
the  color  response  to  the  application  of  heat  being 
a  reddish  purple,  while  the  response  to  heat  over 
the  fatty  area  was  quick  and  pinkish  red  in  color. 
To  the  ice  cube  there  was  no  blanching  of  the  skin 
over  the  emaciated  area,  the  contact  point  grad- 


June.   1941 


PROGRESSIVE   LIPODYSTROPHY— Wilkinson 


317 


ually  turning  red.  Over  the  lower  limbs  the  skin 
blanched  promptly  with  the  cold  contact  and 
goose-flesh  appeared  below  which  did  not  occur 
over  the  emaciated  area.  Stroking  the  skin  with 
the  fingernail  produced  a  fine  white  line  which 
gradually  turned  pink,  then  failed  to  spread  ap- 
preciably. Stroking  the  skin  over  the  lower  ex- 
tremities, the  line  appears  white,  is  wider,  turns 
pink  quickly  and  a  wheal  is  formed.  These  differ- 
ences in  response  indicate  some  difficulty  with  the 
autonomic  nervous  system  and  tend  to  support 
the  contention  of  Pollak  and  Serejski. 

Summary 

1.  A  typical  case  of  progressive  lipodystrophy 
is  reported. 

2.  The  pathogenesis  of  this  disease  is  probably 
diencephalic  in  origin;  the  trigger  mechanism  en- 
docrine, traumatic  or  bacterial. 

Bibliography 

1.  Kraus:  Cecil's  Textbook  of  Medicine,  pp.  1167,  fifth 
edition. 

2.  Serejski,  M.:  The  Problem  of  Progressive  Lipodystro- 
phy.   Wien.  klin.  Woch.,  50:562,  April  30,  1938. 

3.  Brain,  R.:  Diseases  of  the  Nervous  System.  Oxford 
Medical  Publications,  pp.  719,  1933. 

4.  Pollak,  F.:  Clinical  Aspect  and  Pathogenesis  of  Pro- 
gressive Lipodystrophy.  Zt.  scltr.  f.  d.  gee.  Neurol.  U. 
Psychiat.,  127:415,  1930. 

5.  Granzow,  J.:  Lipodystrophia,  Progressiva.  Zentralbl. 
f.  gynak.,  58:870,  April  14,  1934. 

Discussion 

Dr.  Graham  Reid,  Charlotte:  I  have  enjoyed  Dr. 
Wilkinson's  presentation  and  we  are  indebted  to  him. 
Either  the  disease  is  rare  (there  are  approximately  80 
cases  reported)  or  it  is  rare  to  find  a  victim  of  such  lipo- 
dystrophy who  is  willing  to  be  photographed  as  proof  for 
the  report. 

The  exact  nature  of  the  mechanism  producing  such 
altered  storage  of  fat  is  open  to  speculation. 

Various  factors  as  you  have  heard  mentioned  have  been 
postulated  as  playing  major  roles.  The  hypothalamus  was 
first  recognized  as  a  factor  in  the  control  of  carbohydrate 
metabolism  in  1916  by  Ashner,  who  found  that  by  elec- 
tric stimulation  of  the  hypothalamic  area  glycosuria  could 
be  produced.  While  there  is  no  uniformity  of  opinion 
regarding  the  extent  or  mechanism  of  this  control,  its  ex- 
istence in  some  form  is  generally  accepted.  Hypothalamic 
obesity  has  been  frequently  reported.  Rony  reports  more 
than  50  cases  of  epidemic  encephalitis  observed  by  Gross- 
man gained  from  50  to  95  pounds  following  the  disease. 
However,  as  progressive  lipodystrophy  involves  not  only 
regional  obesity  but  regional  emaciation,  hypothalamic 
pathology  as  the  all-embracing  etiological  factor  would 
have  to  explain  the  emaciation  as  well  as  the  obesity. 
Clinical  evidence  in  favor  of  hypo'halamic  emaciation  is 
not  very  impressive,  and  thus  far  no  one  has  been  success- 
ful in  producing  emaciation  in  exncrimental  animals  by 
hypothalamic  injury.  Symmetrical  lipodystrophy  has  been 
attributed  by  some  to  disturbance  in  the  peripheral  auto- 
nomic nervous  system.  However,  Cannon  and  others  have 
removed  the  whole  sympathetic  nerve  supply  of  one  side 
of  the  body  in  kittens  and  allowed  the  animals  to  live 
until  they  doubled  their  weight.    N'o  difference  was  found 


in  the  amount  or  distribution  of  fat  on  the  two  halves  of 
the  body.  It  is  difficult  to  reconcile  this  result  with  the 
idea  of  specific  peripheral  autonomic  control  of  fat  distri- 
bution. 

It  is  well  known  that  fat  has  an  affinity  for  different 
subcutaneous  regions  of  the  body,  that  regional  obesity  is 
likely  to  occur  in  many  members  of  a  family,  and  wide 
variations  may  be  considered  normal.  Certain  races  have 
a  predisposition  to  obesity  and  to  regional  collections  of 
fat.  Anthropologists  generally  agree  that  the  Dutch,  the 
South  Italians  and  the  Jews  have  a  racial  tendency  to 
characteristic  regional  fat  accumulation.  There  is  a  tribe 
in  Africa  in  which  tremendous  accumulation  of  fat  in  the 
lower  segment  of  the  body  is  a  tribal  characteristic.  While 
writers  on  the  subject  can  come  to  no  unanimity  of  opin- 
ion as  to  the  specific  nervous-system  lesion  or  endocrine 
disturbance  producing  lipodystrophy,  most  authors  agree 
that  the  essential  element  in  the  origin  of  this  disease  and 
other  Iipophilia  is  a  congenital  tissue  predisposition,  with 
glandular  or  nervous-system  disturbances  as  provocative 
factors.  Davenport,  in  studying  the  family  tree  of  region- 
ally obese  patients,  found  that  parents  and  offspring  exhib- 
ited the  same  type  of  obesity  in  a  surprisingly  high  per- 
centage of  cases,  and  worked  out  an  elaborate  scheme 
showing  that  the  inheritance  of  regional  obesity  follows  a 
mendelian  pattern. 

It  is  a  distinct  possibility  that  progressive  lipodystrophy 
characterized  by  affinity  of  fat  to  the  lower  body  seg- 
ments in  women  is  but  an  extreme  case  of  genetically  de- 
termined Iipophilia. 


TRANSURETHRAL    REMOVAL    OF    LARGE 
PROSTATIC    CALCULI. 

(J.  L    Emmett,   Rochester,   in  Proc.   Stiff  Meetings  Mayo   Clinic, 
May   7) 

The  majority  of  prostatic  calculi  do  not  cause  symp- 
toms and  the  patient  is  never  aware  of  their  presence. 
Such  calculi  are  of  no  importance  clinically.  The  most 
common  symptoms  arise  because  of  infection  or  obstruc- 
tion of  the  vesical  neck,  or  both,  frequency  and  urgency 
of  urination,  inadequate  stream,  burning  and  pain,  hema- 
turia and  partial  and  complete  retention.  In  2  cases 
prostatic  calculi  caused  chills  and  fever,  though  no  local 
symptoms. 

The  type  of  operation  to  be  employed  depends  on  the 
experience  and  proficiency  of  the  surgeon  in  the  various 
types  of  operations.  It  would  seem  desirable  to  employ 
a  measure  insuring  complete  removal  of  calculi,  how- 
ever, one  must  not  advise  too  extensive  a  procedure  frr 
minor  pathologic  conditions.  My  experience  is  against 
complete  removal  of  the  prostate  and  capsule  for  pros- 
tatic calculi.  More  conservative  operations  achieve  en- 
tirely satisfactory  results,  remove  all  the  calculi  in  most 
cases,  and  most  of  the  calculi  in  the  rest.  I  have  seldom 
found  it  necessary  to  repeat  an  operation  because  cf  a 
few  small   calculi   which   remain   in   the   prostatic   capsule. 

Contrary  to  the  opinion  generally  held,  very  few  pros- 
tatic calculi  are  too  large  to  be  removed  or  crushed  tran- 
surethrally.  Stones  too  large  to  be  removed  through 
the  cystoscope  can  be  maneuvered  into  the  bladder  to  be 
crushed  by  means  of  a  lithotrite.  In  cases  in  which 
very  extensive  calculous  replacempnt  of  the  prostate  gland 
has  occured  a  few  calculi  may  be  left  after  transurethral 
operation ;  usually  the  stones  in  question  remain  because 
it  is  impossible  to  palpate  the  few  remaining  calculi 
against  the  cystoscope  with  the  finger  in  the  rectum  or 
because  some  small  calculi  are  embedded  in  the  prostatic 
capsule  too  near  the  rectum  to  allow  of  safe  removal. 
In  most  such  cases  the  few  remaining  calculi  will  giv 
the  patient  no  trouble. 


SOUTHERN  MEDICINE  &  SURGERY 


June.    1941 


Gunshot  Wounds  of  the  Pregnant  Uterus* 
T.  C.  Bost,  M.D.,  F.  A.C.S.,  Charlotte 


IT  SEEMS  STRANGE  that  gunshot  wounds 
of  the  pregnant  uterus  are  so  rare  as  to  offer 
a  kind  of  medical  curiosity.  Especially  is  this 
true  when  we  consider  the  important  place  of  fire- 
arms in  the  social  affairs  of  the  Negro  race  and 
the  great  number  of  other  gunshot  wounds,  inten- 
tional and  accidental,  among  this  people.  Since 
during  her  period  of  possible  childbearing  the  aver- 
age Negro  woman  is  pregnant  about  half  the  time, 
and  since  Negroes  live  crowded  together  in  small 
houses,  and  since  there  is  hardly  a  gathering  of 
them  without  a  woman  advanced  in  pregnancy  be- 
ing present,  it  would  be  expected  that  the  large 
target  afforded  would  be  oftener  struck.  And  to 
this  chance  must  be  added  that  of  accidental  gun- 
shot wounds  and  attempts  at  suicide  in  other  races. 

In  a  review  of  the  literature  I  find  mentioned 
eleven  cases  occurring  previous  to  1910,  but  since 
I  can  find  no  available  information  concerning  the 
extent  and  outcome  of  these  cases  I  am  unable  to 
include  these  in  my  report.  For  the  30  years, 
since  1910,  I  find  only  nine  reported  cases,  not  in- 
cluding the  one  I  am  here  reporting,  which  brings 
the  total  to  ten  cases  in  30  years.  Four  of  these 
cases  occurred  in  this  country,  the  other  six  in  a 
number  of  foreign  countries.  No  mention  is  made 
of  a  case  in  the  Negro  race. 

Because  of  the  small  number  of  reported  cases 
it  is  impossible  to  draw  general  conclusions.  It 
would  seem  that  each  case  must  be  decided  on  its 
own  merits. 

These  injuries  are  of  great  interest  to  both  those 
doing  obstetrics  and  those  doing  surgery.  They 
differ  from  the  usual  gunshot  wounds  in  that  two 
lives  instead  of  one  are  at  stake;  and  it  is  the 
general  opinion  that  in  any  kind  of  disease  or 
trauma  and  shock  the  patient's  condition  is  made 
more  hazardous  by  the  state  of  pregnancy. 

If  a  lesson  may  be  drawn  from  the  cases  of 
which  we  have  record,  the  reverse  appears  to  be 
true,  pregnancy  apparently  offering  a  kind  of  pro- 
tective influence,  so  that  the  mortality  appears  to 
be  much  less  than  the  general  mortality  in  gun- 
shot wounds  of  the  abdomen. 

The  indications  for  opening  the  abdomen  would 
appear  to  be  the  same  as  though  the  pregnancy  did 
not  exist.  The  probability  of  other  viscera  being 
injured  is  such  that  operation  for  exploration  can 
scarcely  be  avoided,  whatever  may  be  the  indica- 
tion as  to  the  effect  on  the  womb  and  its  fruit. 
By  the  same  token  the  severity  of  the  injury  is 
determined  chiefly  by  three  factors:    (1)    the  de- 


gree of  visceral  damage;  (2)  the  amount  of  hem- 
orrhage; (3)  the  time  elapsing  from  the  time  of 
injury  to  the  completion  of  the  surgical  repair. 

When  exploring  the  abdomen  and  no  serious 
injury  is  found  to  any  viscus  in  addition  to  the 
uterus,  there  is  room,  perhaps,  for  a  difference  of 
opinion  as  to  subsequent  treatment.  The  general 
opinion  is  that  the  uterus  should  be  emptied  if  the 
uterine  cavity  has  been  penetrated.  The  first  ques- 
tion then  to  decide  is  whether  to  empty  the  uterus 
by  cesarean  section;  or  to  suture  the  wound  or 
wounds  in  the  uterus,  close  the  abdominal  wound 
and  await  the  expulsion  of  the  fetus.  Fowler  ad- 
vised a  cesarean  section  if  the  fetus  is  alive  and 
so  far  along  as  to  probablv  survive.  Otherwise  he 
advises  emptying  the  uterus  from  below  unless 
there  is  already  a  large  opening  in  the  uterus 
through  which  the  organ  could  be  easily  emptied 
and  then  repaired.  The  general  opinion  would 
seem  to  be  that  the  uterus  should  be  emptied  bv 
cesarean  section  at  the  time  of  exploration,  at 
almost  anv  stage  of  pregnancy;  and  most  of  the 
cases  have  been  treated  this  way.  In  six  of  the 
ten  reported  cases  including  my  own — all  these  in 
the  various  stages  of  pregnancy — cesarean 
section  was  done;  in  two  cases  hysterectomy  was 
done  "to  arrest  pelvic  hemorrhage;"  in  one  case 
operated  on,  the  bullet  was  removed  from  the  fun- 
dus of  the  uterus  and  the  child  delivered  normally 
17  days  later;  one  case  was  not  operated  on  and 
labor  came  on  and  a  living  child  was  delivered 
normally  three  days  later. 

Case  Reports: 

Housewife,  aged  20,  with  two  children.  She  has  never 
had  a  serious  illness  and  her  health  has  been  generally 
good.  Menstruation  always  normal,  last  period  September. 
1938.  Since  cessation  much  nausea  and  vomiting  and  slight 
vaginal  bleeding,  but  has  had  no  treatment  for  this.  She 
did  not  want  another  child  or  to  endure  this  pregnancy. 
She  shot  herself  in  the  abdomen  with  a  .22  rifle  February 
19th,  1939,  and  was  admitted  to  Mercy  Hospital  an  hour 
later  in  mild  shock  complaining  of  pain  in  epigastrium 
and  right  side,  also  slight  nausea.  Pulse  was  100,  temper- 
ature 98°,   respiration   24. 

Patient  was  well  developed,  pregnancy  appeared  to  be 
of  five  months'  duration.  There  was  a  bullet  wound  with 
powder  burns  just  below  the  right  costal  margin,  and 
moderate  rigidity  and  tenderness  in  the  epigastrium  and 
over  the  right  side.  No  tenderness  or  rigidity  of  left  side. 
No  vaginal  bleeding. 

Preparation  was  made  for  immediate  operation.  While 
this  was  being  done  a  flat  x-ray  picture  (Fig.  1)  was 
nade  by  Dr.  Robert  H.  Lafferty.  on  which  he  reported: 
The  bullet  entered  just  below  the  right  costal  margin, 
course  downward,  is  buried  in  the  pubis.  In  the  passage 
the  distribution  of  lead  fragments  leads  us  to  think  that 
it   touched  the  cranium  of  the  fetus. 


eeting   of   the    Tri-State    Medical    Association    of    the    Carolinas    and    Vi 


held    at    Greensbor 


TABLE  1 
TEX  CASES.  GUNSHOT  WOUND    OF  THE  PREGNANT  UTERUS 


Term  of 
Pregnancy 


Symplon 


Extent  of  Injur 


Uterine  contrac-  Lover  pressed  revolver  .32 
tion,  very  little  against  right  side  of  abdo- 
shock.  3  hours  men.  Bullet  passed 
after  injury.  No  through  uterus.  No  other 
vaginal  bleeding,  visceral  injury.  Exit  left 
side  of  abdomen. 


Cesarean 
section. 


Fet  us 
Result 


Mother 
Outcome. 


3  fingers  of 

right  hand.      Recovered 

Recovered. 


Fudge 

8  to  9 

Moderate 

1912 

Mos. 

amount  of 

Elmira, 

shock.  Consider- 

N. Y. 

able  hem- 
orrhage from 
wound.   No    va- 
ginal   bleeding. 

Tucker 

9  Mos. 

12   hours   after 

1912 

injury.    Patient 

Shanghai. 

in    marked 

China 

shock  and 
weak  from 
great  loss  of 
blood. 

Belcher 

? 

3  days  after  in 

1917 

Far  ad- 

jury   comforta- 

Northern 

vanced 

ble   until   labor 

France 

came  on. 

Saint 

6  Mos. 

Very   little 

Goehlinger 

shock.    Moder- 

and Poier 
1920 
Paris. 
France 

ate  tenderness 
and   rigidity. 
Vaginal  bleed- 
ing. 

Stiglbauer 

1924 

Wien. 

? 

6  hours  after 
injury.  Acute 
abdominal 

Austria 

symptoms. 

Attempted  suicide  rifle  .32.      Child  removed         Through  Recovered 


Entrance  right  flank.  Exit 
1   inch   left   umbilicus. 
Uterus   incised   by   bullet. 
Child  expelled  from  uterus 
into   abdomen. 


Shot  by  robber.  Bullet 
entrance  3  inches  above 
and  to  left  umbilicus.  No 
exit.  Entered  at  fundus  of 
uterus.  No  other  visceral 
injury. 


Revolver   bullet.   Entrance 
in  perineum  near  anus, 
ranged  upward   and  lodg- 
ed in  uterus. 

Shell  gutter  wound  an- 
terior abdominal  wall  and 
gutter  wound  of  uterus. 
No    other   visceral    injury. 


Browning  pistol  7.65  mm. 
Entrance  left  gluteal  re- 
gion and  lodged  in  uterus. 
3  perforations  small  intes- 
tine 1  sigmoid.  Pelvic 
hemorrhage. 


from    peritoneal     pelvis  and 
cavity.    Wound       spine.   Dead, 
closed    through 
which  child 
was  expelled. 


Cesarean  sec- 
tion.   (No   men- 
tion of  trans- 
fusion.) 


No  operation. 
Labor    came    on 
and   delivered   3 
days  later. 

Cesarean  sec- 
tion.  Repair  of 
uterus   and 
anterior   ab- 
dominal  wall. 


Suturing  per- 
forations and 
hysterectomy 
to  control  pel- 
vic   hemorrhage. 


Bullet 
lodged  in 
back. 
Recovered. 


Bullet   in 

head. 

Born    dead. 


Had   sudden 
collapse    on 
third  day. 
Thought    to 
be  hemor- 
rhage.  Died. 


Recovered 


Back    injury.  Recovered 

Lived  15 

hours. 


Placint- 

Last 

Uterine    cramps 

iamu  and 

Month 

no  symptoms  of 

Turcanu 

peritoneal    reac- 

1928 

tion  at  first. 

Bucharest, 

Fourth  day 

Rumania 

pain  in  left 
side. 

Bullet  wound.  Entrance 
to  right  of  umbilicus  and 
lodged  in  fundus  of  uter- 
us. No  other  visceral  in- 
jury. 


Bullet    removed 
from  fundus 
uterus.   Child 
delivered    nor- 
mally  17  days 
later. 


Injury  to 
left   leg. 
Recovered. 


Recovered 


Moderate   shock  Bullet     wound.     Entrance  Cesarean  sec- 

with    symptoms  mid-epigastrium.  tion.  Perfora- 

of  peritonitis  11  Through  fundus  of  uterus,  tions  closed. 

hours  after  Two  perforations  of  lower 


injury. 


ileum. 


Injury  to 
child's   arm. 
Recovered. 


Recovered 


Belknap 

1939 

Damaris- 

cotta. 

Maine 

Bost 
1940 

Charlotte, 
N.  C. 


\Tos 


After  several 
hours.  Mild 
symptoms  of 
shock. 


Pain   in   epigas- 
trium,   moderate 
tenderness   and 
rigidity.    Mod- 
erate shock. 
Leucocytes 
18,000,   urine 
clear. 


Attempted  suicide  rifle  .22. 
Entrance  to  left  of  umbil- 
icus. Through  uterus  and 
lodged  in  pelvis.  Pelvic 
hemorrhage 

Attempted  suicide  rifle  .22. 
Entrance  right  costal  mar- 
gin, ranging  downward 
and  lodged  in  pubes.  2 
holes  in  ileum  passed 
through  uterus  and  2 
holes  in  bladder. 


Hysterectomy 
to  control  pel- 
vic   hemorrhage 


Cesarean   sec- 
tion. Closing 
holes   in   ileum 
and  bladder. 
Indwelling 
catheter. 


Wound   of 

chest. 

Dead. 


No   injury. 
Lived  1  hr 

Premature. 


Recovered 


320 


GUNSHOT   WOUNDS   OF   THE  PREGNANT   UTERUS— Bost 


June,    1941 


A  catheter  specimen  of  urine  was  clear,  w.b.c.  18,000, 
r.b.c.  3,500,000,  hemoglobin  65  per  cent. 

Operation:  Ether  was  administered  by  the  referring 
physician.  Dr.  Van  Matthews.  A  midline  incision  to  the 
right  and  below  the  umbilicus  was  made  since  it  was 
apparent  that  the  injury  was  in  the  lower  abdomen,  al- 
though the  entrance  wound  was  rather  high.  There  were 
several  ounces  of  blood  in  the  abdominal  cavity.  Two 
holes  were  found  in  the  uterus,  one  in  the  fundus  and  the 
other  in  the  lower  segment  anteriorly.  Cesarean  section 
was  done  by  incising  the  area  between  the  two  uterine 
wounds,  which  were  about  five  inches  apart.  Removing 
the  few  blood  clots  and  some  free  blood,  the  fetus  and 
membranes  were  found  to  be  intact.  The  uterus  was 
emptied  and  sutured.  Search  disclosed  two  perforations  In 
the  lower  ileum  two  feet  from  the  ileocecal  valve,  which 
were  closed  with  00  chromic  catgut ;  and  two  in  the  dome 
of  the  bladder,  which  were  closed  and  a  drain  put  in  this 
area.  A  self-retaining  catheter  was  put  in  the  bladder. 
Recovery  was  uneventful  and  the  patient  was  dismissed 
from  the  hospital  on  the  fourteenth  day.  The  fetus  was 
not  injured  by  the  bullet  but,  being  about  five  months 
premature,  it  lived  only  about  one  hour. 

Further  pertinent  information. — This  patient  again  be- 
came pregnant  and  an  elective  cesarean  section  and  sterili- 
zation were  done  by  Dr.  Van  Matthews,  May  14th,  1940, 
thirteen  months  after  the  injury.  Both  mother  and  child 
made  a  good  recovery  and  are  now  in  good  health. 

Summary 

Of  the  prospective  mothers  whose  cases  are  re- 
ported (Table  1),  three,  including  my  own,  at- 
tempted suicide  with  rifles.  They  all  recovered. 
One  woman  was  shot  by  her  lover;  two  were  vic- 
tims of  war  wounds — one  from  a  shell  fragment 
and  the  other  from  a  pistol  ball;  one  was  shot  by  a 
burglar.  In  the  other  four  cases  the  manner  of  in- 
jury was  not  stated. 

In  seven  cases  there  was  no  visceral  injury  other 
than  that  to  the  uterus.  In  these  cases  perhaps  the 
force  of  the  missiles  was  so  used  up  in  the  preg- 
nant uterus  and  its  fruit  as  to  prevent  disastrous 
results  to  other  viscera.    Also  in  these  seven  cases 


the  enlarged  uterus  apparently  offered  further  pro- 
tection in  filling  the  lower  abdomen  and  forcing 
the  intestines  out  of  range  of  the  missile.  In  three 
cases  there  were  intestinal  perforations;  in  my  own 
case,  bladder  perforations  in  addition.  This  was 
the  only  bladder  injury  in  the  series. 

Nine  mothers  recovered  and  one  died,  a  mortal- 
ity of  10  per  cent.  Although  this  series  of  cases  is 
small,  yet  it  tends  to  show  a  remarkable  contrast 
to  the  general  mortality  of  gunshot  wounds  of  the 
abdomen — 30  to  70  per  cent  or  even  higher. 

Of  the  six  viable  children  four  recovered  and 
two  died,  a  mortality  of  33  per  cent. 

The  case  here  reported,  together  with  the  other 
reported  cases,  would  tend  to  show  that  pregnant 
women  can  tolerate  violent  trauma,  and  that  the 
pregnant  uterus  itself  is  very  resistant  to  both 
trauma  and  infection,  as  no  mention  was  made  of 
puerperal  sepsis  in  any  of  these  cases. 

This  case  also  illustrates  the  importance  of  a 
flat  x-ray  picture  when  there  is  no  exit  wound,  to 
determine  the  course  of  the  bullet  and  the  possible 
injury,  so  that  the  proper  incision  can  be  predeter- 
mined. Also,  that  a  negative  urinalysis  report  does 
not  rule  out  bladder  injury. 

References 

1.  Fowler,  R.  S.:  New  York  State  Jour,  o)  Med.,  11:525- 
527,  Nov.,   1911. 

2.  Fudge,  H.  W.:  Gunshot  wound  of  the  pregnant  uterus. 
Jour.  A.  M.  A.,  1912,  lviii,  779. 

3.  Tucker,  A.  W.:  A  case  of  gunshot  wound  of  the  preg- 
nant uterus.   Jour.  A.  M.  A.,  1912,  lviii,  1685. 

4.  Belcher,  C:  Bullet  wound  in  pregnant  uterus;  recov- 
ery.   Brit.  M.  J.,  1917,  1,  896. 

5.  Salnt  et  al:  Regarding  a  cesarean  due  to  a  burstine 
shell.  Progres  medicate,  Paris,  31:196.  Oct.  16.  1920. 

6.  Stiglbauer,  R.:  Schussverletzung  des  uterus.  Wien  klin. 
Wchnschr.,  1924.  xxxvii,  69. 

7.  Placintianu,  Gh.,  Turcanu,  Gr.:  A  case  of  a  gunshot 
wound  of  the  uterus  during  the  last  stage  of  pregnancy. 
Spitalul.  Bucuresti,  1928.  xlviii,  224-225. 

S.  Motta,  M..  and  Veanna,  G.:  Feremento  por  bala  em 
utero  gravido.  Rev.  de  gynec.  e  d'obstet.,  Rio  de  Jan. 
1929,  xxiii,  319-322. 

°.  Belknap,  R.  W.:  Gunshot  wound  of  'he  pregnant  uter- 
us; report  of  a  case.   J.  Maine  M.  Assn.,  1939,  30:13. 

Discussion 

Dr.  Charles  Stanley  White,  Washington:  Mr.  Chair- 
man: Dr.  Bost  is  to  be  congratulated  on  the  handling  of 
this  case.  It  is  a  very  rare  case  indeed.  Remembering 
what  Dr.  Barker  said  last  night  about  reduced  birth  rate 
and  increased  use  of  contraceptive  methods,  it  will  prob- 
ably be  a  long  time  before  we  have  another  case.  I  don't 
see  how  anyone  can  formulate  and  plans  to  treat  such  a 
case.  I  never  had  a  case  of  the  kind  and  therefore  I  am 
not  qualified  to  discuss  it.  I  think  it  would  be  useless  to 
draw  up  a  plan  for  treating  these  cases.  Each  case  is 
treated  as  a  separate  entity. 

We  Washington  doctors  are  having  lawyer  trouble. 
What  would  be  the  charge  against  the  mother  of  the  child 
killed — whether  she  shot  the  child  or  whether  someone  else 
shot  it.    What   would  be  the  legal  involvement? 

Dr.  Deryl  Hart,  Duke  University  School  of  Medicine: 


June.    1941 


GVXSHOT   1V0CXDS  OF   THE  PREGNANT   UTERUS- 


521 


Mr.  Chairman  and  Members:  I  have  no  particular  discus- 
sion to  make  of  this,  having  never  had  a  case  or  seen  a 
case.  The  nearest  approach  toward  a  contribution  would 
be  a  somewhat  similar  case  where  a  young  man  suspected 
his  sister  of  promiscuity  and  in  taking  his  punishment  out 
on  her,  shot  her  in  the  vagina.  How  he  took  aim  I  do  not 
know.  I  do  not  know  what  the  sequelae  were.  The  onlv 
way  I  could  treat  a  gunshot  wound  of  the  abdomen  if  it 
came  to  me  would  be  to  take  care  of  it  as  Dr.  Bost  did 
and  by  emptying  the  uterus  if  it  were  damaged.  I  should 
think  the  greatest  factor  in  increasing  the  chances  for  re- 
covery there  would  be  a  fair  probability  in  certain  cases  of 
the  intestines  and  the  bladder  being  missed  entirely. 

I  have  nothing  to  contribute  to  this  very  interesting 
case.  I  want  to  congratulate  Dr.  Bost  and  thank  him  for 
presenting  it.    I  have  enjoyed  it  very  much.    (Applause.) 

Dr.  Orex  Moore,  Charlotte:  Mr.  President  and  Gentle- 
men: There  are  man)'  interesting  features  to  the  case 
presented,  not  only  because  of  its  rarity,  but  because  of 
the  history  of  the  operator.  Dr.  Bost  is  one  of  those  who 
have  greatness  thrust  upon  them.  He  sees,  those  unusual 
cases  that  no  one  else  sees.  The  case  needing  a  simple  ap- 
pendectomy or  squeezing  a  black  head,  he  wouldn't  know 
what  to  do  with.  But  a  fellow  falls  on  a  circular  saw  and 
is  cut  in  two  in  the  middle,  then  he  drives  fifty  miles  with 
his  abdomen  wide  open;  Dr.  Bost  sews  him  together  and 
soon  he's  as  good  as  new.  Another,  sixty  years  old,  is 
gored  by  a  bull  and  left  with  thirty  feet  of  his  intestines 
dragging  around  the  barn  lot.  Unfortunately  that  was  not 
so  simple,  getting  thirty  feet  of  intestines  to  stay  in  place. 
Dr.  Bost  would  sew  up  one  end  and  the  other  would  get 
out.  but  he  saved  the  man.  The  rest  of  us  could  see  thou- 
sands and  thousands  of  cases  and  never  see  one  like  those— 
a  pregnant  woman  with  a  gunshot  wound  or  a  man's  belly- 
torn  open  by  a  bull. 

Two  boys  drive  a  car  against  a  convex  wooden  handrail 
of  a  bridge.  A  two-by-four,  sharp  at  one  end,  is  driven 
through  one  boy,  tearing  away  most  of  his  bladder  and 
several  feet  of  intestine  and  destroying  most  of  his  pelvic- 
girdle.  The  doctor  on  the  spot  saws  off  a  yard  of  the 
timber  so  as  to  be  able  to  get  the  patient  into  his  car, 
calls  Dr.  Bost  to  meet  him  at  the  hospital:  result,  a  well 
patient,  now  father  of  a  thriving  family. 

It  is  amazing  with  the  multiplicity  of  things  that  have 
been  going  on  since  the  invention  of  firearms  and  the 
number  of  women  who  have  been  shot-not  to  sav  anv 
thing  of  the  number  that  ought  to  have  been  shot-that 
we  wouldn  t  have  had  a  crossing  up  of  the  two  factors  in 
more  than  19  cases  that  the  doctor  has  been  able  to  dis- 

Obviously  our  info  mation  on  this  sort  of  thing  will  be 
sad  y  multiplied  when  p  get  the  records  from  the  present 

h^  h  W  K  e  ^  f'rSt  'imC  that  dvilian  Populations 
ha\c-  been  subjected  to  the  hazards  of  battle.  We  will  cer- 
tainly have  proven  all  sorts  of  injuries  to  pregnant  women 

now  rU  ^f  thC  fina'  hist°ry  °n  the  conflict  that  is 
now  in  the  world. 

As  to  how  to  handle  this  case.  Dr.  White  and  Dr  Hart 
have  solved  that  problem. 

As  to  what  is  the  legal  status— I  asked  Dr.  Bost  if  he 
had  any  information  and  he  didn't  have-I  am  able  to 
furnish  you  with  this  much  information,  sir.  An  injury  to 
a  child  unborn  at  the  hands  of  some  other  person  is  in 
the  State  of  Xorth  Carolina-injuries  resulting  in  death- 
grounds  on  which  to  indict  for  manslaughter.  That  has 
been  done  several  times. 

As  to  the  question  of  whether  murder  is  involved  here 
when  suicide  is  attempted,  there  is  on  record  a  recent  case 
in  the  State  of  North  Carolina  in  which  a  young  man tried 
to  stop  his  financee  from  committing  suicide.  She  at- 
tempted ,t  and  just  as  she  grabbed  the  .32  to  fire  on  her 
own   head,   it   went   off   and   the   bullet   hit   something   and 


ricocheted  and  tore  through  his  neck  and  he  bled  to  death 
before  help  reached  him.  That  young  lady  was  indicted 
for  murder,  the  grand  jury  holding  that  any  accident  re- 
sulting in  death  and  motivated  by  malice  constituted  mur- 
der. This  young  woman  was  in  the  act  of  committing  a 
crime— that  is,  suicide  or  attempted  suicide— and  that  act 
motivated  by  malice,  resulted  in  the  death  of  her  boy 
friend,  and  she  was  tried.  The  petit  jury  in  that  case 
turned  her  loose.  Still,  it  didn't  affect  the  legal  status  of 
the  case. 

An  interesting  case  reported  by  Dr.  Robert  McKay,  of 
Charlotte— and  then  I  am  through.  Dr.  Wilkinson— and 
that  ought  to  make  twenty.  Dr.  Robert  McKay  said  dur- 
ing the  World  War  a  French  officer  was  taking  leave  of 
his  sweetheart  after  he  had  been  home  a  few  days.  A  Ger- 
man sniper  took  a  crack  and  the  bullet  went  through  his 
testicles  into  the  abdomen  of  his  sweetheart  and  lodged  in 
the  uterus.  Just  in  no  time  it  met  the  ovum  coming  down 
and  carrying  a  few  sponges.  The  young  lady  recovered 
and  pregnancy  followed  and  went  to  term,  and  when  the 
baby  was  born  it  held  in  its  hand  a  bullet  with  German 
markings  on  it. 

Dr.  Bost:  Mr.  President,  I  am  deeply  indebted  to  these 
gentlemen  for  their  discussion  and  I  am  certainlv  glad 
none  of  these  things  happened  to  me  and  have  just  hap- 
pened to  my  patients. 

I  believe  Dr.  Moore  answered  Dr.  White's  question  and 
I  am  sure  I  have  no  immediate  information  on  this  not- 
withstanding the  fact  that  I  have  been  sued  several 
times. 

I  have  a  summary  here  that  I'd  just  like  to  go  over  that 
I  haven't  read.    (Applause.) 


DIGITALIS  IN  TREATMENT  OF  OBESITY 

(Israel    Brpm,    Philadelphia,    in    Med.    Rcc,    May    7th) 

The  chief  difficulty  in  any  weight  reduction  plan  is  the 
patient's  abnormal  capacity  to  eat,  which  amounts  to  habit, 
urgent  hunger  pains,  or  both.  Last  year  we  reported  a 
series  of  140  cases  of  alimentary  obesity  treated  with  the 
aid  of  digitalis.  A  second  series  of  60  cases  of  mixed 
etiology  similarly  treated  is  here  reported. 

The  value  of  digitalis  as  an  appetite-obtunding  measure 
is  confirmed.  With  its  aid  in  a  regimen  including  a  reduc- 
tion dietary  and  practical  psychothe"apy,  results  were 
highly  gratifying.  Before  administering  digitalis,  the  pa- 
tient must  be  properly  examined  with  a  view  to  the  detec- 
tion of  contraindications,  and  must  remain  under  the  doc- 
tor's observation  and  control  until  formally  discharged. 


CHOLAGOGUE  AND  CHOLERETIC  EFFECTS  OF 

BILE  ACIDS  AS  COMPARED  WITH  OLEIC 

ACID 

(E.    W    Lipschutz   &   1.   A.    Feder.    I'.rooklyn,   in   Amcr.   Jl    Dia 

Dis.,  May) 

The  cholagogue  effect  on  the  gallbladder  of  ten  normals 
of  0.5  grams  of  (a)  bile  acid,  and  (h)  oleic  acid  bv  mouth 
in  a  gelatine  capsule,  followed  by  water,  was  observed  on 
different  days  by  duodenal  drainage  and  cholecystography. 

The  choleretic  effect  of  these  two  drugs  was  studied  on 
the  same  len  subjects  on  different  days  by  means  of  trans- 
duodenal drainage. 

Cholecystography  studies  made  on  the  same  ten  subjects 
one  and  two  hours  after  ingestion  of  (a)  0.5  grams  of  bile 
acids  and  (b)  5  c.c.  of  oleic  acid,  on  different  days  closely 
corroborated   the   results  obtained   with   duodenal   drainage. 

Two  of  the  ten  subjects  showed  gallbladder  emptying 
when  bile  acids  were  used.  When  o'eic  acid  was  used,  nine 
of  the  ten  subject.'-  showed  gallbladder  emptying,  manifest- 
ing itself  in  partial  or  total  disappearance  of  the  gallblad- 
der shadow. 

Our  observations  indicate  the  oleic  acid  possesses  cho- 
leretic properties. 


SOITHERX  MEDICINE  6  SVRGERY 


June,   1941 


Glaucoma  in  the  General  Practice  of  Medicine* 

Herbert  C.  Xeblett,  M.D.,  Charlotte 


NO  ATTEMPT  will  be  made  here  to  pre- 
sent the  technical  aspects  of  the  various 
types  of  glaucoma,  its  pathology,  etiology, 
symptomatology,  diagnosis  and  medical  and  surgi- 
cal treatment,  save  to  briefly  discuss  the  procedure 
for  its  diagnosis  in  the  hands  of  those  who  come  in 
frequent  contact  with  it.  Good  medical  practice 
includes  the  conservation  of  vision,  and  family  doc- 
tors make  up  the  group  who  have  the  opportunity 
to  recognize  glaucoma  in  its  early  stage  and  thereby 
materially  lessen  the  incidence  of  blindness  from  it. 
For  many  years  the  National  Society  for  the  Pre- 
vention of  Blindness  has  bent  its  efforts  to  warn 
the  profession  and  to  educate  the  laity  to  the  se- 
riousness of  glaucoma  as  a  cause  for  defective 
vision  and  blindness.  It  is  recognized  as  one  of  the 
major  causes  of  blindness,  comprising  one  per  cent 
of  all  classes  of  eye  diseases  and  ranks  about  fifth 
in  the  category  of  conditions  producing  blindness 
in  this  country.  It  has  now  become  an  important 
problem  of  the  National  Health  program  and  its 
diagnosis  and  treatment  is  being  aided  by  the  Fed- 
eral, State  and  local  organizations  for  Rehabilita- 
tion of  the  Blind.  In  some  of  the  larger  cities  spe- 
cial clinics  have  been  organized  and  endowed  for 
the  care  and  treatment  of  glaucoma  victims.  These 
clinics  have  a  registry  of  all  known  cases  in  their 
vicinity,  a  specially  trained  nurse  makes  frequent 
visits  to  the  patient's  home  to  take  the  intraocular 
tension,  to  see  that  prescribed  treatment  is  being 
carried  out  and  that  the  patient  reports  regularly 
to  the  clinic  for  urgent  or  routine  medical  and  sur- 
gical care. 

Glaucoma  simplex  is  one  of  the  most  difficult  of 
the  diseases  of  the  eye  to  control  even  by  the  best 
means  we  can  now  command.  This,  predicated  bv 
the  fact  that  glaucoma  simplex  is  more  common 
than  all  other  types  combined,  is  the  cause  of  blind- 
ness in  the  great  majority  of  all  glaucoma  cases.  It 
is  least  amenable  to  treatment;  it  is  insidious, 
rarely  causing  pain  or  loss  of  central  vision  until 
late  in  the  disease.  At  that  stage  neither  medical 
nor  surgical  treatment  can  materially  prevent  its 
progress. 

These  factors  seriously  handicap  us  in  diagnosis 
and  treatment.  The  patient  is  often  not  conscious 
of  the  condition,  pays  little  if  any  attention  to  the 
symptoms  of  narrowing  of  his  visual  fields,  glim- 
mering vision,  ill-sustained  ability  to  use  the  eves  as 
before,  and  gradual  depreciation  of  visual  acuity. 
Because  of  his  ignorance  of  the  nature  of  his  con- 
dition and  because  pain  is  not  a  prominent  early 


symptom,  he  often  does  not  seek  medical  advice 
for  relief  of  the  general  depreciation  of  his  visual 
function  until  the  disease  is  well  advanced.  If  ap- 
prized of  the  status  of  his  eyes,  it  is  difficult  to 
convince  him  of  the  seriousness  of  his  condition, 
even  when  he  is  earnestly  advised  that  an  operation 
is  urgently  indicated  for  the  preservation  of  what 
vision  he  has  and  to  prevent  or  retard  the  develop- 
ment of  total  blindness.  All  too  frequently  these 
people  become  the  victims  of  itinerant  glass-fitters 
and  others  who,  though  they  are  licensed  to  fit 
glasses,  because  of  the  lack  of  special  medical 
training  are  not  qualified  to  recognize  the  disease 
with  which  they  are  confronted.  When  vision  can 
not  further  be  improved  by  glasses,  if  the  patient 
is  then  referred  for  special  care  the  case  is  well- 
nigh  hopeless  of  improvement  or  even  staying  by 
the  use  of  any  means  known  to  ophthalmology. 

Glaucoma  simplex  should  be  considered  by  every 
physician  as  part  and  parcel  of  the  general  practice 
of  medicine,  and  its  diagnosis,  or  a  well-grounded 
suspicion  of  its  presence,  should  be  readily  enter- 
tained when  the  following  symptoms  and  signs, 
named  in  the  order  of  their  prominence,  are  present 
in  a  person  from  the  4th  decade  of  life  onward. 

Symptoms. — Glimmering  of  vision,  ill-sustained 
ability  to  read  without  discomfort  with  eyes  here- 
tofore functionally  capable,  halos  around  a  light 
when  facing  a  single  light,  occasionally  a  brief  stab- 
bing pain  in  one  or  both  eyes,  a  dull  ache  within 
the  eyeball;  more  often  pain  in  the  temple,  cheek, 
or  brow,  slow  but  progressive  depreciation  of  vis- 
ion, narrowing  of  the  visual  fields. 

Signs. — With  a  history  of  recent  frequent 
changes  to  stronger  and  stronger  glasses;  a  dilated 
immobile  pupil,  a  shallow  anterior  chamber  as  if 
the  iris  were  impinging  upon  the  posterior  surface 
of  the  cornea,  slight  injection  of  the  scleral  blood 
vessels  at  the  sclerocorneal  junction,  increased  in- 
traocular tension,  a  deep  optic  cup  with  the  vessels 
bending  over  its  edge  and  lost  to  view  beneath  the 
rim  of  the  cup,  pallor  of  the  nerve  head  and  bilat- 
eral involvement  in  the  chronic  simple  type. 

The  symptoms  given  are  all  subjective.  The 
signs  listed  can  be  readily  ascertained  by  a  careful 
survey  of  the  eyes  in  good  artificial  or  daylight 
for  the  external,  and  an  ophthalmoscope  will  show 
the  external,  as  well  as  the  interna],  findings.  A 
gross  analysis  of  the  visual  fields  can  be  gotten  by 
the  confrontation  test,  an  accurate  analysis  by  a 
modification  of  the  Bjerrum  screen.  This  can  be  a 
black  curtain  40  inches  square  with  a  white  object 


if    the    Tri-State    Medical    Association    of    the    Carolina^    and    Vi 


June,   1941 


GLAUCOMA  IN  GENERAL  PRACTICE— Nebktt 


a  half-h'ch  in  diameter  at  its  center  for  the  patient 
to  fixate  while  being  tested.  The  curtain  may  be 
hung  on  a  well-lighted  wall  in  the  office.  This, 
with  a  white  test  object  one-sixth  inch  in  diameter 
on  the  end  of  a  small  black  rod  or  wire,  is  all  that 
is  required  for  rapid  work  and  a  tentative  diagno- 
sis. The  patient  in  this  test  is  placed  40  inches 
from  the  curtain  and  the  eye  not  being  tested  is 
occluded.  The  intraocular  tension  can  be  fairly 
accurately  estimated  by  palpating  each  globe  sep- 
arately while  the  patient  sits  and  looks  down,  his 
head  erect,  and  fixes  his  gaze  on  his  hands  which 
are  folded  in  his  lap.  This  makes  the  upper  por- 
tion of  the  globe  present  beneath  the  supraorbital 
arch  and  the  balls  of  the  two  index  fingers  can 
palpate  the  body  of  the  globe  with  facility  while 
the  hands  are  supported  by  the  other  fingers  rest- 
ing lightly  on  the  brow  and  temporal  area.  Con- 
stant and  equal  pressure  with  the  two  fingers 
should  not  be  made;  but  palpation  alternately 
with  one  and  then  the  other  finger,  both  fingers 
being  applied  to  the  globe  throughout  the  test. 

This  requires  practice.  If  the  test  is  correctly 
done,  and  on  every  patient  presenting  for  a  general 
physical  examination,  one  becomes  capable  of  de- 
tecting as  little  as  eight  to  10  millimeters  of  in- 
creased pressure.  An  intraocular  tension  of  35  to 
40  millimeters  or  more  can  be  readily  detected  by 
practice.  This  entire  procedure,  as  outlined,  re- 
quires no  more  than  five  or  six  minutes,  no  equip- 
ment but  that  which  can  be  had  for  a  trifle,  the 
ophthalmoscope  excepted,  and  practice  in  the  use 
of  the  ophthalmoscope  facilitates  the  solution  of 
many  serious  medical  diagnostic  problems  in  addi- 
tion to  glaucoma. 

Use  of  the  ophthalmoscope  should  be  a  part  of 
the  daily  practice  of  every  physician,  just  as  the 
use  of  the  blood-pressure  apparatus  and  the  steth- 
oscope should  be  a  part  of  the  daily  work  of  every 
oculist.  A  brief  examination  of  the  eyes  with  the 
ophthalmoscope  in  routine  practice  aids  the  exam- 
iner in  making  many  a  diagnosis  in  general  sys- 
temic diseases;  and  of  itself  brings  to  light  many 
early,  undetected  cases  of  glaucoma.  It  is  unfor- 
tunate that  scarcely  one  physician  in  five  uses  an 
ophthalmoscope  at  all,  when  any  doctor  may  have 
for  his  patients,  at  a  small  expenditure  of  money 
and  time,  the  great  benefits  to  be  derived  from  the 
use  of  this  valuable  instrument. 

Chronic  congestive  and  acute  glaucoma  need  not 
be  difficult  to  diagnosticate.  Suffice  it  to  say  that 
in  such  a  case  the  sclera  is  highly  injected,  the 
cornea  hazy,  the  pupil  dilated  and  fixed,  vision 
markedly  depreciated,  the  globe  hard  and  exquis- 
itely painful.  Frequent  are  nausea,  vomiting  and 
severe  shock.  A  differential  diagnosis  from  acute 
iritis  presents  the  most  important  problem.  Nau- 
sea,   vomiting   and   shock   may   suggest   an   intra- 


abdominal catastrophe.  In  potential  glaucoma  pa- 
tients an  acute  attack  is  not  infrequently  precipi- 
tated by  some  severe  emotional  shock  as  from  a 
like  cause  an  acute  thyrotoxicosis  may  be  produced. 
Likewise  the  oral  administration  of  atropine  and 
its  derivatives  to  the  middle-aged  and  aged  and 
those  of  a  like  age  with  hypertension,  because  of 
its  mydriatic  effect  on  the  pupil,  may  precipitate  a 
latent  glaucoma. 

The  dilated  and  immobile  pupil  of  glaucoma  sug- 
gests a  cerebral  new  growth  or  late  svphilis.  The 
fundus  picture  may  be  confused  with  optic  nerve 
atrophy,  physiological  cupping  of  the  disc,  and 
high  myopia.  It  is  not  infrequently  mistaken  for 
incipient  cataract  by  the  uninitiated  and  by  him 
the  patient  is  advised  to  wait  until  the  cataract  is 
"ripe"  before  anything  is  done.  In  any  kind  of 
glaucoma  the  use  of  atropine,  cocaine  or  other 
mydriatic  may  be  disastrous. 

In  conclusion: 

The  diagnosis  of  glaucoma  is  an  item  in  the 
field  of  general  medicine.  Such  cases  make  a  not 
inconsiderable  part  of  the  practice  of  everv  busy 
physician.  It  is  through  his  thoroughness  that 
many  of  these  unfortunate  people  can  have  the 
threatening  condition  of  their  eyes  detected,  and 
be  directed  in  the  path  of  light;  while  a  cursory  ex- 
amination with  a  mistaken  diagnosis  may  give  the 
patient  a  false  sense  of  security  with  disastrous 
results.  By  maintaining  in  his  daily  practice  the 
consciousness  of  the  existence  of  this  menace  to 
vision,  every  doctor  can  be  instrumental  in  saving 
annually  one  or  more  patients  with  incipient  glau- 
coma from  ultimate  blindness.  Surely  this  is  an 
accomplishment  worthy  of  the  effort  required.  It 
is  a  problem  in  preventive  medicine,  as  in  other 
fields  of  medicine,  a  challenge  to  our  knowledge 
and  effort.  Traquair  says:  "We  must  regard  glau- 
coma as  a  disease  of  the  patient  and  not  a  disease 
of  the  eye." 

A  person  blind  is  devoid  of  sight;  if  vision  is 
10  per  cent  of  normal  he  is  economically  and  in- 
dustrially blind.  His  ultimate  status  is  the  same 
whether  his  visual  deficiency  be  the  result  of  in- 
jury or  of  disease. 

If  blindness  from  glaucoma  is  to  be  prevented, 
the  disease  condition  must  be  detected  and  treated 
in  its  incipiency,  and  every  practicing  physician 
should  serve  as  a  means  to  that  end,  utilizing  the 
same  knowledge  and  interest  that  he  uses  in  pre- 
venting other  diseases  destructive  of  our  economic 
and  social  welfare. 


Hypothyroidism. — Of  42  children  with  h.  seen 
in  past  S  years,  most  were  clinical  pictures  of  cretinism 
or  juvenile  h.  Elaborate  biochemical  studies  only  con- 
firmed already  clearcut  diagnoses. — Wilkins  &  Fleisch- 
mann.  in  //,  A.  M.  A. 


SOVTHERX  MEDICINE  &  SURGERY 

What  is  Cancer,  and  Do  We  Need  to  Fear  It?* 

Paul  Kimmelstiel,  M.D.,  Charlotte 


June,   1941 


THE  public  has  become  more  concerned 
about  cancer  in  recent  years  than  ever  be- 
fore. It  is  true  that  the  medical  profession 
has  greatly  contributed  toward  the  enlistment  of 
this  wholesome  interest.  Doctors  have  done  that 
and  are  doing  it,  purposely,  because  they  have 
realized  that  under  the  present  circumstances  an 
effective  battle  against  this  dreadful  disease  can  be 
fought  only  if  the  public,  itself,  does  its  part  in 
bringing  about  earlv  recognition  of  the  condition. 

It  seems  as  if  the  number  of  persons  who  die 
from  cancer  steadily  increases.  This,  although  sta- 
tistically true,  should  not  arouse  fear.  We  must 
bear  in  mind  that  this,  like  all  statistical  record- 
ings, must  be  carefully  analyzed  before  it  can  be 
interpreted  properly.  Cancer,  you  must  know,  is 
broadly  speaking  a  disease  of  old  age.  True,  it  does 
occur  in  the  young,  but  relatively  rarely,  and  the 
incidence  increases  with  increasing  age.  Modern 
hygiene  and  medicine  have  prolonged  considerably 
the  average  lifetime.  We  should  therefore  not  be 
surprised  that  those  who  would  formerly  have  died 
from  diseases,  now  preventable  or  curable,  live  long 
enough  to  experience  cancer  they  would  not  have 
had  had  they  died  in  early  life  from  an  epidemic 
disease,  a  ruptured  appendix,  pneumonia  or  other 
condition  which  we  now  are  so  much  better  able 
to  prevent  or  cure.  Furthermore,  with  increasing 
medical  knowledge  and  improvement  of  diagnostic 
methods  cancer  is  recognized  now,  more  often  than 
formerly,  to  be  the  cause  of  death.  The  statistical 
truth  of  increasing  incidence  of  cancer  must  there- 
fore not  discourage  us. 

In  spite  of  the  tremendous  efforts  which  are 
being  made  in  many  research  institutes  throughoul 
the  world,  in  spite  of  surprising,  and  indeed  prom- 
ising, results  which  have  been  achieved,  we  do  not 
fully  understand  the  cause  of  cancer.  However,  we 
have  learned  to  recognize  cancer  as  a  distinct  group 
of  ailments,  and  we  have  learned  some  of  the  ways 
and  means  by  which  cancer  kills  us.  The  knowl- 
edge of  the  strength  and  the  strategy  of  our  enemy 
wins  half  our  battle. 

What  is  cancer?   How  does  it  affect  the  body? 

When  you  think  seriously  about  the  structure 
of  your  own  body,  with  all  its  various  organs  and 
parts  and  tissues,  you  find  it  hard  to  grasp  how 
miraculously  well  the  different  structures  with 
their  millions  of  tiny  cells  are  organized.  The 
cells  are  specialized  in  groups  and  communities. 
and  detailed  to  certain  functions.  They  all  do  their 


work  to  the  benefit  of  the  body  as  a  whole.  They 
live  and  die  for  it  all  the  time,  and  in  return  are 
supplied  with  water  and  food  by  the  common- 
wealth through  an  intricate  system  of  channels 
which  we  call  vessels.  At  any  time,  however,  and 
for  some  reason  we  do  not  know,  this  system  of 
good-fellowship  may  break  down  in  one  of  the 
communities,  in  one  of  our  organs.  A  small  group 
of  laboring  cells  begins  to  revolt.  At  first  you  can 
hardly  distinguish  them  from  their  fellow-workers, 
and  only  a  trained  eye  may  recognize  them  under 
the  microscope;  but  soon  they  begin  to  multiply, 
to  form  their  own  little  colony  within  their  com- 
munity and  then  they  are  identified  more  easily. 
Under  the  microscope  they  are  aggressive-looking 
fellows;  their  colony  is  not  in  good  order:  it  is  dis- 
organized, anarchistic.  The  colony  grows  rapidly 
and  entirely  out  of  proportion  to  the  rate  of  growth 
of  the  normal  cells  of  their  community.  They  have 
lost  discipline,  and  no  longer  share  in  the  burden 
of  work  which  the  commonwealth  of  cells  must 
have  for  its  existence  to  be  sustained.  Just  like 
human  aggressors,  they  disregard  boundaries  and 
break  into  neighboring  countries,  destroying  and 
looting  as  they  advance.  And  then  through  the 
channels  of  transportation,  the  vessels,  they  send 
out  a  small  group  of  pioneers  into  remote  coun- 
tries, into  organs  far  distant  from  the  original  site 
of  growth.  Here  again  the  tiny  colony  begins  to 
expand  and  invade.  In  short,  cancer  acts  like  a 
parasite  which  takes  shelter  in  our  body  and  lives 
at  our  expense.  It  eats  at  our  table  and  replies 
with  poison.  It  is  true  that  with  the  final  death  of 
the  host  the  parasite  will  also  die;  but  in  order  to 
save  the  host  we  have  to  get  up  early.  We  cannot 
wait  until  the  parasite  has  already  begun  to  invade 
its  neighborhood  or  send  out  its  pioneers  to  other 
parts  of  the  body. 

If  we  knew  what  makes  some  of  our  good  fellow- 
citizen  cells  suddenly  change  into  aggressors  we 
would  probably  know  how  to  prevent  it.  But  we 
must  face  the  fact  that  we  can  cure  cancer  only 
bv  complete  eradication  after  we  have  recognized 
its  existence.  The  only  means  at  our  disposal  at 
the  present  time  are  surgical  excision,  x-ray  and 
radium  treatment.  It  is  clear,  however,  that  the 
chance  of  curing  cancer  will  be  less  and  less,  the 
longer  the  time  the  parasite  has  been  allowed  to 
establish  itself  and  do  its  destructive  work. 

I  can  give  you  some  striking  examples  of  the 
results  of  treatment  in  early-  and  late-recognized 


•Read  on  Station  WBT.  Charlotte,  on  May  3rd.   in  behalf  o£  the  Women's  Auxiliary  of  the  Field  Army  for  Cancer  Control. 


June.   1941 


CA.XCER  &  FEAR  OF  IT—Kh 


cancers.  Of  cases  of  cancer  of  the  breast  recog- 
nized and  treated  early,  75  per  cent  have  been 
cured,  at  least  over  a  period  of  five  years.  Of 
those  recognized  late  only  20  per  cent  have  been 
cured.  If  cancer  of  the  womb  is  diagnosed  early 
80  per  cent  of  the  cases  are  curable;  if  recognized 
late  only  10  per  cent.  And  so  on  down  the  line. 
The  main  difficulty  in  early  recognition  of  cancer 
lies  in  the  fact  that  our  parasite,  if  established  in 
inner  organs,  may  gain  considerable  size  and 
strength  of  aggression  without  causing  much  dis- 
comfort or  otherwise  making  its  presence  known. 
Sometimes  the  growth  is  discovered  accidentally  by 
feeling  a  lump  somewhere  in  the  body.  All  should 
bear  in  mind  that  cancer  is  a  growth,  a  vegetation, 
and  at  that  a  surreptitious  aggressor.  Wherever 
you  can  feel  a  lump,  for  instance  in  the  breast, 
though  that  lump  may  not  be  sore,  have  it  exam- 
ined to  rule  out  the  possibility  of  cancerous  growth. 
Don't  misunderstand  me,  not  all  lumps  are  can- 
cers; but  your  physician  is  the  person  to  say 
whether  or  not  a  lump  is  a  cancer,  and  your  own 
best  interests  demand  that  you  take  your  problem 
to  your  physician  immediately. 

Cancer  destroys  the  surrounding  tissue  and  eats 
into  the  vessels.  You  can  see  that  this  will  often 
be  the  cause  of  minor  bleedings.  Do  not  dismiss 
repeated  minor  bleedings  from  your  mind,  wher- 
ever they  may  come  from,  until  you  have  found 
out  just  what  is  causing  them.  They  are  often  the 
earliest,  the  only,  sign  of  cancer,  particularly  of 
cancer  of  the  womb.  Irregular  bleeding  or  inter- 
mittent spotting  should  be  given  your  full  atten- 
tion. 

Quite  often  the  parasite  we  nourish  somewhere 
in  our  body  will  grow  to  considerable  size  without 
causing  any  local  disturbance.  General  discomfort, 
weakness,  fatigue,  loss  of  weight,  anemia  or  vague 
complaints  of  indigestion  may  be  the  only  clues, 
and  most  of  these  symptoms  are  late  in  appearing. 
Although  it  mav  seem  to  you  that  such  a  general 
effect  on  your  body  may  already  indicate  advanc- 
ed progression  of  your  enemy,  it  may  not  be  too 
late  to  be  cured.  Don't  be  ashamed  to  consult  your 
doctor  about  such,  as  they  may  seem  to  you,  trivial 
and  vague  complaints.  If  he  tells  you  that  there  is 
nothing  seriously  wrong,  well  and  good;  you  have 
not  lost  the  chance  of  an  early  diagnosis.  If  he 
finds  that  you  have  very  early  cancer,  you  are  al- 
most certainly  saved  from  months  of  suffering  in- 
validism terminated  by  death — saved  for  ten, 
twenty,  thirty  years  of  happiness  and  usefulness. 

With  all  these  talks  the  medical  profession  mav 
seemingly  have  implanted  an  unnecessary  fear  of 
cancer  in  some  minds;  but  certain  cure  of  cancer 
can  be  accomplished  only  in  its  earliest  phase  of 
growth,  at  a  time  when  its  existence  is  not  yet 
obvious  to  your  eves.    Cancer  fear — not  irrational 


terror,  but  wholesome  dread — cannot  be  avoided; 
in  fact  it  is  a  part  of  our  cancer  defense  program. 


EASING  CONVALESCENCE 

(E.    K.    Clarke,    Minneapolis,    in    //.-Lancet,    May) 

Problems  of  convalescence  can  be  greatly  reduced  it 
there  is  conscious  planning  to  improve  the  mental  attitude 
of  the  patient  during  this  time.  This  article  deals  with  the 
management  of  children  during  convalescence,  but  the 
fundamental   principles  are   equally   applicable   to   adults. 

It  requires  a  personal  experience  of  prolonged  illness  to 
appreciate  how  long  a  day  can  be  for  an  unoccupied  in- 
valid. Mealtimes  and  the  taking  of  temperature  represent 
important  breaks  in  the  monotony.  Convalescence  will 
become  less  tedious  if  there  is  a  definite  plan  to  follow 
that  dispels  boredom. 

The  idle  child  is  prone  to  be  discontented.  The  constant 
demand  for  attention  from  mother  or  nurse  tries  the  pa- 
tience and  causes  irritability,  thus  adding  to  the  strain  of 
care.  A  planned  routine  breaks  up  long,  dull  periods  into 
short  spells,  each  with  a  diversion. 

Between  breakfast  and  the  morning  bathing  and  tidying 
up — reading,  drawing,  cutting  out  pictures.  After  morning 
care — for  the  child  who  can  be  propped  up  in  bed,  a  bed 
table  useful  for  serving  meals  and  as  a  work  bench  can  be 
constructed  for  a  small  amount,  stored  in  a  small  space, 
and  used  repeatedly.  Soap  carving,  leather  work,  bead 
work  on  looms,  rings  created  from  the  handles  of  discard- 
ed tooth  brushes  softened  with  acetone  for  ease  in  mold- 
ing. Scrap-books,  cutouts,  paper  weaving  and  card  darn- 
ing serve  a  useful  purpose  in  keeping  younger  children 
contented. 

Plan  activity  for  a  definite  period,  terminated  before 
interest  lags. 

From  mid-morning  to  noon  books,  picture  puzzles,  or 
games  that  can  be  played  alone. 

Rest  in  a  darkened  room  for  V/2  hours  should  be  en- 
couraged in  early  afternoon,  followed  by  reading  aloud 
and  playing  games.  Planned  radio  programs  should  be 
fitted  into  the  schedule. 

The  early  evening  should  offer  some  diversion  through 
such  games  as  Chinese  or  regular  checkers,  dominoes,  or 
simple  card  games  that  can  be  played  quietly.  During  this 
time,  members  of  the  family  who  have  been  at  school  or 
work  during  the  day  can  bring  new  faces  and  interest  into 
the  sick  room. 

For  older  children  a  wide  array  of  interesting  books  can 
usually  be  suggested  by  the  librarian  of  any  public  library. 
Even  with  adults,  short  stories  that  can  be  completed  in 
about  20  minutes  are  usually  preferred. 

It  is  important  that  the  patient  not  keep  up  his  play 
for  attention  through  making  physical  complaints.  Hap- 
hazard, ill-defined  routines  during  convalescence  perpetuate 
bad  mental  attitudes  that  retard  recovery. 


GOUT—A  FORGOTTEN  DISEASE 
(E.  L  Tuohy,  Duluth,  in  Minn.  Med.,  April) 
Gout  is  practically  as  enigmatic  as  when  Sydenham  had 
it  and  described  it.  We  cannot  deny  its  familial  tendency 
and  constitutional  background.  Uric  acid  is  deposited  in 
the  tissues  in  certain  areas.  Rich,  fatty  diets  and  alcohol 
(beer  and  ale)  precipitate  attacks.  These  attacks  come  in 
individuals  with  a  certain  background  of  gouty  diathesis. 
The  disease  does  not  kill  and  is  therefore  lost,  for  the 
most  part,  to  statistical  enumerations.  The  x-rays  offer 
little  in  the  way  of  positive  selective  criteria.  Colchicine 
as  a  therapeutic  test  in  acute  attacks  is  the  most  reliable 
diagnostic  measure — more  determinative  than  either  hyper- 
uricemia, the  presence  of  aural  tophi,  or  bursitic  accumula- 
tions. Gout  is  a  disease  ideally  suited  to  sharper  the  phy- 
sician's clinical  acumen  and  judgment.  Without  these  fac- 
ulties it  will  be  frequently  overlooked. 


SOUTHERX  MEDICINE  &  SURGERY 


June,    1941 


The  Roentgen  Treatment  of  Cutaneous  Epitheliomas  * 

Allen   Baker,  M.D. — Charles  H.  Peterson,  M.D. 
Charles  D.  Smith,  M.D. 
Roanoke 


IMPROVEMENTS  in  roentgen  apparatus,  to- 
gether with  a  vast  increase  in  our  knowledge 
of  the  treatment  of  cancer  in  general  during 
the  past  few  years,  have  made  it  possible  to  cure 
practically  all  skin  cancers.  In  spite  of  these  facts 
about  four  thousand  persons  die  each  year  from 
the  disease.  It  then  becomes  obvious  that  many 
patients  either  do  not  seek  treatment  at  all  or  are 
improperly  treated  when  they  do.  The  latter 
probably  accounts  for  most  of  the  deaths. 

For  purposes  of  brevity  and  simplicity,  a  dis- 
cussion of  lip  and  intraoral  cancers,  which  require 
complicated  and  varied  techniques,  has  been 
omitted. 

The  present-day  treatment  of  any  malignant 
growth,  whether  of  the  skin  or  other  organs,  con- 
sists of  irradiation,  or  surgery,  or  a  combination 
of  the  two.  In  a  small  percentage  of  cases  of  skin 
cancer  both  may  be  necessary  and  occasionally 
surgery  alone  may  be  preferable.  However,  the 
roentgen  apparatus  of  today,  with  increased  ex- 
perience in  its  use,  has  practically  eliminated  the 
necessity  of  either  surgery  or  radium.  Patients 
frequently  object  to  a  surgical  procedure,  more 
often  than  not  accompanied  by  poor  cosmetic  re- 
sults, especially  if  the  lesion  is  large.  With  ra- 
dium, dosage  is  more  difficult  to  estimate,  treat- 
ment time  is  much  longer,  and  the  small  amount 
of  radium  available  in  most  institutions  where  the 
demand  for  it  is  great,  make  it  uneconomical  to 
use. 

The  great  majority  of  skin  cancers  fall  into  one 
of  three  classifications:  (1)  basal-cell,  (2)  mixed, 
and   (3)  squamous-cell. 

Success  in  the  treatment  of  these  lesions  de- 
pends, as  in  any  other  disease,  on  accurate  diag- 
nosis, which  can  be  obtained  only  by  biopsy  in  all 
doubtful  cases.  It  is  not  our  practice  to  do  biopsy 
on  all  small  typical  epitheliomas.  While  an  occa- 
sional error  may  result  from  such  practice,  these 
do  not  in  our  opinion  outweigh  the  disadvantages 
of  additional  expense  and  time  consumed,  partic- 
ularly for  those  patients  with  meager  finances  who 
live  at  a  great  distance.  One  must  not  underesti- 
mate the  value  of  a  microscopic  study  of  these 
lesions,  but  it  is  a  mistake  to  rely  entirely  on  the 
microscopic  findings  in  determining  the  dosage  to 
apply  as  the  histology  may  vary  from  one  area  to 


another.  A  section  from  one  place  may  show  only 
basal  cells  while  from  another  squamous  cells  are 
found.  Such  a  lesion  would  not  be  cured  by  a  dose 
of  radiation  sufficient  only  to  cure  a  basal-cell 
growth.  In  practice,  therefore,  a  dose  sufficient  to 
destroy  squamous  cells;  i.e.,  8  ,  to  12  erythema 
doses,  should  be  administered  regardless  of  the 
biopsy  findings. 

Care  should  be  used  in  obtaining  a  biopsy  as 
the  improper  removal  of  tissue  may  cause  a  very 
malignant  lesion  to  metastasize,  thereby  rendering 
a  relatively  simple  lesion  highly  dangerous.  Skin 
cancer,  as  is  true  in  all  cases  of  suspected  malig- 
nancy, should  receive  a  preoperative  dose  of  roent- 
gen therapy  before  tissue  is  removed.  This  proce- 
dure renders  less  viable  any  cells  which  might 
escape  into  the  blood  or  lymph  stream  at  the  time 
of  the  operation.  To  further  lessen  the  opportunity 
for  metastases  the  electrosurgical  knife  is  prefer- 
able to  sharp  incision,  as  this  instrument  destroys 
any  cancer  cells  with  which  it  comes  in  contact 
and  seals  blood  and  lymph  spaces  as  it  cuts,  there- 
by decreasing  the  chances  for  malignant  cells  to 
enter  the  circulation. 

It  is  well  to  emphasize  that  good  surgery  is  pref- 
erable to  poorly  administered  radiation  and  vice 
versa,  as  the  successful  management  of  any  cancer 
depends  upon  adequate  initial  treatment.  Recur- 
rent cancer  anywhere  taxes  the  ingenuity  of  both 
surgeon  and  radiologist. 

The  quality  of  roentgen  radiation  employed  in 
these  cases  is  determined  largely  bv  the  size  and 
thickness  of  the  lesion,  its  location  and  histologi- 
cal structure.  No  preestablished  routine  can  be 
adhered  to,  as  each  case  must  be  individualized 
and  techniques  may  have  to  be  modified  from  time 
to  time  during  treatment. 

It  is  possible,  however,  to  describe  in  a  general 
way  the  treatment  technique  employed  in  the  dif- 
ferent types  of  epitheliomas:  Comparatively  small 
lesions,  those  2  cm.  or  less  in  diameter  with  little 
or  no  elevation,  are  given  one  massive  dose  of  low 
voltage  (100  Kv.  P.)  unfiltered  x-ray,  usually  be- 
tween 4000  and  6000  roentgen  units.  Larger  le- 
sions with  little  or  no  elevation  are  given  the  same 
quality  of  radiation  and  approximately  the  same 
total  dose,  but  the  dose  is  fractionated  into  three 
or  four   treatments  given  at   intervals   of  two  or 


*Presented    to   tin 
24Jh  and  25th. 


meeting   of   the    Tri-State    Medical    Association    of    the    Carolina 


lid    Virginia,    held    at    Gr 


June.   1941 


ROEXTGEX  TREATMENT  OF    EPITHELIOMAS— Barker  et   at. 


327 


three  days.  The  divided-dose  technique  permits 
more  rapid  recovery  of,  and  less  permanent  dam- 
age to,  normal  structures — a  factor  of  great  im- 
portance when  any  large  area  is  heavily  radiated. 

Large  thick  carcinomas  are  treated  by  a  com- 
bination of  filtered  and  unfiltered  rays,  with  volt- 
ages varying  between  100  Kv.  P.  and  200  Kv.  P. 
and  filter  between  zero  and  2  mm.  cu.  The  aver- 
age daily  dose  is  300  to  400  r  administered  dailv 
or  every  second  day  for  a  total  of  4000  to  6000  r 
and  completed  within  a  period  of  three  weeks. 

Cancer  involving  cartilage  is  a  much  more  dan- 
gerous lesion  and  more  difficult  to  treat.  This 
.tissue  does  not  tolerate  radiation  well,  especially 
soft  low-voltage  rays,  and  cancer  cells  imbedded 
in  cartilage  are  more  radioresistant.  Therefore 
great  care  must  be  exercised  to  obtain  a  permanent 
cure  with  good  cosmetic  results.  Roentgen  rays 
generated  at  220  Kv.  P.  and  filtered  through  the 
equivalent  of  2  mm.  cu.  are  employed  in  the  treat- 
ment of  these  cases.  Daily  doses  of  300  to  400 
roentgen  units  are  given  until  a  total  of  4S00  to 
6000  r  is  reached.  This  method  reduces  the  chances 
of  cartilage  necrosis  and  gives  much  better  cos- 
metic results. 

Proper  screening  is  as  essential  as  adequate  dos- 
age. Too-close  screening  leaves  viable  cancer  cells 
in  the  margins,  and  is  certain  to  result  in  recur- 
rences, while  too-wide  margins  may  cause  unnec- 
essary destruction  of  healthy  tissue.  In  small  le- 
sions a  margin  of  at  least  ^  to  1  cm.  should  be 
included  and  in  the  larger  ones  up  to  2  cm. 

It  can  be  seen  that  many  factors  must  be  reck- 
oned with  in  the  care  of  these  cases  if  permanent 
cures  with  good  cosmetic  results  are  to  be  expect- 
ed. Success  depends  almost  entirely  upon  ade- 
quate initial  treatment  as  recurrent  lesions  are 
radiation-resistant  and  usually  appear  in  an  area 
already  greatly  damaged  by  previous  radiation. 
We  then  have  a  lesion  requiring  much  larger  doses 
in  an  area  which  will  tolerate  little,  if  any,  more 
radiation  without  the  danger  of  radionecrosis. 
Wide  surgical  excision  is  probably  preferable  in 
many  of  the  recurrences  but  this  method  leaves  a 
wound  difficult  to  heal,  prone  to  subsequent  de- 
formity. 

If,  in  the  management  of  these  patients,  one 
keeps  in  mind  the  most  frequent  causes  of  failure, 
many  of  the  mistakes  we  have  made  ourselves  or 
have  seen  made  by  others  can  be  avoided.  At  the 
head  of  the  list  should  be  placed  inadequate  initial 
treatment,  whether  it  be  radiation,  surgery,  or  a 
combination  of  the  two.  We  see  many  cases  where 
total  dosage  has  been  ample  but  fractionated  over 
so  long  a  period  of  time  that  tumor  cells  have  had 
an  opportunity  to  recover  between  treatments  and 
finally    become    radiation-resistant.     In     most    of 


these  lesions  the  total  treatment  should  be  admin- 
istered within  a  period  of  three  weeks  or  less. 
Any  cancer  which  does  not  receive  within  a  period 
of  six  weeks  sufficient  radiation  to  destroy  it  be- 
comes extremely  dangerous  and  much  more  diffi- 
cult to  cure. 

Too-close  screening;  i.e.,  failure  to  include  a 
wide  enough  margin  of  healthy  tissue  in  the  field 
of  radiation,  probably  ranks  second  in  importance 
as  a  cause  of  failure.  In  these  instances  recur- 
rences develop  at  the  margins  of  the  lesion. 

A  less  frequent,  but  none  the  less  important, 
cause  of  failure  is  the  use  of  improper  quality  of 
radiation.  A  dose  of  low-voltage  radiation  suffi- 
cient to  cure  a  thin  lesion  may  fail  entirely  to  cure 
a  thick  one  of  the  same  diameter,  as  the  tumor 
mass  itself  filters  out  too  large  a  percentage  of  the 
rays  before  they  reach  the  base  of  the  growth; 
whereas  the  same  number  of  roentgens  generated 
by  higher  voltages  and  moderately  filtered  would 
be  ample  to  produce  a  cure. 

In  conclusion,  we  have  outlined  in  a  general 
way  the  methods  of  roentgen  therapy  which  have 
proved  satisfactory  to  us  in  the  management  of 
skin  cancer.  No  claims  are  made  for  originality 
of  the  methods  of  treatment  described  and  it  is 
recognized  that  other  methods  or  variations  of  the 
techniques  mentioned  may  produce  results  as  grat- 
ifying as  those  illustrated  here.  It  is  obviously 
impossible  to  describe  in  detail  the  treatment  of 
each  different  type  of  epithelioma,  as  it  is  often 
necessary  to  substitute  one  regimen  for  another 
after  treatment  is  begun.  The  most  frequent  and 
important  causes  of  failure  have  also  been  men- 
tioned. It  should  be  emphasized  again  that  suc- 
cess in  the  care  of  skin  cancer,  as  in  all  forms  of 
malignancy,  depends  upon  adequate  initial  treat- 
ment. 

Discussion  was  with  that  of  paper  of  Dr.  Clarkson,  and 
will  be  published  with  Dr.  Clarkson's  paper. 


PRIMARY  OVARIAN  CANCER 


(J.   E.    Hall,   Brooklyn, 


ooklyn   Hasp.  Jl.,  April) 


Primary  ovarian  cancer  is  one  of  the  most  fatal  forms — 
mortality  90%.  In  view  of  the  fact  that  over  80%  of  the 
patients  were  women  over  40  years  of  age  and  because  the 
disease  is  practically  symptomless  until  it  is  well  advanced, 
every  woman  over  40  should  have  a  pelvic  examination 
every  6  months.  This  procedure  probably  would  enable  us 
to  discover  a  much  higher  percentage  of  these  tumors  be- 
fore they  become  so  far  advanced.  Furthermore,  other 
early  lesions  of  the  genital  tract  would  be  found. 

The  procedure  of  choice,  as  soon  as  diagnosis  is  made, 
would  seem  to  be  complete  removal  of  the  pelvic  organs, 
then  extensive  postoperative  roentgen  therapy.  Under  such 
a  plan  of  treatment  in  early  ovarian  cancer,  before  the 
onset  of  pain  and  abdominal  enlargement — which  are  late 
symptoms  in  the  disease — the  survival  rate  would  be 
greatly  increased. 


SOUTHERN  MEDICINE  &  SURGERY 


June,    1941 


CASE  REPORT 

ALLERGIC  REACTION  TO  SILVER 

NITRATE 

George  R.  Laub,  M.D..  Hemingway.  S.  C. 

Johnson    Memorial    Hospital 

Quite  recently  the  chance  to  observe  two  cases 
with  the  same  unusual  reaction  to  silver  nitrate 
presented  itself. 

Case  1. — A  white  woman  of  52  in  good  health, 
past  history  irrelevant,  came  to  the  office  with  an 
acute  tonsillar  pharyngitis.  Noticing  that  I  in- 
tended to  mop  her  throat  she  told  me  that  she  had 
been  warned  in  the  past  by  another  doctor,  not  to 
allow  anyone  to  use  silver  nitrate  on  her.  as  it 
caused  her  to  have  asthma  attacks.  She  explained 
that  the  local  application  of  this  preparation  was 
the  only  thing  that  had  ever  caused  such  attacks 
and  so  far  as  she  knew  she  had  no  other  allergic 
reactions.  I  thought  that  an  attack  such  as  she 
mentioned,  might  possibly  have  been  produced  by 
some  silver  nitrate  having  dropped  into  her  larynx. 
For  psychological  reasons  I  misled  her  into  be- 
lieving I  was  going  to  use  another  drug,  but  did 
apply  a  1-per  cent  solution  to  her  tonsils.  To  my 
surprise  the  patient  immediately  was  seized  with 
a  severe  attack  of  asthma  which  required  an  injec- 
tion of  adrenalin. 

Case  2. — A  white  man  of  55  who  could  not  re- 
call having  ever  visited  a  doctor  came  with  a  sub- 
acute tonsillitis  for  which  12-per  cent  silver  nitrate 
was  applied  locally.  Immediately  upon  touching 
his  throat  he  was  seized  with  a  severe  attack  of 
bronchial  asthma  with  typical  expiratory  stridor, 
which  lasted  15  minutes.  This  man  had  not  had 
asthmatic  attacks  before.  It  is  of  interest  in  both 
these  cases  of  bronchial  asthma  that  neither  had  a 
personal  or  family  history  of  allergy,  and  their  at- 
tacks were  occasioned  by  the  use  of  silver  nitrate 
only. 

Allergies  due  to  local  applications  or  internal 
use  of  divers  drugs  are  not  infrequent.  Local  treat- 
ment to  the  rhinopharvngeal  tract  and  to  the  eyes 
is  especially  noted  for  producing  allergic  reactions. 
In  a  study  of  literature,  however,  no  like  cases 
were  found,  although  the  local  application  of  sil- 
ver nitrate  is  so  general.  In  a  round-table  confer- 
ence on  allergy,  Tuft1  mentions  -'shock  organs 
which  after  contact  with  a  specific  allergen  become 
sensitized,  thus  resulting  in  one  of  the  clinical  man- 
ifestations of  allergy."  These  shock  organs  are  not 
limited  to  any  tissue  of  the  body.  He  believes  that 
a  patient  with  hayfever  has  a  potential  shock  or- 
gan in  the  bronchial  tubes.  Glover,1  reporting  on 
ocular  allergies  at  the  same  conference  mentioned, 
as  do  Black2  and  YVeiner,3  drug  allergies  of  the 
eyes  due  to  atropine,  eserine,  butyn  etc.,  and  that 
silver  nitrate  rarely  gives  a  reaction,  and  what  re- 


action there  is  appeared  to  be  "a  purely  corrosive 
response."  Applebaum*  reports  two  cases  with 
atropine  blepharoconjunctivitis,  both  patients  sen- 
sitive to  other  cycloplegics.  After  surgically  clear- 
ing their  ethmoid  sinuses  both  became  desensitized. 
Hurlbut'  even  recommends  as  one  of  the  treat- 
ments for  allergy  a  10-per  cent  solution  of  silver 
nitrate  as  a   cauterizing   agent. 

A  review  of  the  literature  is  quite  contusing. 
There  can,  however,  be  no  doubt  that  abnormali- 
ties of  the  upper  respiratory  tract  are  directly  or 
indirectly  related  to  asthmatic  attacks.  Sinus  dis- 
eases, septum  deviations,  polyps  etc.  have  long 
been  considered  responsible  for  allergic  reactions. 
Dietary  and  environmental  conditions,  as  well  as 
endocrinological  ones,  are  factors  which  have  to  be 
considered.  However,  none  of  these  theories  ex- 
plains certain  drug  reactions  which  appear  quite 
suddenly  and  with  no  evident  reason. 

Summary 
Two  cases  are  reported  in  which  the  local  ap- 
plication of  nitrate  of  silver  in  the  throat  produced 
immediate  attacks  of  bronchial  asthma,  though 
neither  gave  any  history  of  such  asthma,  or  of 
hayfever  or  any  other  allergic  condition. 

Bibliography 

1.  Round  Table  Conference  on  Allergy.  Venn.  Med.  Jour., 
43,  1081,  May,  1940. 

2.  Black,  W.  B.,  5.,  G.  &  0.,  68,  406.  Feb..  1939. 

3.  Wiener,  M.,  South.  Med.  Jour.,  28,  1011.  Nov.,  193S. 

4.  Appelbaum,  A.,  Arch,  of  Ophth.,  24,  803.  Oct..   1940. 

5.  Hurlbut,  J.  A.,  Wis.  Med.  Jour.,  38,  471.  June,  1939. 


SYNTROPAX   IN  PARKINSONISM. 

(N.   S.    Schlezinger  and    B    J.    Alpers,    Phila.,   in    Am.   Jl.   Med. 

Sc,    Mch.) 

Recently  it  has  been  generally  conceded  that  atropine 
and  the  closely  related  belladonna  preparations  constitute 
the  most  effective  forms  of  symptomatic  treatment  avail- 
able  at   the  present  time. 

A  group  of  16  patients  having  Parkinson's  disease  were 
treated  by  means  of  syntropan.  The  maximum  thera- 
peutic dose  has  been  determined  to  be  2400  mg.  daily. 
Of  14  patients  who  Were  potentially  capable  of  reaching 
this  dose,  in  10  mild  or  moderate  symptomatic  relief 
was  obtained  without  the  development  of  any  toxic  mani- 
festations. From  these  results  it  would  appear  that  syn- 
tropan is  useful  in  many  of  those  cases  where  atropine 
cannot   be  administered  because  of  toxic  symptoms. 


THE  USE  OF  A.  T.  10  IN  CHRONIC  TETANY 

(E    T.  Ryan  &  E.  P.  McCullagh,   Cleveland,  Ohio,  in   Ohio  Med. 

Jl.,  May  I 

In  tetany  A.  T.  10  is  often  more  effective  than  other 
method  of  treatment.  Danger  of  resultant  hypercalcemia 
makes  necessary  frequent  serum  calcium  and  phosphorous 
readings  during  the  period  of  initial  control. 

The  concurrent  use  of  large  doses  of  calcium  by  mouth 
increases  the  efficacy  of  A.  T.  10  and  lessens  the  amount 
required.  Only  rarely  is  it  necessary  to  initiate  treatment 
with  more  than  2  c.c.  per  day  and  maintenance  levels 
average  0.5  c.c.  to  0.75  c.c.  on  alternate  days. 


June.    1941 


SOUTHERN  MEDICINE  &  SURGERY 


DEPARTMENTS 


HUMAN  BEHAVIOUR 

James   K.   Hall,  M.  D.,  Editor,   Richmond,   Va. 


DR.  HEXRY  BATTLE  MARRIOTT 
For  at  least  two  hours  on  Saturday,  May  24th, 
I  behaved  just  as  if  time  were  not  a  reality  but 
only  a  sort  of  linguistic  nuisance.  As  I  was  passing 
through  Battleboro,  in  Edgecombe  County,  in 
North  Carolina,  I  stopped  for  communion  and  rem- 
iniscence with  my  friend,  Dr.  Henry  Battle  Mar- 
riott. Some  cynic  has  said  that  being  bored  is 
only  being  conscious  of  time.  But  one  can  have 
no  realization  of  time  while  one  is  with  Dr.  Mar- 
riott. He  has  lived  a  life  of  such  usefulness  to  his 
fellow-mortals,  and,  in  consequence,  of  such  satis- 
faction to  his  own  soul,  that  he  has  been  generally 
unmindful  even  of  the  existence  of  time. 

There  is  a  story  in  the  family  that  Dr.  Marriott 
finally  emerged  from  the  home,  where  he  had  been 
making  a  professional  call  for  at  least  two  hours, 
and  remarked  to  his  two  little  children  in  the 
buggy  that  the  sick  man  had  malaria.  But  his 
little  son  asked  if  he  had  been  waiting  for  the  sick 
man  to  have  a  chill.   "No,  son",  the  father  replied, 


"but  no  doctor  can  instantly  tell  what  is  the  mat- 
ter with  a  sick  person." 

That  remark  of  Dr.  Marriott,  made  many  years 
ago  to  two  of  his  little  children  as  they  were  ac- 
cumpanying  him  on  his  professional  rounds,  epi- 
tomized his  conception  of  his  duty  to  his  patients. 
Not  only  his  own  two  restless  little  children,  sit- 
ting impatiently  in  the  buggy  and  holding  the 
horse,  must  wait  until  their  father  had  satisfied  his 
medical  conscience  about  his  patient's  condition; 
not  only  must  his  own  little  children,  eager  to  be 
en  the  way,  await  their  father's  return,  but  all 
others,  too,  must  wait,  and  time  itself  must  be  for- 
gotten, until  Dr.  Marriott  could  find  out  what  was 
the  matter  with  the  sick  man. 

From  a  medical  father  he  had  inherited  a  sense 
of  his  professional  duty,  for  that  sacred  calling  he 
had  been  trained,  and  to  that  high  purpose  he  had 
made  his  avowal  of  life-service.  Though  his  step  is 
.not  so  springy,  nor  his  gait  so  steady  as  in  distant 
days,  his  eyes  twinkle,  he  laughs  heartily,  and  he 
is  without  self-reproach  and  without  fear;  for  he 
has  been  true  to  himself  and  he  has  given  himself 
generously  to  his  fellow-man. 

Some  of  the  events  associated  with  my  incursion 
into  my  native  state  tended  to  remind  me  of  the 
mutations  of  life.  The  journey  down  to  Rocky 
Mount  was  made  hurriedly  in  weather  all  but  in- 
tolerably hot.  In  the  evening  I  spoke  some  words 
to  a  group  of  graduating  nurses,  young,  vital, 
eager,  quick  and  enthusiastic,  and  ready  for  ser- 
vice in  peace  or  in  war.  And  before  midnight  had 
come  the  heat  had  gone  and  the  breezes  were  de- 
lightful. As  I  returned  on  the  next  day  I  enjoyed 
the  coolness,  and  the  retrogression  with  Dr. 
Marriott  into  other  days. 

Only  the  past  can  teach.  The  present  affords 
opportunity  for  correction  and  for  testing,  and  the 
future  encourages  hope  and  aspiration.  But  only 
the  past  offers  instruction.  I  sat  at  the  feet  of  Dr. 
Marriott.  I  had  been  stimulated  by  the  buoyant 
enthusiasm  of  the  young  nurses.  Youth  for  aspira- 
tion and  for  action;  age  for  contemplation  and  for 
retrospection.  How  balancing  and  how  stabilizing 
the  two  are — youth  and  age — the  same  thing, 
merely  either  the  more  or  the  less.  Youth  is  eager 
to  step  forward  into  the  unknown,  but  the  beckon- 
ing, future;  age  would  go  back  again  and  again 
into  that  past  out  of  which  it,  when  a  youth,  was 
so  eager  to  emerge. 

There  is  no  total  acceptance  of  things  as  they 
are.  Youth  would  have  them  now  as  they  are  to 
be;  age  would  have  things  once  again  as  they  once 
were.  It  is  well — well  that  youth  is  youth  and  age 
is  age.  One  chews  the  food  of  sustenance;  the 
other  the  cud  of  rumination. 

My  associations  with  many  of  the  physicians 
of  the  Carolinas  and  Virginia  during  the  years  of 


SOUTHERN  MEDICINE  &  SURGERY 


June.    1941 


my  secretaryship  of  the  Tri-State  Medical  Asso- 
ciation were  highly  agreeable.  Dr.  Marriott  re- 
minded me  that  I  had  induced  him  and  the  late 
Dr.  Cyrus  Thompson  to  come  into  the  Association 
at  the  same  time.  He  and  Dr.  Thompson,  though 
both  eastern  Carolinians,  had  never  met,  and  they 
became  devoted  friends.  Dr.  Marriott  still  chuckles 
about  some  of  the  Thompsonian  stories  as  he  did 
when  he  heard  Dr.  Thompson  tell  them. 

But  Dr.  Marriott  remembers  with  most  apprecia- 
tion the  progress  that  medicine  has  made  since  he, 
still  a  boy  only  twenty  years  of  age,  but  a  medical 
graduate,  visited  his  first  patient.  Born  in  Nash 
County,  in  1863,  the  same  discordant  year,  by  the 
way,  in  which  Jack  DaCosta  was  born,  he  was 
graduated  in  medicine  by  the  University  of  Mary- 
land in  1883.  Since  that  distant  day  Dr. 
Marriott  has  devoted  himself  to  the  practice  of 
medicine  at  Battleboro  and  in  the  parts  'round 
about  of  Edgecombe  and  of  Nash.  While  he  was 
still  scarcely  grown  the  responsibilities  of  a  gen- 
eral practitioner  came  upon  him.  In  his  early 
years  of  practice  typhoid  fever  was  prevalent; 
diphtheria  was  unmanageable  and  often  fatal;  ap- 
pendicitis was  beginning  to  be  heard  of;  the  term 
allergy  had  not  come  into  use  and  vitamins  were 
not  known.  Most  of  the  tuberculous  died,  and 
malaria  was  a  scourge.  The  cause  of  syphilis  was 
not  known.  The  x-rays  had  not  been  discovered 
and  radium  had  not  been  added  to  the  list  of 
known  elements.  There  were  few  hospitals  in 
North  Carolina  when  Dr.  Marriott  began  his  prac- 
tice. He  tells  of  some  astounding  recoveries  from 
grave  conditions  necessitating  operations  in  the 
homes.  Now  the  automobile  or  the  ambulance  can 
convey  most  patients  from  their  homes  to  nearbv 
hospitals.  In  his  early  days  the  roads  were  of  dust 
in  summer  and  of  mud  in  winter  and  travel  was  by 
horseback,  gig  or  buggy.  But  that  method  of 
travel  was  not  objectionable  to  him.  He  had 
grown  up  with  horses;  they  were  his  companions 
and  his  friends,  and  he  often  kept  racehorses. 
Only  recently  he  surprised  his  household  and  per- 
haps himself  by  deciding  all  at  once  to  go  again  to 
the  races  at  Saratoga. 

Before  he  was  twenty-one  he  was  a  medical 
licentiate:  before  he  was  twenty- four  he  had  mar- 
ried Miss  Emily  Pippen,  of  Tarboro,  and  she  is 
still  sprightly  and  alert,  though  the  mother  of 
five,  the  grandmmother  of  ten,  and  the  great 
grandmother  of  two! 

Few  intellectual  families  are  long  able  to  retain 
their  supremacy.  The  Battle  family  constitutes  an 
exception.  High  intelligence  and  wholesome  char- 
acter are  still  assets  of  most  of  them.  Dr.  Mar- 
riott's mother  was  a  member  of  that  vigorous  fam- 
ily. Though  her  husband,  Dr.  Robert  Henry  Mar- 
riott, died  rather  young,  she  reared  and  educated 


the  children  and  had  brought  one  son  into  medi- 
cine before  he  was  fully  grown.  Dr.  Cyrus  Thomp- 
son once  told  me  that  he  was  certain  the  three 
things  could  be  found  in  the  travelling  bag  of 
every  man-member  of  the  Battle  family  that  be- 
long in  the  luggage  of  every  gentleman — a  copy  of 
the  Book  of  Common  Prayer,  a  copy  of  Bacon's 
Essays,  and  a  small  flask  of  good  whiskey.  I  as- 
sured Dr.  Marriott  that  two  toddies  each  day  will 
do  him  only  good. 

Physician,  husband,  father,  citizen,  large  farmer, 
generous-hearted  lover  of  his  fellow-man.  Dr. 
Henry  Battle  Marriott  —  seventy-eight,  wise, 
kindly,  genial,  courageous.  His  wife,  his  four 
daughters,  his  son,  his  grandchildren  and  his  great 
grandchildren  thank  God  for  him  every  day  of 
their  lives.  Some  day  when  I  can  escape  from  the 
dominance  of  old  King  Chronos  I  am  going  again 
to  Battleboro  and  learn  of  Dr.  Marriott  what  hu- 
man nature  is  and  something  of  that  high  art  with 
which  the  family  doctor  deals  with  it. 

In  the  exchange  of  the  family  doctor  for  the 
specialist  the  sick  man  has  suffered  a  grievous  loss 
and  society  a  dreadful  deprivation.  I  cannot  think 
of  the  wise  and  kindly  old  village  doctor  down  in 
Battleboro  without  recalling  the  lines  of  Words- 
worth: 

"His  little,  nameless,  unremembered  acts, 
Of  kindness  and  of  love". 


SURGERY 


Geo.   H.   Bunch,  M.   D.,  Editor,   Columbia,   S.   C. 


THE  TREATMENT  OF  INGESTED  FOREIGN' 
BODY 

Except  in  infants  and  in  the  insane  the  inges- 
tion of  foreign  bodies  is  practically  never  inten- 
tional. Hair  balls  in  the  stomach  of  the  insane 
sometimes  reach  enormous  proportions  and  may 
contain  an  unbelievable  variety  and  number  of  for- 
eign bodies.  Fish-bone  is  the  most  commonly  in- 
gested foreign  body.  Stomach  secretion  of  normal 
acidity  will,  as  a  rule,  digest  fish-bone  before  it 
reaches  the  intestine.  It  is  surprising  that  most 
needles,  pins,  pieces  of  glass,  tacks,  bones  and 
other  sharp-pointed  rigid  objects,  by  becoming  in- 
corporated in  fecal  masses,  pass  through  the  intes- 
tinal tract  without  causing  symptoms. 

When  the  physician  is  consulted  soon  after  a  for- 
eign body  has  been  swallowed,  particularly  if  the 
patient  is  a  child  and  the  body  is  of  bone  or  of 
metal,  x-rays  should  be  used  to  be  sure  if  the  body 
has  been  swallowed.  The  mother,  unable  to  find  a 
misplaced  safety-pin.  thinks  the  baby  has  swallow- 
ed it.  As  an  ingested  pin  may  be  identified  in  the 
plate  its  relative  position  in  subsequent  pictures 
will  show  what  progress  it  has  made  in  the  intes- 
tine.   Instead  of  prescribing  potatoes  after  a  for- 


June,    1941 


SOUTHERN  MEDICINE  &  SURGERY 


eign  body  has  been  swallowed  the  patient's  ordi- 
nary diet  should  be  continued.  If  the  foreign  body 
is  sharp  bulky  foods  do  no  good  and  if  it  is  large 
they  tend  to  cause  obstruction.  Laxatives  should 
never  be  given. 

The  treatment  should  be  one  of  watchful  expect- 
ancy. Complications  making  surgical  intervention 
necessary  are  perforation  and  obstruction. 

It  is  estimated  that  only  one  per  cent  of  ingest- 
ed foreign  bodies  cause  perforation;  even  this  inci- 
dence is  too  high,  however,  for  the  physician  is 
not  even  consulted  about  the  ingestion  of  most 
bodies.  The  tendency  to  perforation  is  greater  in 
blind  segments  like  the  appendix  and  diverticula, 
in  loops  of  intestine  incarcerated  in  irreducible 
hernias. 

The  symptoms  are  those  of  perforation  from 
any  cause — pain,  tenderness,  fever,  leucytosis.  If 
localization  of  infection  occurs  an  abscess  forms  or 
an  inflammatory  mass  without  suppuration  devel- 
ops. Sometimes  the  foreign  body  migrates  and 
may  cause  an  abscess  far  removed  from  the  site  of 
perforation.  A  toothpick  has  been  found  in  a  liver 
abscess. 

The  treatment  is  entirely  surgical. 

Because  of  its  relatively  fixed  position  and  small 
lumen  obstruction  from  a  foreign  body  is  more  apt 
to  take  place  in  the  duodenum.  Vomiting  is  an 
early  and  a  persistent  symptom.  If  the  site  of  ob- 
struction is  high  distention  is  confined  to  the  epi- 
gastrium or  may  be  entirely  wanting.  If  relief  is 
not  obtained  by  continuous  decompression  of  the 
stomach  through  the  Levine  tube  immediate  opera- 
tion should  be  done  for  the  relief  of  the  obstruc- 
tion. 


CARDIOLOGY 

C.  M.  Gilmore,  M.D.,  Editor,  Greensboro,  N.  C. 


A  NEW  MERCURIAL  DIURETIC  FOR  ORAL 
ADMINISTRATION 

Although  parenteral  administration  of  mer- 
curial diuretics  always  has  been,  and  probably 
always  will  be  the  best,  oral  administration  is  ef- 
fective, and  in  chronic  cases  and  those  where  the 
patient  lives  far  from  a  physician,  it  is  much  more 
practicable.  Calomel  is  unsatisfactory,  as  frequent- 
ly mercurial  poisoning  ensues  before  enough  mer- 
cury is  in  the  kidneys  to  promote  diuresis.  Salyrgan 
and  mercupurin  by  mouth  are  worthless. 

In  the  American  Journal  oj  Heart  Disease  for 
January,  Batterman  et  al.  report  on  the  value  of  a 
new  mercurial  not  vet  on  the  market.  It  is  salyrgan 
combined  with  theophylline,  which  latter  drug  ap- 
parently makes  the  mercury  both  effective  and 
relatively  non-toxic.  The  dosage  is  5  tablets,  each 
of  which  contains  80  milligrams  of  salyrgan  (30 
mgms.  mercury)  given  usually  every  3  to  5  days. 


In  a  group  of  48  patients,  stabilized  on  rest,  digi- 
talis, ammonium  chloride  and  restricted  fluid  in- 
take, 29  were  given  the  tablets,  24  salyrgan-theo- 
philline  intravenously,  and  30  mercupurin  intra- 
venously. Mercupurin  suppositories  were  not  used, 
as  by  rectum  has  been  shown  to  be  inferior  to  by 
vein,  and  frequently  productive  of  rectal  irritation. 

A  loss  of  three  pounds  or  more  within  48  hours 
was  considered  a  good  effect.  The  parenteral  prep- 
arations were  more  consistently  effective,  working 
in  90  to  95  per  cent  of  the  cases;  the  oral  prepara- 
tion gave  satisfactory  results  in  12  per  cent  of  the 
cases;  suppositories  give  about  SO  to  60  per  cent 
good  results.  In  some  patients  a  good  response 
was  not  obtained  on  first  administration,  but  was 
obtained  on  the  next;  and  few  patients  were  con- 
sistently refractive  to  the  tablets.  The  onset  and 
the  peak  of  the  diuresis  was  usually  a  little  later 
with  the  tablets,  but  was  generally  complete  within 
24  hours.  Two  patients  had  a  diarrhea  and  one 
some  epigastric  discomfort,  but  none  of  them  was 
so  bothered  on  subsequent  administrations.  There 
were  no  signs  in  any  patient  of  renal  irritation. 

There  is  available,  then,  a  fourth  satisfactory 
method  of  obtaining  the  diuretic  effect  of  mercury. 
It  is  not  recommended  that  these  tablets  be  used 
routinely,  but  they  should  prove  very  convenient 
where  a  patient  chronically  ill  needs  a  mercurial 
diuretic  at  regular,  frequent  intervals,  and  in  those 
patients  who  are  unable  to  report  to  a  doctor  fre- 
quently. 


PROCTOLOGY 

Russell  von  L.  Buxton,  M.D.,  Editor,  Newport  News,  Va. 


In  presenting  a  department  of  Anorectal  Dis- 
eases, the  Journal  oj  Southern  Medicine  &  Surgery 
is  keeping  abreast  of  the  times,  and  no  apology  is 
being  offered  for  this  department.  In  no  branch 
of  medicine  can  neglect  lead  to  more  disastrous  re- 
sults and  in  no  other  branch  of  medicine  is  diag- 
nosis so  easy,  if  a  few  fundamental  rules  are  fol- 
lowed. The  importance  of  including  a  thorough 
rectal  examination  in  the  course  of  any  general 
physical  examination,  and  the  necessity  for  exam- 
ination before  advising  a  patient  who  presents 
himself  with  complaint  referable  to  the  lower 
bowel,  need  to  be  kept  constantly  in  the  front  of 
the  mind. 

The  examination  of  the  "itching  touch  hole" 
(Stokes)  should  be  undertaken  with  gravity  and 
with  proper  appreciation  for  the  feelings  of  the 
patient.  For  male  patients  the  knee  chest  position 
on  the  examining  table  provides  best  visibility  and 
makes  possible  an  adequate  digital  examination. 
For  women,  the  Sims  position  is  less  embarrassing 
and  will  suffice  for  an  ordinary  rectal  examination. 
The  Sims  position  should,  also,  be  used  for  very  ill 


SOUTHERN  MEDICINE  &  SURGERY 


June,   1941 


patients.  A  good  light  is  a  necessity,  and  inspec- 
tion of  the  area  is  first  done.  Any  changes  in  color 
of  skin  or  mucosa,  in  shape  or  conformity  should 
be  noted.  A  digital  examination  should  determine 
the  degree  of  spasticity  of  the  sphincter,  the 
amount  of  tenderness  at  the  anal  margin  and  the 
presence  or  absence  of  masses  in  the  rectum.  Fol- 
lowing digital  examination,  it  is  well  to  insert  a 
small  anoscope  into  the  rectum  so  that  any  changes 
of  the  mucosa  at  the  anal  margin  may  be  noted. 
While  proctoscopy  is  not  difficult,  it  is  best  left  to 
those  physicians  who  have  had  experience  in  th" 
use  of  the  proctoscope.  Familiarity  with  the  ap- 
pearance of  pathological  lesions  which  may  be 
present  in  the  bowel  mucosa  is  essential  to  proper 
diagnosis. 

During  all  phases  of  a  rectal  examination  par- 
ticular search  must  be  made  for  changes  in  the 
mucosa,  and  any  growths  or  abnormal  discharge. 
A  smear  for  Entamoeba  histolytica  should  be 
made  routinely,  as  the  diagnosis  is  often  missed 
and  symptomless  cases  are  not  rare.  If  an  abnor- 
mal quantity  of  mucus  is  found  to  be  present,  or 
if  blood  is  discovered  and  its  source  cannot  be 
ascertained,  proctoscopic  and  roentgenological  ex- 
aminations should  be  insisted  upon.  It  seems  need- 
less to  add  that  a  portion  of  any  growth  that  may 
be  discovered  should  be  removed  and  sent  to  the 
pathological  laboratory  for  section  and  microscopi- 
cal examination.  At  the  termination  of  a  rectal 
examination  it  is  often  worthwhile  to  insert  into 
the  rectum  a  small  amount  of  an  anesthetic  oint- 
ment, such  as  nupercainal  or  hasacaine. 

After  the  examination  is  completed,  the  patient 
should  be  allowed  to  dress,  and  then  should  be 
acquainted  with  the  findings  so  that  if  further  ex- 
amination or  treatment  is  indicated,  plans  for  it 
may  be  made  immediately. 


GENERAL  PRACTICE 

Walter  J.  Lackey,  M.D.  Editor,  Fallston,  N.  C. 


SOME  PROBLEMS   INVOLVED   IN   SELECT- 
ING AND  REARING  ADOPTED  CHIL- 
DREN 

Most  family  doctors  have  at  some  time  the  re- 
sponsibility of  advising  childless  couples  as  to 
whether  or  not  they  shall  adopt  children,  and  as  to 
the  child  to  be  chosen.  A  good  many  doctors  have 
the  responsibility  of  deciding  as  to  the  suitability 
of  certain  couples  for  the  role  of  adoptive  parents. 

The  psvchiatrist  sees  and  treats  enough  adopted 
children  in  their  late  teens  and  early  twenties  to 
perceive  a  number  of  ordinarily  unrecognized  fac- 
tors which  should  play  a  decisive  part  in  the  adop- 
tion of  the  child  and  his  subsequent  management. 
An    essay   on   this   subject    by   a   psychiatrist1   of 

1.   R.    P.   Knight,   in  Bull.   Menninger   Clinic.   Topeka,  May. 


large  experience  in  this  field  is  given  in  substance. 

Few  married  couples  consider  adopting  a  child 
in  the  absence  of  reasons  which  prevent  them  from 
having  a  child  of  their  own,  chief  of  which  is  ster- 
ility in  one  of  them — due  to  maldevelopment,  sur- 
gical removal  of  a  generative  organ,  or  natural  or 
artificial  menopause  from  surgery,  x-ray  or  disease. 
The  generative  organs  may  seem  to  be  normal, 
but  conception  does  not  occur,  even  though  no 
contraceptive  measures  are  used.  Not  infrequentlv 
a  childless  wife  becomes  pregnant  some  time  after 
adopting  a  child,  although  the  adoption  did  not 
take  place  until  the  couple  were  thoroughly  con- 
vinced conception  was  impossible;  and  then  the 
thought  comes  up  that  unconscious  opposition  to 
childbearing  might  have  been  responsible,  and  that 
this  unconscious  opposition  was  somehow  over- 
come by  the  experience  of  adopting  and  taking 
care  of  a  child.  Conscious  opposition  is  attributed 
to  convictions  that  they  cannot  afford  children, 
that  they  do  not  want  to  have  their  social  life  and 
freedom  from  responsibility  interfered  with;  even 
active  antagonism  to  children.  After  some  years 
may  come  realization  of  the  need  for  a  child  to 
make  a  home,  or  a  growing  feeling  that  the  mar- 
riage is  nearing  the  rocks  and  that  a  child  may 
avert  this  disaster.  The  unconscious  opposition, 
however,  has  not  changed  and  still  operates  to 
prevent  pregnancy. 

That  strong  opposition  still  lingers  may  be  man- 
ifested by  prolonged  indecision  as  to  just  when 
they  will  carry  out  the  adoption  or  by  rigid  speci- 
fications as  to  what  kind  of  child  will  be  accept- 
able. Such  a  couple  will  not  be  likely  to  make 
good  foster  parents,  for  they  will  tend  to  reject  the 
child  if  it  does  not  come  up  to  their  expectations  or 
if  the  previously  feared  loss  of  freedom  and  re- 
sponsibility become  burdensome. 

Agencies  have  control  of  the  situation  and  can 
rule  against  parents  in  whom  searching  interviews 
reveal  the  presence  of  strong  negative  feelings  re- 
garding children.  The  best  foster  parents,  other 
factors  being  equal,  are  those  couples  in  whom  the 
sterility  is  organic,  especially  if  they  had  and  lost 
a  child  prior  to  the  onset  of  the  organic  sterility, 
or  those  in  whom  the  functional  sterility  exists  in 
spite  of  sustained  and  consistent  desire  to  have  a 
child;  provided  the  child  is  not  desired  merely  to 
preserve  a  shaky  marriage. 

Requiring  that  the  child  be  "  'a  brown-haired, 
blue-eyed  boy  aged  two  and  one-half  with  dimples 
in  his  cheeks'  is  often  evidence  of  the  rigid  condi 
tions  on  which  they  reluctantly  lifted  their  boycott 
on  all  children;"  that  a  child  not  younger  than  a 
certain  age  may  be  evidence  of  the  mother's  re- 
pulsion regarding  toilet  training.  These  are  not 
good  omens  for  the  success  of  the  adoption. 

Sometimes  this  specifying  of  exact  characteris- 


June.    1941 


SOUTHERN  MEDICINE  &  SURGERY 


333 


tics  is  found  to  be  the  parents'  wish  to  find  a 
miniature  image  of  one  of  them  or  some  combina- 
tions of  them.  Parents  who  have  their  own  blood 
children  obtain  this  satisfaction  through  natural 
transmission  of  characteristics,  and  prospective 
foster  parents  may  expect  such  returns.  However, 
such  insistence  bodes  ill,  for  the  future  as  a  child 
who  may  almost  meet  exact  requirements  at  the 
time  of  his  selection  but  who  later  develops  char- 
acteristics which  do  not  suit  his  new  parents.  A 
healthier  attitude  insists  on  a  sound  body,  normal 
emotional  and  intellectual  development,  and  free- 
dom from  bad  inheritance. 

The  older  the  child  at  the  time  of  adoption  the 
surer  one  can  be  of  his  physical  and  mental  status. 
On  the  other  hand,  if  prospective  parents  do  not 
adopt  a  child  until  he  is  four  or  five  years  of  age, 
they  have  lost  the  chance  to  be  the  persons  to 
whom  he  made  his  first  emotional  attachments.  He 
comes  to  them  with  impressions  already  made  of 
whatever  adults  took  care  of  him,  and  he  will 
make  comparisons  between  his  previous  and  his 
new  "parents."  Then,  a  child  available  for  adop- 
tion at  age  four  to  five  very  likely  has  had  a 
somewhat  checkered  career,  usually  before  he  came 
into  the  hands  of  the  adoption  agency.  A  final 
important  risk  is  the  one  pertaining  to  the  feelings 
of  rejection  and  insecurity  arising  in  the  child  at 
the  disturbance  of  his  previous  home  arrange- 
ments, even  if  his  condition  is  greatly  improved 
by  the  change;  some  attachments  must  be  broken, 
and  a  child  of  four  or  five  is  acutely  aware  of  such 
a  change. 

The  best  advice,  probably,  would  be  for  the 
prospective  parents  to  decide  on  adopting  a  very 
young  baby  whose  background  is  well  known  to 
the  agency,  and  whose  careful  examination  reveals 
no  abnormalities.  It  is  likely  that  the  child  adopt- 
ed after  the  age  of  two  will  be  consciously  aware 
of  the  change  in  his  home  situation. 

It  is  a  common  occurrence  for  blood  children  to 
have  phantasies  that  they  are  only  adopted,  and 
that  their  "own"  parents  are  wonderfully  kind  or 
important  people.  Such  phantasies  often  occur 
after  the  child  has  been  denied  something  or  pun- 
ished or  otherwise  frustrated,  and  he  may  even 
express  to  his  parents  the  idea  that  he  is  not  their 
child  or  they  would  not  treat  him  so  badly;  or 
a.fter  hearing  that  one  of  his  schoolmates  is  adopt- 
ed he  may  come  home  and  ask  what  that  means 
and  then  seek  reassurance  that  he  is  not  adopted. 
Without  having  had  any  basis  for  suspecting  the 
fact,  their  adopted  child  may  have  similar  phanta- 
sies or  ask  similar  questions.  To  avoid  this  condi- 
tion of  continuous  dread,  and  especially  to  avoid 
the  eventuality  that  the  child  may  discover  the 
fact  and  confront  his  parents  with  it,  with  result- 
ant loss  of  faith  in  them,  it  is  much  better  to  in- 


form the  child  tha.t  he  is  adopted. 

When  should  he  be  told?  How?  Probably  as 
soon  as  he  can  comprehend  the  statement.  Very 
likely  he  will  forget  all  about  it,  but  as  he  devel- 
ops more  understanding  he  should  be  told  several 
more  times  until  he  thoroughly  comprehends  it. 
The  first  time,  some  time  in  the  fourth  year,  he 
should  be  told  a  story  about  a  daddy  and  mother 
who  didn't  have  any  children  of  their  own  and 
who  looked  and  looked  for  the  right  one  until  they 
found  a  baby  that  just  suited  them;  and  then  they 
took  it  home  and  loved  it, — and  so  on,  ending  with 
the  statement  that  they  had  gotten  him  in  that 
way,  too.  Each  time  that  the  child  is  told,  the 
same  atmosphere  should  surround  the  telling,  and 
never  should  the  child  be  reminded  that  he  is 
adopted  when  the  parent  is  feeling  angry  at  him. 
For  a  foster  parent  to  say  to  an  adopted  child, 
"I'm  sorry  I  ever  adopted  you"  is  as  much  of  a 
crime  as  for  a  blood  parent  to  say  to  a  child,  "I'm 
sorry  you  were  ever  born,"  or  "I  wish  you  were 
dead." 

It  is  easy  for  him  to  reinterpret  their  disciplin- 
ary efforts  as  evidence  that  they  do  not  and  never 
have  loved  him,  and  that  they  have  been  mistreat- 
ing him  in  a  way  his  real  parents  would  never  have 
done;  and  with  realization  that  they  are  not  re- 
lated to  him  comes  the  feeling  that  he  owes  them 
no  blood  allegiance,  and  his  resentments  can  ex- 
pand into  ill-concealed  or  open  hostility  and  de- 
fiance. 

Every  parent  with  several  children  realizes  that 
there  are  countless  times  when  a  child  is  annoying 
in  small  ways,  and  a  considerable  number  of  times 
when  the  child's  perverse  or  antisocial  behavior  is 
alarming.  The  child's  sexual  activities  may  be  dis- 
turbing or  his  untruthfulness  or  dishonesty  in  mat- 
ters of  money  or  property  may  arouse  concern.  In 
blood  parents  such  misbehavior  does  not  ordinarily 
arouse  any  alarming  thoughts  about  bad  inheri- 
tance. With  adoptive  parents,  however,  the  be- 
havior of  their  adopted  child  is  due  to  bad  inheri- 
tance the  idea  may  not  be  so  unwelcome,  for  it  is 
a  convenient  method  of  sparing  themselves  any 
feeling  of  guilt  at  not  having  brought  him  up  bet- 
ter and  at  their  own  anger  about  it.  So  these  foster 
parents,  discussing  between  themselves  this  sup- 
posed "outcropping"  of  bad  inheritance,  may  de- 
cide that  strenuous  remedial  measures  are  indi- 
cated. 

There  are  far  more  demands  for  children  to 
ndopt  than  the  agencies  can  fill.  Pre-adoption  con- 
siderations for  prosp"ctive  parents  and  adoption 
agency  must  include  the  factor  of  why  the  prospec- 
tive parents  want  a  child,  why  they  have  no  child 
of  their  own,  and  what  their  real  attitudes  are 
about  children.  After  the  adoption  has  been  ef- 
fected, the  parents  have  to  be  prepared  for  some 


SOVTHERX  MEDICI  SE  &  SURGERY 


June.    1941 


difficulties  to  be  anticipated,  especially  the  reac- 
tions in  themselves  and  in  the  child  to  the  knowl- 
edge that  the  child  is  not  their  own.  They  must 
tell  the  child  early  and  often,  always  with  pleasur- 
able connotations,  that  he  is  adopted:  they  must 
be  prepared  to  comprehend  with  tolerance  the 
child's  outbursts  of  hostility  and  his  various  per- 
verse acts,  realizing  that  all  normal  children  ex- 
hibit these  things.  They  must  never  express  to  the 
child  in  any  way  feelings  of  regret  that  they 
adopted  him  or  attribute  his  misbehavior  to  his 
not  being  their  own  child:  and  they  must  even 
avoid  thinking  within  themselves  that  his  behavior 
is  alien  and  attributable  to  inheritance.  Forewarn- 
ed in  these  respects,  possessed  of  a  natural  toler- 
ance and  affection  for  children,  there  is  no  reason 
why  foster  parents  may  not  successfully  rear  a 
child  who  is  not  their  own. 

The  information  Dr.  Knight  gives  us  may  well 
enable  any  one  of  us  to  so  advise  as  to  cause  wise 
decision  in  a  matter  vitally  affecting  the  happiness 
of  at  least  three  persons.  It  is  worthy  of  careful 
study. 


TUBERCULOSIS 

J.  Donnelly,  M.  D.,  Editor,  Charlotte,  N.  C. 


THE  PHYSICAL  EXAMINATION  IN 
PULMONARY  TUBERCULOSIS 

The  stethoscope  was  introduced  by  Laennec 
in  1816,  and  foundation  of  modern  physical  diag- 
nosis laid  by  him  in  1819;  then  followed  by  the 
text  on  physical  diagnosis  by  Austin  Flint  in  1856. 
which  served  for  many  years  as  the  standard  guide 
in  diagnosis  of  pulmonary  diseases. 

Laennec  understood  the  role  of  scar  tissue  in 
healing  in  tuberculosis.  He  recognized  the  latency 
of  the  disease,  and  was  the  first  to  describe  bron- 
chiectasis. Austin  Flint  introduced  the  term, 
broncho-vesicular  breathing,  and  the  recordings  of 
his  physical  examinations,  written  nearly  one  hun- 
dred years  ago,  are  far  more  complete  and  more 
carefully  done  than  those  produced  in  our  so-called 
modern  era. 

In  the  last  few  years  the  introduction  and  wide- 
spread use  of  the  x-ray  film  in  the  diagnosis  of 
diseases  of  the  lungs  has  pushed  physical  diagnos- 
tic procedures  into  the  background,  and  such  pro- 
cedures seem  to  be  rather  rapidly  becoming  a  lost 
art. 

The  x-ray  film  in  diagnosis  is  one  of  the  most 
valuable  additions  to  the  medical  armamentarium 
of  all  time.  However,  the  physical  examination 
still  has  an  important  place  in  the  recognition  of 
pulmonary  disease;  much  necessary  information 
which  cannot  be  supplied  by  the  x-ray  film  can  be 
obtained  by  its  means.   The  x-ray  film  is  essential 


to  the  diagnosis  of  primary  tuberculous  lesions, 
healed  and  active,  in  children  and  in  young  adults; 
since  such  infections  seldom  show  symptoms,  and 
only  in  the  rarest  instances  do  the  lesions  show  any 
auscultatory  evidences  of  disease.  Often  also  the 
adult  type  of  pulmonary  tuberculosis  in  teen-age 
children  gives  no  physical  signs.  The  film  is  of 
great  value  also  in  visualizing  small  lesions  difficult 
or  impossible  to  detect  by  the  physical  examina- 
tion, although  the  examination  and  the  symptoms. 
if  any,  should  be  correlated  with  the  films  in  arriv- 
ing at  the  final  diagnosis. 

The  three  requisites  of  a  proper  physical  exam- 
ination: (1)  mental  concentration  on  the  subject 
in  hand,  (2)  allowance  of  sufficient  time  for  the 
proper  evaluation  and  recording  of  the  physical 
signs  and  symptoms,  and  ( 3 )  an  examining  room 
as  quiet  and  free  from  extraneous  noises  as  possi- 
ble. Some  examiners  claim  that  thev  are  able  by 
concentration  to  disregard  outside  noises  during 
the  performance  of  chest  examinations,  but  the 
more  quiet  the  examining  room  the  better  the  re- 
sults. Time  must  be  allowed  for  baring  the  chest 
completely  and  for  the  work  to  be  thoroughly 
done.  It  seems  in  order  to  emphasize  a  few  find- 
ings. Noticeable  prominence  of  the  clavicles  and 
sloping  of  the  shoulders  suggest  apical  contrac- 
tions; contraction  of  the  lower  ribs,  unilateral  or 
bilateral  pleural  thickening  and  adhesions;  defi- 
ciency of  chest  expansion,  and  expansion  not  equal 
on  th«  two  sides,  lagging  in  expansion  over  certain 
areas — underlying  pleural  adhesions,  or  the  forma- 
tion of  varying  degrees  of  fibrosis  in  the  lung 
itself;  and  the  widening  or  narrowing  of  the  inter- 
costal spaces,  or  asymmetrical  bulging  of  the  ribs 
— these  are  a  few  of  the  visible  indications  of  dis- 
ease. 

Percussion,  though  the  least  valuable  method, 
properly  performed  will  give  much  information. 
The  light  stroke  is  preferable.  In  consolidated 
areas,  in  addition  to  the  dullness,  the  finger  can 
detect  a  certain  vibration  in  the  percussed  area, 
while  over  pleural  effusions  there  is  resistance 
without  vibration.  In  atelectatic  conditions  the 
heart  and  mediastinum  will  be  displaced  toward 
the  diseased  side;  in  pleural  effusions,  toward  the 
sound  side.  Yarving  degrees  of  impaired  resonance 
can  be  detected  over  areas  of  thickened  pleura 
and  fibrotic  areas  in  the  lung  itself,  always  remem- 
bering that  in  health  the  resonance  over  the  right 
apex  is  always  less  than  that  over  the  left.  Increase 
of  tactile  fremitus  over  consolidated  areas  and  de- 
crease to  absence  over  pleural  effusions  serves  well 
in  many  cases.  Normally  tactile  fremitus  over  the 
right  apex  is  slightlv  greater  than  over  the  left. 

The  most  valuable  method,  auscultation,  requires 
the  utmost  in  mental  concentration,  and  requires 
more  or  less  continuous  use  for  the  making  of  the 


June.    1941 


SOUTHERN  MEDICINE  &  SURGERY 


fine  distinctions  required.  The  rale  is  the  most 
widely  recognized  physical  sign  of  pulmonary  tu- 
berculosis, but  there  are  other  stethoscopic  evi- 
dences of  the  disease  quite  as  important.  To  say 
the  tuberculous  rale  is  persistent  does  not  mean 
that  it  is  continuously  present  in  a  certain  area. 
After  cough  it  may  disappear,  to  return  later  to 
the  same  area  and  be  again  recognized  at  a  subse- 
quent examination.  Many  times  rales  are  present 
on  ordinary  or  deep  breathing,  while  in  other  cases 
they  can  be  elicited  only  on  inspiration  following 
expiratory  cough.  No  examination  for  pulmonary 
tuberculosis  can  be  considered  thorough  without 
the  use  of  the  expiratory  cough.  Care  is  to  be 
taken  to  note  any  areas  of  prolongation  of  expira- 
tion as  compared  to  the  normal  4-to-l  ratio  of 
inspiration  to  expiration  and  of  roughening  of  the 
inspiratory  sound.  There  are  grades  of  this  change 
of  ratio,  from  the  broncho-vesicular  breathing  of 
Austin  Flint  to  the  bronchial  type  in  which  the 
expiratory  sound  may  be  longer  than  the  inspira- 
tory. These  abnormal  breath  sounds  indicate  dif- 
ferent degrees  of  condensation  of  pulmonary  tissue 
bv  fibrotic  change  or  consolidation. 

Increase  or  decrease  in  volume  of  transmission 
of  the  whispered  voice  is  of  very  great  value.  Whis- 
pered pectoriloquy  is  usually  distinctive  of  cavity 
formation,  although  it  may  be  present  over  dense, 
rather  extensive  areas  of  consolidation.  Transmis- 
sion of  the  whispered  voice  is  decreased  as  a  rule 
in  pleural  effusions  and  spontaneous  pneumothorax, 
but  the  latter  condition  mav  be  recognized  by  the 
hyperresonant  percussion  note,  in  contra-distinc- 
tion  to  the  wooden  dullness  present  over  pleural 
effusions. 

Every  case  of  suspicion  of  tuberculosis  requires 
examination  of  the  sputum:  but  a  single  specimen 
being  negative  for  tubercle  bacilli  should  never  be 
accepted  as  ruling  out  tuberculosis.  Tubercle  ba- 
cilli never  appear  in  the  sputum  unless  there  has 
been  some  caseation  and  destruction  of  pulmonary 
tissue,  and  in  many  cases  this  process  has  not  yet 
occurred. 

The  repetition  of  a  few  of  the  basic  principles 
of  trr-  physical  examination  of  the  lungs  has  been 
made  in  this  short  article  in  the  hope  that  the 
waning  interest  in  this  diagnostic  method  may  be 
revived.  The  modern,  precision-machine  method 
of  diagnosis  should  not  eliminate  or  cast  into  the 
background  the  physical  examination  which  has 
served  us  so  well  in  previous  years.  Physical  diag- 
nosis can  give  us  a  mass  of  valuable  information 
which  the  x-ray  film  cannot  supply,  and,  conse- 
quently, should  never  be  assigned  to  a  minor  role 
in  medical  practice. 


DENTISTRY 


J.   H.   Guion,    D.  D.  S.,   Editor,   Charlotte.    N.    C. 


ON  DENTAL  FOCAL  INFECTION 

Some  say  much,  some  say  little,  disease  is 
caused  by  focal  infection.  Opinion  as  to  which  or- 
gan is  the  source  of  the  greatest  number  of  cases  is 
divided.  A  German  dentist  makes  what  is  prob- 
ably a  fair  statement  of  the  case. 

A  careful  examination  with  application  of  all 
available  tests  should  be  made  in  order  to  rule  out 
all  other  pathologic  conditions  before  assuming  fo- 
cal infection.  The  minimum  requirements  before  a 
diagnosis  of  focal  infection  include  always  a  cer- 
tain blood  picture  and  sedimentation  rate,  if  possi- 
ble with  the  figures  after  1,  2,  3  and  24  hours, 
and  record  of  the  rectal  temperature  mornings  and 
evenings  for  several  days. 

In  endocarditis,  glomerulonephritis,  rheumatic 
fever  and  acute  septicemia,  focal  infection  is  to  be 
suspected.  In  chronic  cases,  the  diagnostic  signifi- 
cance of  even  the  slightest  increase  of  the  rectal 
temperature  and  of  slight  tachycardia  should  be 
emphasized.  The  blood  sedimentaton  rate  will 
usually  show  a  slight  increase,  particularly  in  the 
figure  after  one  hour.  The  blood  picture  will  show 
a  slight  shift  to  the  left.  None  of  these  signs  is  in 
itself  significant;  a  combination  of  them  justifies 
the  assumption  of  a  likelihood  of  focal  infection. 
The  diagnosis  will  be  supported  when  regional  en- 
larged and  tender  lymph  glands  are  found  or 
Slauck's  phenomenon  of  muscle  fibrillations.  As 
accurate  a  diagnosis  as  possible  should  be  made 
before  sending  the  patient  to  the  dentist,  as  the 
pulling  of  a  number  of  teeth  is  no  minor  affair  and 
no  success  can  be  guaranteed. 

Any  tooth  with  a  dead  pulp  has  to  be  taken 
into  consideration  as  a  possible  focus,  and  the 
roentgenogram  is  only  of  limited  diagnostic  value, 
as  a  granuloma  may  be  projected  into  the  root  of 
a  tooth  and  thus  not  visualized. 

As  a  rule  the  roentgenogram  will  show  a  number 
of  teeth  with  granulomas  or  cysts  and  the  question 
will  arise  whether  one  or  several  active  foci  are 
present;  the  situation  becomes  even  more  compli- 
cated as  it  has  been  shown  that  teeth  without 
granulomas  may  nevertheless  be  carriers  of  focal 
infection.  The  roentgenogram  is  indispensable  for 
the  discovery  of  cysts,  impacted  roots,  and  residual 
granulomas  which  cannot  be  diagnosed  by  any 
other  method. 

There  is  no  method  by  which  the  activity  of 
granulomas  or  of  teeth  withoul  pulp  can  be  deter- 
mined with  certainty. 


1.  Tauchert,    Munch. 
Wed.  Dig.,  April. 


■d.     Woch.,     H 


SOUTHERN  MEDICINE  &  SURGERY 


June,    1941 


In  exceptional  cases,  even  living  teeth  may  have 
to  be  taken  into  consideration  as  a  cause  of  focal 
infection,  particularly  if  they  are  surrounded  by 
deep  gingival  recesses  in  which  secretions  may  be 
retained. 

Thorough  examination  of  the  paranasal  sinuses, 
the  nose,  the  ears  and  the  tonsils  should  always 
precede  sanitation  of  the  teeth. 

Not  even  extraction  of  a  tooth  guarantees  re- 
moval of  the  focus,  as  closed  residual  granulomas 
^nd  radicular  cysts  may  be  found  after  extraction. 
When  anterior  teeth  are  involved,  resection  of  the 
apices  of  the  roots  is  often  carried  out  in  order  to 
save  the  tooth;  this  operation  must  be  preceded  by 
careful  treatment  of  the  root,  and  is  less  reliable 
than  extraction  but  will  often  be  successful. 

The  author  is  of  the  opinion  that  dental  focal 
infection  is  more  frequent  than  all  other  types  to- 
gether, including  the  tonsils. 

Failures  may  be  due  to  inaccurate  diagnosis,  to 
psychic  inhibitions  against  radical  measures,  or  to 
the  fact  that  independent  metastases  are  present 
which  are  not  influenced  by  elimination  of  the  pri- 
mary focus.  Activation  of  hitherto  latent  foci 
must  be  taken  into  consideration. 


INSURANCE  MEDICINE 


PUBLIC  HEALTH 

N.  Thomas  Ennett,  M.D..  Editor,  Greenville,  N.  C. 


SWIMMING  AS  RELATED  TO  PUBLIC 
HEALTH 

With  warm  weather  comes  the  swimming  sea- 
son. 

The  beach,  the  municipal  swimming  pool,  and 
the  "old  swimmin'  hole"  are  patronized  by  a  large 
percentage  of  the  general  population,  the  younger 
age  group,  of  course,  predominating.  All  people 
think  of  swimming  as  a  delightful  pastime  but  few 
think  of  it  as  a  dangerous  pastime. 

In  addition  to  its  being  responsible  for  many 
deaths  by  drowning  each  year,  it  is  also  responsi- 
ble for  much  disease. 

Polluted  water  can  be  responsible  for  typhoid 
fever,  middle-ear  disease,  sinus  disease  and  certain 
kinds  of  skin  disease. 

So  important  is  it  that  the  public  know  the 
dangers  that  accompany  swimming,  it  is  our  con- 
viction that  the  health  officer  should  inform  the 
public  through  the  daily  press  and  the  radio  and 
that  the  family  physician  should,  in  the  swimming 
season,  in  his  daily  rounds  sound  a  note  of  warn- 
ing or  at  least  a  note  of  caution  to  the  families 
who  look  to  him  for  health  and  safety  advice. 

Of  course,  the  main  object  of  this  article  is  to 
enlist  the  active  cooperation  of  the  private  physi- 
cian in  this  public  he?,lth  problem  for  in  the  last 
analysis  it  is,  as  it  should  be,  the  family  physician 
and  not  the  health  officer  to  whom  the  individual 
looks  for  advice  and  guidance. 


For  this  issue,  Harry  Dingman,  M.D.,  Chicago 

Vice   President  and   Medical   Director 

Continental    Assurance   Company 

Medicine  has  developed  many  specialties 
through  the  ages,  not  the  least  interesting  of  which 
is  prognosis.  Prognosis  has  never  become  a  clinical 
specialty,  but  it  is  the  foundation  of  insurance 
medicine.  Differing  from  other  medical  specialties, 
insurance  medicine  has  its  basis  in  averages.  The 
insurance  medical  man  makes  no  effort  to  foretell 
length  of  life.  He  accepts  a  risk  with  no  thought 
as  to  how  many  years  the  individual  may  live. 
He  ventures  no  opinion  on  expectation  of  life. 
What  he  does  prognosticate  is  expectation  of  death. 
The  medical  director  thinks  of  an  applicant  as 
multiplied  by  a  thousand,  and  tells  his  company 
what  mortality  results  may  be  expected  according 
to  the  law  of  averages.  He  makes  his  calculation 
on  whether  there  may  be  ten  deaths  a  thousand 
annually — as  might  be  expected  at  age  41  by  the 
American  Experience  Table — or  twenty  deaths  a 
thousand,  which  would  be  200  per  cent  mortality. 

If  ten  deaths  annually  are  expected  in  any  par- 
ticular group  of  a  thousand  risks,  990  will  be  living 
at  the  end  of  a  twelve-month  period.  With  200  per 
cent  mortality,  there  will  be  980  living  after  one 
year,  and  after  ten  years  this  same  200  per  cent 
mortality  group  would  have  200  deaths,  plus  a 
few  more  because  the  group  is  growing  older.  There 
would  remain  almost  800  who  conceivably  continue 
to  pay  premiums;  and  it  is  the  premium-paying 
members  of  the  group  whose  money,  with  due 
allowances  for  interest  and  expenses,  must  pay  the 
claims  in  their  class. 

Many  factors  determine  appraisal  of  a  risk,  per- 
haps none  more  important  than  heredity.  The 
formula  for  attaining  old  age  is  to  make  careful 
selection  of  one's  parents  and  grandparents.  It  is 
a  perpetual  surprise  to  insurance  selectors  how  lit- 
tle our  applicants  know  about  their  forebears. 
Heredity  might  seem  to  be  that  phase  of  insur- 
ability where  insurance  would  have  built  the  most 
dependable  statistics.  A  vast  experience  might  be 
expected  to  have  been  available  since  1762  when 
the  Equitable  Society  of  England  started  life  in- 
surance selection  on  a  scientific  basis,  but  we  have 
more  accurate  knowledge  of  the  effect  of  heredity 
on  barnyard  animals  than  on  humans.  The  major- 
ity of  insurance  applicants  cannot  give  dependable 
information  concerning  their  grandparents,  and  far 
more  than  a  few  are  uninformed  about  their  own 
parents,  why  they  died  if  they  did  die,  what  their 
health  is  if  they  still  live.  Insurance  records  on 
family  history  have  so  much  "don't  know,"  so 
much  misinformation  where  applicants  refuse  to 
admit  cancer  and  tuberculosis  and  many  other 
things,  that  the  statistics  have  a  limited  value. 


June,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


Personal  history  comes  to  us  more  dependably. 
•  The  individual  may  not  know  about  father  and 
grandfather — they  were  born  to  die  anyhow — but 
he  is  deeply  concerned  with  himself,  and  can  re- 
member all  he  thinks  he  should.  Occasionally  an 
applicant  forgets  to  remember  about  going  west 
for  his  health,  about  a  prostate  that  bothers  him, 
about  an  annoying  dyspepsia.  Accordingly  very 
satisfactory  statistical  experience  has  been  built 
on  impairments  such  as  pleurisy  and  peptic  ulcer 
where  our  reliance  for  the  basic  information  is  on 
personal  history  as  given  by  the  individual. 

Most  dependable  of  all  statistics  are  those  that 
pertain  to  physical  factors  measurable  with  rea- 
sonable accuracy.  Time  and  space  permit  com- 
ment on  two  such  impairments,  height  and  weight. 
It  is  easy  to  determine  exact  height  with  shoes  on, 
exact  weight  with  ordinary  clothes  on.  A  huge 
experience  tells  with  almost  uncanny  accuracy 
what  the  mortality  will  be  if  the  applicant's  build 
is  5.11.120,  and  what  it  will  be  if  5.  11. 220.  The 
women  are  upsetting  calculations  a  little  because 
they  insist  on  being  slimmer  than  their  mothers 
and  their  aunts,  and  what  was  average  for  Aunt 
Bella  makes  present-day  Mary  Jane  Smith  look 
like  a  fatty.   That  is  how  she  feels  about  it. 

Blood-pressure  has  had  many  statistical  studies 
by  insurance  medical  men  in  association  with  their 
actuaries.  Dr.  J.  W.  Fisher  reported  on  19,339 
Northwestern  Mutual  cases  in  1911-14;  Dr.  L.  F. 
Mackenzie  on  18,637  Prudential  cases  in  1915; 
Dr.  Oscar  Rogers  and  Arthur  Hunter  on  67,000 
New  York  Life  cases  in  1919;  Dr.  Brandreth 
Symonds  on  150,419  Mutual  Life  cases  in  1922. 
From  these  data  on  mor-  than  a  quarter  million 
persons,  it  became  manifest  that  120  systolic  is 
average  at  age  20,  124  at  aie  30,  128  at  a-ze  40, 
132  at  age  50,  135  at  age  60.  The  old  time  rule 
of  100  plus  your  age  went  into  the  discard. 

Average  is  not  necessarily  normal,  of  course. 
We  may  may  be  average  individuals  in  letting  our 
arteries  harden  up  with  age.  but  hard  arteries  are 
not  normal  arteries.  So  135  systolic  may  be  aver- 
age at  age  60,  but  who  wouldn't  prefer  the  driving 
efficiency  of  the  cn-culation  that  120  indicates? 
Few  of  us  are  strictly  normal.  Most  of  us  are 
more  or  less  average.  If  a  little  better  than  aver- 
age, perhaps  we  are  standard.  A  standard  risk,  in 
insurance  terminology,  is  an  average  risk  with 
leaning  toward  the  normal  side.  When  an  actuary 
figures  the  premium  rates  that  we  must  pay  to  gH 
our  life  insurance  policies,  he  requires  a  mortality 
table,  a  compound  interest  table,  and  a  schedule 
of  expenses  that  shnws  how  much  it  costs  to  pay 
the  agent  and  the  medical  examiner  and  the  printer 
and  the  clerk  who  sends  notices,  and  the  taxes.  He 
realizes  that  the  premium  would  be  lower  at  age 
60  if  systolic  120  were  average,  rather  than   135; 


but  he  has  to  calculate  rates  on  conditions  as  are, 
rather  than  as  might  be,  glad  to  modify  his  calcu- 
lations by  recognition  that  the  age  60  group  un- 
doubtedly does  have  many  120  systolics.  His 
standard  rate  leans  on  the  normal  side  of  average. 
It  is  understood,  of  course,  that  blood-pressure  is 
used  illustratively  as  one  of  many  factors  that 
concern  the  appraisal  of  a  risk. 

In  1939  appeared  a  Blood-pressure  Study  so 
large  that  it  involves  1.309.000  policies  with  49,098 
deaths.  It  is  highly  informative  on  what  happens 
when  systolic  is  high,  diastolic  is  high,  either  or 
both.  It  suggests  strongly  that  149/90  is  sub- 
standard: the  mortality  result  for  all  ages  com- 
bined was  126  per  cent.  Which  means  there  were 
126  deaths  in  a  group  of  (say)  10,000  persons 
where  100  would  be  expected  if  they  had  been 
average.  Think  of  it  as  a  medium-size  town  with 
126  funerals  a  year  where  100  might  be  consid- 
ered usual.  When  blood-pressure  readings  were 
145/90  the  mortality  ratio  was  159.  When  150/ 
100,  mortality  ratio  was  223. 

Certain  associated  factors  are  strongly  influenc- 
ing. Interrelationship  of  some  impairments  may 
be  simply  addative  in  their  effect  on  mortality. 
Some  may  actually  offset  each  other,  as,  for  in- 
stance, tuberculosis  in  the  overweight.  But  hyper- 
tension in  the  overweight  has  an  accelerative  effect. 
The  heavy-set  person  who  is  hypertensive  has  an 
early  rendezvous  with  his  forefathers,  who  very 
probably  were  themselves  heavy-set  and  hyperten- 
sive. Heredity  endows  us  with  our  physical  char- 
acteristics and  that  involves  such  vital  factors  as 
integrity  of  circulation  and  efficiency  of  metabol- 
ism, as  well  as  the  more  esthetic  attributes  of  color 
of  eyes  and  shape  of  nose. 

Interrelationship  of  impairments  is  an  absorb- 
ing study.  In  these  1939  blood-pressure  statistics 
were  20,210  cardiovascular-renal  deaths.  The 
death  rate  advanced  relentlessly  as  systolic  read- 
ings went  up,  equally  surely  as  diastolic  readings 
went  up.  That  fact  might  well  have  been  anticipated. 
But  the-  same  relationship  showed  when  diabetes 
deaths  were  analyzed.  So  also  cirrhosis  of  the 
liver.  The  cancer  death  rate  advanced  as  systolic 
pressure  showed  higher:  as  diastolic  went  up  the 
death  rate  went  down.    Now  why  would  that  be? 

And  what  is  the  explanation  of  2,850  suicides? 
The  death  rate  decreased  as  systolic  readings  went 
higher.  Would  it  be  because  suicide  is  associated 
with  the  hypotensive  states  of  depression  and  mel- 
ancholy? Then  why  did  the  suicide  rate  go  up  as 
diastolic  readings  were  higher? 

Insurance  medicine  asks  many  questions  that  it 
cannot  answer.  In  a  sense  insurance  is  group  med- 
icine, non-therapeutic  group  medicine  with  empha- 
sis on  prognosis.  Yet  it  requires  appraisal  of  each 
individual  even  as  clinical  medicine.   A  group  has 


SOITHER.X  MEDICI\E  &  SURGERY 


June,   1941 


its  component  parts  and  each  individual  has  to  be 
assessed  before  assigned  to  his  class.  If  properly 
classified,  the  individual  necessarily  partakes  of 
whatever  advantages  and  hazards  the  class  has. 
As  these  results  become  known  in  mortality  studies, 
we  apply  the  experience  of  the  past  to  the  present- 
day  individual  in  scientific  endeavor  to  prognosti- 
cate the  future. 


THERAPEUTICS 

J.  F.  Nash,  M.  D.,  Editor,  Saint  Pauls,  N.  C. 


TREATMENT  OF  FRESH  BURNS  WITH 

SCARLET  RED  BANDAGE  AND  MOIST 

SULFANILAMIDE  DRESSINGS 

The  tannic-acid  spraving  of  burns  is  a  great  im- 
provement over  former  methods  of  treatment.  It 
is  not  as  satisfactory  as  some  of  its  proponents 
represent  it  to  be.    Few  measures  are. 

A  means  of  treatment1  which  appears  to  be 
worthv  of  trial,  and  which  we  are  now  using  hope- 
fully is  outlined. 

General  anesthesia  raav  be  necessary  for  the 
cleansing  of  grossly  soiled  burns;  topical  anesthe- 
sia with  metacaine,  2  per  cent,  frequently  suffices, 
and  in  those  fairly  clean  the  opiate  alone  furnishes 
adequate  analgesia  for  gentle  debridement  and  re- 
moval of  surface  contamination,  by  use  of  sterile 
soap  solution,  gentle  friction  with  gauze  dressings 
and  forceps  and  scissors.  Be  as  careful  to  prevent 
introduction  oj  bacteria  as  in  handling  exposed 
viscera.  Preparation  should  include  the  usual  sur- 
gical scrubbing  oj  hands  and  use  oj  cap,  gown  and 
mask. 

The  most  widely  used  cover  for  the  prepared 
burned  surface  is  some  forms  of  coagulum.  such  as 
tannic  acid,  gentian  violet.  An  alternative  method 
is  described  which  has  given  excellent  results. 

The  surgically  prepared  burned  surface  is  first 
overlaid  with  strips  of  sterile  scarlet  red  bandage 
which  extend  considerably  bevond  the  limits  of 
the  burn,  or  in  the  case  of  an  extremity  may  en- 
circle the  limb.  Over  this  is  laid  a  massive  sterile 
pad  of  gauze  and  cellulose  cotton  which  is  mois- 
tened before  application  with  a  freshly  boiled  1- 
VA  per  cent  solution  of  sulfanilamide  in  water. 
Such  solutions,  being  supersaturated,  precipitate 
out  in  the  dressing.  The  moistened  pad  is  applied 
after  it  is  sufficiently  cool,  then  covered  with  waxed 
paper  and  bandaged  in  place  with  an  elastic  band- 
age prepared  by  slitting  2  in.  stockinette.  Adhesive 
strips  may  be  used  to  help  anchor  the  finished 
dressing. 

Leave  undisturbed  until  healing  of  areas  of  sec- 
ond-degree bum  is  complete  unless  systemic  or 
local  evidences  of  infection  occur.    Burns  uncov- 


ered after  8  to  10  days  may  be  found  healed  com- 
pletely except  in  areas  of  third-degree  involvement. 
Scarlet  red  bandage  is  kept  under  gentle  counter 
tension  to  prevent  separation  from  the  underlying 
surface. 

If  healing  is  complete  the  scarlet  red  bandage 
will  be  found  to  be  dry  and  it  can  be  carefully 
removed.  If,  however,  the  central  area  is  moist  it 
is  indicative  of  incomplete  healing.  If  not  obvious- 
ly purulent  the  scarlet  red  bandage  is  not  disturb- 
ed and  a  second  massive  dressing  moistened  with 
sterile  sulfanilamide  solution  is  applied  for  several 
days. 

Obviously  infected  areas  encountered  in  any 
stage  of  the  management  are  treated  by  direct  ap- 
plication of  the  moist  sulfanilamide  dressing  to  the 
wound  and  the  maintenance  of  some  degree  of 
pressure  by  incorporating  moistened  sea  sponges  or 
a  layer  of  sponge  rubber  in  the  bandage.  The 
dressings  are  changed  daily  until  the  wound  ap- 
pears clean  after  which  the  scarlet  red  bandage 
may  again  be  used  if  the  areas  to  be  covered  by 
ingrowth  of  epithelium  are  ^  in.  or  less  in  width. 

Early  grafting  materially  reduces  the  period  of 
disability  and  the  extent  and  depth  of  scar  tissue 
formation  and  its  resulting  disability. 

We  are  not  as  careful  as  we  should  be  to  main- 
tain surgical  cleanliness  in  the  management  of 
wounds  already  infected.  All  of  us  can  improve 
our  surgical,  including  obstetrical,  results  by  ob- 
taining and  maintaining  the  rigid  aseptic  technique 
of  the  operating  room  in  performing  our  office  and 
home  surgery.  And  with  reasonable  care  and  pa- 
tience it  can  be  done. 

PROCAINE  INJECTIONS  IN  MUSCULAR 
SPRAINS  OF  THE  LOWER  BACK 

My  experience  with  injections  of  an  anesthetic 
solution  for  relief  of  certain  lower-back  pains  has 
been  gratifying.  The  technique  described  by  Fur 
man1  is  recommended  by  this  Department. 

Muscular  sprains  of  the  lumbar  and  lower  dor- 
sal portions  of  the  erector  spinae  group  are  fre- 
quent cause  of  prolonged  disability  and  suffering. 
The  affected  muscles  are  spastic,  there  are  spots  of 
marked  tenderness,  and  in  the  more  chronic  forms 
a  reference  of  pain  to  remote  parts  of  the  segmen- 
tal arc. 

With  2-per  cent  procaine  solution  subcutaneous 
blebs  are  made  over  the  points  of  maximum  ten- 
derness. A  20-gauge  intravenous  needle  with  a 
short  bevel  is  then  introduced  through  the  anes- 
thetized skin  and  carefully  passed  down  to  the 
lumbodorsal  fascia  (which  may  be  distinctly  felt). 
The  patient  should  be  warned  that  his  pain  will  be 
momentarilv    increased    when    the    needle    passes 


J.  W.  E.  Gower,  Pacahontas,  in  //.  Iowz  Med.  Soc„  June. 


1.  Thos.    Furrnan,     Greenville,    in    Bui.    Greenville 
Ssc,  May. 


June.   1941 


SOUTHERN  MEDICINE  &  SURGERY 


through  the  fascia.  We  know  by  the  patient's  re- 
action that  the  injection  is  being  made  in  the 
right  spot.  Barely  pass  the  needle  through  the 
fascia,  not  deep  into  the  muscle;  slowly  inject  not 
more  than  2  c.c.  of  procaine;  withdraw  the  needle; 
and  repeat  the  process  over  the  other  areas  of  max- 
imum tenderness.  It  is  rarely  necessary  to  use 
more  than  6  or  8  c.c.  of  the  procaine  solution,  in 
all.  After  the  injections  are  completed,  lightly 
massage  the  muscles  with  an  alcohol  sponge.  At 
the  end  of  five  minutes  let  the  patient  arise  from 
the  table  and  try  a  wide  range  of  active  motion. 
Ac  this  time  a  smile  of  pleasant  satisfaction  usually 
spreads  over  his  face. 

If  the  injection  has  been  correctly  made  he  is 
able  to  resume  his  usual  activities;  which  he  should 
be  encouraged  to  do.  The  relief  afforded  in  a  ma- 
jority of  cases  is  permanent.  The  pain  does  not 
recur  after  the  wearing  off  of  the  anesthesia;  and, 
when  permanent  relief  is  not  established,  there  is 
usually  an  interval  of  several  days  before  the  in- 
jection needs  to  be  repeated.  Only  a  small  amount 
should  be  injected,  that  just  beneath  the  lumbo- 
dorsal  fascia.  Large  amounts  injected  deep  into 
the  muscle  itself  will  cause  a  bruised  feeling  after 
the  anesthesia  has  worn  off. 

IMMUNIZATION  AGAINST  INFECTIOUS 

DISEASES  IX  THE  UNITED  STATES 

ARMY 

We  are  often  asked,  "How  often  should  one  be 
vaccinated?''  As  reliable  information  as  any  is 
that  on  which  the  Army1  relies  and  on  which  it 
makes  its  decisions. 

Vaccination  against  smallpox,  typhoid  fever  and 
tetanus  has  long  been  required  for  all  in  the  United 
States  Army,  and  active  immunization  against 
tetanus  is  now  advocated  by  scientists  throughout 
the  world  as  good  military  practice. 

A  calf-lymph  vaccine  is  employed  against  small- 
pox, using  the  multiple  pressure  method,  revacci- 
nating  at  intervals  of  three  years,  or  earlier  if  indi- 
cated by  transfer  to  a  theater  of  operations,  or  in 
the  event  of  a  threatened  outbreak  of  smallpox. 

Against  typhoid  and  paratyphoid  fevers  the 
triple-typhoid  vaccine  used  contains  per  ex.,  1,000 
million  typhoid  bacilli  and  250  million  each  of 
the  parathyphoids  A  and  B.  One  revaccination  is 
required  at  the  end  of  three  years,  except  for  indi- 
viduals over  45  years  of  ace.  Additional  vaccina- 
tions may  be  required  for  troops  leaving  for  a  the- 
ater of  operations,  or  confronted  with  an  epidemic. 

Tetanus  antitoxin  has  been  largely  replaced  by 
tetanus  toxoid,  which  has  come  into  general  use 
for  the  production  of  an  active  immunity.    Initial 

1.  Lt.-Col.  .1.  S.  Simmons.  Washington,  in  The  Diflomatc, 
May. 


vaccination  consists  of  three  1-c.c.  doses  given 
three  weeks  apart;  subsequent  doses  of  1  c.c.  each, 
given  as  follows:  a)  at  the  end  of  one  year,  b)  at 
the  time  of  departure  for  a  theater  of  operations,  if 
this  occurs  more  than  six  months  after  the  last 
dose  received,  and  c)  whenever  the  individual  is 
wounded  or  otherwise  exposed  to  infection  with 
tetanus.  For  the  treatment  of  any  cases  of  clinical 
tetaus  that  may  occur,  or  for  the  passive  protection 
of  any  wounded  individuals  who  have  not  been  im- 
munized with  toxoid,  a  single  dose  of  antitoxin  will 
be  administered  and  active  immunization  with 
toxoid  started  at  the  same  time. 

Other  agents  may  be  required  only  for  small 
groups  of  susceptible  men  exposed  to  localized  out- 
breaks of  certain  diseases  common  in  this  country. 
For  example,  diphtheria  toxoid  or  scarlet  fever 
toxin,  particularly  when  outbreaks  of  these  dis- 
eases appear  among  young  recruits. 

Our  troops  may  be  sent  where  they  will  be  ex- 
posed to  disease  uncommon  in  this  country.  Con- 
sideration has  bern  given  to  the  possibilities  of 
vaccination  against  yellow  fever,  cholera,  plague 
and  typhus  fever. 

Yellow  fever  vaccine  has  been  manufactured 
since  1936  by  the  Rockefeller  International 
Health  Board.  It  is  administered  in  a  single  sub- 
cutaneous dose  of  1  c.c;  and  it  can  be  used  ad- 
vantageously under  epidemic  conditions.  Since 
1938,  this  vaccine  has  been  given  to  almost  two 
million  persons  in  Brazil. 

Anti-cholera  vaccines  have  been  used  for  many 
years,  and  there  is  evidence  to  indicate  that  a 
killed  suspension  of  the  vibrios,  of  the  type  used 
in  Japan  and  in  India,  affords  protection. 

Our  troops  may  be  exposed  to  epidemic  plague, 
of  either  the  bubonic  or  pneumonic  type.  It  would 
be  logical  to  use  a  bacterial  vaccine,  although  there 
is  some  controversy  as  to  the  protection  afforded. 

Delousing  of  troops  is  a  valuable  control  meas- 
ure in  typhus  fever,  but  it  is  not  considered  ade- 
quate in  the  presence  of  epidemic  conditions.  Vac- 
cines are  now  being  studied  for  prophylactic  use, 
and  the  results  in  animals  indicate  that  they  may 
afford  adequate  protection  in  man.  Arrangements 
have  been  made  for  the  manufacture  of  large  quan- 
ties  of  typhus  vaccine  for  use  in  the  Army. 

The  preparation  of  vaccines  to  protect  against 
three  different  types  of  influenza  is  being  under- 
taken for  experimental  testing  in  the  winter  of 
1941-1942.  Results  to  date  suggest  that,  although 
this  vaccine  is  by  no  means  perfect,  it  may  have 
some  practical  value. 


Rocky  Mountain  Spotted  Fever. — A  case  is  reported 
(Med.  An .  D.  C.)  developing  during  a  post-partum 
period,  confirmed  by  guinea-pig  and  Weil-Felix  tests,  and 
by  post-mortem  findings. 


SOUTHERN  MEDICI  XE  &  SURGERY 


June,   1941 


OPHTHALMOLOGY 

Herbert  C.  Neblett,  M.  D.,  Editor,  Charlotte,  N.  C. 


MIRROR-WRITING  AND  WORD- 
BLINDNESS 

Prior  to  Thomas  Orton's  paper  in  1925  on  mir- 
ror-writing and  word-blindness  it  was  not  known 
that  the  two  conditions  were  intimately  associated. 
The  problem  occasionally  arises  in  the  practice  of 
every  oculist  and  a  brief  resume  of  the  subject 
seems  in  order. 

There  may  be  many  gradations  and  degrees  of 
the  two  conditions  in  the  same  individual,  one  or 
the  other  may  predominate,  or  one  only  may  be 
present.  In  children,  especially,  the  diagnosis  as 
to  which  condition  is  being  dealt  with  presents 
difficulty  which  requires  more  than  a  casual  study. 
Orton  states  that  directional  confusion  in  reading 
and  writing  is  a  clinical  entity  and  is  based  on 
cerebral  dominance.  These  conditions  may  be  im- 
posed by  training.  They  are  the  result  of  failure 
to  establish  the  physiological  habit  of  working  ex- 
clusively from  the  engrams  of  one  hemisphere. 
Since  the  two  hemispheres  of  the  brain  are  so 
geared  for  visual  impressions  that  the  impressions 
formed  on  one  are  refracted  upside-down  on  the 
other  and  vice  versa,  and  when  only  one  hemi- 
sphere is  active  in  this  function  there  is  incomplete 
elision  (striking  out)  of  one  set  of  antitrophic 
(against  a  turn)  engrams;  hence  upside-down 
vision — i.e.,  mirror  vision,  confusion  in  the  direc- 
tion of  reading.  This  is  based  on  the  theory 
(mnemic  hypothesis)  that  stimuli  or  irritants  leave 
definite  traces,  marks  or  imprints  (engrams)  on 
the  protoplasm  of  the  animal  or  plant,  and  when 
these  stimuli  are  regularly  repeated  they  induce  a 
habit  which  persists  after  the  stimuli  cease.  As- 
suming that  the  germ  cells  share  with  the  nerve 
cells  in  possessing  engrams,  acquired  habits  may 
thus  be  transmitted  to  the  descendants.  Then  the 
conditions  favorable  to  mirror-writing  or  word- 
blindness  may  be  summarized  as  follows.  Every 
child  at  some  period  of  its  development  will  pro- 
duce mirror-writing.  Proficiency  at  mirror-writing 
may  be  acquired  by  anyone  by  practice.  It  is  pos- 
sessed by  all  persons  to  some  degree  but  remains 
unobserved.  It  is  sometimes  associated  or  produced 
by  defects  in  vision  and  in  some  cases  can  be 
corrected  by  glasses.  It  is  seen  in  mental  weak- 
ness, in  hysteria  and  in  moral  perversion.  A  neu- 
rotic inheritance  may  cause  it.  It  is  more  common 
among  men  than  among  women,  among  children 
with  impaired  intelligence  and  deaf  mutes,  in  kata- 
tonia  and  in  absent-minded  persons  otherwise  nor- 
mal. Most  investigators  emphasize  the  point  that 
mirror-writing  is  the  normal  way  for  left-handed 


persons  to  write.  It  can  be  produced  under  hypno- 
sis, after  anesthesia,  under  the  influence  of  alcohol 
and  certain  drugs;  as  result  of  congenital  lesion  of 
the  angular  gyri  from  hereditary  factors  and  from 
traumatic  lesions  of  the  gyrus;  in  the  left-handed, 
after  practice  in  writing  with  both  hands  at  the 
same  time,  one  hand  writing  normally,  the  other 
doing  mirror-writing.  Spiritualists  write  mirror 
fashion  and  telegraphers  in  jotting  down  messages. 
It  is  also  produced  by  lack  of  control,  environ- 
ment, experience  and  impressions  on  the  brain  in 
early  childhood.  In  congenital  word-blindness  it  is 
the  higher  visuo-psychic  centers  which  are  at  fault. 
A  child  so  afflicted  has  grea,t  difficulty  in  writing 
and  in  correcting  his  errors  of  omission,  misspelled 
words,  elisions  etc.  So  when  a  child  writes  with 
his  left  hand  the  kinesthetic  or  motor  memory 
centers  are  in  control  of  the  situation  and  act  inde- 
pendently of  the  visual  control  factors,  and  mirror- 
writing  results.  According  to  Orton  these  children 
are  always  in  doubt  as  to  whether  words  should 
go  from  left  to  right  or  vice  versa.  He  thinks  this 
is  due  to  maldevelopment  of  the  angular  gyri 
wherein  the  motor  memory  sense  is  not  super- 
vised, held  in  control,  or  fully  corrected  by  the 
visual  imagry  factors.  When  using  the  right  hand 
words  are  misspelled,  letters  omitted  or  redupli- 
cated, wrong  letters  used,  words  inverted,  letters 
written  backwards.  If  using  the  left  hand,  though 
words  are  misspelled,  they  are  written  mirror-wise 
and  with  greater  ease  and  dexterity  than  with  the 
right  hand.  The  writer  is  then  oblivious  of  this 
mistake  and  will  write  his  name  normally  with  his 
right  hand  and  with  his  left  will  write  his  name 
beneath  the  first  mirror-wise.  Both  are  read  with 
ease,  the  child  not  knowing  which  is  the  correct 
one. 

The  frequency  is  one  in  every  2500  children 
(Beely).  Gordon  found  0.5  per  cent  among  nor- 
mal children,  8.5  per  cent  among  feeble-minded 
children.  This,  he  thinks,  is  not  proof  that  it  is  an 
indication  of  feeble-mindedness.  Four  per  cent  of 
persons  are  left  handed.  Wild  says  that  these 
conditions  are  more  often  encountered  in  left- 
handed  persons  whose  right  eye  is  the  fixing  eye, 
than  in  left-handed  persons  whose  left  eye  is  the 
fixing  eye.  The  same  is  true  of  right-handed  per- 
sons whose  left  eye  is  the  fixing  eye. 

In  the  milder  tvpes  in  children  special  classes 
in  school  and  individual  instruction  are  aids  to  re- 
covery or  improvement.  It  seems  unwise  to  at- 
tempt to  make  a  naturally  left-handed  writer  use 
his  right  hand.  Stuttering,  greater  confusion  and 
other  difficulties  are  prone  to  result. 


Essential  Hypertension. — To  differentiate  from  Graves' 
disease  may  be  very  difficult.  Here  moderate  elevation 
of   BMR  js  not   uncommon. 


June.   1941 


SOUTHERN  MEDICINE  &  SURGERY 


341 


PEDIATRICS 


THE  NATIONAL  FOUNDATION  FOR 

INFANTILE  PARALYSIS  PROVIDES 

SPLINTS 

One  of  the  many  responsibilities  that  the  Foun- 
dation has  assumed  is  the  free  distribution  of  Tor- 
onto splints  and  Bradford  frames  in  epidemic  areas 
and  to  indigent  persons,  regardless  of  age,  who 
may  need  them.  Over  3,000  of  these  appliances 
have  been  used  during  the  past  two  years  and  the 
central  supply  depot  in  New  York  City  is  ready 
to  meet  any  future  deserving  requests  for  these 
splints  and  frames. 

Where  a  Chapter  of  the  National  Foundation 
exists,  splints  and  frames  should  be  ordered 
through  such  agency.  Where  Chapters  have  not 
yet  been  formed  they  may  be  ordered  direct  from 
the  National  Foundation's  office,  120  Broadway, 
New  York  City. 

Splints  and  frames  will  be  supplied  only  as 
needed  and  are  not  to  be  stocked  in  anticipation 
of  local  needs.  Transportation  charges  will  be  col- 
lected from  the  consignee  as  there  is  no  other 
charge  for  the  equipment.  Except  during  epidem- 
ics these  splints  and  frames  are  made  available 
only  to  indigent  patients.  For  effective  results  it 
is  necessary  that  sizes  be  accurate  and  agree  with 
those  measurements  given. 

Used  splints  should  ordinarily  remain  in  the  cus- 
tody of  the  Chapter  or  other  agency  to  whom  they 
have  been  consigned.  It  is  expected  that  the  Chap- 
ter or  other  agency  will  repair  and  otherwise  make 
the  best  possible  use  of  such  splints.  Unused 
splints  must  be  returned  in  their  original  container 
to  The  National  Foundation  for  Infantile  Paraly- 
sis, care  of  the  Metropolitan  Device  Corporation, 
1250  Atlantic  Avenue,  Brooklyn,  New  York,  or  to 
some  other  depot  designated  by  the  Foundation. 
The  original  borrower  is  also  expected  to  pay  re- 
turn express  charges. 

Each  agency  receiving  splints  and  frames  from 
the  National  Foundation  is  requested  to  acknowl- 
edge receipt  of  such  appliances  and  to  furnish  a 
report  covering  the  service  rendered,  giving  details 
as  to  the  number  of  patients  served,  part  involved, 
degree  of  paralysis  and  state  of  patient  on  removal 
of  splints. 

For  arm  splint  measure  the  distance  from  the 
tip  of  the  olecranon  to  the  web  of  the  thumb.  The 
arm  splint  is  attached  to  the  Bradford  frame  by 
means  of  special  clamps,  which  are  shipped  with 
each  frame. 

Distance  between  tip  of  Size  of 

elbow  and  web  of  thumb.  Splint 

7'A—  9'4  inches 1 

9^—12i4  inches  2 

\2lA  amd  over  inches  3 


For  leg  splint   measure  the   distance   from   the 
center  of  the  patella  to  the  sole  of  the  foot. 
Distance  between  centre  Size  of 

of  patella  and  sole  of  foot.  Splint 

8—8%    inches   C 

834 —  9%   inches  B 

9]/2 — 10       inches    A 

10%— 11       inches    1 

11%— 12%  inches  ll/2 

12y2—Uy2  inches  2 

1334 — 15       inches  2% 

15%— 16%  inches  3 

1634 — 184  inches  3% 

isy2—20y2  inches 4 

Over     20%  inches  5 

For  Bradford  frame  measure  the  length  of  the 
patient  from  the  top  of  the  head  to  the  sole  of  the 
foot,  and  the  breadth  from  the  tip  of  one  shoulder 
to  the  other. 

Size  of 
Measurement  Frame 

47"   x    16" No.  1 

53"  x  18"  No.  2 

59"  x  I9y2" No.  3 

65"  x   21" No.  4 

71"  x   22" No.  5 

77"   x    23" No.  6 


GENERAL  PRACTICE 

James    L.    Hamner,    M.  D.,    Editor,    Mannboro,    Va. 


DIAGNOSIS  AND  TREATMENT  OF 
PULMONARY  TUBERCULOSIS. 

The  front  line  trenches,  says  a  distinguished 
specialist  in  tuberculosis'  are  occupied  by  general 
practitioners,  who  must  ever  be  alert  to  the  possi- 
bility that  octive  pulmonary  tuberculosis  may  be 
the  cause  of  their  patient's  disability.  And  he  says 
that  even  with  the  exercise  of  our  keenest  judgment, 
diagnostic  errors  will  occur. 

A  good  deal  of  what  he  goes  on  to  say  is  perti- 
nent: The  responsibility  for  determining  the 
presence  or  absence  of  active  pulmonary  tubercu- 
losis must  rest  upon  the  general  practitioner.  His 
is  the  opportunity  to  make  an  accurate  diagnosis, 
he  must  realize  that  to  many  patients  admission  to 
a  hospital  for  the  tuberculous  is  a  stigma  which 
must  be  avoided,  if  at  all  possible. 

The  time-tried  dicta  by  the  late  Lawrason  Brown 
continue  to  render  invaluable  service.  These  diag- 
nostic criteria  are:  1)  a  history  of  pleurisy  with 
effusion  without  apparent  cause;  2)  a  history  of 
hemoptysis  of  a  drachm  or  more,  out  of  a  clear 
sky;  3)  stethoscopic  findings  of  persistent,  local- 
ized, moist  rales,  after  cough,  usually  above  the 
second  rib;  4)  demonstration  of  tubercle  bacilli  in 
a  certified  specimen  of  sputum;    5)   definite  local - 

1.   in   Bull.   St.   louts  Med.   Soc, 


SOUTHERN  MEDICINE  &  SURGERY 


June.    1941 


ized  x-ray  shadows,  particularly  in  the  same  area 
in  which  rales  were  heard.  Later,  he  asserted 
that    tuberculin   reaction   was   very   helpful. 

For  demonstration  of  tubercle  bacilli,  a  com- 
bination of  methods  is  required,  viz:  direct  smear, 
concentrates,  flotations,  cultures,  animal  inocu- 
lations and  gastric  washings.  Even  with  this  ap- 
proved technique,  about  4  per  cent  of  patients 
with  evident  pulmonary  tuberculosis  will  fail  to 
demonstrate  tubercle  bacilli. 

Contrary  to  formerly  accepted  opinion,  primary 
infection  by  the  tubercle  bacillus  may  occur  almost 
at  any  age,  although  relatively  uncommon  after 
the  age  of  25.  All  reasonable  efforts  must  be  made 
to  find,  isolate  and  close  the  open  case,  if  our  fur- 
ther efforts  are  to  be  reasonably  successful  in 
eradication  of  tuberculosis. 

Increased  reliance  must  be  placed  upon  x-ray- 
films  of  the  chest,  as  physical  signs  are  often  diffi- 
cult to  determine  and  may  be  deceiving. 

The  most  beneficial  measure  is  absolute  bed 
rest  while  toxic,  then  properly  graduated  exercise 
and,  later,  readaptation  of  the  patient  to  work. 
The  character  of  food,  the  adequacy  of  vitamins, 
improved  environment  and  heliotherapy  are  all 
factors  which  aid  resistance. 

Collapse  therapy  is  a  great  therapeutic  meas- 
ure, even  for  ambulant  cases.  Complications 
should  be  treated,  both  tuberculous  and  non-tuber- 
culous. The  skillful  physician  uses  no  one  method 
but  combines  all  useful  methods.  To  judge  the 
efficacy  of  treatment:  treat  and  watch  the  results; 
change  may  be  necessary  in  therapy  almost  daily. 

The  time  of  healing  is  approximately  four  years, 
although  there  are  periods  of  exacerbation  of  dis- 
ease and  times  of  apparent  arrest. 

In  30  per  cent  of  tuberculosis  patients  pulmo- 
nary lesions  heal  spontaneously;  another  30  per 
cent  are  fulminating,  terminating  fatally  without 
regard  to  quality  or  character  of  treatment,  leav- 
ing 40  per  cent  of  variables,  which  make  up  the 
bulk  of  our  sanatorium  cases. 

All  of  us  family  doctors  should  accept  this,  the 
most  important  role  in  the  war  on  tuberculosis; 
be  on  the  lookout  for  tuberculosis;  be  able  to  di- 
agnose it  early  and  continue  the  cure  after  re- 
turn from  sanatorium.  And  we  should  make  it 
plain  that  we  expect  reports  on  our  patients  in 
sanatoria  at  reasonable  intervals,  and  a  report  at 
time  of  discharge,  stating  present  condition  and 
making  recommendations  as  to'  post-sanatorium 
management.  However  willing,  energetic  and 
competent  the  family  doctor  may  be  he  can  not 
possibly  cooperate  in  perfecting  the  cure  unless 
all  instructions  and  recommendations  for  care 
after  discharge  from  sanatorium  be  conveyed  to 
the  patient  through  the  family  doctor. 


PERSONALITY   DISORDERS   CAUSING   DI- 
GESTIVE  COMPLAINTS    USUALLY 
NEED  NO  SPECIALIST 

To  obtain  maximum  benefit  for  patients  pre- 
senting gastrointestinal  complaints,  a  good  phy- 
sician must  be  a  practical  psychologist  and  psy- 
chiatrist.1 The  deviations  from  normal  personality 
producing  complaints  referred  to  the  gastroin- 
testinal system  include  excessive  emotional  re- 
actions to  various  situations  (situational  neuro- 
ses) ;  inadequate  personalities  (usually  notable 
for  general  nervousness);  anxiety  neuroses;  hypo- 
chondriacal and  hysterical  reactions;  and  de- 
pression. 

Many  patients  have  digestive  symptoms  as  a 
manifestation  of  personality  disorder  before  they 
develop  organic  disease  of  the  digestive  tract, 
which  might  be  prevented  if  successfully  treated. 
This  seems  especially  true  with  respect  to  peptic 
ulcer.  Functional  nervousness,  including  fatigue 
and  anxiety,  is  by  far  the  greatest  detectable  cause 
of  recurrences.  The  question  mav  be  raised  as  to 
how  many  of  these  patients  might  have  escaped 
peptic  ulcer  if  their  functional  nervousness  had 
been  recognized  and  treated. 


1X3.  C.  Robii 


lull.  Joints  Hopkins  Hosp..  Mar 


TREATMENT  OF  THRUSH  WITH  NITRATE 
SILVER 

Trousseau  first  recommended  silver  nitrate 
therapy  in  thrush  and  it  has  been  thus  employed 
somewhat  largely  since.  In  order  to  be  effective 
the  drug  must  pass  into  the  esophagus  and  Millet1 
advocates  a  simple  means  for  so  doing.  Balls  of 
cotton  wool  (three  are  enough)  are  tied  round  the 
middle  with  a  strong  thread  and  then  soaked  in  a 
one  per  cent  solution  of  silver  nitrate.  One  ball  is 
given  to  the  patient  to  suck  every  four  hours.  Car- 
bonated water  is  given  in  the  intervals.  At  the  end 
of  12  hours;  i.e.,  after  the  three  silver  nitrate  balls 
have  been  sucked,  the  thrush  has  disappeared  com- 
pletely from  the  tongue  and  palate,  and  the  lingual 
mucous  membrane  is  clean.  No  difficulty  is  en- 
countered as  regards  the  sucking  of  silver  nitrate 
balls  by  adults.  With  children  the  balls  may  be 
sprinkled  with  a  little  vanilla-flavored  sugar  or 
honey,  and  in  the  case  of  infants  the  soaked,  fla- 
vored cotton  wool  can  be  placed  inside  a  slit 
dummy.  The  method  is  simple  and  effective.  There 
is  no  painting  of  the  throat  and  thus  no  desire  to 
vomit  on  the  part  of  the  patient. 

1.  Medical  Record,   March,    1941.   From  Presse  Medicate. 


FIRST  AID  TREATMENT  OF  SNAKE  BITE 

Have  the  patient  lie  down  in  a  warm  dry  place 
and  apply  a  tourniquet  1  to  2  inches  proximal  to 
the  wound,  just  tight  enough  to  obstruct  the  veins 

1.    Pender.    J.    W.,    Proc.    Staff   Meetings    Mayo    Clinic.    Feb. 


June.    1941 


SOUTHERN  MEDICINE  &  SURGERY 


but  not  the  arteries;  every  20  minutes  loosen  the 
tourniquet  for  1  minute  and  as  the  swelling  pro- 
gresses move  it  farther  up  the  limb.  The  bite  of 
most  of  our  poisonous  snakes  leaves  two  small 
punctures,  that  of  the  non-poisonous  a  horseshoe- 
shaped  row  of  teeth  marks  or  a  series  of  scratches. 
Treatment  for  shock  should  be  instituted  at 
once.  Make  criss-cross  incisions  J^xJ^  inch 
through  each  fang  mark  and  well  through  the  skin 
to  allow  free  bleeding.  Apply  suction  for  at  least 
half  an  hour  by  mouth  or  otherwise.  As  the  swell- 
ing spreads,  make  a  ring  of  incisions  %x%  inch 
just  in  the  swollen  area  2  inches  from  the  primary 
incisions  and  apply  suction  to  each  incision  for  15 
minutes  of  each  hour  for  10  to  15  hours.  Pain  is 
severe  and  shock  must  be  continually  combated. 
The  majority  of  deaths  due  to  the  toxemia  occur 
in  24  to  36  hours. 


ROSEOLA  INFANTUM  (EXANTHEM 
SUBITUM) 

The  infant  becomes  suddenly  ill  with  a  high 
fever,  is  restless,  irritable  and  refuses  most  of  his 
food,  but  is  not  toxic.  The  physical  examination 
discloses  little.  There  is  a  lymphocytosis  and 
usually  a  leukopenia.  The  fever  lasts  three  days 
and  then  drops  by  crisis  or  lysis.  After  the  t.  is 
normal  for  a  few  hours,  a  measles-like  rash  appears 
over  the  body  and  lasts  for  two  days.  There  are 
no  complications  and  no  sequelae. 

"The  diagnosis  is  made  from  the  sequence  of 
events,  first  the  fever  and  then  the  rash  after  the  t. 
is  normal."  There  are  no  Koplik's  spots.  In 
measles  the  t.  does  not  drop  when  the  rash  ap- 
pears, but  remains  high  for  two  or  three  days 
longer.  In  German  measles  the  rash  appears  the 
first  day  of  illness  and  the  highest  t.  is  coincident 
with  the  eruption.  Scarlet  fever's  eruption  and 
blood  picture  are  different,  and  there  is  a  very  red 
throat. 

Most  observers  consider  roseola  infantum  a  clin- 
ical entity,  a  few  that  it  is  a  grippal  infection  or  a 
reaction  to  food  or  drugs. 

There  have  been  epidemics  in  hospitals  of  ros- 
eola infantum.   The  incubation  is  about  10  days. 

The  etiology  is  unknown  and  cultures  of  the 
throat  have  been  of  no  help.  The  cause  may  be  a 
virus. 


AMINOPHYLLIN  IN  ASTHMA 
The  Council  on  Pharmacy  and  Chemistry  of  the 
A.  M.  A.  declares: 

"The  therapeutic  claims  for  all  accepted  prod- 
ucts of  aminophyllin  should  be  restricted  to  those 
recommending  it  for  the  diuretic  effect,  and  as  a 
myocardial  stimulant There  is  no  satisfac- 
tory evidence  that  aminophyllin  or  other  known 
theophyllin   preparation   acts  as   a   dilator   of  the 


coronary  arteries  or  has  effect  in  reducing  the  pain 
of  angina  pectoris." 

We1  have  assembled  the  results  of  aminophyllin 
therapy  in  31  patients  treated  recently  for  acute 
respiratory  distress  of  asthmatic  origin  in  the  Im- 
munology Clinic  and  in  the  hospitals  of  the  Med- 
ical College  of  Virginia.  All  of  these  patients  were 
given  from  0.24  to  0.48  Gm.  of  aminophyllin  in 
10-20  c.c.  of  salt  or  glucose  solution  intravenously. 
Repeated  doses  of  aminophyllin  were  given  the 
same  patient  on  a  number  of  occasions. 

Twenty-nine  per  cent  of  our  31  patients  experi- 
enced at  one  time  or  another  complete  relief, 
51. 6%  experienced  moderate  relief,  9.6  slight  re- 
lief. Results  were  not  constant,  a  patient  experi- 
encing complete  relief  might  show  no  relief  at  all 
in  his  dyspnea  when  given  the  same  dose  on  an- 
other occasion. 

The  effects  were  not  always  proportionate  to 
the  size  of  the  dose.  Although  there  were  25%  oi 
failures  when  0.48  Gm.  were  given  and  31.4% 
when  0.24  Gm.  were  given,  complete  relief  was  ex- 
perienced by  28.5%  of  those  patients  receiving  the 
smaller  dose,  while  only  16%  were  equally  im- 
proved by  the  larger  dose. 

In  our  experience  aminophyllin  is  a  valuable 
drug  in  the  treatment  of  intractable  asthma.  Sev- 
enty-five out  of  every  100  injections  gave  relief, 
often  immediate  and  complete.  In  some  instances 
relief  was  slow  in  appearing,  in  others  it  was  tran- 
sitory. We  encountered  no  unfavorable  reactions. 
Our  experience  confirmed  the  observation  made  by 
others  that  epinephrine-fast  cases  frequently  re- 
spond to  aminophyllin,  while  on  the  other  hand 
cases  of  intractable  asthma  are  favorably  influ- 
enced by  epinephrine  after  failure  with  aminophyl- 
lin. 

The  author  of  this  column  has  found  this  a  very 
beneficial  treatment.  The  smaller  dose  is  somewhat 
slower  but  less  depressing  or  weakening;  the  larger 
dose  dramatic  in  its  effect  but  the  patient  very 
weak  afterward. 


1.  Brown,  A.  G.,  Ill,   &  Blanton,  W.   B.,  Richmond,  S.  M.  J., 
■iu  Dig.   of  Treatment,  Jan. 


Measles,  Reading. — The  conjunctivitis  need 
not  deprive  a  child  of  the  pleasure  of  reading.  It 
is  light,  not  reading  that  makes  the  eyes  smart. 
Put  smoked  glasses  on  the  child  and  let  him  read. 


Tobacco  increases  the  metabolic  rate  by  2  per 
cent  in  men  and  women. — Hadley. 


Congo  Red.— A  1%  sol.  in  water  has  value  in  many  in- 
fections. It  is  non-toxic  in  doses  far  greater  than  required 
for  therapy,  has  hemostatic  powers,  and  can  be  success- 
fully used  in  many  cases  in  which  a  sulfonamide  has  failed 
or  proved  too  toxic. — W.  L.  Green,  in  //.  Ind.  Med.  Soc, 
June. 


SOUTHERN  MEDICINE  &  SURGERY 


June,    1941 


SURGICAL  OBSERVATIONS 


OF  THE  STAIF 

DAVIS  HOSPITAL 

Statesville 


THE  THYMUS 

The  thymus,  ordinarily  spoken  of  as  the  thy- 
mus gland,  Marshall  and  Piney  regard  as  being  an 
epithelial  organ  extensively  infiltrated  with  lym- 
phocytes. It  is  developed  from  the  third  branchial 
pouches  (entodermal)  and  later  becomes  filled 
with  lymphocytoid  cells  of  mesoblastic  origin.  The 
thymus  is  divided  into  lobules  in  which  a  cortex 
and  medulla,  can  be  differentiated. 

At  birth  the  thymus  gland  weighs  from  12  to  15 
grams,  and  it  increases  in  weight  for  some  time. 
According  to  some,  the  thymus  reaches  its  maxi- 
mum development  in  the  first  two  years  of  life; 
others  say  it  continues  to  grow  until  puberty — to 
as  much  as  35  grams — when  it  rapidly  undergoes 
fatty  degeneration  and  is  replaced  by  adipose  tis- 
sue. 

The  function  of  the  thymus  is  in  doubt,  but  it 
is  supposed  to  ha,ve  some  specific  part  in  the  de- 
velopment of  the  bony  structure  of  the  body. 
Our  interest  in  this  structure  is  particularly  be- 
cause of  its  possible  connection  with  sudden  death 
in  children. 

A  number  of  years  ago  a  young  mother,  who 
lived  in  the  country,  came  to  the  hospital  with  her 
infant  child  which  was  evidently  dead.  The  frantic 
mother  had  concluded  that  during  her  sleep  she 
had  in  some  way  smothered  the  child.  An  x-ray 
picture  showed  a  greatly  enlarged  thymus,  and  it 
was  explained  that  death  was  probably  due  to  an 
enlarged  thymus  and  that  the  child  had  not  been 
smothered  at  all. 

Many  cases  are  reported  where  children  have 
ditd  suddenly  just  as  they  were  being  given  a  gen- 
eral anesthetic,  as  for  a  tonsillectomy.  No  such 
accident  has  ever  been  recorded  in  this  clinic; 
however,  the  fact  that  an  enlarged  thymus  gland 
has  been  associated  with  sudden  death  under  dif- 
ferent circumstances  makes  it  important  that  chil- 
dren be  examined  for  this.  Infants  and  young 
children  who  have  any  unusual  symptoms  with 
reference  to  breathing  should  have  x-ray  examina- 
tion of  the  chest  to  determine  whether  or  not  there 
is  any  enlargement  of  the  thymus  gland.  Unex- 
plained cyanosis  in  infants  and  young  children 
may  be  due  to  an  enlarged  thymus.  The  diagnosis 
is  usually  easy  from  an  x-ray  picture  properly 
made,  and  treatment  by  x-rays  usually  gives 
prompt  relief. 

In  some  cases  there  are  no  symptoms,  even 
though  the  thymus  gland  is  much  larger  than  aver- 
age. Frequently  we  see  a  child  with  attacks  of 
cyanosis  of  severity  according  to  the  enlargement 
of  the  gland.    Possibly  interference  with  respira- 


tion is  due  to  compression  of  the  trachea  by  the 
thymus  becoming  congested  from  time  to  time. 
Enough  tracheal  compression  may  cause  noisy 
breathing,  difficult  inspiration  and  expiration — 
thymic  stridor.  Thymic  asthma  is  a  condition 
which  should  be  suspected  in  children  who  have 
respiratory  difficulty,  although  every  possible 
source  of  trouble  should  be  ruled  out. 

So-called  thymic  death  may  occur  from: 

1.  Pressure  of  the  enlarged  gland  upon  the 
trachea,  by  suffocation.  It  is  possible  that  the 
sudden  congestion  or  rapid  hemorrhage  into  the 
thymus  in  small  children  may  cause  death  by  suf- 
focation. 

2.  In  the  other  type  of  thymic  death  the  patient 
just  dies  suddenly  and  unexpectedly.  In  this  type 
of  death,  as  Haramar  has  stated,  death  may  be  due 
to  some  other  cause  entirely,  although  a  very  large 
thymus  may  be  present. 

The  diagnosis  of  the  thymus  gland  as  the  cause 
of  trouble  is  made  principally  by  x-ray  examina- 
tion made  with  the  child  in  a  vertical  position. 
The  exposure  must  be  rapid — one-tenth,  better 
one-twentieth,  of  a  second — at  a  distance  sufficient 
to  give  a  clear  picture  with  no  distortion.  The 
exposure  may  be  necessary  to  produce  negatives  of 
this  density  in  order  to  get  the  true  outline  of  the 
heart  and  thymus  gland. 

While  a  diagnosis  can  usually  be  made  from  the 
antero-posterior  view,  yet  a  lateral  view  may  show 
compression  of  the  trachea  not  shown  by  the 
antero-posterior  picture. 

The  x-ray  or  fluoroscopic  examination  of  a  sus- 
pected thymic  case  should  always  be  made  before 
any  anesthetic  is  given  and  should  be  a  routine 
part  of  examination  in  all  cases  where  there  is  res- 
piratory difficulty  of  unexplained  origin. 

IMPROVEMENTS     IN     THE     DETAILS     OF 

INSERTION  OF  THE  SMITH-PETERSEN 

NAIL  IN  FRACTURES  OF  THE  HIP 

JOINT 

In  the  typical  intracapsular  fracture  of  the  neck 
of  the  femur  insertion  of  the  Smith-Petersen  nail 
holds  the  fragments  in  correct  position;  but  the 
insertion  requires  a  great  deal  of  skill  and  the 
cooperation  of  an  efficient  x-ray  department. 

The  Engel  and  May  localizer  is  a  great  help  in 
this  procedure  and  by  means  of  this  it  is  much 
easier  to  localize  the  point  where  the  guide  pin  is 
to  be  placed. 

When  the  antero-posterior  film  is  made  and  the 
correct  position  found,  for  one  plane,  for  the  inser- 
tion of  the  nail;  instead  of  using  a  short  pin  to 
hold  the  localizer  in  the  vertical  position  while  the 
transverse  picture  is  being  made,  we  substitute  a 
long  localizing  pin  placed  as  near  the  estimated 
angle  as  possible,  and  insert  this  down  into  the 


June.    1941 


SOUTHERN  MEDICINE  &  SURGERY 


345 


head  of  the  femur.  This  enables  a  very  accurate 
localization  to  be  accomplished  without  any  great 
delay  and,  at  the  same  time,  serves  as  a  fixation 
for  the  head  of  the  femur  and  prevents  any  dis- 
placement in  case  the  leg  is  moved  at  the  time  the 
transverse  x-ray  picture  is  made.  The  insertion  of 
the  pin,  as  a  rule,  extends  well  up  into  the  head 
of  the  femur  and  ordinarily  this  will  hold  very 
well.  In  some  cases,  however,  especially  where 
the  fracture  is  near  the  head  of  the  femur,  it  is 
well  to  insert  the  pin  within  three-eighths  of  an 
inch  of  the  articular  surface  of  the  femur.  This 
gives  excellent  fixation  and,  at  the  same  time,  the 
firm  tissue  of  the  head  of  the  femur  holds  the 
Smith-Petersen  nail  more  firmly. 

It  is  necessary  to  make  an  x-ray  picture  of  the 
femur  neck  before  closing  the  incision  so  that  the 
nail  may  be  driven  in  a  little  further  if  necessary. 

It  is  useful,  too,  to  consider  the  length  of  the 
pin  and  from  the  x-ray,  by  means  of  a  localizer, 
estimate  the  exact  length  of  the  neck  of  the  femur 
from  the  surface  of  the  trochanter  to  the  articular 
surface  of  the  head.  This  enables  the  operator  to 
insert  the  guide  pin  the  right  distance  and  not 
penetrate  the  articular  surface  of  the  acetabulum. 
A  transverse  view  should  always  be  obtained  to 
be  certain  that  the  pin  is  in  the  right  position  and 
plane  posteriorly. 

Recently  we  have  been  using  a  small  nail  to 
anchor  the  Smith-Petersen  nail  firmly  so  that  il 
will  not  work  out.  This  nail  is  driven  through  the 
small  opening  in  the  end  of  the  Smith-Petersen 
nail  and  on  down  into  the  shaft  of  the  femur  and 
in  this  way  will  prevent  the  nail  from  working  out 
or  becoming  loose. 

The  use  of  the  Smith-Petersen  nail  has  done 
much  to  save  those  who  are  unfortunate  enough  to 
have  a  fracture  of  the  hip  from  a  life  of  semi-in- 
validism.  The  majority  of  fractures  of  the  hip 
treated  in  this  way  recover.  The  period  of  hos- 
pitalization is  short,  averaging  around  seven  days. 
Then  the  patient  returns  home  and  is  treated  there 
until  healing  takes  place,  as  shown  by  the  x-ray 
picture.  The  pin  may  be  removed  in  a  few  months 
or  may  be  left  in  for  an  indefinite  period  of  time. 
So  far  wo  have  never  noted  the  least  sign  of  trou- 
ble from  the  pin  itself. 


THE  USE  OF  THE  CATHETER  IN  GYNECOLOGICAL 
DIAGNOSIS— ILLUSTRATIVE  CASES 

(W.  S.  Bainbridge,  New  York,  in  U.  &  C.  Review.  Sept.,   19401 

Catheterize  a  woman  before  examination. 

A  woman,  24.  married,  was  sent  to  one  of  our  stale  in- 
stitutions as  a  manic  depressive.  Pregnancy  was  suspected, 
and  the  tumor  of  the  abdomen  was  well  above  the  umbili- 
cus, cervix  pushed  upward  and  backward.  Breasts  were 
not  as  developed  as  would  be  expected  by  the  size  of  the 
abdomen.  This  case  was  brought  to  my  examining  clinic 
with  the  diagnosis  of  possible  pregnancy  and  ovarian  cyst. 
Catheterization   was   done  with   the   patient   on   the   tabic. 


The  tumor  gradually  descended.  The  cervix  came  well 
within  reach — 2,250  c.c  of  urine  having  been  withdrawn 
the  tumor  entirely  disappeared.  Early  pregnancy  was 
established  and  corresponded  well  with  the  menstrual  and 
glandular  picture. 

A  young  woman  had  been  referred  to  me  for  a  retro- 
pesed  uterus,  which  was  crowded  backward  by  a  tumor 
anterior  to  the  womb,  and  to  the  right  by  a  large  mass  in 
the  left  lower  quadrant.  Before  being  sent  to  me  she  had 
had  a  low  enema.  I  found  the  rectum  empty,  but  a  loop 
cf  redundant  sigmoid  in  the  left  lower  quadrant  contained 
a  large  mass  of  feces.  I  ordered  a  dose  of  oil  by  mouth,  a 
co'onic  irrigation,  and  just  prior  to  returning  for  further 
examination,  a  bladder  catheterization.  At  second  exam- 
ination the  uterus  had  resumed  its  normal  position,  and 
there  was  no  longer  a  mass  in  the  left  lower  quadrant  or 
anterior  to  the  uterus. 

Another  woman  I  was  called  to  see  with  what  was  diag- 
nosed as  tonsillitis  and  a  very  large  pelvic  tumor.  The 
patient  was  in  abdominal  distress.  Catheterization  netted 
2,150  c.c.  of  urine.  There  was  nothing  but  the  full  blad- 
der, and,  in  fact,  no  tonsillitis  in  this  case. 

I  was  called  to  a  hospital,  400  miles  from  New  York,  to 
operate  on  a  woman  under  observation  for  ten  days  for  a 
blow-growing  tumor  of  the  abdomen.  The  diagnosis  had 
been  made  by  the  specialists;  it  was  a  clear  case  and  I  was 
simply  to  proceed  with  operation.  When  the  patient  was 
under  the  anesthetic,  a  few  minutes  after  I  had  seen  her 
for  the  first  time,  I  asked  the  doctor  if  she  had  been 
catheterized.  She  had  not,  but  that  there  was  no  need  for 
this,  since  she  had  evacuated  360  c.c.  of  urine  just  before 
coing  on  the  table.  The  tumor  was  in  the  middle  line, 
!.bout  the  size  of  a  human  head.  After  2,340  c.c.  of  urine 
had  been  withdrawn  by  the  catheter,  the  tumor  entirely 
disappeared. 

A  woman,  36,  had  been  sent  to  a  state  hospital  with  the 
diagnosis  of  pregnancy,  latent  syphilis,  and  manic  depres- 
sive psychosis.  No  pregnancy  had  been  determined  on  x- 
ray  examination,  and  a  diagnosis  was  made  of  abdominal 
tumor.  I  was  called  to  see  the  patient  and  it  was  sug- 
gested that  I  perform  a  panhysterectomy.  The  patient  had 
been  passing  urine  more  frequently  and  in  greater  quantity 
than  usual.  The  tumor  completely  disappeared  after  950 
c.c.  of  urine  had  been  withdrawn. 

A  widow,  56,  had  been  morbid  since  the  death  of  her 
husband  two  weeks  before  I  was  called  to  see  her  at  a 
Government  hospital.  I  was  given  the  history  of  a  slow- 
growing  abdominal  tumor,  and  a  three-plus  Wassermann. 
The  neurologist  emphasized  the  luetic  condition,  the  medi- 
cal man  felt  it  was  a  gynecological  case,  and  the  gynecol- 
ogist stated  that  the  abdominal  tumor  extended  to  the 
umbilicus,  that  the  uterus  was  retroflexed  and  attached  to 
the  rectum,  that  the  mass  was  more  to  the  left  than  to  the 
right.  I  examined  in  the  presence  of  the  neurologist,  psych- 
iatrist, and  medical  man.  I  called  the  nurse  and  asked  if 
the  bladder  had  been  emptied,  and  she  replied  that  the 
patient  had  been  passing  a  great  deal  of  urine.  I  requested 
that  catheterization  be  done,  and  while  I  was  outside  talk- 
ing with  the  doctors,  1,000  c.c.  of  urine  was  evacuated  and 
the  tumor  disappeared.  My  next  request  was  that  the  pa- 
tient be  given  a  colonic  irrigation.  Nearly  two  large  pus 
basins  of  fecal  matter  were  removed.  The  uterus  was  no 
longer  pushed  backward.  The  great  mass  in  the  intestine 
on  the  left  side  was  gone;  the  patient  was  relieved.  Three 
months  later  she  has  not  had  any  trouble  since  the  "tu- 
mor" was  removed,  that  she  is  practically  normal  and 
is  receiving  the  usual  antiluetic  treatment. 


Testosterone  Propionate  in  daily  dosage  of  SO  to  75 
mgm.  after  delivery  have  been  efficient  in  suppressing  lac- 
tation. 


346 


SOUTHERN  MEDICINE  &  SURGERY 


June,   1941 


SOUTHERN  MEDICINE  &  SURGERY 

Official  Organ 

TRI-STATE    MEDICAL    ASSOCIATION    OF    THE 

CAROLINAS  AND  VIRGINIA 

James  M.  Northlngton,  M.D.,  Editor 


Department  Editors 
Human  Behavior 

James   K.    Hall,   M.D Richmond,   Va. 

Orthopedic   Surgery 
Oscar  Lee  Miller,  M.  D.  | 
John  Stuart  Gaul,  M.D.  f Charlotte,  N    C 

Urology 

Hamilton  W.  McKay,  M.D.  I Charlotte,  N.  C 

Robert  W.  McKay,  M.D J 

Surgery 

Geo.  H.  Bunch,  M.D Columbia,  S.  C. 

Obstetrics 

Henry  J.  Langston,  M.D Danville,  Va. 

Ivan  M.  Procter,  M.D Raleigh,  N.  C. 

Gynecology 

Chas.  R.  Robins,  M.D Richmond,  Va. 

G.  Carlyle  Cooke,  M.D Winston-Salem,  N.  C. 

Pediatrics 

G.  W.  Kutscher,  Jr.,  M.D Asheville,  N.  C. 

General  Practice 

J.  L.  Hamner,   M.D Mannboro,   Va. 

W.  J.  Lackey,  M.D Fallston,  N.   C. 

Clinical  Chemistry  and  Microscopy 

C.  C.  Carpenter,  M.D | 

n    ti    »/r  t.  o     »»  a     .*  Y-.    /Wake  Forest,  N.  C 

R.  P.  Morehead,  B,S.,  M.A.,  M.D..  | 

Hospitals 
R.  B.   Davis,   M.D Greensboro,   N.   C 

Cardiology 
Clyde  M.  Gllmore,  A.B.,  M.D Greensboro,  N.  C 

Public  Health 
N.  Thos.  Ennett,  M.D Greenville,  N    C 

Radiology 
Wright  Clarkson,  M.D.,  and  Associates.. ..Petersburg,  Va. 
R.  H.  Lafferty,  M.  D.,  and  Associates,     Charlotte,  N.  C. 

Therapeutics 
J.  F.  Nash,  M.  D., Saint  Pauls,  N.  C. 

Tuberculosis 
John   Donnelly,   M.D Charlotte,   N.    C. 

Dentistry 
J.  H.  Guion,  D.D.S Charlotte,   N.  C 

Internal  Medicine 
Georce  R.  Wilkinson,  M.  D Greenville,  S.  C. 

Ophthalmology 
Herbert  C.  Neblett,  M.  D., Charlotte,  N.  C. 

Rhino-Oto-Laryngology 

Clay  W.  Evatt,  M.  D Charleston,  S.  C. 

Proctology 
Russell  von  L.  Buxton,  M.D Newport  News,  Va. 


Offerings  for  the  pages  of  this  Journal  are  requested  and 
given  careful  consideration  in  each  case.  Manuscripts  not 
found  suitable  for  our  use  will  not  be  returned  unless 
author  encloses  postage. 

As  is  true  of  most  Medical  Journals,  all  costs  of  cuts, 
etc.,  for  illustrating  an  article  must  be  borne  by  the  author 


THE  AGING  HEART 

An  authority1  on  heart  disease  has  written  a 
sprightly  article  from  which  much  of  value  may 
be  learned.  He  tells  us  our  people  have  largely 
succeeded  in  their  attempt  to  grow  old  and  are 
now  much  concerned  about  the  fact  that  they  are 
dying  of  old-age  diseases,  which  is,  perhaps,  not 
inconsistent  with  a  desire  to  grow  old  comfortably. 

Dublin  is  quoted  as  saying  that  in  1930  aboli- 
tion of  all  deaths  from  cardiovascular-renal  disease 
would  have  added  7.2-7.5  years  to  the  average  life, 
whereas  the  disappearance  of  all  deaths  from  can- 
cer at  that  time  would  have  added  1.1-1.8  years 
to  the  average  life. 

Any  notable  decrease  in  deaths  from  cardiovas- 
cular disease  is  regarded  as  unlikely,  because,  as 
Warthin  has  emphasized,  normal  or  biologic  death 
is  essentially  cardiovascular  death;  when  acceler- 
ated senescence  becomes  pathologic,  then  old  age 
becomes  a  disease.  "We  must  decide  the  limits  of 
normality,  or  ask,  Abnormal  in  relation  to  what?" 
The  changes  incident  to  growing  old  start  at  birth 
and  are  essentially  a  continuous  process.  Often 
structural  changes  do  not  define  the  functional 
ability  of  the  circulation. 

That  great  pathologist  and  philosopher  War- 
thin's  summary  is  given  in  part: 

When  allowed  to  be  about  after  confinement  to 
bed,  the  atrophic  heart,  which  has  lost  tone 
through  the  period  of  inactivity,  cannot  recover  its 
oxygenation  power,  and  there  results  dilatation  and 
sudden  death.  The  only  lesions  of  any  significance 
found  in  some  of  these  cases  are  more  or  less  coro- 
nary sclerosis,  atrophy  and  fatty  infiltration  of  the 
heart  muscle.  Precisely  the  same  conditions  will 
be  found  in  the  hearts  of  old  people  who  have  died 
quietly  in  bed.  It  is  fair,  I  think,  to  ascribe  these 
deaths  to  senility,  although  such  a  term  is  not  an 
accepted  designation  as  a  cause  of  death.  In  one 
case  that  of  an  old  man  in  the  late  90s,  who 
showed  practically  no  sclerotic  changes  in  any  of 
his  arteries,  the  only  pathologic  change  found  in 
any  of  his  organs  was  that  of  simple  atrophy  in 
the  heart  leading  to  cardiac  insufficiency,  arterial 
anemia  and  passive  congestion.  I  would  regard 
myocardial  atrophy  and  inadequacy  as  the  most 
probable  natural  terminal  lesion.  The  purely  senile 
death  should  be,  therefore,  a  cardiac  death.  The 
vital  function  of  the  circulation  is  more  likely  to 
cease  before  that  of  respiration  or  of  the  central 
nervous  system. 

Examining  people  who  have  exceeded  three- 
score years  and  ten,  the  essayist  has  been  impress- 
ed with  the  number  of  instances  in  which  the  heart 
is  not  enlarged,  the  rate  is  slow,  the  sounds  may 
have  some  decrease  in  intensity,  but  often  there 
are  no  murmurs;   the  blood  pressure  is  normal  or 


rd  Med.  School,  in  Med.  An 


SOUTHERN  MEDICINE  &■  SURGERY 


low.  X-rays  show  the  heart  to  be  of  normal  size  or 
small,  more  horizontal;  the  aorta's  elasticity  de- 
creased, its  size  increased;  at  about  the  age  of  45 
the  aorta  is  for  the  first  time  larger  than  the  pul- 
monary artery. 

In  the  group  in  which  various  important  elec- 
trocardiographic findings  were  discovered,  there 
was  a  high  degree  of  inconstancy  of  these  findings 
on  serial  electrocardiograms.  We  are  warned  not 
to  be  too  rigorous  in  our  interpretation  of  the  elec- 
trocardiogram as  indicating  cardiac  disease,  if  un- 
supported by  other  evidence,  and  how  little  the 
mere  factor  of  age  may  be  expected  to  alter  the 
electrocardiogram. 

The  chief  types  of  normal  aging  individuals  are 
given  as  two.  The  first  is  a  small  group  of  indi- 
viduals in  whom  the  chances  of  senescence  are 
largely  those  of  desiccation,  although  some  degree 
of  coronary  sclerosis  will  almost  invariably  be 
present.  The  changes  in  the  vessel  walls  will  either 
not  encroach  greatly  upon  the  lumen  of  the  ar- 
teries, or  will  be  so  slow  in  their  development  that 
they  will  result  in  occlusion  of  arterial  branches  in 
the  heart  without  gross  infarction.  The  second 
type  of  normal  we  may  consider  the  individual 
who  lives  the  average  life  expectancy,  but  who 
may  not  be  entirely  free  from  cardiac  symptoms 
or  signs  during  his  later  years.  He  may  be  expect- 
ed to  show  coronary  atherosclerosis  with  some  oc- 
clusion, and  if  not  gross  infarction,  at  least  a  more 
diffuse  replacement  of  heart  muscles  by  fibrous 
tissue. 

The  range  of  electrocardiographic  normality  at 
all  ages  is  considered  greater  than  we  used  to 
think.  It  still  remains  questionable  if  inversion  of 
the  T  wave  in  the  first  lead  can  ever  be  considered 
normal. 

Hypertension  in  itself  may  be  considered  evi- 
dence of  an  aging  system,  but  in  this  condition 
the  diagnosis  is  generally  obvious  and  the  most 
important  evidence  is  cardiac  enlargement.  Per- 
haps frequent  premature  beats  should  be  looked  on 
with  suspicion  after  middle  age,  and  also  high  de- 
grees of  sinus  arhythmia,  especially  when  associ- 
ated with  displacement  of  the  pacemaker. 

The  closing  paragraph  asks  for  agreement  that 
aging  of  the  heart  is  mediated  almost  entirely  by 
coronary  integrity,  but  coronary  function  is  often 
inexplicable  in  terms  of  structural  change  seen  at 
autopsy;  that  angina  pectoris  and  congestive  fail- 
ure define  cardiac  function  in  coronary  degenera- 
tion, probably  neither  occurring  without  some  de- 
gree of  coronary  occlusion  in  the  absence  of  hyper- 
tension; that  a  careful  history  must  still  be  consid- 
ered as  giving  the  best  evidence  of  significant  de- 
generative cardiac  disease. 


subject!  Warthin  knew  and  Sprague  knows  that 
death  is  as  physiological  a  process  as  is  birth. 
Either  may  become  or  come  to  be  pathological. 
Our  vital  statistics  would  mean  much  more  if  a 
goodly  percentage  of  deaths  were  recorded  as 
caused  by  the  wearing-out  processes  of  nature. 

There  was  a  time  when  news  that  a  typhoid  pa- 
tient had  suffered  a  relapse  could  be  depended  on 
to  elicit  the  question,  "What  did  he  eat?"  Maybe 
a  time  will  come  when  it  will  be  as  generally 
known  and  accepted  that  one  may  die  from  a  cause 
other  than  disease  or  trauma,  as  surely  as  he  may 
have  a  relapse  in  typhoid  without  having  eaten  a 
morsel. 

And  all  of  us  may  well  recall  that  norma  means 
rule,  average — and  ponder  "Abnormal  as  to  what?", 
to  the  clearing  up  of  the  confused  idea  that  abnor- 
mal and  pathological  are  synonyms. 


INTELLIGENCE  vs.  COCKSURENESS  IN 
HERNIA  DIAGNOSIS 

How  many  of  us  have  ever  heard  a  teacher  ex- 
press any  doubt  as  to  whether  or  not  hernia  exists 
in  the  person  of  one  just  examined?  Our  own 
doubts  have  been  frequent,  particularly  as  to  per- 
sons examined  for  insurance  companies  and  for  the 
Government. 

It's  a  comfort  to  find  a  teacher1  setting  himself 
down  as  having  difficulty  in  learning  if  one  have 
hernia.  Evidently  this  surgeon  is  not  disposed  to 
accept  a  statement  at  face  value  just  because  it  is 
hoary  with  age.   Here  is  his  teaching: 

To  instruct  the  student  that  an  impulse  percep- 
tible on  coughing  or  straining  while  the  examining 
finger  is  in  the  external  inguinal  ring  is  diagnostic 
of  a  hernia  is  to  create  a  misconception.  The  in- 
sertion of  a  finger  into  the  external  inguinal  ring 
produces  a  cremasteric  reflex  and  the  cord  struc- 
tures are  retracted  or  pushed  upward,  not  infre- 
quently without  pain.  When  the  patient  is  now 
advised  to  cough,  the  contraction  of  this  muscle 
is  overcome  and  a  sudden  relaxation  results  in  the 
production  of  a  thud  on  the  examining  finger  from 
the  cord  structures. 

There  are  cystic  and  solid  tumors,  especially 
lipomatous  masses  in  this  region,  which  undergo  a 
similar  retraction  owing  to  the  action  of  the  cre- 
masteric muscle,  and  on  its  release  these  tissues 
may  give  an  impulse  and  a  false  impression  of  a 
hernia. 

The  differential  diagnosis  of  hernia  is  not  always 
an  easy  matter.  Some  surgeons  challenge  its  possi- 
bility in  many  instances.  To  distinguish  between 
a  direct,  an  indirect  and  a  femoral  hernia  with  any 
degree  of  accuracy  may  constitute  a  surgical  prob- 
lem. 


What  a  lot  of  sound  teaching  on  an  important         1.  s.  A.  Zi< 


Chicago,  in  //.  A.  M.  A..  Nov.  30th. 


SOUTHERN  MEDICINE  &  SURGERY 


June,    1941 


I  suggest  a  method  which  has  proved  very  en- 
couraging in  clarifying  these  difficulties.  The 
method  consists  in  placing  the  first,  second  and 
third  fingers  over  the  inguinal  region  in  such  a 
manner  that  the  index  finger  rests  on  the  so-called 
weak  spot.  The  middle  finger  lies  along  the  direc- 
tion of  the  inguinal  ring,  while  the  third  finger 
covers  the  femoral  canal  and  the  fossa  ovalis.  With 
the  hand  in  this  position  it  is  possible  to  perceive 
a  peculiar  sliding,  pushing  motion  of  a  viscus  under 
one  or  another  of  the  examining  fingers  when  the 
patient  is  directed  to  cough  or  strain.  Thus  imme- 
diately a  direct,  an  indirect  or  a  femoral  hernia  is 
determined.  If  there  is  a  bulging  mass  apparent 
to  the  eye,  the  examining  hand  forces  the  mass 
inward  and  again  coughing  or  straining  immediate- 
ly differentiates  the  type  of  hernia  present. 

The  patient  is  always  examined  in  the  upright 
position,  the  examiner  standing  somewhat  be- 
hind and  to  the  right,  using  the  left  hand  for  a 
left  inguinal  hernia.  A  peculiar  gurgling,  sliding 
or  slipping  motion  under  one  or  another  finger 
alone  determines  the  presence  of  a  hernia.  The 
feeling  of  solid  or  cystic  masses  results  in  an  en- 
tirely different  sensation.  Straining  is  a  better 
method  for  eliciting  the  essential  diagnostic  factor 
than  is  coughing. 


"WILL  HIS  HEART  STAND  THE 
ANESTHETIC?" 

How  many  times  have  all  of  us  been  asked  that 
question?  And  how  many  times  have  we  asked 
ourselves  that  question?  Beginning  with  my  in- 
terne days,  I  have  believed  that  patients  with 
heart  disease  stand  the  anesthetic  and  all  else  that 
goes  with  a  major  surgical  operation  just  about  as 
well  as  do  those  whose  hearts  appear  to  be  healthv. 

One  of  our  most  renowned  diagnosticians  is 
credited  with  having  said  that  he  did  not  know 
that  the  familv  history  had  ever  helped  him  to 
make  a  diagnosis,  but  that  he  just  could  not  make 
up  his  mind  to  quit  taking  family  histories.  It 
seems  that  our  examining  hearts  and  talking  about 
the  findings  in  cases  in  which  surgical  operation  is 
being  considered  is  somewhat  in  the  same  case. 
Certainly  the  instances  are  few  in  which  an  opera- 
tion otherwise  clearly  indicated  should  be  denied 
the  patient  because  of  any  heart  findings. 

Such  examinations  should  be  made  and  the  find- 
ings minutely  recorded.  The  heart  may  be  the 
seat  of  the  disease  producing  the  symptoms  which 
are  mistakenly  ascribed  to  the  organ  whose  re- 
moval is  being  contemplated;  and,  against  the 
chance  of  disaster  in  any  case,  it  is  well  to  be  in 
position  to  answer,  Yes,  when  some  lawyer  de- 
mands to  know.  Did  you  examine  the  heart? 

A  physician  is  frequently  asked  by  a  surgeon 
for  an  opinion  as  to  whether  a  candidate  for  sur- 


gery is  a  suitable  candidate — in  the  version  of  the 
laity,  "Whether  his  heart  will  stand  the  anes- 
thetic." Often  there  is  no  organic  heart  disease 
present,  or  the  blood  pressure  elevation  is  found  to 
be  due  to  the  nervous  strain  incident  to  the  haz- 
ards of  the  situation. 

"Too  frequently,"  so  says  one1  of  these  consult- 
ants, "the  medical  man  is  not  called  upon  until 
the  appendix  or  gallbladder,  for  example,  has  been 
investigated  surgically  and  found  to  be  normal." 
The  pain  of  acute  pericarditis  may  be  referred  to 
the  abdomen.  A  patient  with  mitral  stenosis  in 
which  the  onset  of  auricular  fibrillation  was  at- 
tended by  acute  right  heart  failure,  and  pain  and 
tenderness  over  the  liver  had  been  sent  to  the 
hospital  with  a  diagnosis  of  acute  cholecystitis; 
medical  consultation  was  requested  because  of  the 
irregular  pulse.  The  arrhythmia  stopped  of  itself 
in  24  hours  and  the  patient  was  spared  an  unneces- 
sary operation. 

Commonly  the  medical  man  is  called  upon  to 
decide  whether  operative  procedures  are  justified 
in  patients  who  have  some  form  of  heart  disease. 
Then  one  must  seek  to  answer  these  questions: 

Is  the  surgical  condition  so  grave  that,  no  mat- 
ter what  the  risk,  an  operation  must  be  perform- 
ed? 

Can  the  cardiac  condition  be  improved  by  de- 
laying the  operation  when  it  is  not  immediately 
urgent? 

In  those  conditions  in  which  operation  is  not 
imperative,  will  surgical  intervention  be  worth 
while?  Will  the  prospective  gain  in  comfort  to  the 
patient  balance  the  risk? 

It  is  pleasing  to  see  it  plainly  stated  that  heart 
patients  withstand  surgical  procedures  well;  to 
learn  that  this  doctor  doubts  if  the  mortality  fig- 
ures in  young  persons  with  well  compensated  heart 
disease  are  raised  bv  surgical  procedures.  There  is 
little  if  any  evidence  that,  in  the  absence  of  clear 
signs  of  heart  failure,  any  sound  heard  over  the 
heart  has  any  significance  as  to  prospect  of  surviv- 
ing an  operation. 

Heart  cases  that  have  undergone  surgical  proce- 
dures, listed  as  major,  at  the  Hospital  of  the  Uni- 
versity of  Maryland  during  the  past  18  months 
were  78;  and  of  these  78  patients,  14  (18%)  died. 
The  highest  mortality  rate  was  found  in  the  arte- 
riosclerotic group.  The  average  age  of  this  group 
was  68  years,  and  there  were  24  patients,  of  whom 
7  (29%)  died.  The  cause  of  death  was  pneumonia 
in  three  instances,  pulmonary  infarct  in  one,  septi- 
cemia in  one,  surgical  shock  in  one,  and  in  one  it 
was  not  determined.  Twenty-nine  patients  with 
hvpertension  and  some  degree  of  arteriosclerosis 
were  operated  upon,  and  of  these  4  died,  a  mortal- 


1.   W.    S.    Love 


in    Med.    Annals   Dist.    Col.,    April. 


June,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


ity  rate  of  13.8  per  cent.  Two  of  these  patients 
died  following  craniotomies,  performed  in  one  in- 
stance for  subdural  hemorrhage  and  in  the  second 
for  a  brain  tumor.  A  third  patient  died  following 
a  nephrosclerosis.  If  we  discard  these  three  cases, 
the  mortality  rate  falls  to  3.4  per  cent.  Of  nine 
cases  of  hyperthyroidism  complicated  by  cardiac 
enlargement,  hypertension  or  arteriosclerosis — one, 
two  or  all  three — deaths  followed  subtotal  thy- 
roidectomy in  two  cases.  Of  sixteen  patients  with 
rheumatic  cardioyascular  disease,  only  one  died 
following  operation.  This  patient  had  mitral  sten- 
osis and  auricular  fibrillation,  and  a  mid-thigh  am- 
putation was  necessitated  because  of  embolism  to 
the  femoral  artery. 

Most  deaths  occurred  in  the  aged,  or  in  those 
in  whom  the  illness  requiring  operation  was  of  an 
unusually  grave  nature. 

We  would  like  to  have  more  reports  bearing  on 
this  subject.  Very  likely  they  may  be  found  by 
diligent  search.  Already  we  have  enough  evidence 
of  the  ability  of  the  average  diseased  heart  to  go 
through  a  major  operation  without  throwing  up  its 
job  to  give  us  confidence  to  advise  our  patients  in 
need  of  surgical  relief  to  accept  operation. 


DON'T  RUN  FOR  A  PULMOTOR:  USE  YOUR 
HEAD  AND  HANDS 

There  is  a  great  tendency  to  demand  a  machine 
for  every  occasion.  An  answer  to  one  of  these  de- 
mands is  the  pulmotor.  And  while  awaiting  the 
arrival  of  the  pulmotor  the  patient  dies. 

Nobody  knows  more  about  respiration  and  re- 
suscitation than  Yandell  Henderson  of  Yale.  He 
tells1  us: 

The  time  lost  in  obtaining  and  adjusting  me- 
chanical devices  may  mean  the  difference  between 
life  and  death  of  the  victim.  Policemen,  firemen, 
seamen,  miners,  boy  and  girl  scouts,  college  stu- 
dents should  be  trained  in  the  application  of  the 
manual  (Schafer)  method. 

If  the  vital  machine  has  fully  stopped  it  cannot 
be  restarted;  it  is  not  like  an  automobile  motor  to 
be  started  by  cranking.  What  resuscitation  does — 
for  example  in  the  case  of  drowning — is  to  prevent 
the  machine  from  coming  to  a  full  stop.  For  this 
purpose  the  essential  is  a  renewed  supply  of  oxy- 
gen while  the  body  still  retains  some  of  its  tonus 
and  the  heart  is  still  beating. 

In  brief,  the  best  method  of  resuscitation  from 
drowning  and  electric  shock  is  prone  pressure  arti- 
ficial respiration  supplemented  by  inhalation  of 
carbon  dioxide  and  oxygen.  The  best  method  of 
resuscitation  from  carbon  monoxide  asphyxia  is  in- 
halation of  carbon  dioxide  and  oxygen,  initiated  in 
cases  of  severe  involvement  by  prone  pressure  arti- 
ficial respiration. 


The  Schafer  method  of  performing  artificial  res- 
piration is,  like  most  valuable  procedures,  very 
simple:  The  patient  flat  on  his  belly  and  chest 
with  forehead  on  one  of  his  arms;  straddle  the 
patient  with  your  knees  on  either  side  of  patient's 
hips,  and  press  with  both  hands  firmly  upon  the 
back  over  the  lower  ribs;  then  raise  your  body 
slowly,  at  the  same  time  relaxing  the  pressure. 
Repeat  this  backward  and  forward  movement 
about  every  five  seconds.  (Have  some  one  hold  a 
watch.  The  tendency  is  to  work  entirely  too  rap- 
idly.) 

If  every  doctor  who  reads  this  would  ask  his 
paper  to  publish  it  in  a  conspicuous  place,  and  if 
every  lifeguard,  policeman,  fireman  and  boy  scout 
were  so  instructed,  a  good  many  of  the  lives  which 
are  due  to  be  lost  this  summer  would  be  saved. 


AS  PUZZLING  AS  HESS'  TRIP 
We  learn  from  The  Rockefeller  Foundation  Re- 
view for  1940  that,  just  before  he  died,  Lord  Loth- 
ian, British  Ambassador  to  the  United  States,  ask- 
ed the  Rockefeller  Foundation  whether  it  would 
consider  giving  a  number  of  British  medical  stu- 
dents the  opportunity  to  complete  their  training  in 
the  medical  schools  of  the  United  States  and  Can- 
ada. While  medical  students  in  England  are  not 
subject  to  draft,  the  air  raids  throughout  Great 
Britain  have  imposed  excessive  demands  upon  all 
medical  schools  and  teaching  hospitals.  Destruc- 
tion has  been  extensive.  In  London,  at  this  writing, 
only  one  teaching  hospital  has  escaped  bombing. 
The  conditions  for  thorough  and  adequate  teaching 
in  medicine  are  therefore  severely  deranged.  A 
considerable  number  of  the  teachers,  moreover, 
have  been  called  to  military  or  special  civilian  du- 
ties, and,  together  with  the  profession  as  a  whole, 
are  exposed  to  injury  and  death  in  a  measure  that 
heightens  the  importance  of  adequate  training  for 
those  who  will  be  their  successors.  Lord  Lothian's 
suggestion  was  warmly  supported  by  leading  Brit- 
ish medical  authorities,  and  as  a  result  the  Foun- 
dation appropriated  $100,000  to  initiate  the  plan. 
And  Lord  Lothian  was  a  disciple  of  Mary  Baker 
G.  Eddy! 

True,  a  member  of  Congress  from  North  Caro- 
lina who  declined  reelection  just  a  few  years  ago 
had  an  osteopath  look  after  his  health,  and  a  wri- 
ter in  the  American  Journal  of  Surgery  (Dec, 
1940)  advises  treatment  of  corns  "by  a  skilled 
chiropodist";  still,  for  a  member  of  a  sect  that  de- 
nies the  very  existence  of  disease  and  obstructs 
and  impedes  Medicine  to  the  utmost  of  its  ability 
— for  such  a  one  to  ask  any  institution  to  train 
medical  students:  that  takes  the  cake. 


I.  Journal  of  A.  M.  A.,  May  5th. 


Post  Mortem  Casarean  Section. — Only  13  successful 
cases  were  reported  in  the  world  in  the  past  10  years — 
5  of  these  in  the  U.  S. — Moran,  in  Iowa  Stale  Med.  Jl. 


SOUTHERN  MEDICINE  &  SURGERY 


June,    1941 


ANENT  DR.  JAMES  K.  HALL  AND  THE 

AMERICAN  PSYCHIATRIC 

ASSOCIATION 

By  BEVERLEY  R.  TUCKER,  M.D. 

It  is  rare  in  this  mundane  world  when  the  man 
and  the  honor  come  synchronously  together.  The 
man  is  one  of  birth  in  Iredell  County,  North  Caro- 
lina, the  son  of  a  physician,  a  graduate  of  the  Uni- 
versity of  North  Carolina,  who  took  his  medical 
course  at  Jefferson  Medical  College  in  Philadel- 
phia. He  was  then  an  intern  at  the  Philadelphia 
Polyclinic  and  thereafter  came  to  be  a  resident 
physician  at  the  Morganton  State  Hospital.  While 
serving  in  this  capacity  he  learned  much.  He 
even  operated  successfully  on  a  case  of  acute  ap- 
pendicitis without  previous  especial  surgical  ex- 
perience. He  proved  an  excellent  doctor  of  the- 
heart  and  lungs  and  kidneys  and  in  the  diseases  of 
the  aberrated  mind  he  found  scope  for  the  exercise 
of  his  inherent  understanding  of  human  nature, 
his  psychologic  and  psychiatric  interest  and  his 
philosophical  contemplations. 

Practicing  neuropsychiatry  in  Richmond,  I  real- 
ized the  need  of  a  private  psychiatric  sanatorium 
in  this  vicinity,  and  I  turned  to  Paul  V.  Anderson, 
with  whom  I  had  fought  the  battle  of  extramural 
activities  of  interns  in  the  great  City  of  Philadel- 
phia. Ere  long  he  and  James  K.  Hall  came  to  look 
Richmond  over  and  the  present  site  of  Westbrook 
Sanatorium  was  selected.  Here  since  1911  they 
have  both  worked  and  wrought  exceeding  well. 
North  Carolina's  loss  was  not  so  much  Virginia's 
gain  as  was  the  fact  that  both  states  gained  and 
profited  by  their  sons  and  adopted  sons. 

Hall  has  pursued  the  even  tenor  of  his  own  se- 
lected way.  He  does  not  wear  a  hat,  an  overcoat, 
or  a  watch,  but  he  always  keeps  his  shirt  and  pants 
on,  so  to  speak.  He  has  never  hurried  in  his  life, 
yet  he  has  accomplished  far  more  than  the  hus- 
tlers. He  may  start  a  speech  or  paper  in  the  nebul- 
ous realms  of  anywhere,  but  soon  you  are  startled 
by  having  the  probe  of  his  subject  injected  right 
into  your  prefrontal  intellectual  area,  the  emo- 
tional centers  of  your  hypothalamus,  or  the  cockles 
of  your  heart.  In  speaking  his  delivery  is  deliber- 
ate, but  you  will  never  go  to  sleep  unless  you  are 
suffering  from  narcolepsy.  And  he  writes  with  a 
diamond  pointed  pen  dipped  into  an  ink  of  liquid 
gold  full  of  sunshine  and  vitamin  D. 

You  mav  not  agree  with  Hall  on  all  occasions, 
but  you  cannot  help  admiring  him.  and  if  you  are 
in  close  contact  with  him  you  will  love  him.  He  is 
a  man  whom  you  may  consciously  analyze  in  all 
the  ways  you  are  familiar  with  and  come  to  no 
conclusion  except  that  he  is  a  real  man,  for  he  is 
sometimes,  ofttimes.  unpredictable,  but  beware — 
while  you  have  been  consciously  analyzing  him  he 
has  sub-  or  unconsciously  sized  you  up  to  your 


weal  or  to  your  woe.  Hall  is  a  man  of  physical, 
moral  and  intellectual  courage.  He  has  locked  the 
door  on  a  younger  and  presumably  stronger  man 
and  fought  it  out  in  the  good  old  Anglo-Saxon 
fashion.  He  does  not  hesitate  to  tell  a  man  what 
he  thinks  of  a  proposition  or  of  him  personally. 
He  has  expressed  unpopular  opinions  without  car- 
ing a  whit  for  fear  or  favor.  And  Hall  is  a  great 
friend  whether  you  have  "the  boast  of  heraldry 
and  the  pomp  of  power"  or  be  you  '"ever  sn  hum- 
ble." 

The  American  Psychiatric  Association  has 
grown  from  small  beginnings  to  a  huge  member- 
ship with  nearly  fifteen  hundred  registering  in  their 
recent  meeting  in  Richmond.  It  has  performed 
many  miraculous  feats  besides  growth,  but  it  never 
did  a  better  thing  than  its  election  of  James  K. 
Hall  as  its  president.  In  this  selection  it  not  only 
obtained  an  executive  of  marked  ability,  but  it 
recognized  a  great  physician,  a  profound  philoso- 
pher, an  honest  man,  and  a  cultured  gentleman. 
And,  alas,  this  can  not  always  be  said  of  those  ele- 
vated to  high  office.  Dr.  Hall  did  not  seek  this 
office — in  fact  he  worked  against  his  being  consid- 
ered, even  declined  the  offer — and  only  accepted  it 
upon  the  obtrusion  and  insistence  of  his  friends 
and  admirers. 

I  have  met  many  men  in  mv  time,  but  James  K. 
Hall  is  one  of  the  few  individualists  that  I  have 
ever  known,  and  I  am  orthodox  enough  to  believe 
that  the  great  directing  Spirit  of  the  multiple  uni- 
verses, whom  we  call  God,  had  something  especial 
to  do  with  making  him  the  kind  of  individual  he 


CENTENNIAL  CELEBRATION 

The  Department  for  Mental  and  Nervous  Diseases  of 
the  Pennsylvania  Hospital  at  4400  Market  Street  in  Phila- 
delphia celebrated  its  centennial  on  June  11th  and  12th. 
On  the  eleventh  the  staff  of  the  Hospital  held  a  symposium 
on  Recent  Advances  in  Psychiatry.  On  the  twelfth  there 
was  a  public  reception  and  an  inspection  of  the  building 
and  facilities  and  grounds;  and  addresses  by  Dr.  Earl  D. 
Bond  and  Dr.  Edward  A.  Strecker.  Dr.  Lauren  H.  Smith 
is  Physician-in-Chief  and  Administrator  of  the  Hospital; 
Dr.  Earl  D.  Bond  is  Medical  Director  of  Research. 

In  1841  Dr.  Thomas  S.  Kirkbride  was  Superintendent 
of  the  Hospital — its  first  superintendent — and  he  remained 
its  head  for  many  years.  He  so  impressed  himself  and  his 
humanitarian  ideas  upon  those  charged  with  the  care  of 
the  insane  that  he  came  to  be  looked  upon  as  the  ideal 
superintendent,  and  his  influence  stamped  itself  for  years 
even  upon  State  Hospital  Architecture.  He  probably 
planned,  through  an  architect,  the  first  State  Hospital  in 
North  Carolina — at  Raleigh.  It  is  well  known  that  the 
Building  Committee  of  the  State  Hospital  at  Morganton, 
before  making  any  other  move,  consulted  Dr.  Kirkbride. 
He  promptly  referred  them  to  Mr.  Samuel  Sloan,  the  Phil- 
adelphia architect  who  planned  the  Hospital  at  Morganton 
as  a  Kirkbride  Building. 

The  centennial  of  the  Pennsylvania  Hospital  in  Philadel- 
phia constituted  an  event  in  American  medical  history. 


June.   1941 


SOCTHER.X  MEDICINE  &  SURGERY 


3S1 


NEWS 


AMERICAN  CONGRESS  OF  PHYSICAL  THERAPY 

INSTRUCTION      COVRSE     THROUGHOUT      SESSION      TO     BE     HELD 
IN    WASHINGTON 

The  20th  annua]  will  be  held  September  1st  to  5th  at 
The  Mayflower,  Washington. 

The  mornings  will  be  devoted  to  the  annual  instruc- 
tion course,  the  afternoons  and  evenings  to  the  research 
and  clinical  sessions.  The  seminar  and  convention  proper 
will  be  open  to  all  physicians  and  qualified  technicians. 
The  program  will  be  of  interest  to  the  general  practitioner 
as  well  as  to  the  specialist  in  physical  therapy. 

For  information  concerning  the  seminar  and  preliminary 
program   of   the   convention   proper,   address 

The  American  Congress  of  Physical  Therapy,  30  North 
Michigan   Avenue,   Chicago. 


\ 'irclvia  Society  of  Ophthalmology  and  Oto- 
laryngology 
Dr.  Mortimer  H.  Williams,  of  Roanoke,  was  elected 
president.  Dr.  Guy  R.  Fisher,  of  Staunton,  president-elect, 
and  Dr.  Meade  Edmonds,  of  Petersburg,  was  chosen  secre- 
tary and  treasurer,  at  the  22nd  annual  meeting  held  in 
Richmond,  May  20th.  Taking  part  in  the  program  were 
Dr.  James  A.  Babbitt,  of  Philadelphia;  Dr.  Edmund  S. 
Spaeth,  of  Philadelphia;  Dr.  Tom  W.  Moore,  of  Hunting- 
ton, W.  Va. ;  Dr.  E.  Tribble  Gatewood,  of  Richmond ;  Dr. 
M.  H.  Williams,  of  Roanoke;  Dr.  William  P.  McGuire,  of 
Winchester;  Dr.  George  M.  Maxwell,  of  Roanoke;  Dr. 
Elbyrne  G.  Gill,  of  Roanoke,  and  Dr.  Francis  H.  McGov- 
ern.  of  Danville. 


At  the  ninety-seventh  annual  meeting  of  the  American 
Psychiatric  Association  in  Richmond  on  May  5th-9th,  the 
following  officers  were  elected: 

President:   Dr.  J.  K.  Hall,  Richmond. 

President-Elect:  Dr.  Arthur  H.  Ruggles,  Providejnce, 
Rhode  Island. 

Secretary-Treasurer:  Dr.  Winfred  Overholser,  Washing- 
ton, D.  C. 

The  Association  will  meet  in  Boston  in  May,  1942.  The 
centennial  meeting  will  probably  be  held  in  Philadelphia 
in  1944,  where  thirteen  superintendents  of  state  hospitals 
organized  the  Association  in  1844.  It  is  our  oldest  national 
medical  association. 


The  American  College  of  Physichns,  recently  in  ses- 
sion in  Boston,  will  meet  in  April,  1942,  at  St.  Paul.  Dr. 
Roger  S.  Lee,  Boston,  is  president,  and  Dr.  James  E.  Paul- 
lin,  Atlanta,  president-elect.  Five  physicians  from  Virginia 
were  inducted  into  Fellowship. 


The  American  Pharmaceutical  Association  has  taken 
over  and  made  a  national  shrine  of  the  old  Hugh  Mercer 
Apothecary  Shop  at  Fredericksburg,  Virginia.  Amongst 
its  customers  were  George  Washington  and  John  Paul 
Jones,  and  it  was  the  meeting  place  of  many  who  became 
famous  in  the  nation's  history.  Dr.  Mercer  closed  his  shop 
when  he  entered  the  Revolutionary  War,  in  which  he  sac- 
rificed his  life  in  the  battle  of  Princeton. 


New  officers  of  the  Roanoke  Academy  of  Medicine 
are:  Dr.  M.  Williams,  president;  Dr.  D.  B.  Stuart  and  Dr. 
A.  M.  Groseclosc,  vice  presidents;  Dr.  H.  B.  Stone,  Jr., 
secretary-treasurer. 


The  Medical  Society  of  Virginia  will  be  in  annual 
session  at  Virginia  Beach  October  6th-8th,  with  headquar- 
ters at  the  Cavalier  Hotel. 


The  second  edition  of  the  Directory  of  Medical  Spe- 
cialists is  in  preparation  and  should  be  ready  for  deliv- 
ery by  February,  1942.  The  volume  will  contain  highly 
epitomized  information  about  each  of  those  listed  by  the 
fifteen  Boards  as  medical  specialists,  and  will  include  al- 
most 20,000  names.  Dr.  Paul  Titus,  Highland  Building. 
Pittsburgh,  is  Directing  Editor,  and  he  is  assisted  by  the 
secretaries  of  the  fifteen  Boards. 


A  portrait  of  Dr.  George  Woodford  Brown  was  pre- 
sented to  the  Eastern  State  Hospital  by  his  friends  on 
May  16th.  Dr.  Brown  has  been  Superintendent  of  that 
institution,  the  first  Hospital  for  the  Insane  in  English- 
speaking  America,  for  more  than  thirty  years. 


Dr.  N.  T.  Ennett,  Health  Officer  of  Pitt  County,  was 
made  president  of  the  North  Carolina  Public  Health  Asso- 
ciation at  its  recent  meeting  at  Pinehurst. 


Drs.  W.  M.  Scruggs  and  L.  E.  Flemmtng,  Charlotte, 
recently  completed  and  are  now  occupying  their  com- 
pletely  appointed  Clinic  Building   on   Howthorne   Lane. 


Dr.  W.  deB.  MacNider  was  toastmaster  at  the  formal 
dinner  of  the  Conference  on  Mental  Health  in  Later 
Maturity  held  in  Washington,  May  23rd-24th. 

Dr.  Charles  M.  Caravati,  of  Richmond,  is  spending 
several  months  in  graduate  work  at  the  Johns  Hopkins 
Hospital.  He  is  preparing  for  specialization  in  Gastroen- 
terology and  Nutrition. 


Dr.  B.  H.  Hartman  announces  the  reopening  of  the  of- 
fices of  the  late  Dr.  G.  W.  Kutscher,  for  practice  limited 
io  Infants  and  Children,  at  176  Woodfin  Street,  Asheville, 
North  Carolina. 


Dr.  George  R.  Wilkinson,  of  Greenville,  S.  C,  an- 
nounces the  removal  of  his  offices  to  300  East  North 
Street. 


Dr.  Calvin  Sandison,  Atlanta,  formerly  associated  with 
Dr.  Lawson  Thornton,  announces  the  opening  of  offices  in 
Suite  Ten  of  the  Doctors  Building  to  continue  his  practice 
of  Orthopedic  Surgery. 


Dr.   Alonzo  Myers,   Charlotte,   announces   the   removal 
of  his  offices  to  Suite  424  Professional  Building. 


Dr.  Wyndham  B.  Blanton,  of  Richmond,  delivered  the 
the  address  to  the  graduating  class  of  the  Medical  College 
of  the  State  of  South  Carolina,  Charleston,  on  June  4th. 
Dr.  Blanton  is  Professor  of  Clinical  Medicine  in  the  Med- 
ical College  of  Virginia. 


Dr.    Mason    Romadje    has    been    elected    all-time    City 
Health  Officer  of  Petersburg. 


Dr.  Fred  Wharton  Rankin,  President-elect  of  the 
American  Medical  Association,  is  a  native  of  North  Caro- 
lina. He  was  born  at  Mooresville  in  1886.  For  a  number 
of  years  Dr.  Rankin  was  a  member  of  the  Mayo  Clinic. 
A  dozen  years  ago  he  established  himself  at  Louisville  in 
the  practice  of  surgery. 

North  Carolina  has  the  unique  honor  of  having,  in  one 
year,  two  of  her  sons  holding  highest  offices  in  the  gift  of 
the  nation's  medical  men.  The  other  is  Dr.  James  K.  Hall, 
new  President  of  the  American   Psychiatric  Association. 


Dr.  W.  Z.  Bradford  and  Dr.  W.  B.  Bradford,  Charlotte, 
announce  the  removal  of  their  offices,  and  the  opening  of 
the  Bradford  Clinic  at  1509  Elizabeth  Avenue. 


352 


SOLTHER.X  MEDICINE  &  SURGERY 


June,   1941 


Dr.  Raymond  S.  Crispell,  of  the  Duke  Hospital,  Dur- 
ham, N.  C,  has  been  ordered  to  active  duty  in  the  U.  S. 
Navy  at  the  Naval  Air  Training  Station.  Pensacola,  Fla. 
He  has  obtained  a  year's  leave  of  absence  from  Duke  Uni- 
versity, and  he  reports  at  Pensacola  June  15th.  As  a  lieu- 
tenant commander  in  the  Medical  Corps,  Dr.  Crispell  will 
teach  Neuropsychiatry  and  will  participate  in  the  research 
and  in  the  clinical  work  in  Psychology  and  Psychiatry  at 
the  Naval  School  of  Aviation  Medicine.  He  will  also  act  as 
neuropsychiatrist  to  the  Naval  Dispensary  and  Hospital 
at  Pensacola,  and  in  these  various  capacities  he  will  be 
engaged  in  the  work  that  has  been  done  for  a  number  of 
years  in  the  Personality  Studies  associated  with  the  selec- 
tion and  with  the  fitness  of  naval  aviators. 


Dr.  Pachero  Sllva,  of  Brazil,  attended  the  recent  meet- 
ing in  Richmond  of  the  American  Psychiatric  Associa- 
tion while  on  his  way  to  visit  the  School  of  Medicine 
of  the  University  of  North  Carolina. 


Dr.  Claude  C.  Coleman,  of  Richmond,  has  been  ap- 
pointed a  member  of  the  Board  of  Visitors  of  the  Col- 
lege of  William  and  Mary. 


MARRIED 

Dr.  Jean  McNutt  Martin,  of  Middlebrook,  Augusta 
County,  Virginia,  and  Mr.  Ralph  Allen  Glasgow,  of  Roa- 
noke, were  married  on  May  30th.  Mr.  Glasgow  is  an  at- 
torney at  Roanoke. 


Dr.  Bradford  Sherwood  Bennett,  of  Lowville,  New 
York,  and  Miss  Lenoah  Araminta  Long,  of  Radford,  Vir- 
ginia, were  married  on  June  4th. 


Dr.  Henry  Boone  Grant,  of  Rocky  Mount,  and  Miss 
Elizabeth  Cheatham  Applewhite,  of  Halifax,  North  Caro- 
lina,  on  May  20th. 


Dr.  Joseph  Samuel  Holbrook,  of  Statesville.  and  Miss 
Nancy  Wheeler  Cox,  of  Raleigh,  were  married  on  May 
3rd. 


Miss  Frances  Rice  Hall,  of  Roanoke,  Virginia,  and  Dr. 
Jerome  Bostic  Hamer,  of  Charlotte.  North  Carolina,  May- 
nth. 


DEATHS 

Dr.  William  T.  Oppenhimer,  Jr..  of  Richmond,  died  on 
April  20th.  He  was  a  graduate  in  1917  of  the  Medical 
College  of  Virginia,  and  he  was  active  during  the  first 
World  War  in  the  United  States  Navy. 


Dr.  George  Johnson  Tompkins,  for  many  years  a  lead- 
ing specialist  in  eye,  ear,  nose  and  throat  work  in  Lynch- 
burg, died  of  a  heart  attack  on  April  2nd. 


Dr.  Richard  H.  Peake.  of  Norfolk,  a  graduate  of  the 
Medical  College  of  Virginia's  class  of  1915,  died  on  March 
6th,  at  the  early  age  of  fifty-two. 


Dr.  Benjamin  Franklin  Babb,  77.  retired  physician  of 
Ivor.  Virginia,  died  on  March  31st.  He  was  graduated  by 
the  Medical  School  of  the  University  of  Maryland  in 
1892. 


Dr.  Benjamin  McGougan,  53.  a  graduate  of  the  Uni- 
versity of  Maryland's  Medical  Class  of  1912,  died  suddenly 
in  his  office  at  Morven.  North  Carolina,  on  the  23rd  of 
May. 


University  of  Virginia 

DOCTORS  OF  MEDICINE,  JUNE  9TH,  WITH  AP- 
POINTMENTS AS  INTERNE  OR  OTHER 
POSITION 

Armistead,  George  Clayton,  Jr.,  B.S.,  University  of  Vir- 
ginia. Roanoke,  New  York  Hospital,  New  York  City. 

Bain.  James  Britton,  B.S.,  University  of  Virginia.  Ports- 
mouth, City  Hospital,  St.  Louis. 

Berner.  Benj.  Walter.  B.S..  University  of  Virginia,  Pat- 
erson.  N.  J.,  University  of  Virginia  Hospital.  University. 

Bigham,  Roy  Stinson,  Jr.,  B.A..  Davidson  College,  Char- 
lotte. N.  C.  University  of  Virginia  Hospital,  University. 

Booker,  James  Motley.  B.A.,  University  of  Virginia, 
Lottsburg.  Hospital  Division,  Medical  College  of  Virginia, 
Richmond. 

Bray.  William  Edward.  Jr.,  B.S.,  University  of  Virginia, 
University,  University  of  Virginia  Hospital.  University. 

Buckner.  Walter,  IT,  Roanoke,  Baroness  Erlanger  Hos- 
pital, Chattanooga. 

Chalmers.  Henry  Rives  Coleman,  Phenix,  Harrison  Me- 
morial Methodist  Hospital,  Fort  Worth. 

Cleveland.  Fred  Edward.  Jr.,  Swoope,  Virginia  Mason 
Clinic.  Seattle. 

Coleman,  John  Gordon,  B.S.,  University  of  Virginia,  Lex- 
inston,  Ky..  LTniversity  of  Virginia  Hospital.  University. 

Couper,  John  Lee,  B.S.,  Virginia  Military  Institute.  Lex- 
ington, St.  Luke's  Hospital,  New  York  City. 

Dandridge,  William  Robert,  B.A.,  Emory  and  Henry 
College.  Kermit,  W.  Ya..  University  of  Virginia  Hospital. 
University. 

Day.  Clara  Lyman,  B.A.,  Vassar  College,  Hartford,  Cor- 
nell Division,  Bellevue  Hospital.  New  York  City. 

Dunn,  Edward  Thomas,  Jr.,  B.S.,  University  of  Virginia, 
Clifton  Forge.  St.  Francis  Hospital,  Pittsburgh. 

Face,  Edward  Gill,  Jr..  Norfolk.  Post-Graduate  Hospital, 
New  York  City. 

Garcia-Bird.  Jorge,  Fajardo,  Puerto  Rico,  University  of 
Virginia  Hospital,  University. 

Giles.  Robert  Harrison.  Jr..  B.S..  LTniversity  of  Virginia, 
Roanoke.  Baroness  Erlanger  Hospital,  Chattanooga. 

Hand,  George  Parker,  Jr.,  Norfolk,  United  States  Ma- 
rine Hospital,  Norfolk. 

Hardie,  George  Anderson,  B.S..  Alabama  Polytechnic  In- 
stitute. Auburn.  Touro  Infirmary.  New  Orleans.. 

Hawkins,  William  Smith.  B.S.,  Furman  University, 
Greenville.  S.  C,  University  of  Minnesota  Hospital,  Min- 
neapolis. 

Helbert,  Hollen  Garber,  B.A.,  Bridegwater  College.  Har- 
risonburg. Church  Home  and  Infirmary,  Baltimore. 

Hendricks.  Willis  Merriman.  B.S.,  University  of  Vir- 
ginia,  Roanoke.  Vanderbilt  University   Hospital,  Nashville. 

Herring,  Alvah  Livingston,  Jr.,  B.S..  University  of  Vir- 
ginia. Richmond.  Hospital  Division,  Medical  College  of 
Virginia.  Richmond. 

Johnson,  Marcellus  Alexander.  Ill,  B.S..  University  of 
Virginia,  Roanoke,  Virginia  Mason  Clinic,  Seattle. 

King.  Thomas  Cobb,  Jr.,  B.S.,  University  of  Virginia, 
Anniston.  Ala..  City  Hospital,  Cleveland. 

Kolodny,  Abraham  Lewis.  Norfolk,  South  Baltimore 
General  Hospital,  Baltimore. 

Larkum,  Newton  Wheeler,  B.S.,  Bates  College;  Ph.D., 
Yale  University,  Charlottesville,  Walter  Reed  Hospital, 
Washington. 

McDaniel.  Samuel  Marshall.  Jr.,  University.  Duke  Uni- 
versity Hospital,  Durham. 

McKee,  Kelly  Tilson,  B.A.,  Emory  and  Henry  College. 
Bristol,  General  Hospital,  Cincinnati. 

Mangus.  Lewis  Edward,  B.A..  Washington  and  Lee  Uni- 
versity, Vesuvius,  St.  Luke's  Hospital.  Bethlehem.  Penn. 

Morris,  John  Richard.  Jr..  B.S..  University  of  Virginia, 


June.    1941 


SOUTH ERX  MEDIC1SE  &  SURGERY 


353 


Charlottesville,  Strong  Memorial  Hospital,  Rochester.  New 
York. 

Moss.  James  Mercer.  Arlington.  University  of  Virginia 
Hospital.  University. 

Mullen,  Edward  Eugene,  Smithfield.  N.  C.  St.  Luke'- 
Hospital,  New  York  City. 

Murray.  James  Spicer.  Jr..  B.A.,  Yale  University,  Balti- 
more, Indianapolis  City  Hospital,  Indianapolis. 

Orzac.  Edward  Seymour,  Norfolk.  Wilkes-Barre  General 
Hospital.  Wilkes-Barre,  Penn. 

Piatt,  Joseph  Lawson.  B.S.,  Emory  and  Henry  College, 
Emory.  University  of  Virginia  Hospital.  University. 

Robertson.  Rowland  Hatton.  Jr.,  Suffolk,  Lewis-Gale 
Hospital.  Roanoke. 

Sawyers,  Thomas  McCreery,  B.S..  University  of  Virginia, 
Hinton.  W.  Va..  Virginia  Mason  Clinic.  Seattle. 

Schilling,  Charles  D..  B.A..  Amherst  College,  Glen  Cove, 
N.  Y..  University  of  Virginia  Hospital.  University. 

Shelton.  Aubrey  Lawrence,  Norfolk.  Hospital  of  St.  Vin- 
cent de  Paul.  Norfolk. 

Shultz.  Philip  Laub.  Charlottesville.  University  of  Vir- 
ginia Hospital.  LTniversity. 

Sinclair.  Cecil  Lowry.  B.S.,  Virginia  Military  Institute, 
Hampton.  Charity  Hospital  of  Louisiana,  New  Orleans. 

Sproul.  Alexander  Erskine.  B.A..  Washington  and  Lee 
University.  Staunton,  Union  Memorial  Hospital,  Balti- 
more. 

Stoddard.  Spotswood  Douglas,  B.S.,  Hampden-Sydney 
College.  Savannah,  St,  Elizabeth's  Hospital,  Richmond. 

Stone.  Carey  Addison,  Jr.,  Crewe,  Central  Dispensary 
and  Emergency  Hospital,  Washington. 

Sulfridge,  Hugh  Leander,  Jr.,  B.S.,  University  of  Vir- 
ginia. Charlottesville,  Harper  Hospital,  Detroit. 

Trapnell.  John  Mackey,  Jr.,  B.S.,  University  of  Virginia. 
Charles  Town.  W.  Va.,  Grady  Memorial  Hospital,  Atlanta. 

Warren,  Allan  Bevier,  Jr.,  Orange,  Johns  Hopkins  Hos- 
pital. Baltimore. 

Whitehead.  Philip  Cary,  B.S.,  United  S'ates  Military 
Academy,  Chatham,  General  Hospital.  Montreal. 

Whitman.  William  Rush.  Jr.,  B.S..  Hampden-Sydney 
College.  Roanoke.  Emory  University   Hospital,  Atlanta. 

Williams.  Armistead  Dandridge,  B.S..  University  of  Vir- 
ginia. Richmond.  Duke  University  Hospita',  Durham. 

Willis.  Betty  Gordon,  B.A..  Agnes  Scott  College,  Culpep- 
er.  Gallinger  Municipal  Hospital.  Washington. 

Yates.  Harold  Taylor.  University,  University  of  Virginia 
Hospital.  University. 

Yuter.  Daniel,  Charlottesville,  Sinai  Hospital,  Balt:more. 

Dr.  Edwin  P.  L2hman  participated  in  a  Post-Graduate 
Course  in  Surgery  conducted  at  Waycross.  Georgia,  in 
April.  The  following  discussions  were  presented:  April 
7th.  Surgical  Shock;  April  9th,  Wa'er  Ba'ance  in  Surgery; 
April  10th,  The  S'gnificance  of  the  Cholecystogram;  and 
on  April  11th.  Hyperthyroidism.  At  a  meeting  of  the 
Eighth  District  Medical  Society  of  Georgia  on  April  8th, 
he  spoke  on  the  subject,  Heparin  in  the  Prevention  of 
Peritoneal  Adhesions. 

Dr.  D.  C.  Smith  attended  the  meeting  of  the  American 
Dermatological  Association  in  New  Orleans  and  on  April 
10th  he  presented  a  paper  on  Acanthosis  Nigricans. 

On  April  15th.  Dr.  E.  C.  Drash  addressed  the  Rocking- 
ham Tuberculosis  Association  and  I  he  members  of  the 
School  of  Nursing  of  the  Rockingham  Memorial  Hospital 
in  Harrisonburg.  His  subject  was  The  Conquest  of  Tuber- 
culosis. 

On  April  15th.  Dr.  Sydney  W.  Britton  gave  a  lecture 
before  the  Staff  and  Graduate  School  of  Iowa  State  Col- 
lege at  Ames.  He  spoke  on  Form  and  Function  in  Primi- 
tive Mammals. 

At  the  meeting  of  the  American  Physiological  Society 
in  Chicago  on  April  18th,  Drs.  E.  L.  Corey  and  S.  W  B.rit- 


ton  presented  a  paper  entitled  The  Antagonistic  Action  of 
Desoxycorticosterone  and  Antidiuretic  Principle  of  the 
Posterior  Pituitary  Gland. 

Dr.  Lawrence  T.  Royster  attended  the  Region  No.  2 
meeting  of  the  American  Academy  of  Ped'atrics  in  Rich- 
mond, and  on  April  25th  gave  a  broadcast  for  the  Acad- 
emy on  the  subject.  The  Importance  of  Periodic  Exam- 
ination of  Children. 

Dr.  Jchn  M.  Meredith  attended  the  meeting  of  the 
American  Society  of  Neurological  Surgeons  in  Richmond 
on  May  1st  and  2nd  and  read  a  paper  on  Experimental 
Head  Injuries:  a.  The  Inefficacy  of  Lumbar  Puncture  for 
the  Removal  of  Erythrocytes  from  the  Spinal  Fluid;  b. 
Can  the  Site  and  Degree  of  Intracranial  Trauma  Be  Deter- 
mined by  Spinal  Fluid  Erythrocyte  Counts? 

At  the  meetings  of  the  Virginia  Academy  of  Science  in 
Richmond  on  May  1st  to  3rd,  the  following  members  of 
the  Faculty  of  the  Department  of  Medicine  of  the  Uni- 
versity of  Virginia  presented  papers:  The  Synchronization 
of  Cerebro-Cortical  Potentials,  by  Dr.  Charlton  Gilmore 
Holland  Jr.;  Study  of  a  Case  of  Osteosclerosis  with 
Myeloid  Leukemia.  With  Special  Reference  to  the  Exten- 
sive Extramedullar  Blood  Formation  by  Drs.  H.  E. 
Jordan  and  James  K.  Scott;  Autopassive  Local  Sensitiza- 
tion and  desensitization  by  Drs.  Oscar  Swineford,  Jr., 
and  W.  Roy  Mason,  Jr.;  Chemistry  and  Sulfonamide 
drugs  by  Dr.  Alfred  Chanutin ;  Heparin  and  Peritoneal 
Adhesions  by  Dr.  Floyd  Boys;  and  An  Analysis  of  Hor- 
monal Influences  on  Fluid  Balance  by  Drs.  S.  W.  Britton 
and  E.  L.  Corey. 

Dr.  Charlton  Gilmore  Holland,  Jr.,  attended  the  organi- 
zation meeting  of  the  American  Federation  for  Clinical 
Research  in  Atlantic  City  on  May  5th  and  discussed  his 
work  on  Electroencephalographic  Studies  in  Myoclonia. 

On  May  6th,  Drs.  J.  Edwin  Wood,  James  K.  Scott  and 
John  L.  Guerrant  presented  a  paper  on  Further  Observa- 
tions on  Blood  Pressure,  Weight  and  Diet  in  Normal  Hy- 
pertensive Dogs,  at  the  meeting  of  the  Association  of 
American  Physicians. 

Drs.  George  C.  Ham  and  Eugene  M.  Landis  a' tended 
the  meeting  of  the  American  Society  for  Clinical  Investi- 
gation and  delivered  a  paper  on  A  Comparison  of  Pituitrin 
and  Antidiuretic  Substance  in  Human  Urines  and  Placen- 
tas. 

Dr.  W.  M.  Craig,  Professor  of  Neurosurgery  at  the 
Mayo  Clinic,  visited  our  Medical  School  on  May  5th. 

The  Department  of  Physiology  was  awarded  a  research 
grant  of  $2,000  by  the  Committee  on  Research  in  Endo- 
crinology of  the  National  Research  Council,  for  investiga- 
tions on  the  function  of  the  suprarenal  under  the  direction 
of  Dr.  Sydney  W.  Britton. 

On  May  7th,  Dr.  Staige  Davis  Blackford  addressed  the 
Augusta  County  Medical  Society  on  the  subject,  Medical 
Treatment  of  Peptic  Ulcer. 

At  the  meeting  of  the  West  Virginia  State  Medical  As- 
sociation in  Charleston  on  May  14th,  Dr.  T.  J.  Williams 
spoke  on  The  Management  of  the  Toxemias  of  Late  Preg- 
nancy. On  May  15th,  he  addressed  the  West  Virginia 
Obstetrical  and  Gynecological  Society  on  the  subject,  Ex- 
perience in  Postpartum  Sterilization. 

On  May  1st,  Dr.  T.  J.  Williams  participated  in  the 
Post-Graduate  Course  in  Medicine  and  Surgery  for  the 
Loudoun  County  Medical  Society  conducted  under  the 
auspices  of  the  Department  of  Clinical  and  Medical  Edu- 
cation of  the  Medical  Society  of  Virginia.  His  subject  was 
Toxemias  of  Pregnancy.  On  May  15th.  Dr.  H.  B.  Mul- 
holland  discussed  Tie  Newer  Phases  of  Pneumonia  Treat- 
ment. 

At  the  meeting  of  the  American  Psychiatric  Association 
in    Richmond    on    May    5th.    Drs.    David    C.   Wilson    and 


SOUTH ER.X  MEDICINE  &  SURGERY 


June.    1941 


Charlton  Gilmore  Holland.  Jr..  presented  a  joint  paper  on 
Electroencephalographs   Studies  in   Myoclonia. 


BOOKS 


Medical  College  of  Virginia 

Mr.  George  W.  Bakeman.  who  has  been  in  charge  of 
the  Paris  office  of  the  Rockefeller  Foundation  for  a 
number  of  years,  has  been  appointed  Assistant  to  the 
President. 

Commencement  exercises  closing  the  one  hundred  third 
session   of  the  college  were   held  June  3rd. 

There  are  172  candidates  for  graduation;  74  in  medi- 
cine, 35  in  dentistry.  29  in  pharmacy,  and  34  in  nursing. 
Dr.  Theodore  Meyer  Greene,  McCosh  Professor  of  Phil- 
osophy, Pr'nceton  University,  will  deliver  the  Com- 
mencement address.  The  Commencement  sermon  will 
he  given  by  Dr.  Vincent  C.  Franks,  Pastor,  St.  Paul's 
Church,  Richmond. 

Dr.  William  Newton  Hodgkin,  an  alumfius  of  the 
school  of  dentistry  of  the  college,  class  of  1912.  and  a 
member  of  the  Council  on  Dental  Education  of  the 
American  Dental  Association,  will  be  awarded  the  hon- 
orary degree  of  Doctor  of  Science  at  the  Commencement 
exercises. 


Hypertension. — In  any  case  of  hypertension,  especially 
in  a  young  person  with  a  previous  history  of  pyelitis, 
we  owe  it  to  the  patient  to  investigate  both  kidneys. — 
J.  F.  Casey.  Boston,  in  Clin.  Med.,  Jan. 


Lyovac  (Latrodectus  Mactans),  Sharp  &  Dohme,  is 
reported  by  Voss  (in  Clinical  Medicine,  May)  as  far  the 
most  satisfactory  remedy  in  cases  of  bite  of  the  Black 
Widow. 


ESSENTIALS  OF  DEMOCRACY,  by  Norman  Tobias, 
M.  D..  Senior  Instructor  in  Dermatology,  St.  Louis 
University.  J.  B.  Lippincott  Company,  Philadelphia;  Lon- 
don;  Montreal.   1941.   S4.75. 

Very  well  is  it  said  that,  since  most  skin  diseases 
!ook  alike  to  the  beginner,  diagnostic  features  are 
emphasized.  The  text  is  not  burdened  with  histori- 
cal information  or  other  matter  of  no  practical  use 
in  diagnosis  and  treatment. 

The  groupings  are  such  as  to  be  of  most  help — 
the  erthema  group,  the  eczema  group,  drug 
eruptions,  the  pyoredmas.  diseases  due  to  vegetable 
parasites,  diseases  due  to  animal  parasites,  diseases 
due  to  psychic  disorders  and  so  on. 

A  handv,  reliable  volume  to  meet  the  needs  of 
the  practitioner  in  this  field. 


EXOPHTHALMOS.- 

ease  is  unknown. 


The    cause    of    that    of    Graves'    dis- 


TEXTBOOK  OF  PEDIATRICS,  by  J  P.  Crozer  Grif- 
fith, M.D.,  Ph.D..  Emeritus  Professor  of  Pediatrics  in  the 
University  of  Pennsylvania;  and  A.  Graeme  Mitchell, 
M.D.,  B.  K.  Rachford  Professor  of  Pediatrics,  College  of 
Medicine,  University  of  Cincinnati.  Third  edition,  revised 
and  reset.  W.  B.  Saunders  Company,  Philadelphia  and 
London.  1941.  $10.00. 

The  new  title  is  chosen  so  as  to  give  a  name 


ASAC 

IS%,  by   volume   Alcohol 
Each    ft.    oz.   contains: 

Sodium   Salicylate,   U.   S.  P.  Powder 40  grains 

Sodium   Bromide,  U.  S.  P.  Granular 20  grains 

Caffeine,    U.    S.    P 4  grains 

ANALGESIC,    ANTIPYRETIC 
AND    SEDATIVE. 

Average    Dosage 
Two  to  four  teaspoonfuls  in  one  to  three  ounces  oi 
water   as   prescribed   by    the   physician. 

How   Supplied 
In  Pints,  Five  Pints  and  Gallons  to  Physicians  and 
Druggists. 

Burwell  &  Dunn  Company 

Manufacturing    g--^=>     Pharmacists 
Established     Dj^)      m    1S87 

CHARLOTTE,  N.  C. 


Sample    sent    to    any    physician    in    the    U.    S.    on 
request 


SOUTHERN  MEDICINE  &  SURGERY 


COURTESY    BECK 


I  f  §T 


Follow  vitamins  from  the  food  market  to  our  bodies,  and  you  will  find  their  course  beset  by  enemy  forces. 
Even  if  the  right  types  of  foods  are  selected  there  are  always  the  hazards  of  processing,  refining,  and  improper 
cooking,  which  may  rob  us  of  the  full  metabolic  utilization  of  their  original  vitamin  content.  Vi-Penta  Perles 
and  Vi-Penta  Drops  offer  a  sensible  and  dependable  means  ot  convoying  an  adequate  supply  of  vitamins  be- 
yond those  danger  zones.  To  overcome  the  lassitude,  the  anorexia,  and  the  poor  resistance  that  are  traceable 
to  vitamin  deficiency  we  confidently  suggest  Vi-Penta  Perles  and  Vi-Penta  Drops.  Perles:  packages  of  25,  100 
and  250;  Drops:  dropper  bottles  of  15  and  60  cc.     •     HOFFMANN-LA   ROCHE,   INC.     •     NUTLEY,  N.  J. 


VI-PENTA        PERLES        AND        V  I   -   P  F   N  T  A        DROPS 

Patronage  of  our  Advertisers  is  a  Mark  of  Friendship  to  the  Journal 


356 


SOUTHERN  MEDICINE  &  SURGERY 


June.    1941 


which  will  include  in  its  scope,  as  does  the  book, 
the  maintenance  of  good  health,  as  well  as  the 
prevention  and  cure  of  disease. 

More  than  sixty  authorities  on  various  phases 
of  child  care  and  cure  have  aided  in  sundry  ways 
in  the  production  of  this  book. 

Diagnostic  measures  are  plainly  stated  and 
detailed  treatment  described  in  a  way  to  convince 
the  reader  and  to  enable  him  to  put  the  instruction 
to  use. 

A  well-balanced,  authoritative  work. 


A  PRACTICAL  MANUAL  OF  DISEASES  OF  THE 
CHEST,  by  Maurice  Davidson,  M.A.,  M.D..  Oxon.  F. 
R.  C.  P.  Lond.,  Physician  to  the  Brompton  Hospital 
For  Consumption  and  Diseases  of  the  Chest  (sometime 
Dean  of  the  Brompton  Hospital  Medical  School),  second 
edition.  Oxford  University  Press,  London:  Humphrey 
Milford.     1941.     $13.50 

Radiology  of  the  chest  is  dealt  with  before  or- 
dinary means  of  examination;  but  it  is  empha- 
sized that  the  new  means  has  not  replaced  the  old, 
that  the  two  are  interdependent.  Conspicuous 
are  the  chapters  on  the  relation  of  chest  disease 
to  general  medicine,  diseases  of  the  upper  respira- 
tory tract,  bronchiectasis,  foreign  bodies  in  the 
bronchi,  asthma,  specific  non-tuberculous  infec- 
tions of  the  lung,  differential  diagnosis,  oxygen 
therapy,  prescriptions. 

The  book  brings  forward  all  that  is  best  from 
the  old,  and  adds  all  that  is  valuable  in  the  new. 
in  diagnosis  and  management  of  diseases  of  the 
chest . 


FRACTURES,  by  George  Perkins,  M.C.,  M.Ch., 
Oxon..  F.R.C.S..  Assistant  GUhopedJic  Surgeon  to  St. 
Thomas's  Hospital.  Oxford  University  Press,  London. 
Humphrey    Milford.      1940.     $6.50 

There  is  no  preface,  no  foreword.  The  author 
is  not  wasteful  of  words,  and  he  writes  with  the 
confidence  of  knowledge.  None  other  would  dare 
say  all  he  has  to  say  on  the  repair  of  bone  on 
one  page;  the  same  as  to  methods  of  obtaining 
fixation;  less  than  a  page  on  treatment  of  non- 
union. 

There  is  no  hocus  pocus.  Treatment  is  either 
so  and  so,  or  "none  is  needed."  Of  fracture  of  the 
clavicle  distal  to  the  coraco-clavicular  ligament: 
"No  treatment  is  required.  A  sling  for  a  few  days, 
and  active  movements  of  the  shoulder  are  begun 
immediately." 

Every  general  practitioner  should  have  a  copy, 
and  most  general  surgeons. 


A  TEXTBOOK  OF  OPHTHALMOLOGY:  by 
Sanford  R.  Gifford,  M.A.,  M.D..  F.A.C.S.,  Professor 
of  Ophthalmology.  Northwestern  University  Medical 
School,  Chicago;  Attending  Ophthalmologist,  Passavant 
Memorial  and  Cook  County  Hospitals.  Second  edition, 
revised.  470  pagrs  with  215  illustrations.  Philadelphia 
and  London:   W.  B.  Saunders  Company,  1941.  Price  $4.00. 


The  second  edition  has  taken  due  cognizance 
of  the  great  advances  made,  in  therapy  particu- 
larly, since  the  appearance  of  the  first  edition 
just  three  years  ago.  The  author  believes  that 
every  physician  should  be  able  to  carry  out  a 
systematic  examination  of  the  eye,  and  to  take 
care  of  most  of  the  eye  conditions  of  his  patients; 
and  the  author  tells  the  general  practitioner  and 
medical  student  how  these  things  should  be  done. 

Instruction  is  given  in  external  and  internal 
and  functional  eye  examination,  refraction,  dis- 
eases of  the  adnexa  and  all  the  elements  of  the 
eye,  injuries  to  the  globe,  opthalmologic  therapy, 
and  the  eve  in  general  diseases. 

If  this  is  not  the  very  best  book  in  this  field, 
it  is  certainly  one  of  the  best. 


CLINICAL  ASPECTS  OF  THE  ELECTROCARDIO- 
GRAM, Including  the  Cardiac  Arrhythmias,  by  Harold 
E.  B.  Pardee,  M.D..  Assistant  Professor  of  Clincal  Medi- 
cine, Cornell  University  Medical  College;  with  219  illus- 
trations on  102  figures ;  4th  edition  revised.  Paul  B. 
Hoeber,   Inc.,   New   York   and    London.      1941.      $5.75. 

The  new  edition  is  really  a  new  edition.  The 
previous  edition  has  been  amended  and  corrected 
and  added  to,  to  meet  the  advances  in  technical 
procedures  and  the  increased  knowledge  of  heart 
disease  diagnosis,  until  a  virtually  new  book  has 
been  produced.  As  was  true  of  the  three  preced- 
ing editions,  the  fourth  is  a  faithful  setting  forth 
of  the  electrocardiography  of  its  year  of  pub- 
lication. 

A  brief  note  is  given  on  the  development  of 
this  means  of  diagnosis.  The  normal  ecg.  is  ana- 
lyzed, then  those  characteristics  of  various  disease 
conditions  of  the  heart. 

There  is  some  account  of  technical  difficulties 
which  may  be  encountered  with  helpful  sugges- 
tions as  to  the  means  of  overcoming  them.  In 
the  appendix  is  described  a  method  of  filing  and 
indexing  the  records. 

The  author  does  not  think  of  electrocardi- 
ography as  an  infallible  means  of  diagnosis,  but 
as  one  of  the  valuable  means,  much  more  valu- 
able in  some  circumstances  than  in  others,  and 
he  undertakes  to  group  the  problems  which  the 
physician   should   refer   to   the  electrocardiograph. 


THE  STORY  OF  CLINICAL  PULMONARY  TU- 
BERCULOSIS, by  Lawrason  Brown,  M.D.,  Late  Direc- 
tor of  Trudeau  Sanatorium.  The  Williams  &  WUkins 
Company,  Mt.  Royal  &  Guilford  Aves.,  Baltimore,  Md. 
1941.     $2.75. 

Perhaps  no  one  was  ever  better  qualified  to 
write  the  story  of  the  disease  wrhich  was  for  centu- 
ries mankind's  greatest  plague,  which,  counting 
morbidity  and  mortality,  may  still  hold  that 
place. 

The  author  divides  his  story  into  the  four 
periods  suggested  by  Osier:     1)  From  the  time  of 


June.    1941 


SOUTHERN  MEDICINE  &  SURGERY 


357 


earliest  records  to  the  middle  of  the  17th  cen- 
tury; 2)  the  latter  half  of  the  17th  and  the  whole 
of  the  18th:  3)  the  first  three  quarters  of  the 
19th;  and  4)  to  the  present. 

Under  Part  I  are  described  the  doctor's  visit 
in  1700,  in  1800,  in  1900. 

Part  II  has  chapters  on:  Laennec  and  His  Suc- 
cessors and  the  Beginnings  of  Early  Diagnosis, 
Early  Publications  in  Germany  and  Austria,  The 
Diffusion  of  Knowledge  in  England,  Diagnosis  in 
America,  Diagnosis  by  X-rays  (by  Homer  L. 
Sampson.) 

Part  Ill's  two  chapters  are  devoted  to:  Artifi- 
cial Pneumothorax  The  Development  of  Surgical 
Methods  in  Treatment  (bv  Edward  W.  Archi- 
bald ) . 

Part  IV  informs  in  detail  on:  Laennec  and  His 
Writings.  The  Story  of  the  Stethoscope,  Early 
Medical  Journals,  Bibliography. 

The  doctor  who  would  understand  how  we  have 
come  so  far  in  conquering  tuberculosis  and  so 
grasp  what  lies  before  us  must  be  familiar  with 
the  story  Dr.  Brown  tells.  For  the  layman  of 
fair  intelligence  and  education  here  is  as  fascinating 
a  tale  as  may  be  seen  on  a  screen;  and  hardly  a 
one  in  either  group  but  has  a  personal  interest 
through  tuberculosis  close  to  him. 


SYNOPSIS  OF  DISEASES  OF  THE  HEART  AND 
ARTERIES,  by  George  R.  Hermann,  M.S.,  M.D.,  Ph.D., 
F.A.C.P.,  Professor  of  Medicine.  University  of  Texas. 
Second  edition.  The  C.  V.  Mosby  Company,  Pine  Boule- 
vard, St.  Louis,  Mo.     1941.     $5.00. 

The  author  says  this  edition  is  the  result  of 
further  experience  with  the  help  of  suggestions 
from  critical  colleagues  and  reviewers.  Only  the 
essentials  of  diagnosis  and  treatment  of  this  group 
of  diseases  are  included,  and  this  fact  makes  the 
book  a  very  godsend  to  doctors  who  want  to  know 
how  best  to  find  out  with  the  least  search  what 
is  wrong  with  certain  patients  and  what  to  do  for 
them. 

The  author  is  sensible  of  the  implications  of  a 
diagnosis  of  heart  disease,  as  well  as  of  the  liability 
to  error  in  undertaking  such  diagnosis.  He  lists 
certain  symptoms  and  signs  as  pathognomonic. 
The  chapter  devoted  to  the  study  of  a  patient 
suspected  of  having  heart  disease  is  worth  the  price 
of  the  book  to  any  doctor  of  general  medicine. 

Radiography  and  electrocardiography  are  evalu- 
ated as  essential  in  some  cases,  useful  in  many, 
but  by  no  means  needful  in  all. 

It  is  plain  that  the  book  is  written,  not  to  tell 
how  many  patients  with  heart  disease  the  author 
has  seen,  or  how  many  books  and  articles  on  the 
subject  he  has  read,  but  for  the  purpose  of  help- 
ing doctors  to  do  most  for  their  patients  wh) 
have,  or  think  thev  have,  heart  disease. 


THE  DOCTOR  TAKES  A  HOLIDAY:  An  Autobiog- 
raphical Fragment,  by  Mary  McKibbfn-Harpeg,  M.  D. 
The  Torch  Press,  Cedar  Rapids,  Iowa.  1941.  $2.50. 

The  holiday  described  was  spent  mostly  in  the 
Orient.  The  author's  descriptions  of  and  com- 
ments on  living  conditions,  customs,  politics,  re- 
ligions, superstitions  as  to  cure  of  disease  and  other 
things,  and  her  pen-pictures  of  persons  and  person- 
ages, keep  the  reader's  interest  and  afford  him  en- 
tertainment and  instruction. 


METRAZOL   NOT  HELPFUL   IN   DEMENTIA 
PRAECOX 

(G.  Wilse  Robinson,  Jr..  K  C,  Mo.,  in  Jl.  Kans.  M.  S..  May) 
Published  reports,  statistical  analysis  and  numerous 
observations  show  that  metrazol  convulsive  shock  is  not 
helpful  in  the  treatment  of  schizophrenia.  Insulin  shock 
is  the  treatment  of  choice  in  the  management  of  schizo- 
phrenia. 

Metrazol  does  have  a  valuable  place  in  the  handling 
of  syndromes  characterized  by  marked  changes  in  the 
mood  (affective  disorders)  and  should  be  used  when 
other  more  conservative  measures  have  failed.  Insulin 
shock,  on  the  other  hand,  apparently  is  not  especially 
beneficial  in  these  cases. 


Benzedrine  Sulphate  has  been  used  with  success  to 
overcome  undesirable  effects  of  morphine  in  cases  of 
coronarv   occlusion. 


Leukemia   may   cause   a  striking  increase   in   the   basal 
metabolic    rate. 


3  58 


SOUTHERN  MEDICINE  &  SURGERY 


June.    1941 


DR.  BRICKELL:  DR.  WALKER 
Dr.  John  Brickell  was  practicing  medicine  in  Edenton, 
North  Carolina,  about  1731.  In  1737  he  traveled  far  into 
territory  that  is  now  part  of  Tennessee,  and  made  his  fa- 
mous study  of  the  natural,  social,  and  economic  conditions 
of  North  Carolina  which  is  now  so  highly  valued  as  an 
early  history  of  that  State.  Indian  customs  were  described, 
and  trees,  animals,  plants  for  medical  use  were  amply  illus- 
trated in  his  book. 

A  few  years  later,  in  1750,  Dr.  Thomas  Walker  went  in 
search  of  good  lands  in  the  western  part  of  the  colony  of 
Virginia,  that  part  which  is  now  in  the  limits  of  Kentucky 
and  Tennessee.  He  named  the  Cumberland  Gap  and  River, 
and  gathered  a  wealth  of  facts  of  interest  to  the  historian, 
geologist,  and  naturalist.  His  exploration  antedated  Daniel 
Boone's  by  twenty  years.  But  he  missed  the  blue  grass 
region  of  Kentucky  on  his  journeys!  A  close  friend  of 
Thomas  Jefferson's  father,  he  later  became  the  young 
man's  guardian. 

NOTES  FROM  NATURAL  HISTORY  OF  NORTH 
CAROLINA,  1737,  BY  THOMAS  BRICKELL,  M.D. 

To  those  who  by  Misfortune  are  incapable  of  work  and 
have  no  way  to  support  themselves,  the  Country  allows 
Fifty    Pounds    per    Annum    for    their    Support. 

Many  women  from  other  places  who  have  been  long 
married  and  without  children,  have  removed  to  Carolina, 
and  become  joyful  mothers. 

It  is  enacted  by  the  Laws  of  the  Country  that  no  person 
shall  be  liable  to  pay  above  forty  Shillings  for  any  pub- 
lick-House  Scores  for  any  Liquors,  let  the  Persons  that 
keep  such  Houses  trust  them  what  they  please,  yet  by  Law 
they  can  recover  no  more. 

The  Indians  use  Sweating  very  much,  especially  if  vio- 
lent Pains  seize  the  Limbs.  They  likewise  use  bathing 
often  in  the  Waters  for  the  like  disorders.  With  Oil  of 
Acorns  they  cure  Burns  beyond  credit ;  I  have  seen  some  of 
those  wretches  burnt  in  their  Drunkenness  so  that  in  all 
Appearances  they  could  not  live;  yet  have  I  seen  them 
cured  and  going  abroad  in  ten  or  twelve  days. 


"Money,   money ;    that's   all   you 


Last  week  elderly,  erudite,  and  good-natured  psychiatrist 
Russ  spoke  to  his  wife,  younger  than  he:  "Now,  now,  my 
dear,  we  must  not  live  above  our  means.  We  must  be 
honest  with  ourselves.  A  person  like  yourself,  a  woman 
of  good  will  and  honest  intellect,  is  possessed  of  emotions 
that  decorate  human  life  instead  of  devastating  it.  Struggle, 
self-denial,  and  conflict  are  a  part  of  human  existence." 
She  curled  up  her  nose  while  he  continued:  "The  very 
state  of  being  alive  is  merely  the  equilibrium  of  opposing 
forces  of  anabolism  and  catabolism.  So  you  see.  everything 
in  life  is  conflict."  Today  my  wife  told  me  that  Mrs.  Russ 
cut  quite  a  figure  in  her  new  mink  coat.  I  will  have  to  use 
a  different  defense. 
—Leaf    from   a   doctor's  diary,   Roche   Review. 

The  continuous  postoperative  fever  following  simple  ap- 
pendectomy  was  found   due  to   the  probation   nurse  for- 
getting to  shake  down  the  thermometer. 
—Leaf   from   a   doctor's   diary,   Roche   Review. 

I  told  lawyer  Rollo  when  speed  is  doubled  the  destruc- 
tive force  increases  four  times;  when  tripled,  nine  times: 
when  quadrupled.  16  times,  then  that  within  last  year 
36,000  deaths  from  one  million  injuries  were  due  to  auto- 
mobiles alone.  "I  wish  there  were  more  of  them,"  he  re- 
marked. "They  bring  me  business."  Today  I  got  an  ur- 
gent call  from  the  hospital.  There  lay  Rollo  with  a  broken 
femur.  The  driver  was  of  the  hit-and-run  variety.  "Guys 
like  those  should  be  lynched,"  he  said.  "But  you'll  be 
making  money  out  of  this  accident  if  thev  find  the  driver.'' 


I   tried   to  console  him. 

think  of,''  he  shouted. 

— Leaf   from  a   doctor's   diary,    Roche    Review. 

I  came  across  The  Flowers  of  Epigrammes,  and  read  this 
one  by  Parker  Davis,  written  in  1577: 

Three   faces  the   Phisitian  hath. 

First  angel  he 

When  he  is  sought ;   next  when  he  helps 

A  god  he  seems  to  be ; 

And  best  of  all  when  he  has  made 

The  sick  diseased  well. 

And  asks  his  guerdon,  then  he  seems 

An  oughly  fiend  of  Hell. 
—Leaf   from   a   doctor's   diary,    Roche   Review. 


RAPID  BREAST  CHANGES  FROM  STILBOESTROL 
(A.   I.  Weisman,   New  Vork   City,  in   Clin.   Med.,  June! 

A  new  chemical  substance,  not  related  structurally  to 
estrone,  but  markedly  estrogenic  in  action,  is  dihydroxy- 
diethyl  stilbene,  commonly  known  as  stilboestrol. 

Some  patients  have  nausea  or  some  gastric  upset,  but 
the  side  reactions  are  minimal  and  disappear  with  its  con- 
tinued use.  In  a  case  of  primary  ovarian  hypofunction, 
with  congenital  aplasia  of  the  uterus,  5-mg.  tablet  of  stil- 
boestrol. given  daily  by  mouth,  produced  growth  of  the 
breasts  and  nipples  to  such  an  extent  that  the  breasts  sim- 
ulated those  of  a  pregnant  woman.  There  was  some  slight 
nausea  for  the  first  day  or  two,  which  was  scarcely  noticed 
by  the  patient.  Continued  treatment  with  stilboestrol  over 
a  period  of  5  months,  with  a  total  intake  of  465  mg.  of 
the  substance,  was  attended  with  no  toxic  symptoms  or 
physical  findings. 


DRUNKENNESS  AS  A  CRIMINAL  OFFENSE 

iTerome   Hall,    Prof,    of    Law,    Indiana    Univ.    Law    School,    in 
Quar.  Jl.   Studies   on   Alcohol.    Mar.; 

To  many  observers  of  the  endless  stream  of  repeaters 
who  make  the  round  from  court-to-jail  an  amazing  number 
of  times,  it  seems  absurd  to  continue  the  existing  punitive 
methods.  Yet  the  present  popular  solution  of  letting  down 
the  punitive  bars  entirely  is  unsound.  The  premises  upon 
which  such  recommendations  rest  are  two:  punitive  meth- 
ods have  failed  entirely;  and.  the  psychiatrists  can  effect 
cures.  Both  of  these  assertions  are  overstatements.  Granted 
that  most  chronic  alcoholics  suffer  from  nervous  ailments, 
does  it  follow  that  punishment  has  no  utility.  Psychiatrists 
can  remove  the  condition  that  is  the  root  of  repeated 
drunkenness  in  some  cases;  in  a  great  many,  assuredly  not. 
The  problem,  as  it  presents  itself  to  thoughtful  persons,  is 
always  difficult.  There  is  great  room  for  improvement  in 
the  drunkenness  laws,  methods  of  treatment,  and  adminis- 
tration ;  many  valuable  reforms  can  be  adopted  that  will 
not  damage  the  existing  political  institutions  or  violate  the 
underlying  ethical  ideals.  The  avenue  to  their  discovery  is 
collaboration  of  various  scholars  and  experts  who  are  fully 
aware  of  the  complexity  of  the  problem. 

Most  of  these  patients  may  be  treated  by  a  practical 
form  of  psychotherapy  within  the  capacity  of  any  physi- 
cian. Sympathetic  and  patient  investigation  of  the  patient's 
mode  of  life  and  environment,  with  the  object  of  bringing 
to  light  unsolved  problems  and  relating  these  factors  to  the 
complaints  will  accomplish  permanent  cure  in  the  majority 
of  cases. 


June.   1941 


SOUTHERN  MEDICINE  &  SURGERY 


359 


THEY  CAN'T  WAIT  MUCH  LONGER 
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and  Allied  Countries 
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iron-«JffiBSBS& 


til  hill  Hi'j"1  „  «,*.*-— 

"«*,»».«  p««»""HE,"t  „f  defense  against  cancer.        r  ^  lhe 

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MOKM  SOCIETY  FOR  THECONTKU    ^rtNY 


June,   1941 


SOUTHERN  MEDICINE  6-  SURCERY 


•      1941      • 
FLORIDA'S  NEWEST  —  FINEST  &  LARGEST 

All- Year  Hotel 


THE      RIVIERA 

Near  Daytona  Beach. 

Ideal  Convention  or  Conference  Headquarters.     Capacity  400. 

The  only  Hotel  Bar  open  all  year  between 
Jacksonville  &  Palm  Beach. 

Radio  and  Fan  in  Every  Room.  Golf  Links.  Artesian  Swimming 
Pool  with  Sand  Beach.  Tennis,  Badminton.  Ping  Pong.  Croquet, 
Horseshoe  and  Shuffleboard  Courts.  Ballroom  and  Convention 
Hall.    Banquet  Facilities.    Spacious  Grounds. 

COOLEST  SPOT  IN  ALL  FLORIDA.  AT  THE  BIRTHPLACE  OF 
THE  TRADE  WINDS  Where  the  Labrador  (Arctic)  Current 
meets  the  Gulf  Stream,  and  Summer  Bathing  and  Fishing  are 
Superb 

Write  for  Special  Summer  Rates.  April  to  December. 

Hotel  Riviera,  Box  429,  Daytona  Beach,  Fla. 

MOUNTAINEER,  TAR  HEEL  &  CRACKER 

VACATION  HEADQUARTERS. 


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PROFESSIONAL  CARDS 


June,    1941 


GENERAL 


N.illa  Clinic    Building 


THE  NALLE  CLINIC 

Telephone— -3-2141    (//  no  answer,  call  3-2621) 


412  North    Church    Street,   Charlotte 


General  Surgery 

BRODIE  C.  NALLE,  M.D. 
Gynecology  &  Obstetrics.. 
EDWARD   R.    HIPP,   M.D. 

Traumatic  Surgery 

PRESTON   NOWLIN,   M  D. 

Urology 


Consulting   Staff 

DRS.   LAFFERTY,   BAXTER   &   PARSONS 
Radiology 
BARRET   LABORATORY 
Pathology 


General  Medicine 


LUCIUS   G.   GAGE,   M.D. 
Diagnosis 


LUTHER   W.   KELLY,   M.D. 
Cardio-Resplratory    Diseases 


J.  R.  ADAMS,  M.D. 
Diseases  of  Infants  &   Children 


W.  B.  MAYER,  M.  D. 
Dermatolocy  &  Syphiloiogy 


C— H— M   MEDICAL   OFFICES 

DIAGNOSIS— SURGERY 

X-RAY— RADIUM 

Dr.   G  Carlyle  Cooke — Abdominal  Surgery 

&  Gynecology 
Dr.  Geo.  W.  Holmes — Orthopedics 
Dr.  C.  H.  McCants — General  Surgery 
222-226  Nissen   Bid.  Winston-Salem 


WADE    CLINIC 

Wade  Building 

Hot  Springs  National  Park,  Arkansas 

H.  King  Wade,  M.  D.  Urology 

Charles  S.  Moss,  M.D.  General  Surgery 

Jack  Ellis,  M.D.  General  Medicine 

Frank  M.  Adams,  M.D.  General  Medicine 
N.  B.  Burch,  M.D.  Eye,  Ear,  Nose  &  Throat 
Raymond  C.  Turk,  D.D.S.  Dental  Surgery 
\    W.  Scheer  X-ray  Technician 

Etta  Wade  Clinical  Pathology 

Marjorie  Wade  Bacteriology 


INTERNAL  MEDICINE 


ARCHIE  A.  BARRON.  M.  D.,  F.  A.  C.P. 
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JOHN  DONNELLY,  M.  D. 

DISEASES  OF  THE  LUNGS 

324'A  N.  Trvon  St.  Charlotte 


CLYDE    M.    GILMO^E,    A.  B.,    M.D. 
CARDIOLOGY— INTERNAL    MEDICINE 
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Medical   Building  Charlotte 


ORTHOPEDICS 


HERBERT   F.   MUNT,   M.D. 
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FRACTURES 
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June.    1941 


PROFESSIONAL  CARDS 


NEUROLOGY  and  PSYCHIATRY 


J.   FRED   MERRITT,   M.  D. 

NERVOUS  and  MILD  MENTAL 
DISEASES 

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Glenwood   Park    Sanitarium  Greensboro 


EYE,  EAR,  NOSE  AND  THROAT 


H.  C.  NEBLETT,  M.  D. 

OCULIST 

Phone  3-5852 

Professional   Bldg.  Charlotte 


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DISEASES  of  the 
EYE,  EAR,  NOSE  and  THROAT 

Phones:  Office  992— Residence  761 

Burlington  North   Carolina 


UROLOGY,    DERMATOLOGY   and   PROCTOLOGY 

THE  CROWELL   CLINIC   of   UROLOGY   and   UROLOGICAL   SURGERY 
Hours — Nine  to  Five  Telephones — 3-7101 — 3-7102 

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JAMES   M.   NORTHINGTON,   M.  D.,   Editor 


CHARLOTTE,  N.  C,  JULY,  1941 


Clinic  On  Rheumatic  Fever* 

Clyde  M.  Gilmore,  M.D.,  Greensboro 


LADIES  AND  GENTLEMEN:  I'd  like  to 
get  your  help  in  the  management  of  a  few 
cases  of  rheumatic  fever,  chiefly  in  those 
who  have  had  rather  severe  cardiac  damage.  This 
will  be  very  informal.  I'd  like  to  be  interrupted 
at  any  time,  and  for  all  attending  to  move  up 
close.  Talk  with  me  and  with  the  patients  and  let 
us  examine  them  together. 

Case  One 
You  know  your  first  case  of  any  disease  is  al- 
ways the  most  impressive.  It  is  rather  singular 
that  in  the  cases  we  know  the  least  about  and  have 
the  least  to  work  with,  we  sometimes  get  our  best 
results.  This  young  man  has  been  under  observa- 
tion for  fourteen  years.  Fourteen  years  ago  he  had  a 
tonsillitis  that  lasted  longer  than  the  average.  He 
ran  fever  about  three  weeks.  Then  about  the  time 
he  should  have  gotten  up  he  developed  acute  sinu- 
sitis that  lasted  three  months.  Then  a  couple  of 
months  later,  about  the  time  he  was  getting  on 
his  feet,  he  got  a  severe  bronchitis  or  bronchial 
pneumonia  that  kept  him  in  another  month.  I  give 
you  the  series  because  at  the  time  we  regarded 
them  as  a  series  of  unrelated  links  in  a  chain  of 
circumstances.  Now  we  know  that  all  those  things 
were  different  manifestations  of  rheumatic  fever. 
Most  rheumatic  fever  patients  have  at  some  time 
some  throat  manifestations.  Joint  manifestations 
may  be  temporary.  They  may  not  be  impressive, 
yet  months  later  we  may  come  upon  marked  le- 
sions. Much  to  his  disgust,  we  kept  this  boy  in 
bed  two  years.  His  recovery  we  attribute  to  a  good 
constitution,  to  careful  nursing  by  his  mother,  to 
codliver  oil  and  to  rest  in  bed.  He  lost  the  first 
year  or  two  of  school.  That,  now,  has  been  four- 
teen years.  He  was  examined  once  a  year,  appar- 


ently he  has  no  residual  damage.  His  heart  is  a 
good  one.  Sometimes  I  can  hear  a  slight  mitral 
murmur;  most  of  the  time  I  can't.  Apparently  the 
examiners  could  not  hear  it  when  they  inducted 
him  into  the  army  from  State  College.  Neither  his 
mother  nor  I  relaxed  our  vigilence  for  fourteen 
years.  The  only  precaution  we  have  used  during 
the  last  ten  years  is  to  strictly  keep  him  in  bed 
during  acute  colds.  If  any  of  you  gentlemen  want 
to  listen,  go  ahead  while  we  go  to  the  next  patient. 
Dr.  Redwine,  Dr.  Starr  and  others  listen. 

Case  Two 
I  want  to  acknowledge  my  indebtedness  to  Wade 
and  to  his  family  for  teaching  me  something  about 
living  under  difficulties.  Before  I  go  into  the  med- 
ical aspects  of  this  case  I  want  to  tell  you  how 
he  passed  three  years  as  an  invalid  with  profit  to 
himself  and  his  community,  and  considerable  ad- 
vantage to  his  career  since  that  time.  This  was  an 
acute  fulminating  type  of  rheumatic  fever,  with 
sore  throat  as  usual,  then  a  tonsillitis  and  sinusitis 
that  lasted  a  year  and  baffled  all  treatment.  He 
had  joint  symptoms  and  a  heart  involvement  sug- 
gestive of  pericardial  lesion  which  was  more  severe 
than  the  rest.  For  approximately  three  years  he 
was  in  bed.  When  things  looked  the  darkest,  when 
his  temperature  was  averaging  102  every  day  for 
weeks  on  end,  when  his  white  count  was  running 
18.000  to  25,000,  when  his  mind  was  showing 
symptoms  of  cerebral  limitation,  his  father  fixed 
up  by  his  hospital  bed  a  bird-feeding  station  and 
got  him  a  book  on  birds.  For  one  year  Wade  did 
not  sit  up  in  bed  and  during  that  time  he  studied 
birds.  At  the  end  of  that  time  he  was  an  author- 
ity on  the  birds  of  this  region  and  entertained  boy 
scouts  and  clubs.   He  is  in  demand  as  a  bird  expert 

[    of    the    Carolinas    and    Virginia,    held    at    Greensboro,    February 


RHEUMATIC  FEVER— Gil  more 


July.  1941 


in  this  section.  For  two  years  he  was  confined  to 
a  wheel-chair  and  could  sit  in  the  back  yard  in 
the  sunshine  where  he  could  watch  the  insects. 
Somebody  got  for  him  a  book  on  the  insects  of 
this  region.  The  two  years  he  spent  on  a  pallet 
were  not  wasted.  Since  he  has  been  at  the  Uni- 
versity he  assists  in  the  Department  of  Entomol- 
ogy. At  any  rate  all  the  thousands  of  bugs  cap- 
tured within  forty  square  feet  in  the  back  yard 
in  time  that  ordinarily  patients  waste  in  fretting 
and  grumbling  have  served  him  to  good  advantage 
and  assisted  him  in  his  work  since  he  has  been  in 
college.  He  spent  some  time  at  Wesley  Long 
Hospital  when  the  going  was  very  rough. 

He  developed  after  the  first  six  months  a  severe 
mitral  lesion  and  pericarditis.  He  had  a  pulmo- 
nary lesion  of  rheumatic  origin.  Then  he  had  a 
recurrence  of  joint  lesions.  When  his  resistance 
was  whipped  out,  and  after  he  had  settled  down 
to  the  sameness  of  day  after  day  after  day,  his 
temperature  ran  99  to  100.  He  had  no  resistance. 
He  had  transfusions  and  infusions  and  liver  ex- 
tract and  in  desperation  we  gave  him  typhoid  vac- 
cine. After  each  injection  he  had  a  reaction.  We 
were  feeling  our  way  very  carefully — we  gave  him 
half  a  dose  of  typhoid  vaccine  intravenously.  Since 
that  time  he  hasn't  had  an  acute  recurrence  of  sinus 
infection,  has  had  no  more  joint  symptoms  and  at 
the  present  he  has  some  enlargement  and  perma- 
nent damage  but  he  is  able  to  go  ahead  with  his 
class  at  the  University  He  just  has  to  take 
things  as  they  are  at  the  present  time.  He  has 
learned  to  live  with  a  crippled  heart  and  raav  out- 
live some  of  the  rest  of  us. 

Patient  takes  cardiograms  with  him  to  back  of  room 
and  Dr.  Cardwell  and  others  study  the  case. 

Case  Three 

Mr.  H.  is  our  third  case  and  shown  to  illus- 
trate the  point  that  in  these  diseases,  no  matter 
how  bad  the  going  or  how  dark  the  outlook,  one 
must  not  give  up.  Now  Mr.  H.  had  a  stormv 
time.  He  was  first  sick  at  the  age  of  ten.  He  was 
in  bed  six  months.  From  then  on  he  was  in  bed  on 
and  off  and  in  and  out  for  years.  He  would  have 
a  spell  and  would  be  in  bed  awhile  and  then 
be  up  and  in  school  a  few  months  and  back  again. 
In  this  time  he  was  treated  by  a  number  of  good 
doctors,  but  attacks  recurred  until  it  was  dis- 
covered that  he  had  an  irreparably  damaged 
heart.  He  had  rather  severe  joint  symptoms — 
swelling  and  pain,  heat  and  tenderness  first  in  one 
joint  and  then  another  until  after  a  period  of  five 
years  his  back,  hips,  knees  and  ankles  were  involv- 
ed. From  the  age  of  ten  to  the  age  of  fifteen  he 
had  to  sleep  on  several  pillows  and  sleep  propped 
up.  He  had  frequent  recurrences  of  joint  attacks. 
Now,  I  said  we  wanted  him  to  illustrate  the  fact 
that  it  doesn't  ever  pay  to  give  up  in  these  cases. 


Let's  have  his  pictures.  The  patient  and  his  doc- 
tor at  home  and  I  have  all.  at  the  time  five  years 
ago  and  in  the  last  illness  that  he  had,  given  up. 
Dr.  Frank  Sharpe.  of  Greensboro,  at  the  Wesley 
Long  Hospital,  came  in  after  a  battle  of  several 
weeks.  The  patient  was  gasping  for  breath  after  an 
attack  of  pulmonary  edema.  Dr.  Sharpe  gave  us  a 
pep  talk.  We  took  courage  and  started  all  over 
again. 

We  gave  a  mercurial  diuretic.  We  digitalized 
him.  We  stepped  up  about  double  the  theoreti- 
cal dose  for  digitalization.  We  filled  him  full 
of  Vitamin  B  and  liver  extract,  and  that  has 
been  nearly  six  years  ago.  Since  that  time  with 
the  damaged  mitral  valve,  the  damaged  aortic 
valve  and  chronic  auricular  fibrillation  for  six 
years  he  has  been  very  comfortable.  He  rests  two 
hours  after  lunch  and  goes  to  bed  when  he  has  a 
cold,  he  is  a  successful  merchant  and  is  getting 
things  together  to  take  care  of  his  old  age,  he  is 
raising  a  family.  We  are  proud  that  he  had  the 
courage  not  to  give  up  when  we  did. 

Dr.  Robert  Wilson,  Charleston:  When  were 
the  films  taken? 

Dr.  Gilmore:  A  week  ago.  Dr.  Wilson,  would 
you  mind  listening  to  him  and  give  me  an  idea 
about  the  future  management  of  this  case. 

Dr.  Wilson  examines  patient. 

Member:  Dr.  Gilmore,  may  I  ask  a  question? 
Just  now  you  mentioned  giving  typhoid  as  a  last 
resort.    Did  it  give  results? 

Dr.  Gilmore:  We  got  some  results  in  this  case. 
I  think  it  should  be  a  last  resort.  We  very  often 
give  it  intramuscularly.  When  a  patient  gets  to 
dragging  along  and  not  free  from  fever,  when  you 
want  to  stimulate  resistance  as  a  last  resort,  it 
can  be  given  intravenously.  I  think  it  is  a  danger- 
ous procedure.  It  worked  in  this  case  and  brought 
us  out  of  a  bad  hole. 

Case  Four 

Martha  and  John  illustrate  one  of  those  tragic 
things  we  sometimes  see  of  rheumatic  fever.  We 
have  had  three  families  recentlv  in  whom  this  dis- 
ease went  like  wild  fire  through  the  whole  family. 
Martha  had  the  first  attack  in  November,  1936, 
with  pain  and  swelling  in  the  knees  and  both  an- 
kles. It  jumped  to  the  middle  finger  of  the  left 
hand  and  lasted  12  weeks  after  the  onset  at  which 
time  she  had  acute  and  violent  cardiac  symptoms. 
She  was  in  bed,  of  course,  during  this  time.  At  the 
end  of  twelve  weeks  she  had  pericardial  effusion 
and  sudden  and  intense  decompensation.  She  was 
digitalized.  She  had  the  usual  treatment.  She  had 
bed  rest  for  a  year  and  about  the  time  that  we 
were  ready  to  give  up  she  finally  began  to  show 
some  improvement.  The  pulmonary  edema  and 
pericardial  effusion  disappeared.    We  gave  typhoid 


July,  1941 


RHEUMATIC  FEVER— Gilmore 


intramuscularly  when  the  fever  was  at  the  low, 
chronic  stage.  Finally,  after  a  two-year  period  in 
bed,  she  began  to  show  improvement  and  has 
come  back  to  make  a  spectacular  clinical  recovery. 
However,  there  is  the  question  as  to  whether  to 
attempt  to  go  to  college,  or  whether  to  try  to  finish 
school,  and  how  much  activity  should  be  restricted 
for  the  future.  She  has  a  mitral  lesion  with  some 
permanent  damage. 

The  doctor  and  I  got  hold  of  John  a  little  ear- 
lier than  Martha.  John  was  put  to  bed  and  didn't 
get  up  until  the  fever  was  normal  for  three  weeks, 
six  months  later.  John  got  much  less  cardiac  dam- 
age. I  think,  too,  that  it  helped  because  we  re- 
moved John's  focal  infection  from  tonsils  two 
weeks  after  the  onset  of  the  disease,  rather  than 
after  15  weeks,  as  we  did  for  Martha.  What  part 
focal  infection  has  in  the  induction  of  the  disease, 
I  don't  know.  Present  active  focal  infection  does 
greatly  affect  the  condition.  I  think  that  in  both 
his  case  and  Martha's,  which  have  come  along 
since  sulfanilamides,  the  sulfanilamides  helped 
keep  down  complications  and  hastened  their  re- 
covery. 

Patients  examined   by   Dr.   Ruben   and   Dr.  Vaughn. 

Case  Five 
The  question  with  Jesse  Ray  is  after  five  years 
of  fighting,  how  much  activity  should  be  allowed. 
Dr.  Wilkinson,  help  us  answer  that  question.  His 
case  is  another  illustration  of  the  fact  that  it 
doesn't  pay  to  give  up.  Several  times  in  the  hos- 
pital he  was  cyanotic,  edematous  and  delirious 
and  it  looked  like  he  had  very  little  chance.  He 
has  had  to  be  digitalized  since  his  acute  illness. 
He  spent  one  year  in  bed  and  we  have  been  very 
leary  about  letting  him  increase  activity  since  that 
time.  He  has  a  damaged  aortic  valve  and  has  the 
typical  auricular  fibrillation,  which  if  very  severe 
requires  digitalization  for  the  rest  of  the  patient's 
life.     He  has  pulmonary  edema. 

Case  Six 

This  case  is  shown  to  illustrate  the  use  of  a  new 
drug,  a  drug  not  yet  on  the  market,  but  if  any  of 
you  want  to  make  a  trial,  if  you  have  a  case  of 
ascites  or  edema,  there  is  developed  now  a  tablet 
of  salyrgan  theocin  that  is  given  by  mouth.  Six 
cases  with  us  had  it  and  it  acted  as  well  or  better 
than  an  intravenous  mercurial  diuretic. 

This  young  lady  came  here  twelve  months  ago 
and  was  in  the  last  stages  of  ascites  and  edema, 
pulmonary  edema  with  the  liver  below  the  navel, 
dependent  edema  and  it  looked  like  the  end  of 
the  row.  She  has  lived  for  a  year  by  occasional 
doses  of  salyrgan  by  mouth.  The  first  time  the 
output  was  increased  from  300  ex.  to  900  c.c.  Her 
edema  disappeared.  She  has  occasionally  to  take 
short  courses  and  is  now  on  them  because  her  liver 


edema  reappeared.  Her  life  will  be  prolonged  some 
time  because  of  the  use  of  this  oral  preparation;  on 
account  of  the  distance  they  live  from  places  where 
she  can  obtain  adequate  medical  treatment  it 
would  make  it  prohibitive  to  go  to  her  home.  You 
can  repeat  the  salyrgran  often  enough  to  give  satis- 
factory results.  I  have  some  samples  of  the  prep- 
aration to  be  given  by  mouth  which  I  will  pass 
around.  It  is  still  in  the  investigational  stage.  I 
think  from  results  in  six  cases  that  it  will  turn  out 
to  be  a  satisfactory  therapeutic  weapon. 

That  is  all  that  I  have,  gentlemen.  I  hope  some 
of  the  doctors  who  examined  patients  will  add 
something  to  them.  We  have  only  a  few  more 
minutes.    Thank  you  very  much. 

Dr.  Cardwell:  One  question.  The  patient  you 
described  with  the  auricular  fibrillation — would  he 
be  permanently  digitalized  or  have  occasional  digi- 
talis on  increased  pulse  rate  and  congestive  fail- 
ure? 

Dr.  Gilmore:  No,  sir,  we  don't  dare  let  them 
get  out  from  under  the  digitalis,  a  grain  and  a 
half  a  day.  We  have  had  some  experience  leaving 
it  off  and  we  had  edema,  dyspnea  and  decompen- 
sation. 

Dr.  Robert  Wilson:  I  want  to  congratulate 
the  doctor  on  his  wisdom  in  handling  these  cases. 
He  gave  a  splendid  demonstration  of  what  can 
be  done  in  heart  cases.  The  danger  which  Dr.  Gil- 
more has  avoided  is  this — frequently  we  convert 
physical  invalidism  into  mental  invalidism.  He 
has  restored  his  cases  to  productive  life  again.  I 
think  it  is  splendid. 

Perhaps  I  might  mention  one  case  some  years 
ago,  one  of  a  family  of  several  children  all  of 
whom  had  rheumatic  involvement.  One  developed, 
unfortunately,  a  very  bad  infection  with  the  usual 
result.  The  other  two  recovered.  One  was  a  very 
striking  case  of  a  boy  in  school.  They  held  him 
back  as  much  as  his  mother  was  able  to  do.  He 
had  one  or  two  periods  of  broken  compensation 
with  considerable  edema.  In  spite  of  the  mother 
and  her  instructions  and  the  teacher's  efforts,  when- 
ever nobody  was  looking  he  would  play  ball.  Sub- 
sequently he  went  to  college  and  played  football. 
Now  it  is  difficult  for  any  one  to  find  the  lesion 
unless  he  is  very  expert  in  his  methods  or  has 
dealt  with  lesions  in  similar  cases.  It  is  very  strik- 
ing how  heart  disease  does  sometimes  get  well.  As 
Dr.  Gilmore  says,  we  should  never  give  up,  never 
despair  of  bringing  them  back  again  to  healthv 
life. 

Dr.  R.  B.  Davis:  Dr.  Wilson's  remarks  bring 
to  the  front  the  importance  of  the  art  of  medicine 
as  well  as  of  the  science  of  medicine.  Dr.  Gilmore 
is  past  master  in  both,  but  particularly  in  the  art 
of  medicine,  and  I  wish  we  had  more  of  him.  We'd 
live  longer  and  be  happier. 


SOUTHERN  MEDICINE  &  SURGERY 


July,  1941 


Clinic  On  Certain  Nervous  and  Mental  Conditions  s* 

Wesley  Taylor,  M.D.  and  J.  Fred  Merritt,  M.D.,  Greensboro 


WE  WILL  CONSIDER  the  case  of  a 
school  girl,  age  12  years,  whom  for 
reasons  not  necessary  to  enumerate,  I 
have  had  very  slight  opportunity  to  more  than 
glance  at. 

She  has  always  been  well.  There  is  nothing  in 
the  entire  history  of  importance  excepting  an  auto- 
mobile accident  in  1937.  She  was  not  hurt.  An 
immediate  examination  was  made  by  a  competent 
surgeon  who  pronounced  her  sound.  There  have 
been  no  sequelae. 

On  the  night  of  Nov.  17th  last  she  had  a  series 
of  convulsions  lasting  from  8  o'clock  until  the 
next  morning.  These  convulsions  were  character 
ized  by  headache,  nausea,  vomiting,  tingling  sen- 
sations and  twitching  of  the  entire  left  side — face, 
arm  and  leg.  The  next  morning  she  had  no  mem- 
ory of  the  occurrences  of  the  preceding  night. 
Marked  tachycardia  persisted  from  the  evening  be- 
fore. There  was  a  very  slight  amount  of  fever — 
99^4°.  The  twitching  in  the  face,  hand  and  arm 
recurred  at  intervals,  and  her  mental  condition 
varied  in  the  same  manner.  There  was  very  defi- 
nite paralysis  of  the  entire  left  side  and  her  grip 
was  poor.  The  tongue  was  protruded  to  the  left. 
There  were  no  sensory  changes  to  be  found  at  any 
time,  but  this  examination  was  difficult.  Pupils 
were  unequal  and  Babinski  reflex  was  present  on 
the  left;  knee-jerks  were  normal.  Reflexes  of  left 
hand  and  arm  somewhat  increased.  She  could  not 
get  her  hand  to  her  face.  Nausea  and  vomiting 
recurred  occasionally.  Speech  was  indistinct  and 
headache,  which  persisted,  was  most  annoying. 

She  was  told  to  remain  in  bed,  take  liquids 
only,  and  tablets  of  empirin  compound  were  given 
for  the  headache. 

The  second  morning  she  was  considerably  better 
and  her  mind  perfectly  clear,  most  of  the  time. 

When  I  went  to  call  two  days  later  she  had 
gone  to  school — "perfectly  well."  She  continued 
to  attend  school  but  I  managed  to  see  her  on  Dec. 
14th.  At  this  time  there  was  some  numbness  of 
the  entire  left  side,  and  the  tongue  still  extended 
to  the  left.  She  complained  of  noises  in  left  ear 
and  blurred  vision.  I  sent  her  to  an  oculist  but  he 
found  normal  vision  and  no  signs  of  choked  disk. 
Pupils  were  normal. 

I  prescribed  sodium  iodide,  five  grains  after 
meals,  and  increased  the  dose  a  half  grain  each 
day. 

I  got  track  of  her  again  on  Jan.  8th.  On  this 
occasion  the  left  side  of  her  face  was  less  mobile 


and  the  hand  and  leg  showed  some  impairment  of 
motion.  She  could  not  unbutton  or  button  her 
clothing  with  the  left  hand.  These  conditions  have 
gradually  increased  in  severity  since  that  time  but 
with  marked  fluctuations.  Sometimes  she  felt  "per- 
fectly well."  The  stools  and  urine  were  entirely 
normal,  and  repeated  blood  examinations  likewise. 
A  spinal  puncture  has  never  been  attempted. 

She  was  told  to  remain  quiet  on  a  couch  at 
home  and  iodide  was  continued. 

From  this  time  on  she  consulted  a  number  of 
different  physicians  and  visited  several  clinics 
where  varying  opinions  were  expressed,  none  of 
which  appears  to  have  been  satisfying. 

Not  having  been  in  touch  with  the  patient  for 
considerable  periods  I  cannot  give  a  very  accurate 
description  of  the  progress  of  the  case.  In  gen- 
eral, however,  this  girl  was  up  and  around  and 
subjected  to  a  great  deal  of  excitement  and  activ- 
ity. 

The  paralysis  of  the  face  increased  somewhat, 
though  it  has  never  been  striking.  There  is  at  least 
some  atrophy  of  disuse  evident  on  the  entire  left 
side.  The  tongue  still  extends  to  the  left  somewhat. 
There  is  no  vertigo,  no  tachycardia  and  no  nausea, 
but  headache  troubles  occasionally. 

She  is  getting  increasing  doses  of  iodide  though 
she  has  not  taken  a  very  high  dosage  as  vet.  On 
Feb.  12th  the  x-ray  examination  was  negative  as 
to  tumor  of  any  kind  but  there  is  very  definite 
evidence  of  increased  pressure  in  the  entire  cranial 
cavity. 

On  examining  this  patient  today  I  find  a  reg- 
ular pulse  of  72  per  minute.  Her  mental  condition 
is  clear,  her  memory  good.  There  are  no  delusions 
or  hallucinations.  She  identifies  objects  normally 
and  there  are  no  speech  disturbances.  (Patient 
pronounces  Hippopotamus  and  repeats  "seven, 
slim,  slick,  slender  saplings.")  She  is  alert — 
there  is  no  drowsiness  and  she  stands  steady  and 
erect  on  her  feet,  so  there  seems  to  be  no  cere- 
bellar trouble.  Headache  does  not  seem  to  be  pro- 
duced by  bending  forward  or  by  coughing.  I  no- 
tice that  my  patient  tires  mentally  much  more 
readily  than  is  usual — in  fact  she  shows  it  very 
clearly  right  now.  Percussion  of  the  head  shows 
some  tenderness,  but  this  is  not  localized  nor  is  it 
a  constant  finding.  The  pupils  are  normal  today 
as  is  the  hearing.  There  have  been  no  signs  what- 
ever of  ocular  paralyses  of  any  kind.  The  Babinski 
sign  is  present  and  all  of  the  reflexes  on  the  left 
side  are  increased  as  compared  with  those  on  the 


'Presented    to    the    meeting    of    the 
24th  and  25th. 


Tri-State    Medical    Associatio  n    of    the    Carolinas    and    Virginia,    held    at    Greensboro,    February 


July,  1941 


CLINIC,   NERVOUS   &   MENTAL— Taylor  &   Merritt 


right.  This  includes  the  abdominal  as  well  as  the 
epigastric  reflexes.  Today  her  tongue  is  extended 
so  straight  out  that  it  is  not  of  diagnostic  value, 
but  in  general  she  is  not  doing  well  clinically. 

Dr.  Mills  made  a  complete  examination  of  her 
eyes  today.  The  vision  is  materially  impaired  in 
both  eyes  and  there  is  very  marked  double  choked 
disk.  There  are  also  signs  of  greatly  increased 
intracranial  pressure.  I  neglected  to  say  that  par- 
oxysms of  yawning  have  been  common  and  on 
one  occasion  she  had  hiccoughs  for  a  couple  of 
hours  and  on  other  occasions  for  short  periods. 

In  considering  the  diagnosis  of  our  case  I  call 
any  expanding  lesion  in  the  skull  a  tumor.  Tumors 
are  not  uncommon  in  neurology.  Dr.  Cushing  said 
that,  in  the  Surgical  Service  of  the  Boston  City 
Hospital,  out  of  2,500  routine  surgical  cases  ad- 
mitted 200  were  cerebral  neoplasms.  The  most 
common  are  gliomas  or  neurogliomas. 

In  the  case  before  us  we  have  a  hemiplegic  con- 
dition involving  the  entire  left  side — face,  arm  and 
leg.  The  only  possible  location  where  one  lesion 
could  produce  such  a  combination  of  symptoms 
would  be  in  the  pons,  at  a  point  below  the  nucleus 
of  the  facial  nerve  and  above  the  decussation  of 
the  pyramids.  If  now  a  lesion  in  this  location 
could  produce  the  other  essential  symptoms  which 
we  find,  we  should  feel  pretty  sure  that  our  loca- 
tion is  the  correct  one.  At  this  point  and  on  the 
same  general  plane  are  located  the  nuclei  of  four 
cranial  nerves;  namely,  the  7th,  8th,  9th  and 
12th.  The  facial,  as  we  see,  is  strongly  involved 
and  affection  of  the  auditory  nerve  may  be  seen 
in  the  tinnitus  which  bothers  at  times.  As  far  as 
the  9th  or  glossopharyngeal  nerve  is  concerned, 
motor  disturbances  in  the  realm  of  this  nerve  are 
usually  slight  and  as  a  rule  exceedingly  difficult  to 
recognize,  even  in  cases  of  its  complete  paralysis, 
so  one  can  scarcely  say  that  this  nerve  is  or  is 
not  affected.  The  hypoglossal  involvement  is  man- 
ifested in  the  deviation  of  the  tongue,  all  of  which 
strongly  confirms  the  correctness  of  locating  the 
lesion  in  this  region. 

As  to  the  nature  of  the  lesion  I  will  not  express 
a  positive  opinion.  In  question  come  gliomas,  sol- 
itary tubercles,  abscesses  and  a  number  of  less 
likely  process  s.  If  I  had  to  make  a  guess  I  should 
take  a  chance  on  a  glioma. 

Treatment  is  likely  to  be  discouraging.  If  io- 
dides fail  then  there  is  little  hop-'  and  one  will 
have  to  depend  on  symptomatic  medication. 

The  prognosis  is  generally  poor — very  poor.  It 
is  poor  because  the  family  do  not  cooperate  at  all; 
poor  because  they  cannot  afford  proper  care  and 
attention  even  if  every  attention  would  avail  any- 
thing, which  is  exceedingly  doubtful. 

It  is  not  necessary  to  tell  you  that  the  lesion 
itself  is  entirely  out  of  any  surgical  reach,  even  if 
one  could  be  found  who  would  be  willing  to  at- 


tempt it.  Spinal  puncture  is  too  dangerous  to  rec- 
ommend and  I  do  not  see  that  pumping  air  into 
the  ventricles  would  accomplish  anything  in  this 


case. 

—Guilford  Building 


WET  AGENTS 

(\V.  W.   Duemling,   Fort  Wayne,  in  Arch.   Derma.  &  Syphil,   Feb.) 

The  most  powerful  wetting  agents  yet  described  are  the 
esters  of  sodium  sulfosuccinates.  One  of  these  is  available 
under  the  trade  name  Aerosol  OT  Dry. 

The  special  properties  of  these  substances  make  them 
useful  locally  in  many  skin  diseaes.  Following  is  the  for- 
mula for  a  semifluid  lotion,  with  excellent  softening  prop- 
erties, which  will  not  produce  an  oily  effect: 

Certyl    alcohol    2  parts 

Stearic    acid   2 

Liquid    petrolatum    10 

Aerosol  OT,   10%  aqueous  10 

Water     76 

The  alcohol,  petrolatum  and  stearic  acid  are  heated  until 
clear,  and  the  aerosol  solution  added,  with  stirring,  while 
the  solution  is  warming.  Water,  brought  to  the  tempera- 
ture of  the  first  component,  is  added  with  agitation.  To 
avoid  foaming,  agitation  is  stopped  when  emulsification 
occurs. 

Vanishing,  cleansing  and  liquefying  creams  can  be  made 
by  using  Aerosol  OT  Dry  in  conjunction  with  the  proper 
substance  to  produce  practically  any  type  of  product  de- 
sired.   Following  is  a  typical  formula: 

White   wax    11  parts 

Paraffin    10 

Liquid   petrolatum    40 

Water    29 

Aerosol  OT,   10%  aqueous  10 

The  wax  and  paraffin  are  melted  in  the  petrolatum  by 
heating  the  mixture  to  65-70  C.  The  aerosol  solution  and 
water,  heated  to  the  same  temperature,  are  added  slowly 
with  stirring. 

An  excellent  shampco  may  be  prepared  according  to  the 
following  formula: 

Aerosol  OT  Dry,   100% 16.00  parts 

Cetyl    alcohol    5.00 

Liquid  petrolatum   5.00 

Lecithin    0.75 

Alcohol,  ethyl   15% 20.00 

Distilled   water   53.25 

The  aerosol,  lecithin,  cetyl  and  ethyl  alcohols  are  mixed 
and  allowed  to  stand  12  hours.  This  component  is  warmed 
over  a  steam  bath  until  melted,  then  stirred  until  clear. 
Petrolatum  is  added  slowly  with  stirring  and  the  distilled 
water  is  added  gradually.  Product  should  be  entirely  clear 
and  fluid.  The  ethyl  alcohol  prevents  turbidity.  Cetyl 
alcohol  and  petrolatum  prevents  a  drying  effect  on  hair 
and  scalp. 

For  dry  hair  and  scalp,  a  dense,  stable  and  copious 
lather  can  be  produced  from  a  shampoo  made  by  dissolv- 
ing 10  parts  of  Aerosol  OT  Dry,  100%,  in  90  parts  of 
olive  oil  heated  to  70  C. 

For  excessively  oily  hair  and  scalp  the  following  formula 
is  recommended: 

Aerosol  OT  Dry,   100%  10  parts 

Alcohol,   ethyl    15%    20 

Distilled  water  70 

Dissolve  I  he  aerosol  in  alcohol  by  warming,  and  add 
water,  or  allow  aerosol  to  soak  in  alcohol  12  hours  and 
add    water   the   next   morning. 


SOUTHERN  MEDICINE  &  SURGERY 


July.  1941 


A  Syndrome  Responding  to  Parenteral  Anterior 
Pituitary  Extract 

J.  Alfred  Wilson,  M.D.,  Meriden,  Connecticut 


DURING  the  past  few  years  it  has  been 
found  that  in  certain  cases  presenting 
some  of  the  symptoms  of  hypothyroidism 
the  response  to  thyroid  therapy  was  not  as  satis- 
factory as  could  be  desired.  A  group  of  patients 
has  been  recognized  that  showed  improvement 
when  given  parenterally  an  aqueous-acetic  acid 
extract  of  fresh  anterior  lobe  of  the  pituitary.  The 
improvement  was  not  permanent,  but  lasted  from 
one  to  eight  weeks.  The  injection  of  the  anterior 
pituitary  extract  then  had  to  be  repeated.  In  this 
paper  a  description  is  given  of  the  symptoms  and 
signs  found  in  this  syndrome. 

Most  of  these  patients  are  women  from  the 
third  to  the  seventh  decade  of  life;  the  youngest 
was  19  years  and  the  oldest  78  years  of  age.  Of 
the  forty-four  such  patients  treated  in  the  last  six 
years,  thirty-six  have  been  greatly  benefited,  and 
eight  received  no  benefit  from  prolonged  treatment. 

Symptoms 
The  symptoms  complained  of  were: 
( 1 )   Heaviness,  tightness,  stiffness  of  the  occip- 
ital region  of  the  head  and  down  the  back  of  the 
neck. 

( 2  )  Fullness  and  heaviness  about  the  eyes.  The 
eyelids  are  heavy  and  stiff.  The  eyes  feel  like  they 
are  looking  through  slits.  There  may  be  difficulty 
in  focusing  the  eyes. 

(3)  A  generalized  feeling  of  bloating  over  the 
body,  with  puffiness  over  the  outer  malleoli,  but 
not  a  pitting  edema. 

(4)  A  moderate  interference  of  the  finer  func- 
tions of  the  fingers,  such  as  writing.  The  fingers 
and  hands  feel  clumsy. 

(5)  Soreness  and  swelling  of  the  smaller  joints, 
such  as  the  fingers  and  toes.  These  joint  symp- 
toms do  not  occur  in  all  of  the  patients. 

(6)  Moderate  degrees  of  exhaustion,  tired  feel- 
ings and  lack  of  ambition. 

(7)  Somnolence  during  the  day.  deep  sleep  at 
night.  Xo  mental  depression,  nervousness  or  in- 
somnia. 

(8)  Loss  of  libido. 

( 9  )  A  small  proportion  of  the  patients  complain 
of  twitching  and  spasms  of  the  thigh  and  calf  mus- 
cles. These  spasms  usually  occur  when  at  rest,  not 
when  exercising. 

Signs 

(  1  )  Xormal  or  moderately  low  basal  metabolic 
rate. 


( 2  )   Slow  pulse  and  low  blood  pressure. 

( 3 )  Xormal  blood  count  in  the  majority  of  the 
cases. 

(4)  Increased  blood  cholesterol. 
( 5  )   Xormal  or  low  blood  sugar. 

(6)  Xormal  blood  urea  and  calcium. 

( 7 )  Bodv  weight  and  height  normal  or  average 
in  the  majority.  Some  of  the  cases  were  moder- 
ately, but  none  greatly,  overweight. 

Treatment 

The  contents  of  a  1-c.c.  ampoule  of  aqueous- 
acetic  acid  extract  derived  from  17  grains  of  fresh 
anterior  lobe  of  the  pituitarv  gland  is  given  hvpo- 
dermicallv  or  intramuscularlv  into  the  outer  arm 
below  the  shoulder  or  in  the  lower  aspect  of  the 
thigh.  The  injection  relieves  the  symptoms  in 
about  24  hours.  The  relief  lasts  from  a  few  days 
to  eight  weeks.  An  effort  is  made,  in  each  case,  to 
find  for  how  long  the  svmptoms  are  relieved,  and 
treatment  is  planned  so  as  to  be  given  just  before 
the  symptoms  might  be  expected  to  return.  There 
is  very  little  likelihood  of  a  cure.  This  is  rather  a 
substitution  or  supplementary  treatment. 

The  injections  are  onlv  moderately  painful,  and 
in  only  two  cases  did  localized  reactions  of  any 
severity  occur.  In  the  one  case  exhibiting  urticaria 
for  a  day.  desensitization  bv  starting  with  small 
injections  and  increasing  the  dose  rapidlv  to  the 
usual  amount  was  entirely  successful. 

The  continued  injection  of  anterior  pituitary  ex- 
tract over  a  period  of  years  obtained  the  same  im- 
provement of  svmptoms.  There  was  no  evidence 
of  the  formation  of  an  antihormone  as  reported  by 
Collip1  2.  One  explanation  of  this  occurrence  may 
be  the  time  elapsing  between  the  injections.  Our 
intervals  have  been  one  to  eight  weeks.  In  the 
tests  cited,  to  develop  antihormones  in  laboratory 
animals  the  injections  of  the  hormone  material 
were  given  twice  a  day  and  in  much  greater 
amount  in  relation  to  body  weight  than  we  have 
used  in  our  patients. 

Apparently  there  is  a  difference  in  the  extracts 
of  anterior  pituitary  of  various  manufacturers. 
Saline  extract  of  anterior  pituitary  made  from 
powdered  extract  does  not,  in  our  experience,  give 
relief  from  this  syndrome.  We  have  used  extracts 
derived  from  this  source,  according  to  the  descrip- 
tion of  the  product,  with  no  amelioration  of  the 
complaints  of  the  patients.    All  the  relief  of  signs 


July,  1941 


PARENTERAL    ANTERIOR    PITUITARY— Wilson 


371 


and  symptoms  have  been  obtained  from  extract  of 
fresh  anterior  pituitary. 

Abstracts  of  Cases 

Case  1. — A  sing'.e  woman  43  years  of  age,  examined  May 
17th.  1934,  height  65J  >",  weight  173  lbs.— gain  of  20  lbs. 
in  past  two  years.  Complaints  were  drowsiness  for  3 
months,  and  indigestion  relieved  by  dilute  hydrochloric 
acid,  headache  every  morning.  Periods  were  regular  and 
painless,  and  for  last  few  months  had  been  growing  less 
in  amount.  Basal  metabolic  rate  was  —22,  blood  sugar 
106  mgm..  blood  urea  12  mgm..  calcium  9.5  mgm.,  phos- 
phorus 3  mgm..  hemoglobin  88.6%.  leucocytes  7,000,  ery- 
throcytes 4,640.000,  smear  negative.  Wassermann  negative. 
Blocd  pressure  120  70,  pulse  72.  She  took  two  grains  of 
desiccated  thyroid  every  other  day  and  felt  better  until 
March.  1935.  She  complained  of  awakening  in  the  morn- 
ing with  a  headache  and  a  grinding  heaviness  of  the  back 
of  the  neck.  The  thyroid  was  continued  and  she  was  given 
1  c.c.  of  antuitrin  hypodermically  on  the  4th,  13th  and 
ISth  of  March.  1935.  Soon  she  felt  much  better.  She  has 
continued  to  take  antuitrin.  1  c.c.  by  hypo  every  10  days. 
She  complains  of  return  of  the  grinding  heaviness  of  the 
neck  and  the  coated  tongue  when  she  needs  an  injection, 
that  her  eyes  feel  heavy,  that  she  has  trouble  in  focusing 
them  and  they  feel  like  they  are  looking  through  slits. 
These  symptoms  subside  in  24  hours  and  she  is  comfortable 
for  about  10  days  to  two  weeks.  The  patient  is  a  nurse 
and  continues  the  treatment  herself.  Her  last  few  basal 
metabolic  rates  have  been  around  —7.  She  has  passed 
through  the  menopause  during  the  last  year  with  very- 
little  trouble. 

Case  2. — Married  white  woman,  no  pregnancies,  43  years 
of  age.  examined  July  13th,  1934,  weight  139I/2  lbs.,  height 
d&Yz" ■  Complained  of  severe  aches  in  the  top  of  the  head 
and  down  the  back  of  the  neck,  sleepiness,  indigestion  and 
chilly  feelings.  Periods  regular  and  apparently  normal. 
Blood  pressure  114  66,  pulse  75.  Blood  count  normal, 
blood  sugar  91  mgm.,  calcium  10  mgm.,  phosphorus  3.8 
mgm.,  cholesterol  307  mgm.  She  was  given  thyroid,  gr. 
2,  daily  and  1  c.c.  antuitiin  by  hypo.  After  a  time  she 
became  very  comfortable.  The  antuitrin  has  been  given 
every  4  to  6  weeks  up  to  the  present  time.  In  1939  her 
periods  became  irregular  and  stopped.  She  had  hot  flushes 
for  some  months,  but  not  severe  enough  to  necessitate 
estrogenic  hormone  therapy. 

Case  3. — A  married  white  woman  aged  19,  seen  in  May. 
1926.  complained  of  nervousness,  indigestion,  pains  in  the 
abdomen  of  indefinite  character,  gain  of  20  pounds  in 
weight  last  year,  delayed  and  slight  menstrual  flow.  Dr. 
Max  Mailhouse  of  New  Haven  made  a  diagnosis  of  dys- 
trophia adiposogenitalis.  She  was  given  injections  of  an- 
tuitrin during  1926  and  1927  with  considerable  benefit.  Her 
periods  increased  in  amount  and  became  regular.  In  1932 
there  was  fullness  and  aching  in  the  back  of  the  head 
which  antuitrin  improved.  In  1934  she  was  delivered  at 
term  of  a  normal  boy.  In  the  latter  part  of  the  pregnancy 
the  ankles  and  hands  were  edematous,  blood  pressure  136 
80.  slight  albuminuria.  Since  1934  she  has  been  treated 
regularly  with  injections  of  antuitrin.  She  is  comfortable 
and  feels  fine  for  about  six  weeks;  then  the  bloating  feel- 
ing in  the  hands  and  feet  returns,  and  along  with  it  stiff- 
ness and  aching  in  the  back  of  the  neck. 

Case  4. — An  unmarried  white  woman,  aged  34,  weight 
135  lbs.,  height  66J/S",  seen  December  11th,  1937,  com- 
plained of  feeling  tired,  eyes  burning  and  seeming  to  jump 
around,  being  unable  to  work  since  June.  In  this  time 
she  went  to  several  doctors,  was  treated  in  an  army  hos- 
pital for  adrenal  insufficiency,  and  by  a  chiropractor. 
Twelve  years  before,  she  was  treated  for  hyperthyroidism. 
Basal    metabolic   rate    —20,   blood   pressure    130  80,   hemo- 


globin 14.73  mgm.,  erythrocytes  4,950,000,  leucocytes 
7,000 — baso.  1.5%,  eos.  3%,  myelo.  0,  juv.  neutro.  0,  stab 
neutro.  5.5%,  seg.  neutro.  53.57c  small  lymph.  18.5%, 
large  lymph.  11%,  mono.  6.5%.  Weekly  injections  of  an- 
tuitrin were  given  hypodermically.  The  eye  symptoms  and 
the  aches  in  the  head  and  down  the  back  of  the  neck  were 
relieved  and  she  returned  to  work  January  7th,  1938.  She 
has  continued  steadily  at  work  up  to  the  present  time. 
When  she  begins  to  feel  a  return  of  the  eye  and  neck 
symptoms  in  three  or  four  weeks,  they  are  promptly  re- 
lieved by   1  c.c.  of  antuitrin. 

Discussion 

These  cases  have  been  classed  as  mild  insuffi- 
ciency of  the  secretions  of  the  anterior  lobe  of  the 
pituitary  because  improvement  follows  promptly 
and  consistently  on  the  empirical  use  of  aqeous- 
acetic  acid  extract  of  the  fresh  gland.  This  seems 
reasonable  because  it  has  been  demonstrated  by 
Simmonds'1  that  severe  insufficiency  of  the  anterior 
lobe  occurs-  -the  Simmonds  syndrome — based  on 
complete  destruction  of  the  gland.  Recently,  Sut- 
ton and  Ashworth4  in  two  papers  reported  several 
cases  in  which  recovery  from  pellagra-like  condi- 
tions had  been  effected  by  treatment  with  polyan- 
syn  and  vitamin  B  complex.  These  cases  had  pre- 
viously failed  to  respond  to  nicotinic  acid,  ribo- 
flavin, liver  parenterally  and  adequate  diet.  If 
there  are  definite  syndromes  recognized  as  occur- 
ring with  the  destruction  of  a  large  portion  of  the 
anterior  lobe  of  the  pituitary,  it  is  reasonable  to  be- 
lieye  that  mild  cases  of  insufficiency  can  be  found 
and  that  they  would  be  relieved  by  extract  of 
anterior  pituitary  parenterally  administered. 

This  syndrome  may  be  presented  by  women  who 
are  menstruating  regularly,  those  passing  through 
menopause,  or  those  several  years  past  the  climac- 
teric. We  think  we  can  differentiate  the  syndrome 
from  the  symptoms  of  menopause  if  the  two  occur 
at  the  same  time.  We  found  that  extract  of  fresh 
anterior  pituitary  does  not  relieve  the  hot  flushes, 
nervousness,  insomnia  and  mental  depression  of 
the  menopause.  To  patients  who  complained  of 
these  symptoms  we  gave  adequate  estrogenic  hor- 
mones and  obtained  relief  of  the  menopausal 
symptoms.  The  anterior  pituitary  insufficiency  was 
then  treated  by  injection  of  anterior  pituitary  ex- 
tract. 

In  a  few  cases  we  examined  the  vaginal  smears. 
Those  that  suffered  from  menopausal  symptoms 
showed  the  small  atrophic  cells  as  described."  In 
the  cases  presenting  no  menopausal  symptoms  nor- 
mal smears  were  found. 

A  lowering  of  the  blood  cholesterol  toward  or 
to  the  normal  level  was  found  to  occur  along  with 
an  improvement  of  the  symptoms.  This  fluctuated, 
but  the  average  blood  cholesterol  level  was  lower 
while  treatment  was  continued. 

The  relief  of  soreness  and  swelling  of  the  joints 
of  the  fingers  and  toes  was  interesting.  In  some 
of  the  cases  there  was  what  appeared  to  be  begin- 


PARENTERAL    ANTERIOR    PITUITARY— Wilson 


July,  1941 


ning  arthritis.  The  joints  of  the  fingers  and  toes 
were  swollen,  tender  and  painful.  Under  treatment 
the  pain  and  soreness  wellnigh  disappeared  and 
the  swelling  of  the  joints  receded  slightly.  No  im- 
provement was  found  in  very  marked  deformity  of 
the  chronic  arthritic  except  a  slight  lessening  of 
the  pain  or  soreness. 

Summary 
A  considerable  percentage  of  middle-aged  wo- 
men, suffering  from  stiffness  of  the  back  of  the 
neck,  heaviness  of  the  eyelids,  generalized  bloating 
over  the  body,  stiffness  and  soreness  of  fingers  and 
toes,  somnolence  and  loss  of  libido;  and  with  low 
blood  pressure,  moderately  low  basal  metabolic 
rate  and  increased  blood  cholesterol  can  be  reliev- 
ed by  injections  of  aqeous-acetic  acid  extract  de- 
rived from  the  anterior  lobes  of  the  pituitary 
gland,  parenterally  administered  at  intervals  of 
one  to  eight  weeks. 

References 

1.  Collip,  J.  B.:    Annals  of  Internal  Medicine,  8:10,  1934. 

2.  Collip,  J.  B.:    Annals  of  Internal  Medicine,  9:150,  193S. 

3.  Simmoxds,  M.:    Deutsche  Med.   Wchschr.,  40:322,    1914 

4.  Ashworth,  J.,  and  Sutton,  D.  C:    J.  Lab.  and  Clin. 
Med.,  25:848,  1940. 

5.  Papanicolaou,  G.  M.,  and  Shorr,  E.:    .4m.  J.  Obst.  and 
Gynec,  31:804,  1936. 

Ibid.    Trans.  Assn.  Am.  Phys.,  51:213,  1936. 


THE  CHOICE  OF  ANESTHESIA  IN  LUDWIG'S 
ANGINA 

(P.  S.  Marcus,  Boston,  in  Anes.  &  Anatg..  May-June) 
Pentothal  is  preferred  and  by  this  technique:  Atropine, 
gr.  1  75,  half  hour  before  operation.  Metrazol  and  addi- 
tional atropine  should  be  on  hand  in  separate  sterile  syr- 
inges. .An  incision  preparatory  to  tracheotomy  should  be 
made  under  local  anesthesia.  A  5  per  cent  solution  pento- 
thal should  be  injected  slowly,  0.5  c.c.  at  a  time,  a  pause 
of  15  seconds.  When  the  patient  can  no  longer  count 
aloud  or  respond  to  questions,  respiration  and  reaction  to 
painful  stimulation,  such  as  pinching  of  the  skin  with  for- 
ceps, are  the  guides  to  further  dosage.  A  nasal  tube  should 
be  gently  inserted  into  the  larger  nostril  to  just  above  the 
vocal  cords  (7  inches  average)  ;  the  tube  is  then  connected 
to  an  oxygen  apparatus  which  will  deliver  a  continuous 
flow  of  3  liters  per  minute.  Any  relaxation  of  the  jaw 
interfering  with  patency  should  be  supported  by  an  assist- 
ant, if  tongue  interferes  it  is  grasped  and  held  forward 
with  a  pair  of  forceps.  For  cyanosis  oxygen  flow  is  increas- 
ed, and  metrazol,  3  c.c.  injected  intravenously,  repeated 
if  no  improvement.  If  coughing  or  gagging  interfere  atro- 
pine gr.  1  150  intravenously.  Reflexes  arising  from  the 
site  of  operation  must  be  abolished  throughout  by  frac- 
tional administration  of  further  pentothal  to  maintain 
constantly  a  sufficient  depth  of  anesthesia.  In  the  event 
that  tracheotomy  becomes  necessary  anesthesia  can  be 
maintained  with  pentothal  while  the  surgeon  completes  the 
tracheotomy  and  the  main  operative  procedure.  Adminis- 
ter oxygen  nasally  for  12  to  24  hours,  or  until  the  patient 
breathes  easily  and  is  of  good  color.  After  the  operation  is 
completed  and  until  the  patient  is  well  beyond  danger  of 
obstruction,  someone  capable  of  completing  the  tracheo- 
tomy, either  the  surgeon  or  the  anesthetist,  should  be  im- 
mediately available  and  a  tracheotomy  kit  should  be  in 
readiness  at  the  bedside. 


CURRENT   PROBLEMS    OF   AMERICAN   MEDICINE 

(F.   H.   Lahey,   Boston,   in  Jt.  A.   M.   A..  June  7th) 

My  own  opinion,  and  I  believe  that  it  is  my  duty  to 
express  it,  is  that  we  are  already  committed  to  a  posi- 
tion, whether  we  like  it  or  not.  I  myself  like  it.  We 
have  dared  the  dictator.  It  is  too  late  to  appease  him ; 
the  word  has  no  meaning  in  his  language.  We  should 
arrive  at  a  conviction  concerning  isolation.  Is  it  right? 
It  is  my  conviction  that  it  is  not.  I  prefer  destruction  if 
it  need  be  to  survival  in  cowering  terror.  Give  me 
positive  commitment  rather  than  compromising,  unsatis- 
fying safety.  If  I  must  face  my  friends  in  democracy 
trying  to  explain  my  reasons  for  seeking  dubious  safety 
and  leaving  them  to  their  fate,  I  prefer  the  uncertainties 
of  the  hazardous  undertaking  frankly  faced  and  hazard- 
ous, and  to  accept  them.  It  is  my  opinion  that  if  dis- 
aster should  overtake  us  in  the  hazardous  undertaking 
it  would  be  no  more  terrible  than  what  will  happen  to 
us  if  we  are  to  try  to  isolate  ourselves.  We  shall  still 
have  ourselves  to  live  with.  This  nation  has  been  gallant 
in  the  past  and  it  can  be  gallant  again.  I  do  not  be- 
lieve that  there  is  a  safe  couise.  In  dangerous  times  such 
as  these  I  would  like  to  make  as  a  closing  statement  that 
it  is  my  conviction  that  a  dangerous  course  has  real 
advantages. 


EGG-YOLK  POWDER  FOR  PUTTING  ON  WEIGHT 

(A.  Steiner    New  York,  in  Jt.  A.  M.  A.,  June  21st) 
The  feeding  of  egg-yolk  powder  caused  9  of  10  patients 
to   gain   weight,   whereas   previous   high-calory    diets   sup- 
plemented by  vitamins  had  failed. 

It  is  believed  that  some  factor  other  than  the  caloric 
value  of  the  egg-yolk  powder  may  play  a  part  in  the  re- 
sultant increase  in  the  nutrition  of  the  body  inasmuch 
as  the  calory  intake  of  5  of  the  patients  was  below  and 
that  of  the  other  5  but  slightly  above  that  of  a  control 
period,  when  they  failed  to  gain  weight  on  an  ample 
diet   that   did  not  contain  the  egg-yolk  powder. 

Egg-yolk  powder  is  said  to  be  a  rich  source  of  vitamins 
A  and  D  and  the  water  soluble  fraction  of  the  vitamin 
B  complex.  The  cost  of  the  egg-yolk  powder  was  15.4 
cents  daily   ($1.08  a  week)   for  each  patient. 


THE  USE  OF  POWDERED  SULFANILAMIDE  IN 

THE  PERITONEUM 

(C.  A.  Kinney,  Florence,  in  Jt.  S.  C.  Med.  Assn.,  June) 

The  drug  used  in  these  cases  was  the  finely  granular 
powder  of  sulfanilamide  in  quantities  of  five  and  10  grams 
in  test  tubes  stoppered  with  cotton,  sterilized  in  a  dry 
oven  at  120°  C.  for  30  minutes. 

In  the  cases  of  generalized  peritonitis  encountered,  we 
used  10  grams  of  the  drug  for  the  average  adult  of  150 
lbs.  In  one  child,  four  years  of  age,  with  ruptured  appen- 
dicitis, we  used  %  of  the  adult  dose  with  complete  recov- 
ery. 

Peritonitis  was  due  to  ruptured  appendix  in  18  cases; 
intestinal  perforations  (gunshot  wound),  2;  intestinal  per- 
foration foreign  body  (fish  bone),  1;  ruptured  divertic- 
ulum, 1;  gangrene  of  small  intestine  with  resection,  4; 
tubo-ovarian  abscess  with  free  pus,   19. 

In  a  series  of  45  cases  of  generalized  peritonitis  treated 
at  The  McLeod  Infirmary,  sulfanilamide  powder  was  used 
in  all  the  cases  with  only  one  death  resulting,  and  this  due 
to  a  cerebral  embolism  shortly  after  operation.  Some  of 
these  cases  appeared  hopeless.  Complications  were  encoun- 
tered less  frequently  than  in  former  years  and  no  severe 
toxic  effects  were  noted. 

The  use  of  sulfanilamide  in  the  peritoneal  cavity  is 
wholeheartedly  endorsed  in  all  cases  of  frank  or  suspected 
generalized  peritonitis. 


July,  1941 


SOVTHERX  MEDICINE  &  SURGERY 


The  Diagnosis  of  Submucosal  Myomas  and  Polyps 
of  the  Uterus* 

W.  B.  Xorment,  M.D.,  and  E.  D.  Apple,  M.D.,  Greensboro 


THE  DIAGNOSIS  of  submucosal  myomas 
of  the  uterus  is  often  very  difficult.  Biman- 
ual examination  of  the  uterus  will  often  re- 
veal that  the  organ  has  a  smooth  contour,  possibly 
that  it  is  slightly  enlarged.  Because  of  its  smooth 
contour  and  our  inability  to  palpate  a  fibroid,  it  is 
assumed  that  no  fibroid  is  present,  and  the  patient 
is  given  some  tvpe  of  therapy  with  no  relief.  In 
those  patients  approaching  menopause,  castrating 
doses  of  radium  or  x-rays  are  often  given  with  the 
result  that  the  continued  bleeding  persists  follow- 
ing the  treatment.  This  is  particularly  true  in 
those  patients  who  have  a  fairly  large  submucosal 
myoma  or  a  fairly  large  polyp  protruding  into 
the  uterine  canal.  It  is  unfortunate  that  sometimes 
a  fibroid  from  the  serosal  surface  is  removed,  and 
the  patient  continues  to  bleed  because  of  a  per- 
sisting submucosal  fibroid  which  was  overlooked  at 
the  time  of  operation.  It  is  probably  safe  to  say 
that  a  fibroid  which  is  distant  from  the  endome- 
trium probably  has  no  causal  relationship  to  bleed- 
ing from  the  uterus.  There  has  been  no  method 
published  whereby  we  could  detect  these  submu- 
cosal myomas  or  large  polyps,  except  by  curet- 
ment.  and  this  is  often  not  satisfactory. 

We  wish  to  present  a  method  whereby  these 
submucosal  mvomas  or  uterine  polyps  may  be  de- 
tected if  they  protrude  into  the  uterine  canal.  One 
year  ago,  we  began  using  a  small  bag  or  balloon 
inside  the  uterine  cavity  into  which  was  instilled 
air  as  a  contrast  medium  for  the  detection  of  these 
tumors  ( Figure  1 ) .  A  myoma  large  enough  to 
protrude  into  the  uterine  cavity  would  depress  the 
bag  and  leave  a  defect  in  the  air  shadow  upon 
x-ray  examination.  The  bag  used  at  that  time 
was  a  prophylactic  rubber  bag  attached  by  a  silk 
thread  to  the  end  of  a  number- 18  rubber  cathe- 
ter. This  was  inserted  into  the  uterine  cavity 
following  dilatation  of  the  cervix  under  gas  anes- 
thesia. We  had  some  difficulty  at  that  time,  due 
to  the  fact  that  into  the  small  uterine  canal  it 
was  impossible  to  instill  a  sufficient  quantity  of 
air  into  the  balloon  or  bag  to  show  plainly  on  the 
x-ray  film.  Also,  the  shadows  of  gas  in  the  in- 
testinal tract  would  oftentimes  fuse  with  the  shadow 
of  air  in  the  balloon,  and  it  would  be  impossible  to 
detect  the  difference  between  the  air  in  the  bag 
and  that  in  the  intestinal  tract.  To  remedy  this 
condition,  we  had  constructed  a  bag  with  an 
opaque    material    impregnated    into    its    lining    in 


order  to  give  a  distinct  opaque  outline  which  could 
be  differentiated  from  gas  in  the  intestinal  tract 
(Figure  9).  We  used  this  bag  with  fair  success, 
but  finally  discarded  it  because  of  the  fact  that 
the  opaque  material  made  the  bag  less  pliable, 
and  less  conformable  to  the  irregularities  in  the 
uterine  wall. 

Since  the  air  medium  and  lining  of  the  bag 
with  opaque  material  were  unsuccessful,  it  was 
thought  best  to  instill  into  the  bag  a  thin  opaque 
material  in  combination  with  air.  A  weak  solu- 
tion of  sodium  iodide  was  used  at  first  followed 
by  an  injection  of  air.  This  failed  to  outline  the 
bag  properly,  as  when  the  air  was  injected  be- 
hind the  dye  it  wfiuld  give  a  diffuse  and  ragged 
appearance  to  the  dye  and  was  not  clear  cut 
enough  to  make  distinction  of  the  uterine  canal. 
Following  this,  diodrast,  or  12.5  per  cent  sodium 
iodide,  was  injected  into  the  bag  and  x-ray  films 
made  of  this  media.  Both  the  diodrast  and  the 
sodium  iodide  solution  were  found  to  form  a 
medium  which  was  too  heavy,  overlying  the  pos- 
sible myoma  protruding  from  the  anterior  and 
posterior  wall  and  thus  preventing  a  displacement 
of  the  dye  as  is  seen  with  stones  in  the  gallbladder 
( Figures  4  &  5 ) .  A  3  per  cent  solution  of  sodium 
iodide  was  then  used  and  it  was  found  that  with 
this  strength  a  polyp  or  myoma  protruding  from 
the  anterior  or  posterior  wall  would  probably  dis- 
place the  thin  dyef  leaving  the  shadow  which 
could  be  interpreted  as  a  possible  fibroid  or  polyp 
(Figure  5).  If,  however,  the  myoma  or  polyp 
were  on  the  side,  it  would  give  a  defect  in  the 
contour  of  the  bag. 

The  advantages  of  this  method  over  that  of 
injecting  lipiodol  into  the  uterine  canal,  as  in  a 
salpingogram,  is  that  the  uterine  canal  is  pressed 
out  from  its  numerous  folds  and  also  there  is  no 
leakage  of  the  dye  through  the  fallopian  tubes 
or  the  cervical  canal.  With  the  use  of  the  rubber 
balloon,  6  to  7  c.c.  may  be  injected  into  the  bal- 
loon and  the  catheter  clamped,  following  which 
the  patient  may  have  x-ray  exposures  made  at 
various  angles  with  distention  of  the  uterine  canal 
of  constant  degree.  This  would  be  impossible  by 
the  method  of  injecting  lipiodol  into  the  canal 
without  the  bag. 

The  patient  is  prepared  as  for  a  dilatation  and 
curettage  of  the  uterus,  with  the  preliminary  medi- 
cation the  same  as  for  any  anesthesia.     The  field 


cuing   of   the-   Tri- State    Medical    Association    of    the    Carolii 


held    at    Greensboro,    February 


DIAGNOSIS    OF    POLYPS,    ETC.—Nortnent    &    Apple 


July,  1941 


Fig  u 
Figu 


2  reveals    a    normal    uterine   c 

3  is  that  of  a  distorted   uterin 


showing   the    normal    wedge-shaped    uterine    canal   with    the    bag    in- 

al,   the  bag  being  tilled   with    12   per   cent   sodium    iodide   solution, 
canal   caused   by   a   submucosal   fibroid.      Compare  with    Figure    1. 


Figure   4   is   the   bag   rilled   with    the   sodium    iodide   solution.-     Notice  the   filling   defect    caused    by    a   polyp. 
Due   to   the   density    of   the   dye,    lateral   view   of   same   specimen    did    not    reveal    the    polyp. 


Figure  5  is  the  same  specimen  with  3   per  cent 
the  polyp. 


iodide,    showing   the    displacement    of    the    dye   by- 


injected   bag  due   to  the 


Figure  6    is   the   specimen. 

Figure  7   is  a  clover-leaf  deformity   in 

Figure  8  is  the  specimen. 

Figure  9  shows  a   banana-shaped   deformity   of   air-injected   bag   due 

Figure  10  is  the  specimen. 


ultiple  submucosal  fibroids. 
.  large   submucosal  fibroid. 


Figure  11  is  that  of  large  abdominal  mass  in  the  lower  abdomen.  When  the 
uterine  canal  and  filled  with  dye,  it  revealed  a  normal  uterine  canal.  The  i 
teratoma   of  the  ovary 

Figure   12  is  the  balloon  attached  to  a  small  mushroom  catheter. 


was    inserted    into   the 
later    proved    to  be    a 


July,  1941 


DIAGNOSIS    OF    POLYPS,    ETC.—Norment    &    Apple 


of  operation  is  prepared  as  for  any  vaginal  opera- 
tion. The  balloon  is  sterilized  in  cyanide.  The 
cervix  is  then  well  dilated  and  the  uterine  probe 
inserted  into  the  uterine  canal.  From  the  ascer- 
tained depth  of  the  uterus  the  surgeon  decides 
what  size  bag  should  be  used — a  bag  three-fourths 
the  length  of  the  depth  of  the  uterine  canal.  This 
will  allow  for  the  distance  of  the  cervix  which 
the  balloon  does  not  occupy.  Following  the  dila- 
tation, the  balloon  is  then  inserted  with  the  uterine 
probe  into  the  uterus.  It  is  best  to  use  the  probe 
to  insert  the  balloon  rather  than  uterine  forceps, 
as  the  forceps  will  tend  to  withdraw  the  balloon 
when  the  forceps  is  taken  from  the  uterus. 

The  procedure  is  very  simple  and  there  is  little 
or  no  danger  of  harm  to  the  uterus.  Certainly, 
not  as  much  harm  as  that  associated  with  a  dila- 
tation and  curettage  of  the  uterus.  Following 
insertion  of  the  balloon,  four  strips  of  gauze  are 
inserted  against  the  uterus — antero-posterior  and 
lateral.  This  is  to  prevent  the  bag  from  being 
expelled  from  vomiting  or  other  straining  when 
the  patient  reacts  following  the  anesthesia.  We 
usuallv  pack  the  vaginal  vault  fairly  tight  with 
gauze  and  inclose  the  catheter  into  the  vagina  so 
that  there  will  be  no  risk  of  the  patient  withdraw- 
ing the  bag  by  pulling  on  the  catheter.  If  a 
mushroom  catheter  is  used,  it  is  not  necessary  to 
use  vaginal  packing  (Figure   12). 

When  the  patient  reacts  from  the  light  gas- 
anesthesia,  she  is  taken  to  the  x-ray  room  and 
from  6  to  10  c.c.  of  the  dve  is  instilled  into  the 
uterine  bag.  When  the  patient  complains  of  the 
slightest  discomfort,  we  immediately  stop  the  in- 
jection of  the  dye.  Since  little  pressure  is  used, 
there  is  practically  no  risk  attached  to  this  pro- 
cedure, and  when  the  patient  complains  of  distress 
it  is  assumed  that  the  uterine  canal  is  fairly  well 
dilated.  A  hemostat  is  then  clamped  on  the  end  of 
the  catheter  and  an  antero-posterior  x-ray  exposure 
is  made;  then  a  right-angle,  and  left-angle,  ex- 
posure. If  it  is  desired,  the  patient  can  then  be 
turned  on  the  abdomen  and  a  postero-anterior  ex- 
posure made,  following  which  a  right-angle  expos- 
ure over  the  sacro-iliac  region  and  a  left-angle 
exposure  made.  By  these  six  exposures,  the  en- 
tire circumference  of  the  uterine  canal  will  be 
covered,  and  if  there  is  a  submucosal  growth  or 
polyp  around  the  contour  in  these  areas  it  should 
be  revealed.  However,  as  we  have  stated  previ- 
ously, when  the  weak  solution  of  sodium  iodide  is 
used,  the  submucosal  fibroid  or  polyp  will  prob- 
ably protrude  through  the  dye,  displacing  the  dye 
and  revealing  the  growth. 

There  have  been  no  untoward  effects  from  this 
procedure.  The  bag  being  constructed  out  of  very 
thin  rubber  of  great  strength  and  little  pressure 
being  put  in  the  bag  at  the  time  of  the  examination, 


the  bag  has  not  ruptured  in  any  of  these  examina- 
tions. In  several  instances  we  have  left  the  bag 
in  for  as  long  as  four  days,  purposely  to  see  if  it 
would  cause  any  irritation  or  subsequent  fever  or 
profuse  drainage.  There  has  been  no  change  in 
the  temperature  chart,  no  vaginal  discharge  more 
than  would  be  expected  from  ordinary  dilatation 
of  the  cervix. 

Our  object  in  working  out  this  method  is  to 
encourage  the  removal  of  myomas  and  intrauterine 
polyps  by  operative  measures  less  formidable  than 
hysterectomy.  If  by  bimanual  examination  the 
contour  of  the  uterus  feels  smooth  and  following 
insertion  of  the  bag  no  defect  is  found  to  suggest 
a  submucosal  myoma  or  polyp,  then  other  methods 
of  investigation  should  be  carried  out  to  determine 
the  cause  of  the  bleeding  before  the  patient  is 
subjected  to  a  major  surgical  procedure. 

We  believe  by  this  method  that  many  of  the  sub- 
mucosal fibroids  or  polyps  which  previously  have 
been  difficult  to  diagnose  may  be  detected.  How- 
ever, we  have  not  had  sufficient  material  to  form 
a  firm  basis  for  definite  claims  beyond  those  ten- 
tatively offered  in  reporting  this  experimental 
work. 


NEW   TREATMENT   FOR   SPRAINS   AND   PULLED 

MUSCLES 

(Hans  Kraus,  New  York,  in  Jl.   A.  M.  A-,  June  7th) 

The  painful  region  is  determined  through  active  motion 
and  ethyl  chloride  is  sprayed  on  this  area  of  skin.  The 
patient  then  starts  careful  active  motion  of  the  part  in- 
volved, in  the  direction  in  which  the  motion  has  been 
painful  and  limited.  As  the  patient  carefully  increases  the 
movement,  new  painful  areas — which  up  to  this  point 
have  been  hidden  through  blocked  motion — will  develop. 
Those  areas  again  are  sprayed  and  active  motion  con- 
tinued. 

These  treatments  last  from  10  to  30  minutes  and  should 
be  performed  well  within  the  limits  of  pain.  Immediately 
after  the  treatment  camphor  liniment  is  to  be  applied  to 
prevent  frostbite. 

Immediate  normal  use  of  the  affected  part  can  be  al- 
lowed in  a  majority  of  cases,  but  no  excessive  strain  or 
sudden  movement.  Patients  with  more  severe  disorders 
should  be  given  a  rest,  but  all  patients  should  be  advised 
to  continue  the  active  movements  taught  them  for  5  min- 
utes from  twice  a  day  to  once  every  hour.  While  a  single 
treatment  will  be  sufficient  in  cases  of  minor  injury,  severe 
ones  will  have  to  be  treated  several  times;  the  first  week 
daily — later  every  other  day.  Effective  treatment  should 
not  call  for  the  anesthetic  after  the  second  week;  active 
motion  will  have  to  continue  until  normal  muscular  power 
is  restored.  Immobilization  after  treatment  is  contrary  to 
the  basic  principle  and  should  never  be  combined  with  it. 

Groups  of  cases  considered  suitable:  if  no  fractures  nor 
complete  tearing  of  ligament,  muscle  or  tendon:  1)  sprains 
of  all  joints;  2)  acute  muscular  spasm  due  to  lumbago, 
acute  bursitis  of  the  shoulder,  pulled  muscles,  and  3) 
chronic  muscular  spasm  due  to  low-back  pain,  sciatica, 
chronic  osteoarthritis,  shoulder  spasm  and  the  like. 

Whenever  treatment  with  ethyl  chloride  spray  gives  a 
negative  result,  it  will  be  necessary  to  look  for  major 
changes  in  the  anatomy.  Thus  this  technic  may  be  used 
as  a  means  of  evaluating  diagnosis  in  cases  of  impaired 
function. 


376 


SOUTHERN  MEDICINE  &  SURGERY 


July,   1941 


Hypertrichosis  With  Particular  Reference  to  Electrolysis* 

Paul  G.  Reque,  M.D.,  Durham 


Introduction 

THE  PROBLEM  of  the  therapy  of  exces- 
sive growth  of  hair  is  one  which  has  never 
been  satisfactorily  solved  from  the  stand- 
point of  either  the  patient  or  the  physician.  No 
present-day  method  of  treatment  is  capable  of 
producing  a  rapid  and  safe  alleviation  of  the  con- 
dition. The  methods  most  used  today  are  gener- 
ally unsatisfactory  from  both  the  therapeutic  and 
the  technical  aspect;  and  the  method  of  hair  re- 
moval using  electric  currents  is  uncomlortable  for 
the  patient,  albeit  not  unduly  so.  The  number  of 
cases  of  excessive  hairiness  is  such  that  every  phy- 
sician sees  it  commonly,  and  since  it  so  often  pro- 
duces mental  complexes  in  the  patient  treatment 
should  be  readily  available. 

Hypertrichosis  afflicts  men  and  women,  but 
those  seeking  relief — mostly  for  cosmetic  purposes — 
are  preponderatingly  women.  In  the  male  exces- 
sive hair  can  be  inconvenient  when  unusually 
marked  about  the  anal  region,  and  in  rare  in- 
stances it  predisposes  to  follicular  eruptions  from 
irritating  substances  in  industry;  but  in  general 
hirsutism  is  considered  a  sign  of  virilism  and  is 
often  so  prized.  Women,  however,  are  considerably 
disturbed  by  a  slight  downy  growth  on  the  face, 
or  a  noticeable  increase  of  hair  on  the  chest,  and 
are  willing  to  undergo  much  to  be  rid  of  it.  The 
widespread  lack  of  equipment  and  of  training  for 
the  removal  of  excess  hair  has  often  led  to  dis- 
tressing inferiority  situations,  these  not  infrequent- 
ly going  on  to  more  serious  mental  states. 

Etiology 
The  cause  of  excessive  hair  growth  is  generally 
conceded  to  be  associated  with  endocrine  dysfunc- 
tion, although  most  of  the  cases  that  are  seen  do 
present  no  other  signs  indicating  such  dysfunction. 
Heredity  seems  to  play  a  role  since  several  gen- 
erations of  a  family  may  show  the  condition.  The 
association  with  both  hyper-  and  hypothyroidism 
is  occasionally  noted,  and  careful  histories  and 
physical  examinations  revealing  signs  of  undue 
tolerance  to  cold,  increased  appetite  with  weight 
loss,  should  lead  the  examiner  to  have  the  basal 
metabolism  rate  determined.  Treatment  with  small 
doses  of  thyroid  extract  in  cases  showing  hypo- 
thyroidism has  been  followed  by  arresting  hair 
growth  but  not  by  hair  shedding.  Concurrent  dis- 
turbances in  the  menstrual  cycle  in  young  women 
may   point    toward   an   ovarian    dysfunction,    and 


therapy  aimed  at  correction  of  this  dysfunction  in 
any  specific  instance  may  arrest  the  growth.  The 
menopause  is  a  common  time  to  find  stimulation 
of  the  growth  of  hair;  but  although  the  treatment 
may  relieve  the  menopausal  symptoms,  it  appar- 
ently does  not  affect  the  course  of  the  growth  of 
hair.  In  hyperpituitarism,  in  both  the  preadult 
and  the  postadult  tvpes,  there  is  usually  an  in- 
crease in  the  hair  on  the  trunk  and  the  extremities, 
but  no  or  slight  increase  on  the  face.  Hirsutism  is 
a  feature  of  Cushing's  syndrome.  In  general  it  may 
be  said  that  most  cases  of  hypertrichosis  show  no 
evidence  of  endocrine  dysfunction,  and  that  the 
treatment  of  the  condition  in  the  absence  of  clini- 
cal evidence  of  such  disturbance  with  any  endo- 
crine substance  is  without  good  effect,  and  may  be 
harmful. 

Symptomatology 
The  sites  commonly  affected  in  the  female  are 
the  upper  lip  and  the  chin,  and  the  inframandibu- 
lar  and  temporofacial  regions.  Localized  hairy 
growths  may  occur  in  any  location,  however,  and 
are  usually  associated  with  nevi.  The  hairs  may 
be  very  fine,  of  light  color  and  numerous;  or  they 
maly  be  few,  dark  of  coarse  texture.  As  a  rule 
there  is  an  admixture  of  both  types,  and  in  ex- 
treme cases  the  growth  may  be  both  heavy  and 
coarse.  The  time  of  onset  varies,  though  it  is  most 
often  seen  at  puberty  or  shortly  after  the  onset  of 
the  menses,  and  about  the  time  of  the  menopause. 
The  appearance  of  the  hair  is  slow  and  makes  its 
first  unsightly  impression  after  months  or  years, 
although  in  a  few  instances  in  which  the  color  of 
the  hair  is  very  dark,  it  may  be  fairly  rapid.  As  a 
rule  the  patient  has  used  various  means  to  combat 
the  condition  before  being  seen  by  the  physician, 
and  often  she  blames  the  type  of  treatment  used 
as  causing  the  hair  to  become  darker  and  more 
coarse;  but,  save  for  the  use  of  the  wax  depilato- 
ries which  jerk  the  hairs  out  from  the  papillae, 
there  is  little  evidence  to  support  the  view  that 
repeated  and  temporary  removal  influences  in  any 
way  the  rate  or  texture  of  the  growth. 

Treatment 
Depilatories,  Bleaching  etc. — Treatment  meth- 
ods include  depilatories  containing  wax-like  sub- 
stances which  are  applied  warm  to  the  area  in- 
volved, and  on  cooling  harden  and  adhere  to  the 
hairs  so  that  removal  of  the  waxy  material  pulls 
the  hairs  out.    Other  depilatories  contain  barium 


rid    Syphilology   of  the   Department  of  Medi. 


Duke  University  School  of   Medi. 


July,  1941 


HYPER  TRICHOSIS—Reque 


377 


ils 


i     i 


sulphide  in  a  paste  which  dissolves  the  surface 
hair  thus  removing  it,  and  frequently  gives  rise  to 
a  severe  dermatitis.  The  following  prescription  is 
a  good  example  of  a  commonly  used  depilatory. 

Rx     Barium   sulphide   S 

Pulv.   zinc   oxide   12 

Starch    12 

Mjt  To  a  non-gritty  powder 
Sig  Add    water    just    prior    to    use    to 
make  a  thin  paste.    Apply  locally 
to    affected    parts    for    about    3-5 
minutes  and  remove. 

Various  bleaching  substances,  particularly  hy- 
drogen peroxide,  are  commonly  used  to  lighten  the 
color  of  the  hair  when  the  number  of  hairs  is  not 
excessive.  A  method  has  been  reported  of  rubbing 
daily  with  a  pumice  stone  over  the  areas  involved 
for  two  or  more  minutes  after  the  patient  has 
shaved  the  areas  closely.  This  keeps  the  hairs  from 
projecting  above  the  surface,  and  it  is  stated  that 
six  months  or  more  of  daily  use  of  this  method 
causes  atrophy  of  the  hair  papillae.  The  author 
has  had  no  report  on  this  method  as  in  the  few 
cases  in  which  he  initiated  it  not  a  patient  was 
able  to  keep  up  the  daily  treatments. 

X-Ray  Therapy. — The  two  most  common  meth- 
ods of  treatment  used  by  the  physician  are  x-ray 
treatment  and  electrolysis.  X-ray  therapy  has 
been  emphatically  condemned  as  dangerous  by  all 
experienced  dermatologists.  Any  type  of  treatment 
which  does  not  single-out  the  hair  papilla  for  de- 
struction cannot  help  but  destroy  other  elements 
of  the  skin,  or  at  least  seriously  injure  them.  X- 
rays  do  not  have  a  more  destructive  effect  on  the 
hair  papilla  than  on  the  other  tissues;  and  the 
amount  of  treatment  required  to  permanently  re- 
move hair  is  sufficient  to  injure  other  structures  of 
the  skin  with  the  probable  end-result  of  disfiguring 
atrophy  and  telangiectasis,  or  even  ulceration 
which  may  give  rise  to  epitheliomata.  It  is  there- 
fore never  advisable  to  use  x-ray  therapy  for  the 
removal  of  excess  hair. 

Electrolysis. — The  only  safe  and  reliable  method 
for  the  removal  of  excess  hair  is  that  of  electroly- 
sis. Its  effects  are  permanent,  and  the  treatment 
is  directed  to  the  destruction  of  the  hair  papilla 
alone.  None  of  the  neighboring  tissues  is  injured 
when  the  treatment  is  properly  carried  out.  A  cer- 
tain amount  of  skill  and  judgment  is  necessary  for 
its  proper  use,  but  a  little  practice  and  patience 
with  the  method  will  insure  a  good  and  permanent 
result.  Because  the  method  is  tedious  in  cases  of 
involvement  of  large  areas,  electrolysis  has  been 
largely  neglected  by  the  medical  profession  and 
allowed  to  drift  into  the  hands  of  beauty-shop 
operators  whose  training  is  entirely  inadequate  for 
carrying  out  the  technique  or  for  deciding  prop- 
erly which  should,  and  which  should  not,  be  treat- 
ed by  this  method.    The  beauty-shop  operator  is 


HYPERTRICHOSIS— Reque 


July,   1941 


willing  to  carry  out  the  procedure  for  a  smaller 
fee  than  the  physician  can  accept,  but  nearly  all 
patients  are  willing  to  pay  a  larger  fee  for  more 
skillful  diagnosis  and  treatment.  At  the  present 
time  few  physicians  outside  the  largest  cities  have 
interested  themselves  in  this  work,  and  equipped 
themselves  to  carry  it  out;  which  is  surprising 
considering  the  fact  that  the  work  may  be  done  at 
his  convenience,  the  remuneration  is  good,  with  an 
initial  outlay  of  less  than  twenty-five  dollars  for 
equipment. 

Method. — Electrolysis  consists  of  inserting  a 
small  platinum  or  steel  needle  into  each  hair  folli- 
cle so  that  the  tip  of  the  needle  is  at  the  hair  pa- 
pilla, and  passing  a  small  current  through  it  by 
means  of  the  negative  pole  of  the  apparatus, 
thus  destroying  the  papilla.  Destruction  is  usually 
evidenced  by  a  few  bubbles  appearing  at  the 
mouth  of  the  follicle  after  about  thirty  seconds, 
when  the  hair  is  easily  pulled  out.  The  part  to  be 
treated  is  first  wiped  off  with  a  fat  solvent  such  as 
carbon  tetrachloride.  (Ether  is  usable  but  there  is 
some  slight  danger  of  ignition.)  Some  method  of 
asepsis  is  used  such  as  soap  and  water  followed  by 
70  per  cent  alcohol,  to  minimize  infection.  The  pa- 
tient supine  on  a  table  of  suitable  height,  the  oper- 
ator sits  comfortably  at  the  head  so  that  both 
elbows  may  rest  on  the  table.  A  good  light  source 
is  needed,  and  a  daylight  bulb  in  a  standing  lamp 
which  may  be  on  a  flexible  neck  is  suitable  for 
the  purpose  ( Fig.  1 ) .  While  binocular  loupes  are 
not  essential,  their  use  enables  the  operator  to  do 
work  much  easier  and  better.  The  needle  is  insert- 
ed in  the  direction  the  hair  normally  projects  from 
the  surface.  The  number  of  hairs  removed  at  a 
single  sitting  varies,  usually  is  thirty  in  a  half- 
hour  period,  but  some  operators  remove  as  many 
as  sixty  in  thirty  minutes.  As  the  work  is  tiring 
and  exacting,  it  is  not  recommended  that  a  treat- 
ment of  more  than  half-hour  be  given.  Contiguous 
hairs  must  not  be  removed  at  the  same  sitting  as 
the  danger  of  local  reaction  is  increased  with  more 
likelihood  of  infection  and  scarring.  At  least  one- 
half  inch  between  hairs  should  be  the  rule. 

The  amount  of  pain  experienced  is  negligible  if 
the  proper  technique  is  used.  Rarely  a  patient  with 
low  threshold  for  pain  is  unable  to  tolerate  the  pro- 
cedure. The  pain  is  to  some  extent  dependent  on 
the  strength  of  current  used,  and  cutting  down  the 
current  will  reduce  the  discomfort.  The  current 
used  is  one-half  to  one  milliampere;  occasionally 
up  to  two  ma.  are  required.  In  general,  the  more 
current  used  the  more  rapid  the  destruction,  but 
it  must  be  remembered  that  this  also  increases  the 
amount  of  scarring  to  be  expected,  and  speed  is  not 
an  important  desideratum.  The  writer  recommends 
the  use  of  the  single-needle  technique;  for,  al- 
though many  needles  up  to  ten  or  twelve  may  be 


used,  the  time  is  consumed  by  the  insertion  of  the 
needle  rather  than  by  the  time  the  current  acts, 
and  very  little  advantage  is  gained  by  using  the 
multiple-needle  technique. 

Equipment.  —  The  accompanying  illustrations 
and  diagram  explain  the  operation  and  method  of 
construction  of  the  apparatus  used.  Most  electroly- 
sis machines  are  equipped  with  dry-cell  batteries 
as  current  consumption  is  very  small,  and  the  cur- 
rent must  be  of  the  direct  type.  The  apparatus 
used  here  was  designed  with  the  aim  of  eliminat- 
ing the  need  for  guarding  the  current  supply,  and 
may  be  operated  from  the  common  source  of  light 
supply  in  the  physician's  office  (Fig.  2).  The  elim- 
ination of  the  batteries  has  also  permitted  the  unit 
to  be  housed  in  a  space  not  much  larger  than  the 
palm  of  the  hand.  The  apparatus  herein  described 
was  made  by  Mr.  F.  L.  Hamilton  of  the  Duke 
University  Instrument  Shop.  The  diagram  (Fig. 
3)  of  the  wiring  will  be  self-explanatory  to  any 
electrical  repairman,  or  electrician,  and  little  fur- 
ther information  is  required  for  the  construction 
of  the  apparatus.  The  cabinet  may  be  made  of 
any  kind  of  material  and  its  size  is  only  limited 
by  the  parts  contained.  The  needle-holder  and 
needles  may  be  obtained  from  any  one  of  the  larg- 
er surgical  supply  houses  and  the  same  is  true  of 
all  other  parts  of  the  unit.  The  forceps  should  be 
epilating  or  cilia  forceps,  but  any  forceps  with  a 
good  grip  may  be  used. 

The  current  delivered  is  a  direct  half-wave  cur- 
rent, and  has  minute  fluctations  of  intensity.  This 
does  not  affect  the  operation  of  the  apparutus  in 
any  way  as  the  rapidity  with  which  one  wave  fol- 
lows another  gives  a  steady  output  to  all  intents 
and  purposes.  In  actual  operation  no  difference 
can  be  noted  in  comparison  with  a  battery  opera- 
ted instrument. 

After  the  patient  has  finished  with  the  treat- 
ment she  is  instructed  to  use  a  mild  antiseptic 
over  the  area  for  the  next  day  or  two  to  minimize 
the  possibility  of  infection.  Some  type  of  lotion 
is  preferable  such  as  calamine  lotion  with  1  per 
cent  phenol,  or  lotio  alba,  or  lime  water — aluminum 
acetate  and  olive  oil  as  a  liniment  may  be  used 
if  the  patient  complains  of  excessive  dryness. 

Points  of  importance  include  the  recognition  of 
scarring  as  indicating  poor  technique,  due  to 
either  carelessness  or  poor  light.  Such  scarring 
is  often  more  disturbing  to  the  patient  than  the 
original  complaint,  and  is  irremediable.  Of  neces- 
sity a  few  small  scars  will  result  under  the  best 
conditions,  but  such  scarring  is  not  noticeable. 
As  a  rule  the  physician  will  do  well  not  to  take  too 
optimistic  a  view  as  to  the  time  necessary  to 
complete  the  removal  of  the  hairs,  as  the  number 
is  difficult  to  judge  accurately,  and  in  addition, 
there  probably  will  be  more  hair  growing  during 


July,  1941 


H  YPER  TRICHOSIS—Reque 


379 


the  time  the  treatment  is  going  on.  A  relatively 
large  percentage  of  treated  hairs,  from  ten  to 
twenty-five  per  cent  depending  somewhat  upon  the 
skill  of  the  operator,  will  return  unavoidably.  Many 
patients  undergo  regular  weekly  treatments  over 
a  period  of  a  year  or  more  if  the  growth  is  diffuse. 
The  time  interval  between  treatments  depends 
largely  upon  the  diffuseness  of  the  growth  and  the 
number  of  hairs  removed  at  each  visit.  Rare  is 
the  case  in  which  a  treatment  can  be  given  more 
frequently  than  twice  a  week,  and  most  often 
one-week  intervals  between  treatments  will  be  re- 
quired to  insure  subsidence  of  any  reaction  of 
consequence  to  the  procedure.  In  the  presence 
of  infection  it  is  best  not  to  continue  until  all 
inflammation  has  subsided,  as  such  infections 
tend  to  be  deep-seated  and  may  be  difficult  to 
control  if  widespread. 

Contraindications  to  Electrolysis. —  There  are 
relatively  few  concurrent  conditions  which  contra- 
indicate  the  use  of  electrolysis  for  removal  of  hair. 
Infections  in  the  region,  whether  coccogenic  or 
mycotic,  are  rigid  contraindications.  Poorly  con- 
trolled diabetes,  or  other  debilitating  disease  which 
predisposes  to  infections  of  the  skin,  requires 
proper  management  before  treatment  is  under- 
taken. Patients  with  a  tendency  toward  keloid 
formation  should  not  be  subjected  to  the  procedure 
as  almost  every  insertion  of  the  needle  may  give 
rise  to  a  disfiguring  keloidal  scar.  This  possibility 
may  often  be  ruled  out  by  scrutiny  of  the  patient's 
skin  for  old  scars,  or  from  a  history  of  such  scar- 
ring suggestive  of  keloid  formation.  It  is  also 
important  before  attempting  to  remove  hairs  from 
pigmented  moles  and  nevi  to  consider  the  chance 
that  stimulation  may  start  malignant  growth. 
Usually  very  dark  growths,  resembling  melanotic 
tumors,  are  better  left  alone.  The  history  of  rapid 
growth  in  a  mole  or  nevus,  or  of  recent  growth, 
bleeding  or  repeated  trauma  in  such  a  lesion, 
should  lead  to  excision  and  biopsy  rather  than  to 
electrolvsis  to  remove  hair. 

Other  Uses  for  Electrolysis. — The  current  used 
in  electrolysis  may  also  be  used  in  the  removal  of 
small  warts  and  moles,  and  when  so  used  leaves 
very  small  scars.  The  needle  is  inserted  vertically 
into  the  lesion  and  the  current  turned  on  for  a 
few  seconds  or  until  the  tissue  turns  white.  In 
lesions  of  pea-size  or  larger,  the  needle  may  be 
inserted  in  a  cross-wise  manner  at  several  points 
in  their  circumference.  Hairy  moles  are  best  treat- 
ed by  electrolysis,  as  thev  tend  to  disappear  after 
removal  of  the  hairs.  The  treatment  of  "liver 
spots,"  or  spider  nevi,  which  are  small  superficial 
dilatations  of  capillary  vessels  such  as  may  be 
seen  frequently  in  acne  rosacea,  is  quite  satisfac- 
tory by  this  method  also,  and  consists  in  inserting 
the  needle  in  the  central  point  of  the  spider  nevus, 


or  along  several  points  of  the  telangiectatic  vessel. 
Electrolysis  may  also  be  used  for  many  small  su- 
perficial and  non-malignant  epithelial  tags  and 
nevi,  and  with  some  success  in  adenomatous  seba- 
ceous cysts  of  the  face.  It  is  useful  in  removal  of 
xanthomatous  growths  of  the  eyelids  and  leaves 
little  scarring. 

Conclusion 
The  condition  of  hypertrichosis  can  be  ade- 
quately treated  by  the  method  of  electrolysis  in 
nearly  every  case,  the  exceptions  being  largely  lim- 
ited to  very  light  growths  on  the  upper  lip,  and 
these  may  be  satisfactorily  controlled  by  other 
methods.  Electrolysis  still  remains  the  only  safe 
method  of  therapy,  in  spite  of  reports  of  other 
agents,  notably  x-rays  and  thallium  acetate,  being 
easier  and  as  effective.  Since  the  equipment  is 
small  in  size  and  expense,  and  since  the  results  are 
good  with  a  little  care  and  experience,  it  is  believed 
that  it  should  be  available  in  competent  hands  in 
every  community  large  enough  to  support  a  physi- 
cian. 

Bibliography 

1.  Cipallare,  A.  C:  /.  A.  M.  A.,  3:27,  2488  (Dec),  1938. 

2.  McCarthy,  L.:  Diseases  of  the  Hair,  1940.  C.  V.  Mosby 
&  Co.,  St.  Louis. 

3.  Cockayne,  E.  A.:  Inherited  Abnormalities  of  the  Skin 
and  its  appendages.     Oxford  University  Press,   1933. 


ACUTE  APPENDICITIS  IN  MIDDLE  AND  LATE 

LIFE 
(F.  F.  Boyce,  New  Orleans,  in  Amcr.  II.  Dig.  Dis.,  June) 

Acute  appendicitis  late  in  life  presents  a  confusing  pic- 
ture and  has  a  high  mortality,  due  both  to  the  seriousness 
of  the  disease  and  to  the  delay  in  operation  caused  by  the 
difficulties  of  diagnosis. 

The  symptoms  and  findings  in  old  people  are  atypical. 
The  patient  gets  sick  slowly,  often  after  a  period  of  vague 
digestive  distress  or  diarrhea.  The  initial  pain  is  mild, 
often  only  a  discomfort.  It  may  be  located  anywhere  in 
the  abdomen,  including  the  left  side,  and  it  localizes 
slowly  if  at  all.  The  period  of  calm  tends  to  be  long- 
lasting,  and  the  patient  is  likely  to  be  only  mildly  un- 
comfortable or  even  to  feel  well.  Nausea,  vomiting,  both 
may  be  absent.  Neither  temperature  nor  pulse  rate  may 
rise  much.  Physical  findings  are  scanty.  Abdominal 
rigidity  is  frequently  absent,  and  pressure  pain  or  a  uni- 
form soft  distention  is  the  commonest  finding.  Leukocy- 
tosis is  seldom  marked  and  is  commonly  absent.  Surgery 
is  safer  in  all  cases,  regardless  of  the  stage  in  which  the 
patient  is  seen.  The  appendix  should  be  removed  if  this 
involves  little  additional  trauma;  otherwise  only  drain- 
age should  be  done.     Anesthesia  must  not  be  deep. 


THE   CHANGING    PICTURE   OF   DIABETES 
MELLITUS 
(Reginald   Fitz,  Boston,  in  Neb.  Med.  .11..  June) 
The  physician  who  thinks  of  specializing  in  diabetes  is 
tempted  to  become  dangerous;  for  diabetes  is  not  a  speci- 
alty.    The  doctor  best  fitted  to  give  diabetic  patients  most 
satisfactory    supervision    will    be    a    broad-gauged    clinician, 
interested    in    all    aspects    of    medicine,    up-to-date    in    all 
fields,  a  keen   student,  a   hard   worker,   and   regarding  dia- 
betes not  as  a  narrow  subject  but  as  a  disease  presenting 
such    varigated    problems    as   to    include   the   whole   scope 
of  medicine. 


SOITHERX  MEDICINE  &  SURGERY 


July,  1941 


CLINIC 


Conducted  By 
Frederick    R.    Taylor,    B.S.,    M.D.,    F.A.C.P. 


A  15-yr.-old  high  school  girl  came  complaining 
that  she  was  nervous  and  had  been  so  all  her  life. 
Often  she  has  no  appetite  for  breakfast.  Two 
years  ago  she  grew  prodigiously,  but  has  grown 
little  since.  She  is  now  5  ft.  7  in.  tall  and  weighs 
104J4  lbs.  She  weighed  about  100  lbs.  two  years 
ago.  She  has  no  gastrointestinal,  circulatory,  res- 
piratory or  urinary  symptoms,  and  her  only  gyne- 
cologic symptom  is  pain  on  the  first  day  of  her 
periods.  She  says  she  doesn't  get  a  bit  nervous 
while  driving  a  car.  She  can  go  through  a  hard 
basketball  practice  without  much  trouble — gets  a 
bit  trembly,  but  no  dyspnea  or  exhaustion.  Her 
past  history,  habits  and  family  history  throw  no 
light  on  her  trouble. 

Examination  of  the  head  is  negative — there  is 
no  exophthalmos.  She  is  very  tall  and  thin,  and 
looks  like  many  girls  of  18.  She  has  a  moderately 
large  smooth  symmetrical  and  slightly  tender 
goiter.  She  has  no  tremor  and  steps  up  on  a  chair 
without  difficulty.  T.  98.0,  p.  88,  of  good  quality, 
r.  16,  b.  p.  92/64.  Her  heart  and  lungs  were  en- 
tirely negative.  Her  abdomen  showed  obvious 
visceroptosis  and  some  epigastric  tenderness.  There 
was  an  obvious  error  in  her  basal  metabolism  re- 
port as  plus  121.    Her  urine  was  negative. 

Discussion:  Her  age,  her  physical  strength,  the 
physical  characteristics  of  her  goiter,  her  normal 
heart  rate,  her  lack  of  appetite  for  breakfast,  the 
lack  of  tremor,  and  the  whole  general  picture,  sug- 
gested a  colloid  adolescent  goiter.  Another  B.  M. 
T.  was  reported  as  minus  291  On  overfeeding  she 
made  an  uneventful  recovery. 

Diagnosis:    Colloid  goiter. 

A  33-yr.-old  wife  of  an  advertising  man  com- 
plained of  nervousness.  She  stated  that  3  wks.  ago 
she  fell  while  walking  across  a  field,  and  her  left 
arm  got  numb.  She  thought  she  had  had  a  stroke, 
but  managed  to  drive  her  car  home.  A  month  be- 
fore this  episode  she  had  a  very  severe  vomiting 
attack,  for  which  another  physician  gave  her  a 
hypnotic,  and  she  slept  all  day.  Then  she  was 
studied  at  a  clinic,  but  nothing  was  found  to  ex- 
plain her  trouble.  She  then  went  to  Florida,  as 
her  trouble  was  supposed  to  be  a  nervous  break- 
down. Two  years  ago  she  had  a  ruptured  appen- 
dix removed.  Even  before  her  operation,  and  also 
since,  she  has  had  attacks  of  blind  staggers  and 
palpitation.  Often  objects  seem  to  move  before 
her  eyes,  and  she  sees  black-and-white  specks. 
These  attacks  come  about  10  days  before  her  men- 
strual periods.  She  feels  numb  all  over  all  the 
time.    No  nausea  or  vomiting  except   in   the  one| 


attack  mentioned — she  does  not  vomit  even  when 
pregnant.  Her  stomach  is  always  sour,  for  which 
she  takes  soda.  Too  much  soda  causes  diarrhea. 
No  sore  throat  or  cough.  Always  short  of  breath 
and  panting.  Feet  do  not  swell,  but  hands  do  oc- 
casionally before  her  periods.  She  gets  a  cold  in 
her  head  and  slight  headaches  before  every  period. 
No  backache.  No  urinary  symptoms.  Periods 
come  every  26  to  28  days,  last  about  a  day,  no 
flooding,  rarely  clots.  No  suffering  other  than  ex- 
treme weakness.  Has  been  taking  liver  extract,  and 
is  on  her  3rd  bottle,  because  her  sister  has  per- 
nicious anemia. 

She  had  diphtheria  in  childhood,  severe  influenza 
in  1918;  measles,  chickenpox,  whooping  cough  and 
mumps  in  childhood,  drainage  appendectomy  as 
noted  2  years  ago,  and  had  her  tonsils  and  ade- 
noids removed  10  years  ago.  When  4  yrs.  old  she 
fell  through  a  banister  and  cut  her  jaw,  and  after- 
wards they  removed  teeth  from  tht  left  side  of  her 
thyroid ! 

Her  appetite  is  usually  poor,  but  she  is  hungry 
for  2  or  3  days  a  few  days  before  her  periods. 
Always  nauseated  on  waking  in  morning.  Says 
meat  makes  her  dizzy.  Does  not  perspire  %'ery 
much.    Habits  in  general  good. 

Her  father  died  of  some  unknown  acute  illness 
when  she  was  quite  small.  He  was  a  rather  heaw 
drinker.  Mother  nervous  and  worries,  and  has 
high  blood  pressure;  1  sister  has  pernicious  ane- 
mia; 1  brother  not  very  strong,  but  in  fair  health; 
2  sisters  died  in  infancy.  Husband  and  3  children 
well.    No  miscarriages. 

Ht.  4  ft.  Wy2  in.  Wt.  88  lbs.  weighed  93  }4 
lbs.  3  mos  ago;  standard  wt.  121  lbs.)  T.  99.0,  p. 
112,  r.  20,  b.  p.  124  78.  Some  exophthalmos. 
Slight  nystagmus  on  attempting  fixation.  Head 
otherwise  negative.  Tonsils  out  clean.  Neck  shows 
a  scar  on  the  left  from  the  removal  of  the  teeth 
from  her  thyroid  at  age  of  4  yrs.  Thyroid  slightly 
enlarged.  Fine  rapid  tremor  of  fingers.  Heart  neg- 
ative except  for  the  tachycardia.  Lungs  negative. 
Abdomen  shows  appendectomy  scar.  There  is  ten- 
derness over  the  left  kidney  in  the  back.  Otherwise 
abdomen  and  back  negative.  Pelvic  examination 
negative  except  for  hemorrhoids  that  do  not  bleed. 
Urine  negative. 

D:agnosis:    Exophthalmic  goiter. 

Discussion:  There  are  several  factors  of  interest 
in  this  case.  The  vomiting  attack  may  have  been 
a  thyroid  crisis.  The  numbness  suggesting  a  cere- 
bral vascular  accident  is  a  bit  unusual,  and  prob- 
ably thr°w  the  physicians  who  evamined  her  in 
'h°  clinic  off  the  track,  as  this  clinic  is  usually  very 
'°en  to  discover  goiters  and  eager  to  operate  on 
.them.  The  diarrhea,  attributed  to  too  much  soda, 
Pmav  have  been  a  toxic  manifestation  of  her  dis- 


July,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


ease.  To  have  vour  teeth  knocked  into  your  thy- 
roid would  certainly  be  an  unusual  experience.  I 
suspect  the  clinic  did  not  learn  about  this  because 
of  failure  to  ask  the  routine  question  as  to  what 
serious  injuries  she  ever  had  in  her  life.  The  lack 
of  free  sweating  is  a  point  in  which  the  clinical 
picture  is  inccmplete.  However,  the  complete  pic- 
ture of  exophthalmic  goiter  is  far  less  common 
than  various  incomplete  syndromes.  The  patient 
consulted  Dr.  Addison  G.  Brenizer,  who  confirmed 
the  diagnosis,  performed  a  thyroidectomy,  and  she 
made  an  uneventful  recovery. 

A  59-yr.-old  wife  of  a  farmer  complained  of  a 
sensation  of  choking  in  her  neck  whenever  she 
would  catch  a  cold.  Five  years  ago,  while  sitting 
before  a  mirror,  she  noticed  a  small  asymmetric 
goiter.  A  vear  later  she  went  to  a  physician  who 
told  her  to  let  it  alone  unless  it  gave  trouble.  She 
thinks  it  is  growing  some,  because  her  throat  now 
feels  full  and  sh«-  has  a  choking  sensation  when 
she  catches  cold.  She  denies  being  more  nervous, 
but  her  son  says  she  has  been  getting  very  nerv- 
ous. Her  appetite  is  good,  but  not  ravenous,  and 
there  has  been  no  recent  change  in  it.  She  occa- 
sionally has  a  sour  stomach,  and  has  noted  some 
increase  of  gas  of  late.  She  has  slight  dyspnea  at 
times.  Her  past  history  throws  no  light  on  her 
present  trouble.  She  had  pneumonia  at  the  age  of 
35.  has  had  many  attacks  of  influenza,  one  in 
1918  being  severe,  and  two  years  ago  had  her  gall- 
bladder drained  for  cholelithiasis  and  her  appendix 
removed.  Her  habits  are  good,  her  family  history 
non-contributory.  Physical  findings  were  negative 
except  for  the  following:  Possible  very  slight  ex- 
ophthalmos and  lid  lag.  She  has  not  noted  any 
increase  in  prominence  of  her  eyes.  There  is  an 
asymmetric  goiter  unusually  low  in  her  neck,  the 
left  lobe  more  enlarged  and  tending  to  dip  down 
behind  the  left  sternoclavicular  joint.  She  has  no 
tremor.  There  is  some  arthritis  of  the  fingers.  Her 
heart  is  normal  and  other  chest  findings  negative. 
The  abdomen  is  negative  save  for  slight  tenderness 
in  the  region  of  cholecystostomy  scar.  The  uterus 
is  fixed  in  the  pelvis,  and  a  mass  that  feels  like 
either  a  fibroid  or  a  dense  mass  of  adhesions  is 
behind  the  cervix. 

The  diagnosis  here,  for  our  purposes,  is  a  non- 
toxic adenoma  oj  the  thyroid.  Incidental  findings 
are  abdominal  adhesions,  a  possible  asymptomatic 
fibroid  of  uterus  and  arthritis  of  the  fingers.  Our 
advice  in  this  case  was  what  Dr.  John  B.  Deaver 
used  to  call  masterly  inactivity.  Let  the  goiter 
alone  unless  it  begins  to  caus-:  pressure  symptoms 
or  deve'op  toxicity.  Should  it  do  either,  consult  a 
surgeon. 

A  39-yr.-old  single  woman,  pastor  of  a  small 
church    in    the   outskirts   of    town,   complained   of 


weakness.  She  had  recently  studied  for  the  minis- 
try in  Cleveland,  where  he  stayed  three  years, 
and  while  there  got  very  nervous.  She  says  she 
overworked  there.  Now  she  is  nervous  only  at  her 
menstrual  periods,  and  has  no  other  menstrual 
difficulties.  She  is  very  subject  to  tonsillitis,  has 
some  general  headache,  worse  in  frontal  region, 
occasionally  frequency  of  urination  without  dysu- 
ria.  Her  appetite  has  increased,  but  her  weight 
decreased  during  the  past  3  months.  Her  past  his- 
tory, habits  and  family  history  are  non-contrib- 
utory. She  is  a  rather  thin  woman.  Her  tonsils 
are  small  and  buried.  There  is  a  slight  irregular 
nodular  enlargement  of  the  thyroid.  Her  heart 
sounds  are  a  little  rapid  and  distant  and  there  is  a 
fine  rapid  tremor  of  her  fingers.  Her  physical  find- 
ings otherwise  negative.  A  clinical  diagnosis  of 
toxic  adenoma  of  the  thyroid  is  made,  B.  M.  T. 
is  plus  22.  Thyroidectomy  was  performed  by  Dr. 
J.  T.  Burrus  and  in  a  few  months  she  had  re- 
gained her  strength  and  gained  considerable  weight 
and  felt  quite  well. 

Through  this  discussion  of  the  various  types  of 
goiter,  I  have  used  Plummer's  classification,  dis- 
tinguishing toxic  adenoma  from  exophthalmic 
goiter.  I  am  fully  aware  that  most  recent  path- 
ologic reports  state  that  the  "toxic  adenoma" 
usually  is  not  an  adenoma.  Many  believe  that 
toxic  adenoma  and  exophthalmic  goiter  are  merely 
different  stages  of  the  same  disease.  The  same 
may  be  said  for  toxic  adenoma  and  non-toxic 
adenoma.  The  classification  is  perhaps  unpardon- 
able from  a  pathologist's  standpoint;  but  in  the 
present  state  of  our  knowledge,  it  seems  to  me  use- 
ful from  a  clinician's  standpoint.  No  doubt  a  bet- 
ter terminology  is  needed  to  define  the  clinical 
groups,  but  such  is  not  available  thus  far. 


MEDICAL   COLLEGE  MAY   RUN   THROUGH   THE 

SUMMER   DURING   THE   EMERGENCY 

(Editorial   in    The  Recorder  of  the   Columbia   Medical   Society   of 

Richland   Co.,   S     C.  June) 

Trustees  of  the  Medical  College  of  South  Carolina,  at 
a  special  meeting  at  Hotel  Columbia,  on  May  20th,  went 
on  record  as  favoring  operation  of  the  college  12  months 
a  year  to  overcome  the  increasing  shortage  of  physicians 
in  the  State.  The  trustees  decided  some  weeks  ago  to 
increase  each  freshman  class  to  SO.  The  financial  need 
to  meet  this  increase  was  carried  before  the  free  confer- 
ence committee  of  the  general  assembly  and  provision 
was  made. 

With  operation  of  the  college  12  months  of  the  year 
instead  of  nine,  the  next  senior  class  would  be  graduated 
three  months  ahead  of  schedule  and  the  present  junior 
class  six  months  ahead  of  schedule. 

It  was  explained  at  the  meeting  May  20th  that  the 
British  government  had  requested  that  English  physicians 
be  educated  in  this  country.  The  board  was  of  the 
opinion  that  vacancies  occurring  in  the  upper  class  could  be 
filled  by  these  foreign  students,  but  that  the  college  was 
operated  by  South  Carolina  money  and  that  needs  of 
the  State  and  its  citizens  must  come  first. 


SOUTH ERX  MEDICINE  &  SURGERY 


July.   1941 


SURGICAL  OBSERVATIONS 

OF  THE  STAFF 

DAVIS  HOSPITAL 

Statesville 

UNDULANT  FEVER 

Four  hundred  years  before  the  time  of  Christ, 
Hippocrates  described  a  disease  characterized  by 
prolonged  fever  with  relapses  and  remissions,  but 
which  usually  did  not  terminate  fatally.  This  was 
probably  what  we  now  call  undulant  fever  or 
Brucellosis. 

About  1863  Marston,  a  medical  officer  in  the 
British  Army,  stationed  at  Malta,  described  this 
disease  in  detail  under  the  name  Mediterranean  re- 
mittent fever. 

In  1886  Bruce  discovered  the  etiological  organ- 
ism. Later  Bang  discovered  another  organism  of 
the  same  family,  which  he  called  Brucella  abortus, 
and  to  which  he  ascribed  the  causation  of  contagi- 
ous abortion  of  cattle.  Then  later  it  was  found 
that  these  two  organisms  were  practically  the  same 
germs. 

Carpenter  in  1927  found  that  the  same  organism 
which  caused  infectious  abortion  in  cattle,  hogs 
and  other  domestic  animals  could  also  produce  in 
human  beings  a  disease  clinically  the  same  as  un- 
dulant fever,  and  which  was  also  known  as  Malta 
fever. 

These  organisms  were  then  reclassified  under 
the  name  Brucella.  From  this  we  get  the  name 
Brucellosis,  which  is  perhaps  the  best  name  for 
the  disease.  Other  names  are  Malta,  Mediterra- 
nean, or  goat,  fever;  Bang's  disease,  Texas,  Gibral- 
tar, Rock,  and  Mediterranean  Coast,  fever. 

Doubtless  many  thousands  of  cases  of  this  dis- 
ease go  unrecognized,  many  such  patients  never 
consulting  a  doctor,  and  many  others  being  wrong- 
ly diagnosed.  It  seems  probable  that  the  disease 
in  a  mild  form  is  the  cause  of  many  thousands  of 
cases  of  ill  health,  or  even  invalidism,  in  all  parts 
of  this  country,  and  in  many  foreign  countries. 

The  chief  method  of  transmission  of  organisms 
of  the  Brucella  group  is  by  means  of  raw  milk 
from  infected  cattle.  The  disease  is  very  conta- 
gious under  certain  circumstances,  and  the  rate  of 
infection  among  those  who  handle  infected  meat  is 
very  high.  This  disease  may  be  prevalent  among 
sheep  and  horses.  Even  dogs  may  harbor  the  in- 
fection. It  is  likely,  however,  that  these  animals 
have  very  Httle  to  do  with  the  transmission  of  the 
disease  to  human  beings.  More  likelv  milk,  carry- 
ing the  organisms  from  infected  cattle  directly  to 
those  who  drink  the  milk,  is  the  principal  means 
of  transmission  to  human  beings.  It  seems  that 
there  is  no  record  of  a  case  in  which  there  has  been 
a  direct  transmission  of  the  infection  from  one  in- 
dividual to  another. 

Owing  to  the  fact  that  this  is  one  of  the  most 


protean  of  all  diseases  and  that  the  laboratorv 
tests  are  not  always  reliable,  the  diagnosis  of  the 
disease  is  often  extremely  difficult. 

We  may  speak  of  Brucellosis  as  acute  or  chronic. 
The  symptoms  of  these  two  groups  vary  greatly 
and  are  often  confusing. 

Acute  Brucellosis  comes  on  sometimes  gradually 
with  malaise,  often  with  a  chill  and  fever,  followed 
by  weakness  and  depression.  The  wave-like  course 
of  the  temperature — down  in  the  mornings,  up  in 
the  evenings — gives  the  disease  the  name  undulant 
(L.  undula=:vra.ve)  fever.  As  soon  as  the  course 
has  become  definite,  we  have  a  patient  who  com- 
plains of  feeling  tired  and  depressed,  with  appetite 
poor,  headache  and  often  backache,  often  chills,  fe- 
ver and  sweating,  mostly  during  the  night — the  bed 
may  be  drenched.  Other  common  symptoms  are: 
pains  about  the  joints,  muscular  pains,  neuritic 
pains  in  the  neck,  shoulder  and  back  and  various 
parts  of  the  body.  The  joint  pains  persist  or  recur 
from  time  to  time.  The  neuritic  and  joint  pains 
cause  a  great  deal  of  discomfort  and  often  agony. 
Sometimes  there  is  arthritis  with  swelling  of  the 
joints.  Headache,  vertigo,  diplopia,  rigidity  of  the 
neck,  aphasia,  may  occur  in  any  of  the  various 
stages.  Some  patients  cannot  sleep;  sedatives  and 
hypnotics  often,  and  opiates  sometimes,  are  re- 
quired to  give  rest.  Delirium  is  common,  from 
slight  to  so  wild  and  violent  as  to  be  distressing  to 
patient,  family  and  friends.  Meningitis,  myelitis, 
encephalitis  may  occur  in  the  course  of  this  dis- 
ease. 

There  may  be  a  psychosis  so  mild  as  to  be  over- 
looked by  the  doctor,  or  so  extreme  as  to  consti- 
tute the  major  feature  of  the  condition.  Gastro- 
intestinal pains  and  constipation  are  common  and 
may  cause  confusion  with  surgical  lesions  of  th» 
abdomen.  Some  say  that  pulmonary  symptoms  are 
commoner  than  most  reports  would  indicate.  Car- 
diac lesions  should  always  be  watched  for.  Vege- 
tative endocarditis  is  not  uncommon  in  this  dis- 
ease. We  may  also  find  prostatitis,  seminal  vesic- 
ulitis or  orchitis  and  epididymitis  as  complications. 
Soon  the  patient  loses  weight  and  strength  and 
these  losses  may  be  extreme.  Sometimes  there  is  a 
maculopapular  skin  eruption.  Recently  I  saw  a 
patient  in  which  the  skin  eruption  was  severe  and 
covered  the  entire  body. 

Chronic  Brucellosis  offers  special  difficulties  as 
to  diagnosis.  The  signs  and  symptoms  may  be 
so  mild  as  not  to  attract  the  patient's  attention 
and  he  never  consults  a  doctor  at  all  about  his 
symptoms.  The  temperature  taken  and  charted 
over  a  period  of  a  few  days  will  often  show  a 
more-or-less  typical  curve.  The  agglutination  test 
and  skin  test  are  not  always  definite,  and  when 
the  disease  is  present  these  tests  may  be  negative. 
The    physical    findings    are    often    practically    nil. 


July.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


383 


A  patient  complains  of  feeling  bad,  of  depression, 
weakness,  loss  of  appetite,  loss  of  strength,  no 
desire  for  work  or  report  for  duty — nothing  even 
strongly  suggestive  of  any  certain  disease.  In- 
somnia, general  depression;  pains  in  various  parts 
of  the  body,  especially  the  neck,  shoulders  and 
arms;  backache,  headache,  severe  and  deep  mus- 
cular pains  are  all  common  in  this  disease.  Sweat- 
ing, especially  heavy  night  sweats,  chilly  sensa- 
tions, dizziness,  tachycardia  and  abdominal  pain 
may  be  present  and  keep  the  patient  uncomfort- 
able, if  not  quite  miserable. 

A  psychosis  so  slight  as  to  be  almost  unrecogniz- 
able, or  any  mild  nervous  symptom  for  which  an 
explanation  is  not  forthcoming  by  a  careful  and 
detailed  examination,  may  well  lead  to  suspicion 
of  Brucellosis.  In  any  case  of  chronic  ill  health, 
not  otherwise  explained,  the  possibility  may  well 
be  taken  into  account  along  with  a  dozen  others. 

The  diagnosis  depends  on  the  symptoms  given 
and  the  results  of  certain  laboratory  tests 
which  may  be  of  help.  Often,  however,  in  pro- 
nounced cases  of  Brucellosis,  the  laboratory  tests 
may  be  negative  throughout,  especially  the  agglu- 
tination test.  The  most  accurate  methods  of  diag- 
nosis depend  on  making  cultures  of  Brucella,  and 
inoculation  of  animals  with  the  spinal  fluid  or 
other  discharges  of  the  body.  The  skin  reaction 
when  the  Brucella  vaccine  is  injected  will  help 
sometimes.  The  diagnosis  of  Brucellosis  may  have 
to  be  made  on  symptoms  and  clinical  findings. 
Being  on  the  alert  for  this  disease  will  cause  it  to 
be  recognized  in  a  large  proportion  of  cases.  Unless 
it  is  kept  in  mind  manv  cases  will  pass  unrecog- 
nized. 

Prevention  of  this  disease  should  be  centered  in 
the  selection  and  testing  of  dairy  cattle.  Milk 
from  cows  having  this  disease  is  not  to  be  used  for 
food.  Such  cows'  meat  may  be  eaten  because  the 
meat  is  cooked  and  that  kills  all  the  germs. 

As  a  routine  preventive  measure  I  advocate  the 
pasteurization  of  all  milk  used  for  human  con- 
sumption. 

Treatment  of  undulant  fever  or  Brucellosis  is 
not  so  very  satisfactory,  though  in  our  experience 
here  excellent  results  have  ensued  on  the  use  of 
fever  therapy.  Of  one  family  several  members  had 
definite  clinical  Brucellosis,  and  a  cure  followed 
fever  therapy  in  each  of  these  patients.  All  recov- 
ered promptly  and,  so  far  as  I  know,  there  has 
been  no  recurrence.  Serum  therapy  may  be  help- 
ful. The  serum  is  available  from  most  of  the  drug 
houses.  Tn  the  chronic  form  serum  therapy  is 
hardly  indicated.  Convalescent  human  serum 
would  be  a  natural  treatment  for  this  disease,  but 
unfortunately  we  have  great  difficulty  in  finding 
immune  patients,  that  is,  those  who  have  had  the 
disease  and  recovered  and  whose  blood  might  be 


used  in  a  transfusion  to  a  person  who  has  the  dis- 
ease in  an  active  form.  Recently  we  tested  care- 
fully the  blood  of  a  number  of  patients  who  have 
recovered  from  Brucellosis  and  almost  none  of  them 
showed  titre  high  enough  to  be  of  much  value  to 
the  patient.  We  did,  however,  give  repeated  blood 
transfusions  of  whole  blood  from  young,  healthy 
individuals  in  some  of  the  cases  and  the  patients 
picked  up  rapidly  and  have  been  recovering  grad- 
ually ever  since.  It  seems  that  the  fever  therapy 
is  almost  a  specific  for  this  disease. 

Now,  since  a  standard  vaccine  is  available,  I  be- 
lieve that  it  would  be  well  to  immunize  donors  who 
can  give  blood  to  a  patient  and  who  have  blood 
compatible  for  that  patient,  and  at  the  proper  time 
give  the  patient  the  advantage  of  this  immune 
blood.  In  such  cases,  I  advocate  a  whole-blood 
transfusion  by  the  citrate  method.  This  is  usually 
very  simple,  very  easy  and  most  satisfactory. 

Prognosis  is  not  always  so  good.  The  disease 
tends  to  persist  for  weeks,  months,  or  even  years, 
and  there  are  sometimes  remissions  and  relapses 
which  are  distressing  and  disappointing  to  all  con- 
cerned. At  the  present  time  we  are  immunizing 
donors  for  the  purpose  of  future  patients.  The 
results  will  be  awaited  with  a  great  deal  of  interest 
and  hope. 

We  have  tried  the  various  sulfonamides.  The 
results  have  been  disappointing.  It  is  stated  that 
sulfathiazole  is  of  value.  Our  opinion  is  that  we 
must  look  elsewhere  for  treatment  which  will  pro- 
duce curative  results  in  this  disease. 

Hospitalization,  blood  transfusions,  especially 
from  immune  individuals,  and  fever  therapy  are 
our  main  lines  of  treatment  in  undulant  fever. 
Treatment  of  the  symptoms  as  they  arise  is  im- 
portant. No  patient  should  be  allowed  to  roll,  toss 
and  tumble  in  the  bed  worrying,  feeling  depressed, 
suffering  from  neuritic  pain,  with  aching  in  the 
muscles,  without  having  something  given  for  relief 
and  for  sleep,  both  of  which  are  extremely  impor- 
tant. 

Brucellosis,  or  undulant  fever,  is  far  more  prev- 
alent, I  believe  than  any  of  us  has  suspected  here- 
tofore. Every  doctor  should  be  on  the  alert  for 
clinical  manifestations  of  this  disease.  The  chronic 
invalid  should  always  be  checked  over  carefully 
and  the  presence  of  this  disease  ruled  out  before  a 
final  diagnosis  is  made.  The  treatment  should 
always  be  initiated  at  the  earliest  possible  time 
and  should  be  kept  up  until  the  patient  is  relieved. 
Persistent,  correct  treatment  usually  gives  good  re- 
sults. There  are,  however,  cases  which  do  not  do 
well  and  in  which  the  prognosis  is  ultimately  very 
bad.  More  and  more  patients  with  obscure  condi- 
tions are  coming  to  the  doctor  nowadays  and  every 
medical  man  should  be  on  the  alert  for  this  disease. 
In  the  history  of  the  patient,  we  should  study  any 


SOUTHERN  MEDICINE  &  SURGERY 


July,  1941 


obscure  condition  carefully,  the  relationship  of  that 
patient  to  sources  of  infection  and  the  probable 
source  of  contagion.  Careful  investigation  of  a 
herd  of  cattle  may  be  necessary  in  order  to  estab- 
lish a  diagnosis. 

Examination  with  every  possible  laboratory  aid 
is  of  vital  importance  and  we  should  overlook  noth- 
ing which  may  enable  us  to  make  an  accurate  and 
definite  diagnosis  in  every  patient  apparently  suf- 
fering from  this  disease.  Prompt,  proper  and  ac- 
tive treatment  often  gives  wonderfully  good  results 
and  a  rapid  clearing  up  of  the  symptoms.  We  must 
remember,  too,  that  in  some  cases  the  progress  is 
slow  and  often  everyone  becomes  discouraged,  de- 
pressed and  doubtful  of  the  outcome. 

To  Dr.  Walter  M.  Simpson  of  the  Kettering  In- 
stitute for  Medical  Research  of  Dayton,  Ohio,  we 
are  indebted  for  a  great  deal  of  information  on 
this  disease. 


THE  HISTORY  OF  ENDOCRINOLOGY 

(A.  P.  Cawadias,  in  Proc.  Royal  Society  of  Med.   (London), 
April) 

As  early  as  the  ISth  century  Theophile  de  Bordeu  wrote 
of  emanations  from  the  various  body  tissues  penetrating 
into  the  blood.  Brown-Sequard  and  d'  Arsonval  in  the 
19th  century  developed  this  idea  more  scientifically.  Inter- 
nal secretion  is  a  function  of  all  cells.  There  are  cells, 
however,  isolated  in  various  tissues,  which  possess  this 
incretory  power  to  a  higher  degree;  somewhat  loose  groups 
of  these  endocrine  cells  constituting  diffuse  endocrine  or- 
gans. The  highest  form  of  specialization  is  the  grouping 
of  such  cells  into  the  real  endocrine  glands. 

The  first  experimental  proof  of  internal  secretion  came 
from  John  Hunter  in  1792.  Berthold  in  1849,  completing 
the  experiments  of  Hunter,  showed  that  castration  in  the 
cock  caused  atrophy  of  the  comb,  but  that  this  could  be 
prevented  if  the  testis  were  transplanted  to  another  part  of 
the  body. 

In  1855,  Claude  Bernard  published  his  Lessons  on  Ex- 
perimental Physiology,  in  which  the  doctrine  of  internal 
secretion  is  definitely  established  experimentally ;  Thomas 
Addison  published  his  classic  On  the  Constitutisnal  and 
Local  Effects  of  Disease  of  the  Suprarenal  Capsules;  and 
Brown-Sequard  made  the  first  experiments  in  adrenalec- 
tomy. From  that  time  onwards  physiological  knowledge 
of  the  endocrine  glands  progressed  rapidly.  Their  internal 
secretion  was  shown  to  consist  of  spacial  chemical  sub- 
stances, the  hormones  (a  term  used  first  by  Starling  in 
1905.) 

The  last  phase  in  the  history  of  the  special  physiology 
of  the  endocrine  glands  is  the  discovery  of  the  integration 
of  these  glands  and  of  their  regulatory  role  in  the  metabolic 
processes  of  the  body.  Through  the  work  of  Harvey  Cush- 
ing  and  of  Langdon-Brown  the  endocrine  glands  have  been 
demonstrated  as  constituting  a  system  integrated  by  the 
pituitary.  All  cells  of  the  body  possess  special  metabolic 
functions.  The  endocrine  system  regulates,  correlates,  and 
integrates  all  these  local  cellular  metabolisms. 

A  new  phase  of  research,  which  has  already  led  to 
startling  results,  bears  on  the  connection  between  hormonic 
and  nervous  functions.  Anatomists,  physiologists,  and 
clinicians  have  demonstrated  that  many  so-called  endocrine 
diseases  are  due  to  nervous  lesions.  Langdon-Brown  holds 
that  most  of  these  nervous  stimuli  act  first  on  the  hypo- 
thalamus. From  this  nervous  fibres  transmit  a  nervous 
impulse  to  the  pituitary,  which  secretes  its  special  or  en- 
docrinotropic  hormone  influencing  other  endocrines.  Others 


have  demonstrated  that  the  "nervous"  function  is  in  fact  a 
neurohormonic  function,  that  the  nervous  impulse  acts 
through  a  hormone  released  at  the  termination  of  the 
nervous  fibre. 

Through  the  extended  nervous  system  the  body  adapts 
itself  to  environmental  stimuli.  Its  effector  component  is 
divided  into  three  sections,  neurosomatic,  neurovisceral, 
and  neurometabolic   (or  neuro-endocrine). 

Hippocrates  studied  hypobrchidism,  the  disease  of  the 
Scyths,  and  climacteric  hypobvarism.  Hypothyroidism  was 
studied  first  by  T.  B.  Curling  in  1S50,  when  the  role  of 
the  thyroid  in  cretinism  was  shown.  This  conception  of 
hypothyroidism  as  a  disease  was  elaborated  later  by  Sir 
Charles  Henry  Fagge  in  his  description  of  congenital 
hypothyroidim  (1871)  and  in  Sir  William  Gull's  descrip- 
tion of  adult  hypothyroidism  (1873).  Other  endocrine 
diseases  have  been  described,  unattached  symptom  com- 
plexes have  been  shown  to  be  linked  with  endocrine  dys- 
function, diseases  described  as  "of  metabolism" — diabetes, 
obesity  and  even  gout — have  been  included  in  endocrine 
nosography.  Diseases  of  metabolism  are  abnormal  states 
of  the  regulators  of  metabolism,  that  is,  of  hormones  and 
vitamins  (which  are  a  sort  of  external  hormone). 

Endocrinotherapy  began  with  Brown-Sequard  in  1889; 
thyroid  organotherapy  with  G.  R.  Murray  in  1890,  and  de- 
veloped intensively  of  recent  years.  Events  are  the  intro- 
duction of  insulinotherapy  by  Banting  in  1921,  of  the 
various  sex  hormones,  and  of  cortin. 

With  knowledge  of  the  neurohormonic  connections  the 
extreme,  localistic  point  of  view  has  been  abandoned,  and 
Graves'  disease,  diabetes  insipidus,  and  many  other  diseases 
are  regarded,  not  always  as  local  endocrine  disturbances, 
but  frequently  as  neurohormonic  disturbances.  Endocrino- 
therapy can  no  longer  be  considered  as  the  sole  method  of 
treating  these  disorders;  and  the  role  of  psychotherapy, 
dietotherapy,  physical  medicine  and  certain  constitutional 
medicines  is  accepted  more  and  more  widely.  Endocrine 
gland  surgery  is  rendered  more  effective  when  used  in 
conjunction  with  general  constitutional  therapy. 

With  the  wider  and  more  synthetic  conception  of  con- 
temporary endocrine  physiology  a  more  complete  and  ef- 
fective therapy  is  possible. 


SUSPECT  HYPOTHYROIDISM  OFTENER 
(A    M.   Schwittay,   Madison,  in   Wise.  Med.  JL,  June) 

Occult  or  mild  hypothyroidism  with  few  or  none  of  the 
physical  signs  of  myxedema,  but  with  the  fairly  constant 
complaint  of  fatigue,  is  very  prevalent  in  Wisconsin  and 
is  too  frequently  overlooked. 

Any  patient  who  gives  a  history  of  having  frequently 
sought  medical  help,  or  been  operated  upon  with  disap- 
pointing results,  and  all  women  with  menstrual  disorders 
should  be  studied  from  the  point  of  view  of  thyroid  func- 
tion. Contrary  to  a  widely-held  prejudice  among  laymen 
and  some  physicians,  toxic  results  from  overdosage  of 
thyroid  will  not  leave  permanent  results.  When  the  drug 
is  withdrawn  or  decreased,  symptoms  subside. 

Thyroid  extract  must  be  fresh  and  of  a  known  potency. 
Physician,  pharmacist,  and  patient  should  be  educated  to 
this.   We  use  Armour's  or  Parke  Davis'  desiccated  thyroid. 

Many  patients  may  need  to  continue  it  all  their  lives. 
In  a  few  it  may  be  discontinued  after  varying  periods. 


There  were  no  deaths  among  11  patients  suffering  from 
meningitis  who  were  treated  (J.  H.  Dingle  &  L.  Thomas, 
in  Jl.  A.  M.  A.,  June  14th)  with  sulfadiazine  and  the 
drug  also  is  preferable  to  sulfapyridine  in  the  treatment 
of  this  disease  because  it  is  less  toxic.  Nausea,  vomiting, 
mental  symptoms  and  other  reactions  often  attributable 
to  sulfanilamide  drugs  did  not  occur. 


July,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


385 


DEPARTMENTS 


HUMAN  BEHAVIOUR 

James   K.   Hall,  M.  D.,  Editor,   Richmond,   Va. 


PSYCHE  AND  MARS 

Annually,  every  mid-summer  since  1927,  at 
the  University  of  Virginia,  the  Institute  of  Public 
Affairs  has  proffered  to  the  citizenship  opinions 
about  current  problems.  Distinguished  speakers, 
from  here  and  there,  have  presented  analyses,  eval- 
uations and  opinions — their  own  opinions,  usually, 
and  sometimes  their  opinions  of  the  opinions  of 
others.  Such  a  ten-or-twelve-day  assemblage  each 
summer  enables  those  who  present  the  program  to 
indulge  the  hope  that  they  are  educating  the  citi- 
zenship; and  those  who  attend  the  Institute  are 
encouraged  and  comforted  by  the  belief  that  they 
are  still  students  in  search  of  truth. 

But  he  who  would  acquire  knowledge  must  first 
make  room  for  it  within  his  mind  by  the  expulsion 
of  ignorance  and  prejudice.  The  willingness  to  ex- 
change ignorance  for  truth  requires  appreciation  of 
ones  predicament  and  the  courage  and  the  zeal 
requisite  for  the  procedure.  Most  of  us  are  intel- 
lectually indolent,  and  we  prefer  to  utilize  our 
energy  in  approving  ourselves  as  we  are  rather 
than  in  attempting  to  make  constant  changes  in 
ourselves.  The  search  after  truth,  once  entered 
upon,  is  a  never-ending  adventure,  which  may  lead 
one  far  from  the  crowd  and  away  from  the  beaten 
path;  and  those  lacking  in  fortitude  and  those  who 
object  to  solitariness  and  to  probable  disapproval 
of  herd-opinion  might  better  stay  at  home,  both 
physically  and  mentally. 

On  the  afternoon  and  the  evening  of  July  3rd, 
Dr.  H.  C.  Henry  and  I  lent  our  ears  to  the  pro- 
gram of  the  Institute  which  was  presented  in  co- 
operation with  the  Mental  Hygiene  Society  of  Vir- 
ginia, under  the  presidency  of  Dr.  David  C.  Wil- 
son, of  the  Department  of  Neurology  and  Psych- 
iatry of  the  University  of  Virginia.  Medical  speak- 
ers, especially,  of  great  intellectuality  and  of  pro- 
found experience  in  dealing  with  the  human  mind 
in  peace  and  in  war,  talked  to  us — on  the  level 
and  not  down  to  us.  Dr.  Harry  Stack  Sullivan,  of 
Washington,  who  is  consulted  by  the  Selective 
Board  about  psychiatric  problems,  gave  us  a  de- 
scriptive account  of  those  individuals  who,  because 
of  their  peculiar  personalities,  cannot  fit  into  an 
army  as  soldiers.  Such  individuals  constitute  dis- 
rupting factors  in  the  service,  and  the  attempt  to 
make  fighters  of  them  produces  wrecks  of  them.  It 
is  easy  enough  to  believe  when  listening  to  Dr. 
Sullivan  that  every  recruit  should  be  as  intelligent 
as  Plato  and  as  stable  and  as  philosophic  as  Soc- 
rates.  But,  one  thinks  of  Joan  of  Arc  and  her  hal- 


lucinations, and  of  Julius  Caesar,  with  his  fits;  and 
here  at  home,  of  Grant,  the  alcoholic;  Forrest,  the 
great  cavalryman,  though  an  academic  illiterate; 
of  old  Sam  Houston,  who  could  endure  no  civiliza- 
tion except  that  fabricated  by  himself,  and  of 
Stonewall  Jackson,  whose  peculiarities  added  to 
his  great  fame.  Had  the  mentally  abnormal  been 
forbidden  always  to  express  themselves  on  the 
field  of  battle,  in  literature,  and  in  other  phases  of 
action,  human  history  would  be  infinitely  duller 
than  it  is.  Mediocrity  and  dullness  are  not,  I  hope, 
synonymous,  but  normality  seldom  arouses  keen 
interest.  The  straight  line  is  shortest,  it  lends  itself 
more  easily  to  inspection,  but  we  are  interested  in 
departures  and  in  deviations.  Military  service  cer- 
tainly offers  the  individual  the  opportunity  to  ex- 
press himself  as  he  is — both  in  the  lower  and  in 
the  higher  levels. 

Dr.  Karl  Menninger,  of  Topeka,  who  gave  us  a 
few  years  ago  The  Human  Mind,  talked  to  us  espe- 
cially about  the  work  of  the  physicians  who  have 
to  pass  upon  the  medical  fitness  of  the  young  men 
for  service.  I  always  feel  that  the  functioning  of 
man's  attributes  in  formulating  his  conduct  is  as 
comprehensible  to  Dr.  Menninger  as  the  move- 
ments are  that  result  from  muscular  activity.  And 
both  he  and  Dr.  Sullivan  are  linguistically  gifted. 
They  can  convey  to  others  by  the  use  of  words 
their  ideas  and  feelings.  And  for  that  great  gift 
they  should  thank  the  gods.  Dr.  Menninger  talked 
analytically  of  the  meaning  of  the  term  civilian 
morale,  and  of  the  fundamental  importance  of  it 
as  an  asset  of  incalculable  value  both  in  the  fight- 
ing man  and  in  the  folks  back  of  him — in  his  own 
family,  in  industry  and  in  government.  The  sol- 
dier fights  with  his  physical  body,  but  he  is  in- 
spired and  sustained  by  his  spirit. 

Dr.  Charles  Macfie  Campbell,  Scotch  through 
and  through,  came  down  from  his  professorship  of 
psychiatry  in  the  Harvard  Medical  School  to  talk 
to  us  about  national  morale.  One  feels  instantly, 
in  meeting  Dr.  Campbell,  that  he  can  think  only 
sensibly  and  that  whatever  he  might  feel  inclined 
to  say  about  anything  would  be  well  worth  hear- 
ing. He  has  been  with  us  and  out  of  his  native 
Scotland  many  a  year,  but  such  mental  sprightli- 
ness  as  his  is  not  often  encountered.  And  the 
Scot,  personally  and  traditionally,  knows  war;  and 
the  Scot  estimates  and  appreciates  perhaps  as  no 
other  individual  does,  the  value  of  the  spirit.  Dr. 
Campbell  is  saturated  with  learning  and  steeped  in 
culture,  but  he  is  a  genial,  unpedantic  scholar,  and 
a  teacher  who  dignifies  the  human  psyche  by  en- 
couraging his  students  to  make  use  of  their  minds. 
It  is  scarcely  necessary  for  him  to  speak  of  the 
meaning  and  the  importance  of  morale— he  demon- 
strates its  value  in  his  life,  and  Scotland's  national 
spirit  has  given  her  immortality. 


SOUTHER.X  MEDICINE  &  SURGERY 


July.   1941 


Most  of  the  addresses  made  at  the  Institute 
have  been  mimeographed  and  they  can  be  had  at 
small  cost. 

It  is  well  for  the  people  to  gather  together  from 
time  to  time  where  they  are  encouraged  to  make  us? 
of  their  minds  in  dealing  with  their  individual  and 
civic  problems.  The  first  preparation  for  war  takes 
place  within  the  psyche.  In  an  emergency  man  is 
sustained  by  his  spirit  rather  than  by  his  brawn. 
I  doubt  not  that  Mars  relies  more  upon  the  psyche 
than  upon  the  soma. 


THERAPEUTICS 

J.  F.  Nash,  M.  D.,  Editor,  Saint  Pauls,  N.  C. 


INCLUSION  BLENNORRHEA 

Since  the  uplift  has  made  syphilis  and  clap  or- 
dinary subjects  of  conversation  anywhere  and 
everywhere,  few  there  be  who  would  not  charge 
one  of  the  parents  with  having  gonorrhea  when 
the  eyes  of  a  child  a  few  days  old  put  out  a  pro- 
fuse whitish  discharge;  and  lucky  would  be  the 
doctor  who  cared  for  the  delivery  to  escape  violent 
censure. 

For  these  and  other  reasons  it  is  well  that  all  of 
us  obtain  familiarity  with  inclusion  blennorrhea.1 

Inclusion  blennorrhea  is  caused  by  a  virus  infec- 
tion, and  is  a  venereal  disease.  The  baby  beco'mes 
infected  while  passing  through  the  birth  canal.  The 
inclusion  bodies  have  been  recovered  from  the 
cervical  epithelium  of  women  whose  babies  have 
been  infected.  The  husband  will  often  give  a  his- 
tory of  some  urethral  or  prostatic  infection  which 
often  has  not  been  proved  gonorrheal. 

Specimens  obtained  by  rubbing  a  knife  gentlv 
across  the  palpebral  conjunctiva  of  the  lower  lid 
until  it  just  bleeds  are  placed  on  a  slide  and  stained 
with  Giemsa  or  Wright  stain.  The  inclusion  bodies 
are  found  as  basophilic  granules  in  the  epithelial 
cells. 

Generally  four  to  seven  days  after  delivery  one 
or  both  eyes  of  the  infant  are  swollen,  and  there  is 
a  large  amount  of  serous  exudate.  The  inflamma- 
tion is  often  confined  to  the  lower  lids.  In  adults  it 
is  generally  a  follicular  conjunctivitis. 

The  advantages  of  making  the  diagnosis  are  ( 1 ) 
the  doctor  may  put  at  rest  suspicions  of  gonor- 
rhea; (2)  he  may  tell  the  parents  that  the  eyes 
will  not  be  injured,  and  (3)  that  sulfanilamide  may 
be  given  to  shorten  the  length  of  the  disease. 

Inclusion  blennorrhea  was  found  34  times  in  261 
cases  of  ophthalmia  neonatorum. 

Conjunctivitis  in  babies  should  be  regarded  as 
a  very  serious  condition.  The  local  treatment  is 
the  same  whatever  the  etiology.  The  patients  are 
isolated  with  a  day  and  night  nurse  who  is  in- 

1.  H.   D.    Barnshaw,   Camden,   N.  J.,   in   //.   Med.   Soc.   N.   J., 


structed  to  irrigate  the  eyes  verv  half  hour,  and  to 
place  ice  compresses  on  the  lids  for  30  minutes 
every  hour.  Aqueous  mercurochrome.  1  per  cent, 
is  dropped  into  the  eyes  every  four  hours.  The 
doctor  once  or  twice  a  day  paints  the  lids  with 
silver  nitrate,  1  per  cent.  If  the  cornea  becomes 
hazy,  the  compresses  are  changed  to  hot.  After  a 
diagnosis  of  blennorrhea  has  been  made  stop  the 
use  of  silver  nitrate,  and  use  1  per  cent  aqueous 
mercurochrome  three  times  a  daw 

Sulfanilamide  is  given  in  milk,  daily,  in  dosage 
of  y2  to  13  rd  grain,  with  daily  check  on  the  red 
blood  count.  In  adults  10  grains,  t.  i.  d.,  with  a 
weekly  check  on  the  red  blood  count,  continued 
for  two  weeks;  then  S  grains  t.  i.  d.  for  another 
two  weeks.  Usually  the  condition  appears  much 
better  at  the  end  of  the  first  week;  and  bv  the 
third  week  is  completely  healed. 

CHRONIC  ALCOHOLISM  AND  ALCOHOL 
ADDICTION1 

Nowhere  in  medicine  is  the  survival  of  archaic 
post  hoc  ergo  propter  hoc  thinking  more  appar- 
ent than  in  theories  concerning  alcoholism  and  its 
treatment.  This  is  the  conviction  as  to  practi- 
tioners of  medicine  participating  with  families 
of  alcoholic  patients  in  various  plans  which  de- 
pend for  their  hoped-for  effect  upon  persuasion 
and  threat,  reward  and  punishment,  usually  ending 
in  eventual  incarceration.  These  plans  and  meth- 
ods conspired  to  wrap  the  alcoholic  even  more 
tightly  in  the  swaddling  clothes  of  emotional  im- 
maturity. The  only  hope  for  the  alcoholic,  psy- 
chologicallv  speaking,  is  to  be  stripped  of  the 
garments  of  his  immaturity  so  that  he  may  learn 
to  face  himself  in  the  nakedness  of  truth. 

Contrary  to  general  opinion,  the  alcoholic  is  not 
so  likely  to  be  a  "hail  fellow  well  met."  There  is 
a  deal  of  drinking  among  those  whose  dominant 
traits  are  out-going  and  social,  but  the  real,  pur- 
poseful consumption  of  alcohol  is  more  common 
among  those  who  tend  to  look  inward  and  who  are 
not  socially  facile.  For  them,  it  lessens  the  usual 
friction  of  the  social  wheels  and  makes  contact 
with  their  fellow  men  bearable  and  even  pleasant. 
Once  the  potential  alcoholic  has  satisfied  the  sur- 
face reasons  for  his  drinking  he  soon  begins  to 
drink  pathologically.  Here  we  are  dealing  with 
the  ever-present  necessity  for  a  technique  which 
may  be  relied  upon  to  blur  the  sharp  outlines  of 
reality. 

A  valid  psychological  method  of  treatment  sub- 
stitutes a  skilled  therapist  for  the  wife,  or  hus- 
band, or  the  family,  and  sometimes  too,  for  the 
physician,  who  has  been  induced  to  play  at  the 
game  of  pseudo-treatment.  His  attitude  is  strictly 
impersonal,  objective  and  unemotional,  and  from 
the  very  beginning  he  declines  to  deal  with  any- 
thing but  the  mature  segment  in  the  personality 


July.   1941 


SOUTHERN  MEDICINE  &  SURGERY 


of  the  patient,  no  matter  how  minute  that  seg- 
ment happens  to  be.  The  therapist  is  the  clinical 
clerk  noting  the  history  as  it  is  unfolded,  inter- 
preting its  significance,  guiding  but  never  dictat- 
ing. He  does  not  even  give  directions  as  to  the 
details  of  living  surrounding  the  question  of  alco- 
hol. "Shall  I  have  alcohol  in  the  house?"  "Shall 
I  serve  it  to  my  friends?'"  "May  I  go  to  the  bar 
of  the  club?"  The  only  mature,  logical  answer 
to  such  questions  is  this:  "You  shall,  may  or  can, 
or  you  shall  not,  may  not  or  cannot,  just  as  you 
yourself  decide." 

The  therapist  acts  as  an  inhibitor  of  the  ten- 
dency of  the  patient  to  travel  into  the  paths  and 
by-ways  of  self-deception  or  rationalization.  The 
therapist  knows  full  well  that  while  an  alcoholic 
person  may  be  genuinely  and  miserably  remorseful 
at  the  contemplation  of  the  unhappiness  of  his 
wife,  the  degradation  of  his  children,  or  the  sad- 
ness of  his  old  mother;  yet  the  inevitable  result 
of  such  pathos  will  be  to  drown  it  in  the  bathos 
of  a  tidal  wave  of  alcohol. 

The  highest  hurdle  that  the  alcoholic  patient 
must  finally  succeed  in  clearing  is  that  of  the 
acceptance  of  a  completely  nonalcoholic  future. 
When  he  finally  does  attain  the  emotional  stature 
of  adulthood,  he  understands  all  too  well  that  no 
ego  belittlement  is  involved  in  the  self-made  de- 
cision, that  the  only  possible  choice  is  never  to 
take  alcohol  again. 

Even  when  a  change  of  occupation  seems  highly 
desirable  it  would  be  unwise,  and  contrary  to  the 
spirit  of  the  treatment,  for  the  patient  simply  to 
take  the  therapist's  word  for  the  change.  In  other 
words,  in  this,  as  in  all  other  things,  the  patient, 
from  the  vantage  point  of  his  increasing  maturity, 
must  make  his  own  decision. 

Too  many  rules  would  negate  the  value  of  such 
a  plan  or  reeducational  therapy.  Two  considera- 
tions to  which  the  prospective  patient  must  sub- 
scribe before  the  therapist  is  willing  to  accept  him 
for  treatment.  The  patient  must  convince  the 
therapist  that  he  is  undertaking  treatment  because 
he,  himself,  has  recognized  the  necessity  of  attempt- 
ing to  emerge  from  the  depths  of  this  alcoholism 
and  because,  too,  he  feels  that  this  plan  of  treat- 
ment promises  a  likelihood  of  accomplishing  this 
purpose.  Patients  who  present  themselves  for 
treatment  under  promise,  overpersuasion,  threat 
or  duress  from  the  family  will  not  succeed  in  get- 
ting well. 

The  patient  must  be  willing  to  agree  to  notify 
the  therapist  as  soon  as  possible  in  the  event  of  a 
relapse. 

This  reeducational  plan  of  treatment  is  psych- 
biological  in  its  perspectives.  It  is  truly  eclectic, 
since  it  utilizes  in  its  plan  every  important  experi- 
ence and  reaction  of  the  personality  in  the  life 
history  of  the  patient. 


The  psychotic,  the  severe  psychopathic  and  the 
feeble-minded  alcoholics  cannot  be  subjects 
of  treatment  for  alcohol  addiction.  The  place  for 
the  psychotic  and  many  of  the  psychopaths  is  in 
the  mental  hospital.  Some  of  the  feeble-minded 
drinkers  belong  in  institutions  for  the  feeble-mind- 
ed and  some  should  be  handled  by  the  penal  sys- 
tem.2 

The  question  of  the  treatment  open  or  closed  in- 
stitution or  outside  of  an  institution  must  be  re- 
considered on  each  individual  case.  A  quick  taper- 
ing off,  rather  than  immediate  withdrawal,  seems 
to  do  no  harm. 

All  types  of  drug  treatment,  including  condition- 
ing, even  if  successful  in  eliminating  the  symptom, 
leave  the  patient  with  the  same  basic  difficulties 
that  he  had  before. 

Drug  treatment  may,  however,  be  useful  and 
even  the  treatment  of  choice  in  the  case  of  those 
drinkers  who  have  come  to  their  addiction  by  way 
of  environmental  factors  rather  than  by  way  of 
basic  conflicts. 

Substitutive  treatments,  mainly  religious  conver- 
sion, do  not  reach  the  underlying  personality  con- 
flicts, but  they  afford  a  radical  reorientation  of  the 
personality  and  therefore  achieve  a  certain  amount 
of  success. 

Psychotherapies,  as  they  are  applied  at  present, 
may  have  an  average  success  of  25  to  30  per  cent 
in  terms  of  2  to  4  years  of  total  abstinence. 

General  hospitals,  although  not  suitable  for  the 
treatment  of  addiction,  should  initiate  such  treat- 
ment in  their  patients  and  establish  contact  be- 
tween the  patient  and  welfare  or  temperance  socie- 
ties. 

Effective  psychotherapy  must  be  made  available 
to  much  larger  numbers  than  is  the  case  at  present. 
Public  provision  is  made  in  this  country  only  for 
the  treatment  of  patients  with  alcoholic  psychoses. 


1.  E.  A.  Strecker,  Philadelphia,  in  Quar.  Jl.  Studies  on 
Alcohol.  June. 

2.K.  M.  Bowman  et  al  New  York,  in  Quar-  Jl.  Studies  OH 
Alcohol,  June. 


PEDIATRICS 


EARLY  DIAGNOSIS  OF  POLIOMYELITIS 

By  keeping  it  constantly  in  mind  that  any  case 
of  illness  coming  on  with  vague  feelings  of  dis- 
comfort and  slight  fever  may  turn  out  to  be  po- 
liomyelitis a  doctor  may  serve  his  patients  better 
and  save  himself  embarrassment.  An  excellent 
article1  on  this  subject  is  given  in  abstract. 

A  report2  made  in  the  past  month  appears  to 
ectablish  the  alimentary  tract  as  the  avenue  of 
entrance  of  the  virus  of  the  disease. 

The  incubation  period  is  14  days,  extremes  7  to 
21   days.     First  is  the  mild  systemic  stage,  then 

1.  S.  O.  Levinson,  Chicago,  in  111.  iltd.  Jl.  June. 

2.  A.  B.  Sabin,  Cincinnati,  to  National  Fnumlation  for  Infan- 
tile Paralysis. 


SOUTHERN  MEDICINE  &  SURGERY 


July.  1941 


the  stage  of  meningeal  irritation,  preparalytic,  and 
the  final  paralytic  stage.  The  disease  may  spon- 
taneously terminate  at  any  stage.  Ample  grounds 
for  belief  that  most  infections  with  poliomyelitis 
never  extend  beyond  the  first  stage  of  a  mild 
malaise  with  upper  respiratory  or  mild  gastro- 
intestinal symptoms,  fever  101°,  a  mildly  injected 
throat  and  some  cervical  lymph  adenopathy.  The 
spinal  fluid  at  this  stage  shows  no  abnormal 
changes. 

The  wise  physician  will  not  ignore  such  an  ill- 
ness, but  will  continue  to  observe  the  patient 
for  further  eventualities.  If  not  abortive,  it  pro- 
gresses to  the  second  stage  either  without  inter- 
ruption, or  after  an  interval  of  12  to  48  hours 
during  which  the  patient  appears  to  have  re- 
covered. 

In  the  second  stage  of  the  usual  spinal  type  of 
poliomyelitis,  fever  is  101  to  102°,  headache  frontal 
or  diffuse,  irritable,  anxious  and  complains  of  pain 
in  the  back  of  the  neck  and  in  the  lumbar  area, 
and  of  the  weight  of  the  bed  clothing  or  if  child, 
does  not  like  to  be  held  by  its  mother.  The  pati- 
ent is  usually  very  alert  and  responsive.  Tremors 
of  the  extremities  of  various  types  may  be  noted. 
The  face  is  usually  flushed;  frequently  there  is 
circumoral  pallor.  Diaphoresis  may  be  marked, 
also  be  moderate  injection  of  the  pharynx 
with  cervical  lymphadenopathy.  Slight  or  moderate 
neck  rigidity  is  present  with  resistance  to  complete 
flexion  of  the  head,  moderate  back  rigidity  may 
be  elicited.  A  head-drop  is  frequently  present. 
The  spine  sign  may  also  be  observed  when  the 
child  is  asked  to  assume  the  sitting  posture,  due 
to  the  rigid  back.  The  Kernig  and  Brudzinski 
signs  are  inconstant.  The  superficial  reflexes,  the 
abdominals  and  cremasterics,  are  either  sluggish 
or  absent.  The  deep  tendon  reflexes  early  are 
often  exaggerated,  but  as  the  illness  progresses 
and  nerve  cell  destruction  occurs,  the  reflexes 
become  sluggish  and  finally  disappear.  The  signifi- 
cant reflex  findings  are:  first,  a  change  in  the 
character  of  the  reflexes  between  examinations, 
second,  an  inequality  of  corresponding  reflexes. 

The  spinal  fluid  is  usually  under  increased  pres- 
sure and  is  clear  or  slightly  hazy,  cell  count  around 
250  per  c.  mm.,  may  range  from  10  to  1000  lym- 
phocytes and  mononuclears,  although  at  times 
early  in  the  disease  polymorphonuclear  predomi- 
nate temporarily. 

Of  the  paralytic  stage,  distinguishing  features 
are  weakness  and  flaccid  paralysis  with  diminution 
or  loss  of  corresponding  reflexes.  Paralysis  may 
be  limited  to  one  muscle  group  or  to  the  muscles 
of  one  extremity,  or  widespread  weakness  of  vary- 
ing muscle  groups:  or  there  may  be  extensive  and 
severe  and  more  complete  paralysis  of  most  of  the 
muscles  of  the  body.     Paralysis  may  extend  over 


a  period  of  days  with  eventual  involvement  of 
the  muscles  of  respiration. 

Bulbar  and  encephalitic  poliomyelitis,  a  form  in 
which  the  major  seat  of  infection  is  in  the  brain 
and  medulla,  is  less  frequent  than  the  spinal  type. 
The  prodromal  symptoms  are  frequently  of  very 
short  duration  and  may  be  absent,  temperature 
usually  104  to  105°,  a  greater  degree  of  prostra- 
tion, extreme  irritability  and  at  times  somnolence 
or  stupor.  Neck  and  back  rigidity  may  be  only 
slight,  at  times  absent.  The  spinal  fluid  cell  count 
between  10  and  SO,  with  a  predominance  of  lym- 
phocytes. 

Accurate  diagnosis  of  acute  anterior  poliomye- 
litis depends  on  a  complete  history,  a  careful  ex- 
amination, and  a  lumbar  puncture.  Examination 
cannot  be  cursory,  it  must  be  deliberate.  A  neuro- 
muscular examination  must  be  performed.  If  any 
or  all  of  the  three  common  signs — stiff  neck,  rigid 
spine,  ataxic  tremor —  can  be  demonstrated,  a 
lumbar  puncture  should  be  done  without  delay. 

The  examination  of  the  spinal  fluid  is  reliable 
confirmation  of  the  diagnosis  before  paralysis 
appears. 


GENERAL  PRACTICE 

James    L.    Hamner,    M.  D.,    Editor,    Mannboro,    Va. 


TREATMENT   OF    GONORRHEA   IN    THE 
MALE  WITH  SULFATHIAZOLE 

We  need  an  evaluation  of  the  sulfonamides  use- 
fulness in  gonorrhea.   Here1  it  is. 

Sulfathiazole  has  been  administered  to  31  pa- 
tients with  gonorrhea,  both  private  and  clinic, 
mainly  acute,  anterior  urethritis;  24  cases  had  pre- 
viously received  sulfanilamide  from  three  to  108 
days  with  no  effect.  Seven  cases  have  received  sul- 
fathiazole only.  In  the  majority  of  instances  the 
urethral  discharge  ceased  in  one  to  three  days,  the 
longest  time  being  seven  davs,  and  the  urine  clear- 
ed (no  shreds)  in  one  to  17  days. 

On  entrance,  two  urethral  smears  are  made,  and 
both  stained  by  the  Gram  method.  One  is  exam- 
ined for  Gram-negative  intracellular  organisms, 
and  the  other  kept  for  future  reference.  When  the 
organisms  are  found,  a  two-glass  test  is  made.  If 
the  second  glass  is  clear,  or  clears  with  acid,  a 
warm  acriflavine  solution  of  1-4000  didution  is 
used  to  irrigate  the  anterior  urethra. 

Then  sulfathiazole  gram  1  every  6  hours  day 
and  night  for  the  first  2  days;  gram  l/2  every  4 
hours  day  and  night  for  the  third  and  fourth  days. 
From  then  on  gram  y2  is  given  every  six  hours  day 
and  night;  patients  are  given  daily  irrigations  in 
the  beginning.  After  5  or  6  acriflavine  irrigations, 
potassium  permanganate  is  substituted  for  irriga- 

1  J.  G.  Strohm  et  at,  Portland,  Ore.,  in  Northwest  Med., 
June. 


July,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


tion  twice  weekly  until  ready  for  the  test  of  cure. 

Sulfathiazole  is  discontinued  and  the  test  of 
cure  begun  when  both  glasses  are  clear  and  free  of 
shreds.  However,  if  one  or  two  shreds  are  found  in 
the  urine  after  the  patient  has  received  an  ade- 
quate total  dosage  of  the  drug  and  sufficient  irriga- 
tions, the  shreds  are  stained  by  the  Gram  method. 
If  no  organisms  are  found  and  very  few  pus  cells, 
it  is  safe  to  begin  the  test  of  cure.  On  the  other 
hand  if  Gram-negative  intracellular  diplococci  are 
present,  as  is  frequently  the  case,  the  drug  and 
the  mild  irrigations  are  resumed.  So  far,  the  aver- 
age total  dosage  is  35  to  SO  grams  of  sulfathiazole. 

In  the  test  of  cure  the  anterior  urethra  is  irri- 
gated with  silver  nitrate,  1-10,000,  and  the  patient 
given  a  slide  to  collect  any  discharge.  When  no 
reaction  occurs,  and  the  urine  remains  clear,  a  1- 
8000  silver  nitrate  irrigation  is  given  at  the  next 
visit  with  the  same  instructions;  similarly,  this  is 
followed  by  a  1-6000  silver  nitrate  irrigation.  Pro- 
viding the  urine  remains  clear  and  no  discharge  is 
present,  the  prostate  is  then  massaged  and  the 
fluid  examined  microscopically  for  the  number  of 
pus  cells.  This  is  followed  by  a  deep  urethral  irri- 
gation of  silver  nitrate  or  permanganate.  When 
pus  cells  are  found,  the  prostate  is  massaged  bi- 
weekly, followed  by  deep  urethral  irrigation  until 
no  pus  cells  are  present.  It  is  then  time  to  pass 
sounds.  Should  no  reaction  occur  one  to  four  days 
after  sounding,  the  patient  is  discharged  as  cured, 
and  instructed  to  return  in  one  month  for  a  check 
on  the  urine. 

The  clear  urine  (which  shows  no  shreds)  pro- 
vides a  safe  criterion  for  discontinuing  the  drug 
and  beginning  the  test  of  cure.  To  date,  we  have 
had  no  case,  complicated  or  uncomplicated,  which 
has  failed  to  respond  in  a  short  time  to  sulfathia- 
zole. 


HOSPITALS 

R.  B.  Davis,  M.D.,  Editor,  Greensboro,  N.  C. 


DONT  LOCK  THE  STABLE  DOOR  AFTER 
THE  HORSE  IS  STOLEN 

Sometimes  people  will  see  with  their  eyes  and 
hear  with  their  ears  and  understand  with  their 
minds  the  numerous  changes  which  are  taking 
place  all  about  them,  and  yet  conduct  themselves 
as  though  it  were  not  so.  The  medical  world  is 
much  inclined  that  way.  The  old  saying  that,  ''If 
it  was  good  enough  for  Paul  and  Silas  it  is  good 
enough  for  me"  concerns  itself,  some  people  think, 
with  only  the  moral  issues.  Those  of  us  who  oper- 
ate hospitals  are  sitting  serenely  by  and  are  failing 
to  appreciate  the  changes  which  are  taking  place  so 
rapidly.  It  will  be  too  late  to  do  anything  about 
reorganization,  rearrangement  and  reestablishment 
of  a  new  fee  system  at  the  end  of  a  year  when 


salaries,  supplies,  rents  and  labor  have  already 
been  advancing  for  a  year. 

The  food  cost  has  gone  up  enormously.  We 
should  look  around  for  foods  grown  locally,  per- 
haps, or  at  least  for  foods  which  are  plentiful,  and 
use  them  rather  than  the  foods  which  are  so  high. 
It  would  be  well,  also,  to  consider  serving  foods  in 
the  wards  different  from  those  in  the  private  rooms. 

Cooking  utensils  have  increased  in  price,  espe- 
cially those  made  of  aluminum  or  part  aluminum. 
We  are  told  that  when  the  present  supply  of  alum- 
inum cooking  vessels  are  sold  from  the  retail  stores 
we  shall  not  be  able  to  get  any  more,  It  would 
seem  wise,  therefore,  for  the  dietitians  and  busi- 
ness managers  to  have  a  conference  and  purchase 
such  aluminum  ware  as  is  necessary. 

Little  can  be  done  about  the  cost  of  labor  and 
material  for  repairs.  No  hospital  can  compete  with 
the  United  States  Treasury  and  no  one  would  ex- 
pect labor  to  work  for  a  penny  less  per  hour  than 
its  government  sets  as  a  standard.  It  would  be 
simplicity  personified  for  the  hospitals  to  consider 
that  they  can  do  anything  about  these  conditions. 
What  the  hospitals  can  and  should  do  is  to  hire 
as  little  labor  as  possible  during  this  period  of  in- 
flation and  make  as  few  repairs  as  are  practicable. 
Salaries  of  a  necessity  must  go  up  for  the  same 
reason  that  labor  cost  has  gone  up.  Why  would 
one  expect  a  nurse  to  remain  in  the  employment  of 
a  hospital  with  two  weeks'  vacation  in  a  year  and 
only  a  half  a  day  on  Sunday  off  when  the  govern- 
ment would  give  her  a  considerable  raise  in  salary 
and  perhaps  one  to  one-and-a-half  days  off  a  week, 
as  well  as  a  month's  vacation  in  the  summer  time? 

Of  course  it  should  be  admitted  that  this  is  a 
temporary  condition,  but  it  is  hard  to  convince  the 
younger  generation  that  it  is  not  going  to  be  a 
permanent  strawberry  festival.  When  the  Govern- 
ment's Treasury  becomes  flat,  which  it  is  bound  to 
do  very  soon  after  the  war,  most  of  these  people 
who  have  been  flocking  to  government  service 
will  be  promptly  and  flatly  dropped  without 
any  argument  or  ceremony.  They  will  then  rush 
back  for  their  civilian  jobs  which  will  be  either 
filled  by  the  far-sighted  employees  or  by  those 
who  have  been  rejected  for  one  reason  or  another 
by  the  Government,  but  this  is  another  story. 
The  fact  remains  that  at  present  salaries  are  rising 
and  we  must  provide  temporary  remedies  for  tem- 
porary conditions. 

There  is  only  one  way  possible  to  remedy  the 
situation  as  far  as  the  hospitals  are  concerned  and 
that  is  strict  economy  and  increased  hospital 
charges.  It  is  imperative  that  this  be  done;  not 
tomorrow  but  today.  The  red  flag  is  flying  in  the 
face  of  all  hospital  books.  It  will  flourish  in  red 
ink  by  December  31st  unless  immediate  steps  are 
taken  to  remedy  the  situation. 


SOUTHERN  MEDICINE  &  SURGERY 


July,  1941 


SURGERY 

Geo.   H.   Bunch,  M.   D.,  Editor,   Columbia,   S.   C. 


PYLEPHLEBITIS 

Pylephlebitis  is  derived  from  the  Greek  and 
means  inflammation  of  the  gate  or  portal  vein 
through  which  the  blood  from  the  intestinal  tract, 
loaded  with  the  products  of  digestion,  is  shunted 
to  the  liver  for  essential  glandular  metabolic 
change  before  restored  to  the  general  circulation. 
The  condition  is  important,  for  it  is  a  secondary 
complication  of  infection  which  originates  primari- 
ly somewhere  in  the  intestinal  tract.  Although  the 
pancreas,  the  spleen,  the  stomach,  the  small  intes- 
tine, the  colon  and  the  rectum  may  be  primary 
sites  the  most  common  source  of  infection  is  the 
appendix.  And  this  is  the  reason  why,  except  in 
the  tropics  where  amebic  infection  is  apt  to  be 
endemic,  suppurative  appendicitis  is  probably  the 
most  common  cause  of  pyogenic  liver  abscess. 

From  the  contaminated  blood  transmitted  by  it 
the  portal  vein  itself  becomes  directly  infected  so 
that  there  may  be  suppuration  within  the  vein  wall. 
Emboli,  from  septic  thrombi,  may  be  spread  by 
the  blood  stream  throughout  the  liver.  The  result- 
ing condition  is  characterized  by  small  miliary  py- 
ogenic abscesses  which  tend  to  form  in  clusters 
about  the  portal  radicals.  Differing  from  this,  mul- 
tiple pyogenic  abscesses  in  the  liver  which  develop 
about  the  intrahepatic  bile  ducts  come  from  infec- 
tion which  has  ascended  through  the  ducts  from 
suppuration  within  the  gallbladder.  And  in  contra- 
distinction to  both  these,  amebic  abscess  of  the 
liver,  which  may  or  may  not  have  been  preceded 
by  dysentery,  is  usually  single. 

Symptoms  of  pylephlebitis  may  appear  within 
three  or  four  days  of  the  onset  of  appendicitis  or 
may  not  come  for  ten  davs  or  more.  Fever,  total 
and  differential  leucocytosis,  chills,  pain  and  ten- 
derness in  the  upper  abdomen  in  a  patient  who  is 
not  doing  well  after  appendectomy  make  one  sus- 
pect the  condition.  It  has  to  be  differentiated  by 
cystoscopic  and  x-ray  study  from  nephritic  ab- 
scess, from  subphrenic  absess  and  from  suppura- 
tion within  the  chest.  The  right  diaphragm  is  high 
and  fixed.  On  deep  pressure  there  is  tenderness 
over  the  liver  which  may  or  may  not  be  grossly 
enlarged.  Mild  jaundice,  developing  after  the  on- 
set of  appendicitis,  makes  the  prognosis  extremely 
grave.  The  writer  has  never  seen  recovery  in  a 
case  of  suppurative  appendicitis  with  jaundice. 

Five  per  cent  of  the  deaths  from  appendicitis  are 
from  pylephlebitis.  The  complication  is  usually 
fatal,  the  mortality  rate  being  about  ninety-five 
per  cent. 

Treatment,  to  be  effective,  must  be  preventive. 
Cases    of    appendicitis   should    be   operated    upon 


early  so  that  all  the  infection  may  be  removed  with 
the  appendix.  After  the  appendix  has  perforated 
and  peritonitis  has  begun,  or  an  abscess  has  form- 
ed, this  is  no  longer  possible.  If  a  pyogenic  ab- 
scess of  the  liver  is  large  enough  to  be  identified 
preoperatively  it  should  be  drained.  When  there 
are  miliary  abscesses  surgical  treatment  is  obvious- 
ly futile.  When  suggestive  symptoms  begin  before 
pylephlebitis  develops  chemotherapy  should  be 
given.  The  early  use  of  the  sulfanilamide  group 
of  drugs  when  freely  given  has  been  a  godsend  in 
combatting  blood  stream  infection. 


RHINO-OTO-LARYNGOLOGY 

Clay  W.  Evatt,  M.  D.,  Editor,  Charleston,  S.  C. 


ESTROGENS  IN  ATROPHIC  RHINITIS 

In  years  gone  by  atrophic  rhinitis  was  the 
enigma  of  the  rhinopharyngologist.  The  various 
operations  designed  for  its  alleviation  were  only 
temporarily  beneficial  and  in  the  end  the  condition 
was  usually  made  worse.  The  unfortunate  ones 
who  suffered  with  this  condition  were  obnoxious  to 
their  friends  and  families  and  in  some  instances 
were  barred  from  vocations  of  their  choice  because 
of  their  halitosis. 

Estrogens  were  first  begun  in  1937  and  have 
been  used  extensively  since  that  time.  They  have 
been  used  locally  in  the  nose  as  a  spray  and  also 
subcutaneously  and  intramuscularly. 

In  my  use  of  an  estrogen,  good  results  have 
been  obtained  only  when  it  was  used  in  the  nose  as 
a  spray.  The  nares  are  first  washed  with  normal 
saline  and  all  the  crusts  are  removed.  Then  the 
estrogen  spray  is  used  in  each  nostril.  This  proce- 
dure is  carried  out  three  times  a  day,  and  may  be 
done  at  home.  It  is  continued  until  there  is  im- 
provement and  then  the  number  of  washings  is 
gradually  reduced.  The  spray  must  be  continued 
after  the  fetor  and  crusts  have  gone,  but  must  not 
be  kept  up  indiscriminately  and  indefinitely.  In 
spite  of  the  fact  that  some  observers  report  no 
change  microscopically  there  is  in  some  instances  a 
gross  hypertrophy.  Indeed  in  one  case,  a  boy  of 
fifteen,  who  continued  the  estrogen  several  months 
while  away  from  the  doctor's  observation,  there 
was  gross  hypertrophy  and  hyperplasia  so  exten- 
sive as  to  almost  cause  obstruction.  This  relation- 
ship between  the  nose  and  the  reproductive  organs 
has  been  recognized  since  antiquity,  but  the  modus 
operandi  is  not  yet  clearly  understood.  Why  should 
this  exuberance  occur?  Does  sex  or  age  play  any 
part  in  it? 

The  patients  seen  in  private  practice  with  atro- 
phic rhinitis  came,  most  of  them,  because  of  re- 
peated small  epistaxes;  a  few  because  family  or 
friends  had  told  them  of  the  fetor.  The  remainder 
had  their  cases  diagnosed  during  routine  examina- 


July,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


tion,  or  while  in  search  of  the  cause  of  some  other 
condition. 

The  drug  I  used  was  estrogenic  hormone — 2,000 
units  per  c.c.  with  equal  parts  of  light  oil — and  the 
method  of  application  was  by  spray.  The  amount 
used  was  1  c.c.  three  times  a  day.  All  of  my  pa- 
tients who  had  primary  atrophic  rhinitis  were 
helped.  Those  not  benefited  were  some  clinic  pa- 
tients who  were  indifferent  and  non-cooperative,  or 
had  syphilis  or  other  chronic,  debilitating  disease. 
Many  general  men  have  to  treat  their  condition 
and  should  be  able  to  do  so  entirely  satisfactorily 
with  this  single  remedy: 

Estrogenic  Hormone 

2,000  U.  per  c.c. 

(Reed   &    Carnrick)  20  c.c. 

Light  Oil  qs.  ad.  40  c.c. 

Sig:  Spray  nose  q.d.  as  directed. 
In  my  experience  this  line  of  treatment  offers 
more  than  anything  thus  far  suggested  for  these 
social  outcasts.  If  taken  in  time  and  pursued 
wisely  with  the  patient  returning  regularly  for  pe- 
riodic checkups  most  of  these  people  will  be  re- 
lieved. 


PUBLIC  HEALTH 

N.  Thomas  Ennett,  M.D.,  Editor,  Greenville,  N.  C. 

STATE  PUBLIC  HEALTH  AND  THE  MERIT 
SYSTEM 

Health  work  in  the  State  takes  two  important 
steps — a  step  toward  efficiency  and  a  step  away 
from  politics.  These  two  simultaneous  steps  are 
the  result  of  the  Merit  System  soon  to  be  inaugu- 
rated in  N.  C.  The  Merit  System  is  similar  to 
the  Federal  Civil  Service.  It  means  that  the  per- 
sonnel of  the  Health  Departments  must  stand  an 
examination  as  to  their  qualifications. 

"To  comply  with  the  Social  Security  Law  as 
amended  on  August  10,  1939,  as  applicable  to 
Title  V,  it  has  become  necessary  for  the  State  of 
North  Carolina  to  adopt  a  Merit  System  for  the 
selection  of  personnel.  Under  rules  and  regulations 
adopted  by  the  Children's  Bureau,  who  are  respon- 
sible for  the  administration  of  Title  V  of  the  Social 
Security  Act,  they  require  the  extension  of  this 
Merit  System  principle  to  local  health  unit  em- 
ployees. By  rule  and  regulation  the  U.  S.  Public 
Health  Service  has  also  required  the  States  receiv- 
ing Title  VI  and  Veneral  Disease  funds  to  adopt 
the  Merit  System  principle  for  personnel  adminis- 
tration. Pursuant  to  these  requirements  the  1941 
session  of  the  Xorth  Carolina  General  Assembly 
passed  a  law  entitled  'An  Act  to  Create  a  Merit 
System  Council  for  Certain  Departments  and 
Agencies  of  the  State  of  North  Carolina.'  This  is 
coded  as  Chapter  378,  Public  Laws  of  North  Car- 
olina, 1941." 

The  Attorney   General's   ruling  with   regard   to 


this  law  passed  by  the  General  Assembly  is  that 
the  act  includes  all  local  health  unit  personnel,  as 
well  as  employees  of  the  State  Board  of  Health, 
regardless  of  the  source  of  funds  from  which  their 
pay  is  derived.  The  Council  created  under  this 
act  and  appointed  by  the  Governor  has  adopted 
rules  and  regulations  as  authorized,  and  appointed 
a  Merit  System  Supervisor,  who  is  Dr.  Frank  T. 
DeVyver,  Associate  Professor  of  Economics  in 
Duke  University. 

In  approving  the  Merit  System  the  State  Health 
officer  takes  another  progressive  step.  It  is  our 
belief  that  the  public  health  workers  throughout 
the  State  are  in  sympathy  with  the  Merit  System, 
realizing  that  the  system  must  be  in  the  interest 
of  the  worker  no  less  than  the  public. 


OPHTHALMOLOGY 

Herbert  C.  Neblett,  M.  D.,  Editor,  Charlotte,  N.  C. 


PROLONGED  RETENTION  OF  A  FOREIGN 
BODY  IN  THE  CRYSTALLINE  LENS 

During  the  present  month,  within  one  week, 
the  writer  in  the  course  of  an  examination  of  the 
eyes  of  two  persons  discovered  a  foreign  body  in 
the  lens  of  the  left  eye  of  each  individual.  The 
findings  and  report  in  each  case  follow. 

Case  1 — White  woman,  aged  33,  hosiery  mill 
worker  whose  occupation  required  prolonged  use 
of  the  eyes  for  fine  detail,  only  complaint  ocular 
fatigue  of  moderate  degree  and  moderate  dimness 
of  vision  both  eyes.  She  had  worn  glasses  for  10 
years,  all  previous  examinations  by  an  optometrist 
and  therefore  had  never  had  an  examination  under 
a  cycloplegic.  Her  general  physical  appearance 
was  excellent,  general  health  and  past  history  good. 
When  questioned  in  regard  to  a  recent  or  remote 
injury  or  disease  to  either  eye  her  reply  was  in  the 
negative  except  she  recalled  when  1 1  years  of  age, 
she  and  several  other  children  had  found  a  RR 
detonating  cap  and  succeeded  in  exploding  it  by 
striking  it  with  a  rock.  She  recalled  that  something 
struck  the  left  eye  cut  caused  no  special  pain  and 
nothing  subsequently  except  the  eye  was  slightly 
bloodshot  for  a  few  days  following  the  injury  and 
full  recovery  followed.  The  services  of  a  physician 
were  not  employed  and  the  incident  was  forgotten. 

Precycloplegic  examination  showed  vision  right 
eye  20/40,  left  20/40  plus,  with  all  external  tissues 
of  both  globes  clear.  A  small  iridodialysis  was 
present  at  the  nasal  limbus  at  10  o'clock  which 
suggested  the  entrance  of  a  foreign  body.  The 
pupils,  media  and  fundi  showed  nothing  patholo- 
gic except  in  the  area  of  the  nasal  pole  of  the  lens 
of  the  left  eye,  where  there  was  a  slight  grayish 
haze  behind  the  pupillary  margin.  Tension  of  both 
eyes  was  normal  by  palpation. 

Under  cycloplegic  examination  the  pupils  dilat- 


SOUTHERN  MEDICINE  &  SURGERY 


July,  1941 


ed  equally  and  round  and  there  was  no  intra- 
ocular lesion  in  either  eye  except  the  hazy  area  in 
the  left  eye  as  described.  This  now  showed  an 
opacity  in  the  nasal  pole  of  the  lens  and  a  brilliant 
sheen  as  of  some  thin  flat  metallic  foreign  body 
presenting  on  the  anterior  surface  of  the  lens 
opacity.  The  right  eye  presented  a  lowgrade  com- 
pound myopic  astigmatism  correctible  to  20/15 
and  the  left  eye  0.7S  diopter  of  hyperopic  astig- 
matism correctible  to  20/25. 

The  patient  was  apprized  of  the  presence  of  the 
foreign  body  in  the  left  eye  and  advised  to  allow 
of  no  interference  with  it,  but,  should  either  eye 
become  inflamed  or  painful  or  there  be  any  rapid 
change  in  visual  function,  to  seek  medical  advice 
without  delay. 

Case  2 — White  man,  aged  38,  structural  steel 
worker,  gave  a  history  of  an  injury  to  his  left  eye 
6  years  ago  from  a  flying  particle  of  some  nature. 
At  the  time  of  the  injury  was  seen  and  treated  by 
a  physician  for  a  brief  period  with  good  recovery 
and  no  subsequent  trouble. 

External  examination  disclosed  a  small  scar  at 
the  limbus  at  9  o'clock  suggesting  the  site  of  en- 
trance of  a  foreign  body,  a  gray  haze  at  the  nasal 
edge  of  the  pupil  and  3  pinpoint  gray  dots  in  the 
substance  of  the  center  of  the  lens.  The  pupil 
was  of  normal  size,  shape  and  reaction  and  neither 
eye  presented  any  other  evidence  of  ocular  disease. 
Tension  by  palpation  of  each  eye  was  normal,  vis- 
ion each  eye  20/20  plus.  There  was  no  complaint 
with  reference  to  either  eye  other  than  from  soon 
after  the  injury  to  the  present  time,  the  patient 
has  been  conscious  of  a  slight  haze  in  the  nasal 
area  of  the  left  pupil  and  desired  to  know  its  prob- 
able cause.  Under  mydriasis  refraction  was  found 
to  be  free  from  error,  and  either  eye  diseased. 
This  now  presented  an  opacity  in  the  nasal  pole 
of  the  lens  and  the  appearance  of  the  lesion  sug- 
gested an  encysted  foreign  body.  Advice  was  given 
him  as  in  case  1 . 

Comment — Experience  teaches  that  the  presence 
of  an  intraocular  foreign  body  is  fraught  with  im- 
mediate and  grave  danger  to  the  eye  harboring  it, 
and  to  a  lesser  extent  to  the  fellow  eye,  whether 
or  not  the  patient  be  promptly  treated.  Also  that 
there  is  danger  to  both  eyes,  even  after  many 
years. 

The  degree  of  danger  varies  with  the  size,  shape 
and  chemical  character  of  the  foreign  body — cop- 
per, lead  and  iron  being  poorly  borne — and 
whether  or  not  infection  was  introduced  with  the 
foreign  body.  Steel  is  better  tolerated,  particularly 
if  sterile  upon  entrance.  As  to  location  of  the  for- 
eign body  and  its  point  of  entrance.  A  foreign 
body  passing  through  the  ciliary  area  presages 
grave  results  and  if  lodged  in  any  part  of  the  uveal 
tract  the  danger  is  magnified.   If  lodged  in  the  lens 


the  prognosis  is  a  great  deal  better  as  the  lens,  an 
epithelial  structure,  can  better  withstand  the  pres- 
ence of  a  foreign  body  more  particularly  if  the 
wound  in  its  capsule  promptly  heals.  The  lens 
may  sooner  or  later  become  totally  cataractous 
without  other  intraocular  trouble.  Then  it,  with 
the  foreign  body,  can  be  extracted. 

In  these  cases  the  true  character  of  the  for- 
eign bodies  is  not  known  but  the  fact  that  they 
have  been  so  well  tolerated  in  the  eye — in  case  1 
for  22  years  and  in  case  2  for  6 — is  due  to  the 
fact  that  they  are  in  the  lens,  were  sterile  upon 
entrance,  in  the  first  case  probably  tin  or  stone,  in 
the  second  steel,  are  of  small  dimension  and  were 
rapidly  incysted  in  the  lens  substance  with  prompt 
healing  of  the  lens  capsule. 


TUBERCULOSIS 

J.  Donneiiy,  M.  D.,  Editor,  Charlotte,  N.  C. 


INDICATIONS  FOR  DISCONTINUANCE  OF 
ARTIFICIAL  PNEUMOTHORAX 

When  to  cease  giving  air-refills  to  tuberculous 
patients  is  a  problem  concerning  which  there  has 
been  much  discussion.  It  is  generally  agreed 
among  men  who  have  had  large  experience  in  the 
use  of  this  type  of  treatment  that  no  hard-and- 
fast  rules  can  be  followed  in  deciding  how  long  to 
continue  the  treatment,  since  the  decision  may 
depend  on  the  extent  and  type  of  the  disease,  the 
effect  of  the  collapse  on  the  toxemia,  whether  or 
not  the  sputum  is  rendered  negative  for  tubercle 
bacilli  by  the  collapse,  the  occurrence  of  exacerba- 
tions of  the  disease  or  of  complications  during  the 
treatment,  the  social  and  economic  factors  affect- 
ing the  individual  patient;  also  the  mental  reac- 
tion of  the  patient  to  discontinuing  the  collapse 
treatment.  The  institution  of  the  treatment  merely 
for  its  psychological  effect  is  a  mistake  which  is 
occasionally  made. 

An  article  by  J.  X.  Hayes  in  a  recent  issue  of 
Diseases  of  the  Chest  covers  the  subject  rather 
completely. 

The  author  first  tabulates  the  degrees  of  effect- 
iveness of  the  treatment  as  follows:  (1)  the  treat- 
ment is  a  failure  when  no  pleural  space  can  be 
found;  (2)  it  is  non-effective  when  a  pocket,  usu- 
ally at  the  base,  is  formed,  but  with  no  effect  on 
the  lesion  or  symptoms;  (3)  it  is  partially  effec- 
tive when  a  fairly  good  collapse  can  be  obtained 
with  some  result  in  symptomatic  improvement,  but 
adhesions  prevent  closure  of  a  cavity;  (4)  the 
treatment  is  effective  when  cavities  are  closed  with 
control  of  the  lesion,  and  the  sputum  rendered 
negative  for  bacilli.  A  non-effective  collapse  is 
usually  recognized  within  a  few  weeks,  and,  as  a 
rule,  it  should  be  discontinued  at  once.  One  par- 
tially   effective    requires    more    observation.    The 


July,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


apex  may  be  adherent,  or  wide  bands  of  adhesions 
may  extend  to  the  chest  wall  from  the  area  of  cavi- 
tation preventing  the  cavity  from  closing;  here 
pneumolysis  or  a  temporary  phrenic  nerve  inter- 
ruption may  be  of  great  benefit.  With  an  addi- 
tional involvement  of  the  contralateral  lung  sound 
judgment  is  required  in  deciding  whether  to  sub- 
stitute, say,  thoracoplasty.  The  author  says  that 
as  long  as  the  cavity  is  closing,  however  slowly, 
and  the  symptoms  of  cough  and  expectoration  im- 
proving, it  is  better  to  give  the  pneumothorax  a 
chance.  Slow-closing  cavities  sometimes  are  re- 
opened by  ree'xpansionof  the  lung  particularly  in 
cases  in  which  the  upper  third  has  become  exten- 
sively adherent  to  the  chest  wall  and  mediastinum. 
On  the  whole,  partially  effective  collapse  bv  pneu- 
mothorax should  be  abandoned  for  some  other 
form  of  collapse  therapy  within  a  few  months  at 
most.  The  time  required  for  healing  by  effective 
artificial  pneumothorax  is  for  minimal  disease,  one 
year;  for  moderately  advanced  disease,  two  to 
three  years;  for  far-advanced  disease,  four  or  five 
years. 

The  most  satisfactory  pneumothorax  is  one 
which  can  be  made  effective  quickly,  and  one 
which  is  mainly  over  the  principal  seat  of  disease — 
the  so-called  selective  pneumothorax.  This  type 
of  collapse  can  be  discontinued  earlier  than  one 
which  has  been  mechanically  less  effective.  In 
many  cases  of  partially  effective  collapse  relapse 
comes  as  the  lung  reexpands.  These  are  usually 
cases  of  old  disease  with  cavitation  in  the  apex 
and  adhesions  to  the  upper  chest  wall.  Adhesions 
may  prevent  closure  of  the  cavity  by  even  a  90- 
per  cent  collapse;  and,  although  it  is  impossible 
to  obtain  such  a  complete  collapse  by  even  an  ex- 
tensive thoracoplasty,  this  operation  should  be 
seriously  considered  as  it  will  offer  fewer  compli- 
cations once  the  postoperative  period  has  been 
passed. 

Repeated  pleural  shock  is  an  indication  for  the 
cessation  of  pneumothorax  treatment  as  is  bron- 
chopleural fistula.  The  latter  is  almost  invariably 
the  indication  for  early  thoracoplasty,  but  pleuro- 
cutaneous  fistula  is  not  often  a  reason  for  stop- 
ping the  treatment.  Some  advise  thoracoplasty 
in  most  cases  of  tuberculous  empyema  without 
bronchopleural  fiustula,  occurring  in  the  course  of 
collapse  treatment.  The  author  prefers  oleothorax 
as  a  substitute  for  pneumothorax  if  the  lung  is  so 
thoroughly  collapsed  that  one  could  not  expect  the 
chest  wall  after  thoracoplasty  to  fall-in  sufficiently 
to  meet  the  lung.  In  such  cases,  after  thoraco- 
plasty, a  pleural  pocket  containing  pus  might  per- 
sist. 

Moderately  advanced  and  far-advanced  le- 
sions that  appear  to  be  healed  after  six  months  to 
two  years  of  treatment  have  been  practically  all 
of  an  exudative  or  mixed    exudative    type,    with 


soft-walled  cavities,  but  one  should  be  careful  and 
not  let  this  type  reexpand  too  soon.  Fibrous  thick- 
walled  cavities  may  remain  unhealed  after  five 
years  of  collapse,  with  walls  in  contact  all  the 
time.  When  a  lung  containing  tuberculous  pneu- 
monia is  collapsed  cavities  tend  to  enlarge  at  first 
and  new  ones  to  develop.  Such  cases  require  pro- 
longed collapse,  sometimes  necessitating  perma- 
nent pneumothorax,  or  a  thoracoplasty  after  sev- 
eral years  collapse. 

Occurrence  of  a  serous  pleural  effusion  is  not 
necessarily  a  reason  for  stopping  pneumothorax. 
Serous  pleural  effusions  continuing  over  a  long 
period  of  time  cause  an  obliterative  pleurisy  in 
about  20  per  cent  of  cases.  The  author  states  that 
in  18.7  per  cent  the  collapse  was  improved  and 
the  patient  better  after  a  serous  effusion. 

Failure  of  the  lung  to  expand  after  voluntary 
cessation  of  pneumothorax  the  author  says  is  from 
bronchial  stenosis  due  to  bronchial  tuberculosis, 
or  from  fibrous  thickening  of  the  visceral  pleura. 
If  the  refills  are  discontinued,  the  mediastinum  is 
pulled  over  to  the  collapsed  side  and  the  remaining 
space  usually  fills  with  fluid.  A  displaced  heart 
and  torsion  on  the  blood  vessels  in  such  cases  may 
lead  to  circulatory  embarrassment,  and  occasion- 
ally the  fluid  may  become  purulent.  In  many  such 
cases  permanent  pneumothorax  should  be  the 
method  of  choice. 

Summarizing:  (1)  After  effective  collapse  in 
minimal  cases  of  one  year,  in  moderately  advanced 
cases  three  years,  and  in  far-advanced  cases  four 
to  five  years;  (2)  review  of  the  x-ray  films  and 
course  of  the  disease  previous  to  pneumothorax  to 
determine  whether  minimum  or  maximum  time  is 
needed;  (3)  whether  active  intestinal  or  laryngeal 
tuberculosis  is  present;  (4)  whether  pleural  or 
pulmonary  complications  have  occurred  during 
treatment,  and  the  present  condition  of  the  pa- 
tient; (S)  an  estimation  of  the  resistance  of  the 
patient  o  the  disease;  (6)  the  original  size  of  cav- 
ities and  the  extent  of  the  disease;  (7)  the  series 
of  sedimentation  rates,  the  leucocyte  count  and 
the  proportion  of  immature  cells  which  have  been 
normal  for  sometime.  If,  during  reexpansion,  there- 
is  low-grade  fever  and  increase  of  purulent  sputum, 
the  collapse  should  be  reinstituted  and  maintained 
longer. 

This  discussion  is  probably  as  definite  as  it  can 
be  made.  No  hard-and-fast  rules  can  be  stated. 
The  decision  is  left  with  the  individual  physician, 
and  the  physician  must  have  a  thorough  knowl- 
edge of  each  patient  and  his  or  her  disease  before 
deciding  what  is  best. 


USEFULNESS  OF  SULFADIAZINE 

(M.  Finland  cl  al,  in  //.  A.  M.  A-,  June  14th) 

Not   only  is  the  drug  an   effective  treatment  agent  for 

the  infections  named;  also  it  is  much  less  toxic  than  sul- 

fathiazole   and  sulfapyridinc.     In   the   treatment   of   pneu- 


394 


SOUTHERN  MEDICINE  &  SURGERY 


July,  1941 


raococcic,  staphylococcic  and  streptococcic  pneumonias, 
acute  infections  of  the  upper  part  of  the  respiratory  tract, 
erysipelas,  acute  infections  of  the  urinary  tract,  acute  gon- 
orrheal arthritis  and  meningitis  sulfadiazine  is  highly  ef- 
fective. Their  findings  are  based  on  the  treatment  of 
446  patients. 


DENTISTRY 

J.   H.   Guion,   D.D.S.,   Editor,  Charlotte,   N.   C. 


ABOUT  CROOKED  TEETH 

Every  doctor  who  has  any  part  in  the  health 
care  of  children  has  problems  about  crooked  teeth. 
A  sensible,  middle-of-the-road  statement  of  the 
case1  is  here  given  in  brief. 

In  mouth-breathing  or  finger-sucking  the  sup- 
port of  the  tongue  and  lips  is  diminished  and  that 
of  the  cheeks  increased  and  the  pressure  of  the 
fingers  or  the  abnormal  position  of  the  tongue 
tends  to  push  the  lower  teeth  backward  and  the 
upper  front  teeth  forward  and  to  press  the  sides 
of  the  dental  arches  inward. 

Not  all  children  who  suck  their  thumbs  or  fin- 
gers or  who  have  enlarged  adenoids  have  crooked 
teeth.  The  harm  resulting  from  the  habit  should 
be  weighed  against  the  harm  that  may  result  from 
attempts  to  correct  it. 

Some  report  success  from  the  use  of  an  appli- 
ance which  hurts  the  thumb  when  it  is  placed  in 
the  mouth.  Stopping  of  thumb-sucking  can  result 
in  but  little  benefit  to  the  teeth  if  the  patient  has 
ceased  to  breathe  through  the  nose.  Orthodontic 
treatment  is  the  only  hope  of  establishing  normal 
function  in  the  mouth  and  these  results  will  prob- 
ably not  be  permanent  if  the  postnasal  space  is 
blocked  off. 

A  child  who  has  a  low  fever,  eats  poorly,  breathes 
badly  and  fails  to  gain  either  in  general  or  as 
regards  the  dental  structures  should  be  under  the 
care  of  a  physician. 

An  abnormal  frenum  is  not  nearly  so  common 
as  was  formerly  thought.  Removal  of  the  frenum 
does  no  good;  and  it  may  leave  scar  tissue  that 
will  prevent  the  normal  movement  of  the  teeth  to 
close  the  space  between  the  upper  central  incisors. 
It  is  sometimes  necessary  to  move  these  teeth  to- 
gether by  orthodontic  means. 

A  ration  containing  all  the  essential  vitamins, 
minerals  and  other  substa,nces  for  the  growth  of 
bones  and  teeth  is  basic.  Many  patients  who  have 
had  every  attention  to  the  mechanical  and  nutri- 
tional conditions  develop  malocclusion  of  varying 
severity.  Constitutional  dyscrasia  as  a  cause  of 
early  pathological  conditions  of  the  teeth,  irregu- 
larities of  placement,  malocclusions  or  even  absence 
of  tooth  buds  may  be  considered  under:  1)  hered- 
itary ectodermal  dysplasia — lack  of  tooth  develop- 
ment, missing   teeth  or   irregularities  of  arrange- 


ment; 2)  mongolism — teeth  may  be  tardy,  struc- 
turally defective,  or  abnormally  placed;  3)  in 
syphilis,  and  4)  in  hypothyroid — almost  any  type 
of  tooth  anomaly. 

Often  parents  of  such  children  suffer  from  simi- 
lar defects.  No  trustworthy  evidence  has  been 
presented  to  show  that  any  benefit  results  from  the 
administration  of  calcium  and  phosphorus. 

Malocclusion  grows  worse  as  time  goes  on.  A 
pronounced  disharmony  in  the  relation  of  the 
decidous  teeth  is  almost  certain  to  be  followed  by 
a  disturbance  in  the  permanent  teeth.  There  is 
but  little  dental  development  after  the  child 
reaches  13  or  14  years  of  age,  hence  the  greatest 
benefits  result  from  early  recognition  and  prompt 
corrective  treatment.  There  are  some  conditions 
that  should  be  treated  in  early  childhood. 


DERMATOLOGY 

J.  Lamar  Calloway,  M.D.,  Editor,  Durham,  N.  C. 


1.   Walter   Hyde,    Minneapolis,    in  Jl.-Lancet,   May. 


MANAGEMENT  OF  ACNE  VULGARIS 
Although  acne  vulgaris  is  as  a  rule  a  disease 
of  adolescence,  it  frequently  involves  people  in 
other  age  groups  and  often  persists  throughout 
adolescence  and  into  the  third  decade.  From  the 
outset,  it  should  be  emphasized  that  the  control  of 
acne  necessitates  much  careful  treatment  and  can- 
not be  left  to  spontaneous  cure  such  as  is  fre- 
quently the  case.  When  these  people  are  untreat- 
ed, scars  develop  which  are  often  quite  disfiguring 
and  result  in  complexion  inferiority  complexes. 

Acne  vulgaris  is  an  affection  of  the  pilo-seba- 
ceous  system,  usually  associated  with  seborrheic 
eczema  of  the  scalp  involving  many  etiological 
factors  including  heredity,  food  allergies,  drug 
allergies,  endocrine  disturbances,  primary  and  sec- 
ondary infections.  Accordingly,  all  of  these  factors 
have  to  be  taken  into  account.  A  definite  regimen 
for  their  management  will  be  outlined  below. 

1.  The  diet  should  be  low  in  carbohydrates 
and  in  excess  fat. 

2.  Chocolate  and  nuts  should  be  specifically 
avoided  and  in  some  cases  oranges  and  to- 
matoes. 

3.  Plain  table  salt  should  be  used  instead  of 
iodized  table  salt. 

4.  No  medications  containing  bromides  or 
iodides  should  be  taken. 

5.  The  face  should  be  bathed  at  least  three 
times  daily  with  a  good  soap — using  hot 
then  cold  water.  When  pustules  are  prom- 
inent, wash  cloths  should  not  be  used. 

6.  Under  no  condition  should  the  patient  pick, 
squeeze,  or  press  pimples  or  blackheads. 
This  spreads  the  infection  and  increases  the 
scarring. 

7.  The   scalp   should    be   shampooed    at    least 


July,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


once  weekly  with  tincture  of  green  soap. 

8.  Cremes  about  the  face  should  be  avoided. 

9.  The  patient  should  get  at  least  eight  hours' 
sleep  and  as  much  outdoor  exercise  and 
sunshine  as  possible. 

10.  Regular  bowel  elimination  without  laxatives 
is  very  important. 

11.  Lotio  alba  N.  F.  or  a  similar  preparation 
should  be  applied  locally  at  night  and  left 
on  overnight. 

12.  X-ray  therapy  (a  very  valuable  adjunct), 
vaccines,  endocrine  preparations  etc.  should 
be  left  to  the  discretion  of  a  dermatologist. 

This  discussion  is  no  attempt  to  cover  the  many 
theories  as  to  etiology,  nor  does  it  attempt  in  any 
way  to  outline  or  judge  other  therapeutic  meas- 
ures. An  outline  of  treatment  is  suggested  for  gen- 
eral use  which  will  have  to  be  modified  in  many 
instances. 

While  most  patients  with  acne  can  be  fairly  well 
managed  on  a  regimen  such  as  has  been  outlined, 
no  case  should  be  allowed  to  go  on  to  a  stage  of 
inevitable  scarring  while  one  is  waiting  for  spon- 
taneous cure. 


GENERAL  PRACTICE 


Walter  J.  Lackey,  M.D.  Editor,  Fallston,  N.  C. 

THINK  OF  SYPHILIS:  THEN  TAKE 
APPROPRIATE  ACTION 

One  of  the  greatest  of  our  surgeons  made  much 
of  his  reputation  by  giving  mercury  and  potassium 
iodide  on  suspicion  in  many  of  his  obscure  cases. 
He  did  not  have  the  advantage  of  the  Wassermann 
test.  We  have.  And  syphilis  is  a  lot  more  com- 
mon now. 

Here's  an  abstract1  that  should  do  us  all  good: 

No  matter  how  long  one  is  in  practice,  how  care- 
ful he  is  in  his  examination,  how  well  or  how  long 
he  has  known  the  families  he  practices  among,  the 
time  will  arrive  when  he  will  be  startled  to  get  a 
positive  serological  report  on  some  case  that  is 
puzzling  him. 

Most  hospitals  today  have  a  standing  order  for 
a  serological  test  on  every  patient.  In  private 
practice — we  know  the  family,  we  have  known 
them  all  for  years,  we  may  have  delivered  the  chil- 
dren, we  just  know  this  illness  could  not  be  syph- 
ilis— and  syphilis  does  not  come  into  our  minds. 

The  general  practitioner  must  be  on  the  lookout 
for  congenital  syphilis,  he  must  detect  the  disease 
prenatally,  must  pick  up  the  cases  with  primary 
lesions — and  give  adequate  treatment.  Many  with 
primary  lesions  do  not  consult  a  physician.  The 
physician  must  keep  in  mind  the  many  and  varied 
aspects  of  secondary  syphilis  so  that  he  can  make 

1.  J.  F.  Casey,  Boston,  in  Miss.   Valley  Med.  Jl..  May. 


the   diagnosis   quickly — and   give   adequate   treat- 
ment. 

An  unmarried  man  of  42  had  fainting  spells, 
stumbled  and  walked  unsteadily.  Twenty  years 
before  a  doctor  used  argyrol  for  a  sore  throat  tor 
30  days  without  result;  another  physician  for  an- 
other week  made  local  applications — worse;  a  third 
took  a  blood  test  and  gave  him  six  intravenous 
injections.  He  felt  perfectly  well  for  20  years.  We 
found  a  positive  blood  and  positive  spinal  fluid. 
Shortly  afterward,  he  had  to  be  sent  to  a  psycho- 
pathic hospital  with  general  paresis. 

In  my  early  practice,  I  saw  a  woman  of  63  with 
large  open  granulating  areas  of  both  knees,  extend- 
ing below  the  knees.  The  physician  who  had  been 
caring  for  her  for  two  months  had  given  up  the 
case  because  she  would  not  go  to  the  hospital  for 
skin  grafts.  I  had  never  seen  anything  like  it; 
finally  the  idea  of  syphilis  dawned  upon  me,  and 
appropriate  treatment  healed  the  lesions  in  a  brief 
time. 

Yet,  a  few  years  later  when  a  woman  of  60 
came  to  me  because  of  a  lesion  in  the  knee  region, 
I  first  thought  of  actinomycosis.  As  I  was  prepar- 
ing to  look  for  yellow  granules,  the  thought  came 
to  take  some  blood  for  a  Wassermann.  I  knew 
her  two  boys  who  were  in  college.  They  were  fine 
healthy  fellows,  and  the  family  was  well  known 
and  respected.  However,  the  serologic  test  was 
positive  and  the  treatment  yielded  good  results. 

A  few  years  later,  a  benevolent  deacon,  the 
father  of  two  healthy  children,  the  grandfather  of 
two  husky  boys;  for  over  a  year  he  had  had  four 
small  ulcers  on  the  upper  part  of  his  leg.  Just 
above  was  a  dilated  vein.  He  had  been  under  the 
care  of  two  physicians  previously.  The  ulcers  had 
not  made  any  progress.  I  cleaned  the  ulcers  and 
cross-strapped  them  with  adhesive.  At  the  end  of 
two  weeks,  they  were  almost  healed.  At  the  end 
of  four  weeks,  the  ulcers  were  as  bad  as  ever!  Bad 
vein?  A  Wassermann,  first.  It  was  positive.  Un- 
der syphilitic  treatment  the  ulcers  healed  and  they 
remained  healed.    He  still  has  his  dilated  vein. 

A  boy  of  12,  right  knee  had  been  getting  stiff 
for  the  past  two  weeks.  He  had  not  injured  it; 
unable  to  go  to  school  because  of  a  knee  stiff, 
rather  than  sore  and  painful.  The  joint  was  full 
of  fluid,  and  he  had  Hutchinson's  teeth.  Wasser- 
mann was  positive.  Father,  mother,  two  sisters 
and  a  brother,  all  well  except  that  the  family  all 
had  positive  Wassermanns;  and  that  two  months 
before  a  mop  had  fallen,  and  the  handle  had  hit 
one  of  the  sisters  over  the  tibia  and  she  had  a 
large,  painless  swelling  over  this  bone.  Six  people 
who  had  been  attended  by  several  physicians — 
four  people  with  congenital  syphilis  which  had  pnir 
undiagnosed  until  the  youngest  was  12  years  old. 

A  man,  23,  was  brought  to  my  office  by  his 


SOUTHERN  MEDICINE  &■  SURGERY 


July,   1941 


mother.  For  two  years  regurgitation,  indigestion, 
pain  in  the  abdomen.  He  was  miserable,  under- 
nourished and  anemic.  He  had  been  under  the 
care  of  a  physician  who  had  had  a  surgical  con- 
sultant; later  under  the  care  of  a  stomach  special- 
ist for  a  year;  many  gastrointestinal  x-rays  by  an 
excellent  x-ray  specialist.  The  treatment  I  gave 
the  first  time  was  without  avail  so  I  went  over  him 
again.  He  had  unequal  pupils  and  his  knee  jerks 
wouldn't  function.  Two  positive  Wassermanns 
ended  the  diagnostic  search. 

It  is  embarrassing  to  the  physician  in  court  for 
his  patient  who  has  suffered  injuries  in  an  auto 
accident  and  is  still  disabled  when  on  cross-exam- 
ination a  lawyer  asks,  "Doctor,  why  do  you  think 
this  wound  has  taken  so  long  to  heal?",  or  "Doc- 
tor, why  do  you  think  these  brain  symptoms  still 
persist?"  And  after  you  answer,  he  again  queries, 
"Doctor,  did  you  take  a  Wassermann  test?" 

A  widow  of  35  suffered  a  head  injury  in  an  au- 
tomobile accident.  X-ray  showed  a  fracture  of  the 
skull  although,  except  for  a  mild  concussion,  she 
showed  no  sign  of  brain  injury.  Not  long  after- 
ward she  began  to  lose  hearing  in  one  ear,  later 
vision  in  one  eye;  for  over  a  year  she  was  under 
medical  care,  and  then  was  sent  to  an  eve  and  ear 
specialist.  A  bit  later  she  had  such  a  tremor  she 
dropped  everything.  I  was  sure  she  had  an  over- 
acting thyroid  due  to  physical  or  psychic  trauma. 
The  metabolism  was  normal.  A  positive  Wasser- 
mann; adequate  treatment;  quick  improvement  of 
eye  and  ear  disturbance;  quick  and  quiet  settle- 
ment out  of  court  completed  the  case. 

The  Man  With  the  Iritis,  The  Child  With 
Epilepsy,  The  Woman  Whose  Foot  Would  Not 
Heal  After  a  Minor  Injury,  The  Man  With  the 
Brain  Tumor,  The  Twins  With  the  Sabre  Shins, 
The  Lady  With  the  Peculiar  Lung  Lesion,  The 
Man  With  the  Cardiac  Lesion — these  are  not  gone 
into. 

Are  these  cases  of  late  syphilis  common?  They 
are. 

Who  sees  them?  You  do.  I  do. 

Who  misses  the  diagnosis?   We  all  do. 

How  shall  we  avoid  our  error?  First  we  must 
raise  what  Stokes  calls  "a  low  index  of  suspicion;" 
second,  Take  a  Wassermann. 

CARE  OF  THE  PREMATURE  INFANT 

Most  doctors  need  to  amplify  and  brush  up 
their  knowledge  of  what  to  do,  right  away,  with 
and  for  a  prematurely-born  infant.  Read  atten- 
tively the  coming  synopsis  of  a  first-class  dealing1 
with  this  phase  of  practice:  and  maybe  you  will 
he  rewarded  by  having  the  next  coterie  of  quin- 
tuplets you  welcome  into  a  difficult  world  all  sur- 

Dcnver,    in    Rocky    Mountain    Med.    JI-, 


vive,  and  you  get  to  endorse  baby  foods,  powders, 
diapers  and  so  on. 

The  care  of  the  premature  infant  is  embraced 
in  four  words:  keep  warm,  protect,  feed.  The  tem- 
perature of  those  born  before  their  time  tends  for 
some  time  to  parallel  that  of  their  surroundings. 
Before  the  cord  is  severed  the  premature  infant 
should  be  placed  in  a  heated  blanket.  As  soon  as 
the  mucus  has  been  removed  from  the  mouth  and 
upper  respiratory  passages  and  the  cord  cut  and 
dressed,  it  should  be  placed  in  a  heated  basket  or 
incubator  bed. 

A  small  clothes-basket  lined  with  cotton  quilt- 
ing and  set  into  a  box  or  bassinet,  leaving  an  ade- 
quate space  between  the  two  for  hot- water  bottles, 
makes  a  serviceable  heated  bed.  Remember  that 
these  infants  are  easily  burned,  and  such  burns  are 
usually  fatal.  Put  hot-water  bottles  around  the 
bed  rather  than  in  it. 

A  combination  pack  of  cotton  and  gauze  so 
arranged  as  to  envelop  the  infant  completely,  ex- 
cept for  the  face  and  genito-anal  regions,  answers 
well  for  clothing.  To  the  genital  region  and  anus 
small  squares  of  cotton  covered  with  gauze  may 
be  applied  as  diapers  and  changed  with  less  dis- 
turbance. 

The  room  temperature  should  be  maintained  be- 
tween 75  and  80°;  humidity,  about  65  per  cent. 
The  t.  inside  the  heated  bed  should  be  between  90 
and  95° — the  amount  necessary  to  maintain  a  nor- 
mal body  temperature.  Overheating  will  tend  to- 
ward dehydration  and  may  be  as  dangerous  as 
chilling. 

Upper-  and  lower-respiratory  infections,  espe- 
cially otitis  media  and  pneumonia,  are  the  most 
frequent  causes  of  death  in  these  infants.  Mucus 
and  secretions  in  the  air  passages  must  be  re- 
moved before  the  infant  takes  his  first  breath  by 
gentle  wiping  of  the  nose  and  mouth  with  a  soft 
pledget  of  gauze,  or  by  careful  aspiration  with  a 
catheter,  as  soon  as  the  head  is  born.  The  face, 
body  and  cord  should  be  protected  from  all  contact 
with  feces  and  other  infected  matter.  After  the 
body  is  born,  the  infant  should  be  held  in  a  de- 
pendent position  to  allow  the  mucus  and  other  se- 
cretions in  the  respiratory  passages  to  escape.  The 
eyes  should  at  this  time  be  treated  with  silver 
nitrate. 

A  competent  nurse  must  be  prepared  to  meet 
all  emergencies,  as  cyanosis  and  asphyxia.  Prevent 
overfeeding  and  handling.  The  less  the  baby  is 
handled,  bathed  and  polished,  the  less  is  the  dan- 
ger of  skin  and  cord  infection.  It  must  not  be 
allowed  to  lie  in  one  position  for  more  than  one 
or  two  hours. 

No  one  with  a  cold  is  to  be  allowed  in  the  same 
room,  and  none  but  the  nurse  and  doctor  in 
charge  should  be  allowed  to  handle  him,  w-hether 
in  the  hospital  or  in  the  home.    Strict  isolation  of 


July.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


the  small  premature  from  the  family  should  be 
enforced  during  the  critical  period. 

Premature  need  relatively  more  food  than  do 
full-term  infants  and  are  less  well  equipped  to 
digest  and  absorb  it.  During  the  first  four  days  of 
life  the  inanition  loss  is  attributed  to  the  loss  of 
feces,  urine,  perspiration,  exhaled  moisture,  eme- 
sis,  and  actual  tissue  loss.  The  amount  of  the  loss 
is  more  influenced  by  fluid  than  food  intake.  Dur- 
ing this  period  the  administration  of  water  or  su- 
gar water  is  in  order.  The  use  of  albumin  water 
or  milk  may  result  in  making  allergic  many  babies 
whose  intestinal  tracts  are  permeable  to  undigest- 
ed proteins. 

It  is  wise  to  withhold  all  food  and  fluid  until 
the  respiratory  and  circulatory  functions  are  well 
established,  from  four  to  eight  hours  for  the  more 
vigorous  infants,  to  12  or  more  for  the  weaker 
and,  especially,  those  with  a  considerable  amount 
of  mucus.  Then  offer  every  two  hours  as  much  as 
he  will  take.  The  weaker  ones  should  be  fed  with 
a  dropper.  Gavage  for  those  too  weak  to  swal- 
low, and  only  by  a  nurse  well  trained.  Gavage  is 
dangerous,  not  so  much  because  of  the  possibility 
of  introducing  the  catheter  into  the  trachea  by 
mistake,  as  to  the  tendency  to  overload  the  stom- 
ach with  embarrassment  of  the  cardio-respiratory 
functions,  or  of  subsequent  regurgitation  and 
aspiration  of  the  stomach  contents.  The  premature 
infant  unable  to  swallow  should  receive,  paren- 
terals, normal  saline  or  Ringer's  solution,  rather 
than  fluids  by  gavage. 

The  first  three  days  the  minimum  food  and 
fluid  is  the  amount  necessary  to  maintain  a  sta- 
tionary weight;  one-seventh  of  the  body  weight  in 
fluids,  and  human  milk  to  furnish  30  calories  per 
pound  of  body  weight  are  required  to  maintain 
life.  The  additional  amount  for  growth  is  deter- 
mined by  the  infant's  weight  curve.  Most  healthy 
infants  will  take  enough  food  and  fluids  to  meet 
these  requirements. 

Human  milk  is  essential  to  a  low  mortality 
in  premature  infants.  An  attempt  should  be  made 
to  establish  and  maintain  the  mother's  milk.  In 
its  absence  milk  from  a  wet  nurse  should  be  pro- 
cured. 


OBSTETRICS 

Henry    J.    Langston,    M.    D.,    Editor,    Danville,   Va. 


A  SKIX  TEST  FOR  THE  DIAGNOSIS  OF 
PREGNANCY 

A  good  many  attempts  have  been  made  to  work 
out  such  a  test.  Here  we  have  described1  a  test 
which  holds  out  the  greatest  promise. 

Reasoning  that  colostrum  must  contain  the  pro- 
teins produced  by  the  breast  in  early  pregnancy, 


it  was  decided  to  use  colostrum  in  various  dilutions 
intradermally  on  pregnant  and  non-pregnant  wo- 
men to  determine  whether  they  reacted  alike  or 
differently.  The  pregnant  women  gave  a  faint  re- 
sponse or  no  reaction  to  the  injections,  while  non- 
pregnant individuals  reacted  vigorously.  As  the 
number  of  cases  injected  increased  the  high  per- 
centage of  correct  diagnoses  made  by  the  test  be 
came  quite  significant. 

From  the  breasts  of  primiparous  pregnant  wo- 
men colostrum  is  expressed  manually  into  a  sterile 
glass  container  after  cleansing  the  nipple  and  are- 
ola with  ether.  Colostrum  is  most  easily  obtained 
at  about  the  twenty-eighth  week  of  pregnancy  and 
to  it  is  added  an  equal  amount  of  sterile  normal 
saline  solution.  To  10  c.c.  of  this  mixture  1/10 
c.c.  of  1-100  merthiolate  is  added  as  a  preserva- 
tive and  it  is  kept  in  the  icebox. 

The  flexor  surface  of  the  forearm  is  sponged 
lightly  with  a  piece  of  cotton  saturated  with  ether. 
A  wheal  is  formed  by  injecting  exactly  1/50  c.c. 
of  the  diluted  colostrum  intradermally,  using  a  tu- 
berculin syringe  and  a  26-gauge  needle  for  the 
purpose.  A  second  syringe  and  needle  are  used  to 
make  a  wheal  of  similar  size  with  physiologic  salt 
solution  a  few  inches  lower  on  the  arm  to  serve 
as  a  control.  The  reaction  is  noted  at  10  minutes, 
l/>  hour  and  1  hour.  Readings  made  at  the  Yi 
hour  usually  indicate  whether  the  test  is  positive 
or  negative. 

If  the  patient  is  pregnant  the  colostrum  wheal 
will  appear  pearly,  resembling  a  fresh  mosquito 
bite,  with  little  or  no  pinkish  areola,  and  in  an 
hour  will  show  only  the  needle  prick  in  the  center. 
The  control  shows  nothing  more  than  an  elevation 
of  the  skin. 

On  the  non-pregnant  the  wheal  tends  to  remain 
raised  and  pearly  a  few  minutes  after  injection, 
then  to  enlarge  gradually  to  two  to  three  times  the 
size  originally,  without  changing  color.  There  then 
appears  a  pink  to  red  areola  1  to  2  inches  in  diam- 
eter projecting  pseudopods  from  its  periphery.  The 
reaction  steadily  grows  in  intensity  for  an  hour 
and  persists  for  four  or  five  hours.  The  control 
injection  with  physiologic  salt  solution  in  these 
patients  gives  no  increase  in  the  wheal  or  pigmen- 
tation of  areola. 

Tests  were  made  of  265  women  in  various  stages 
of  pregnancy,  toxic  as  well  as  nontoxic;  and  of 
358  non-pregnant  persons — 100  adult  males,  45 
children  below  the  age  of  15,  50  menstruating  wo- 
men, 50  postpartum,  and  113  normal  non-preg- 
nant women  or  women  with  carcinoma,  fibroids, 
ovarian  cysts,  et  cetera.  Finally,  50  unknown 
problem  cases  were  tested  to  establish  the  diagno- 
sis. 

Of  the  265  women  known  to  be  pregnant  there 
were  five  false  reactions.    In  two  cases  non-preg- 


SOUTHERN  MEDICINE  &■  SURGERY 


July,  1941 


nancy  reactions  were  obtained  and  later  it  was 
shown  that  a  living  fetus  was  in  the  uterus.  One 
of  thest  later  gave  a  positive  pregnancy  reaction, 
in  the  other  there  was  no  opportunity  to  retest. 

In  three  cases  a  weak  reaction  indicated  non- 
pregnancy.  However,  this  reaction  persisted  for 
only  45  minutes  and  had  disappeared  by  the  end 
of  the  hour.  Early  in,  and  toward  the  end  of, 
pregnancv  a  slight  reddening  around  the  vesicle 
produced  by  the  injection  might  be  termed  a  weak 
or  false  non-pregnancy  reaction,  differing  from  the 
true  in  width  of  areola,  depth  of  color  and  in  the 
wheal  not  enlarging.  It  differs  from  pregnancv 
reaction  in  that  there  is  some  color  around  the 
wheal.  A  similar  reaction  has  been  seen  in  the 
early  puerperium.  A  group  of  IS  patients  was  test- 
ed during  labor  and  it  was  seen  that  the  stage  of 
labor  made  no  appreciable  difference  . 

Of  the  113  women  known  to  be  non-pregnant 
tested,  45  were  out-patients  and  68  were  in-pa- 
tients in  gynecology,  mostly  post-operative.  Typi- 
cal non-pregnancy  reactions  were  obtained  in  all 
but  four  patients,  in  whom  typical  pregnancy  re- 
actions were  obtained  which  would  have  led  to  an 
incorrect  diagnosis  if  the  test  alone  had  been  relied 
upon.  The  four  women  who  gave  this  reaction 
were  all  in  the  menopause  for  from  five  to  17 
years;  three  had  advanced  carcinomas  of  the  cer- 
vix, and  the  fourth  a  simple  procidentia  17  vears 
after  the  last  menstrual  period.  The  50  menstruat- 
ing women  all  gave  non-pregnancy  reactions.  In 
the  study  of  45  children  of  both  sexes,  aged  2  to 
15,  a  reaction  similar  to  that  of  pregnancy  was 
obtained  in  all  to  age  10;  beyond  this  age  modi- 
fied non-pregnancy  reactions  were  seen  in  both 
boys  and  girls. 

Of  100  males  of  varying  ages — routine  medical 
service  patients  with  cardiac  disease,  hypertension. 
blood  dyscrasia,  et  cetera — studied,  none  gave 
positive  pregnancy  reactions,  three  gave  modified 
non-pregnancy  reactions. 

Of  the  50  two  to  eight  weeks  post-delivery,  in 
all  but  three  the  reaction  was  that  of  non-preg- 
nancv,  whether  or  not  the  patient  was  nursing  her 
baby.  The  three  pregnancy  reactions  were  all  in 
women  eight  weeks  postpartum;  one  was  menstru- 
ating, the  other  two  admitted  exposure,  but  suffi- 
cient time  had  not  elapsed  to  determine  whether 
or  not  pregnancy  existed. 

Conclusion 

An  intradermal  injection  of  a  colostrum  solution 
gave  no  reaction  in  98  per  cent  of  pregnant  wo- 
men. 

Non-pregnant  women  reacted  to  similar  injec- 
tions with  the  formation  of  a  characteristic  wheal 
and  areola  in  96  per  cent  of  cases. 

Males  reacted  similarly  to  non-pregnant  fe- 
males. 


Children    before    puberty    reacted    similarly    to 
pregnant  women. 


INSURANCE  MEDICINE 

H.  F.  Starr,  M.D.,  Editor,  Greensboro,  N.  C. 


EFFECT  OF  ASTHMA  ON  INSURABILITY 

That  asthma  is  a  symptom,  not  a  disease,  is  the 
proper  approach  to  a  prognosis  as  to  the  effect  of 
asthma  upon  longevity.  It  is  the  cause  of  the 
asthma  that  determines  the  mortality. 

Two  things  to  be  determined  in  each  case  are: 

1.  Is  the  asthma  due  to  an  extrinsic  cause,  an 
intrinsic  cause,  or  both? 

2.  Are  there  associated  diseases  or  impairments 
which  affect  the  outlook? 

Asthma  due  to  extrinsic  causes  depends  upon 
allergy  or  sensitiveness  to  foreign  substances,  while 
the  intrinsic  type  is  due  to  some  condition  present 
within  the  patient.  The  types  may  be  mixed.  As  it 
is  not  practicable  to  employ  skin  tests  (even  if 
these  were  as  trutsworthy  as  enthusiasts  think 
them  to  be)  in  the  routine  insurance  examination 
we  must  rely  largely  upon  the  history  for  deter- 
mining the  type. 

A  history  of  allergic  manifestations  in  the  family 
is  suggestive.  On  the  other  hand,  certain  diseases 
in  the  family — e.g.,  tuberculosis  or  two  or  more 
cases  of  heart  disease — suggest  an  intrinsic  basis. 
Generally  speaking,  the  earlier  the  onset  and  the 
longer  the  history  of  attacks,  the  more  likely  it  is 
to  be  of  the  extrinsic  type.  Asthma  beginning  be- 
fore age  twenty  is  usually  an  entirely  different 
thing  from  that  beginning  after  middle  life. 

The  dates  of  the  attacks,  when  painstakingly 
determined,  may  show  a  seasonal  occurrence,  sug- 
gesting an  extrinsic  cause.  The  occupation  and 
working  conditions  as  well  as  the  home  and  its  sur- 
roundings may  furnish  important  clues.  A  history 
of  eczema,  hayfever  or  other  allergic  manifesta- 
tions strongly  suggests  an  allergic  origin. 

With  a  history  of  periods  of  freedom  from  at- 
tacks, a  study  of  conditions  existing  at  such  times 
determine  why  attacks  do  not  occur  may  furnish 
the  key,  whereas  the  approach  to  the  problem  with 
the  view  to  finding  why  the  attacks  do  occur  has 
failed.  If  freedom  from  attacks  for  a  time  follow- 
ed removal  to  a  new  home,  or  the  purchase  of  a 
new  mattress;  if  no  attacks  are  suffered  when 
away  from  home,  or  following  the  disposal  of  a  cat 
or  dog.  or  a  change  in  diet,  the  implication  is  ob- 
vious. 

About  one  case  of  asthma  out  of  five  is  of  the 
intrinsic  type  which  is  a  much  more  serious  prob- 
lem. The  majority  of  these  cases  begin  at  middle 
life  or  beyond.  Some  of  these  cases  start  as  typical 
extrinsic  asthma  and  the  condition  goes  from  bad 


July.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


to  worse.  Others,  after  many  years  of  freedom 
from  the  extrinsic  attacks  which  began  in  childhood, 
develop  the  intrinsic  type  after  middle  life.  Colds 
or  bronchitis  bring  on  attacks  in  some. 

Our  greatest  problem  in  prognosis  is  presented 
by  those  who  have  always  been  in  good  health  and 
without  warning  develop  severe  attacks  of  asthma 
at  about  age  50,  with  no  evidence  of  allergy.  Here 
the  examiner  is  faced  with  a  problem  that  calls  for 
exercise  of  his  best  abilities.  He  thinks  of  emphy- 
sema, a  new  growth,  tuberculous  hilus  glands  that 
have  become  active,  bronchitis  due  to  sundry 
causes,  sinus  infection,  heart  disease  and  so  on. 
The  prognosis  is  far  less  favorable  than  in  the  ex- 
trinsic type. 

Asthma  associated  with  a  severe  chronic  vaso- 
motor rhinitis  is  most  unfavorable  as  to  mortality. 
Preceding  the  onset  of  asthma,  which  is  generally 
sudden  and  severe,  there  is  usually  a  history  of 
chronic  nasal  trouble  and  in  most  cases  there  is 
sinus  disease.  The  death  rate  is  high  and  the  end 
comes  in  an  attack  of  asthma. 

A  careful  physical  examination  is  essential  in 
every  case.  Some  impairments  which  alone  give 
rise  to  a  moderate  increase,  when  associated  with 
asthma  increase  the  mortality  hazard  markedly. 
In  a  group  of  asthmatics  20  per  cent  or  more  over- 
weight the  mortality  was  59  per  cent  in  excess  of 
the  expected  in  the  experience  of  the  Penn  Mu- 
tual. Dublin,  of  the  New  York  Life,  reported  a 
mortality  one  and  one-half  times  the  normal  in 
asthmatics  ten  pounds  or  more  overweight  and 
twice  the  normal  mortality  in  those  10  pounds  or 
more  underweight.  Any  evidence  of  cardio-vascu- 
lar-renal  disease  adds  greatly  to  the  mortality 
hazard.  Many  say  the  better  risks  in  the  extinsic 
group  will  show  a  normal  or  nearly  normal  mor- 
tality. Insurance  evidence  is  not  sufficient  on  this 
point  because  up  until  the  present  time  it  has  not 
been  possible  to  follow  a  large  enough  group  of 
purely  allergic,  uncomplicated  cases  for  a  sufficient 
length  of  time.  We  are  certain  that  asthmatics 
have  shown  a  decided  excess  in  insurance  mortal- 
ity. The  mortality  is  excessive  during  the  early 
years  after  examination  for  insurance  but  high  at 
all  ages,  especially  between  30  and  50.  The  more 
recent  the  history  of  the  last  attack  the  higher  the 
mortality.  Evidence  is  not  clear  as  to  whether 
mortality  varies  with  the  severity  of  the  attacks. 
Emphysema  or  bronchitis  greatly  increases  the 
hazard.  Even  a  moderate  departure  form  the 
average  weight  has  a  significant  effect  upon  mor- 
tality. 

Finally,  the  causes  of  death  responsible  for  the 
excessive  mortality  of  asthmatics  give  us  valuable 
indications  as  to  the  line  of  thought  we  should 
follow  in  collecting  the  evidence  for  appraising  the 
insurability  of  the  individual.   The  combined  insur- 


ance experience  indicates  that  with  a  history  of  at- 
tacks of  asthma  within  five  years  of  examination, 
the  deaths  due  to  organic  heart  disease  have  been 
Syi  to  2y2  times  normal,  tuberculosis  of  the  lungs 
\Y\  times  normal,  influenza  2l/\  times  normal, 
pneumonia  3  J/2  times  normal  and  deaths  during 
attacks  of  asthma  many  times  normal. 


GYNECOLOGY 

G.  Carlyle    Cooke,  M.  D.,  Editor,  Winston-Salem,  N.  C. 


EMPIRIC  VERSUS  SPECIFIC  TREATMENT 
Soon  after  sulfanilamide  made  its  debut,  I  was 
called  to  see  a  white  twelve-year-old  girl  with  pain 
and  tenderness  in  the  lower  abdomen,  temperature 
of  103,  blood  count  of  16,000.  The  pain  had  be- 
gun two  days  earlier.  She  was  sent  to  the  hospital. 
Rectal  examination  showed  the  pelvic  organs  fixed 
in  place  by  adhesions.  There  was  no  vaginal  dis- 
charge and  repeated  vaginal  smears  showed  no 
specific  organisms.  She  was  put  in  Fowler's  posi- 
tion, ice  caps  were  applied  to  the  abdomen  and 
sulfanilamide  was  given  until  10  milligrams  show- 
ed in  the  blood.  Symptoms  did  not  abate  and 
temperature  ranged  between  103  and  104  for  a 
week.  She  was  able  to  take  nourishment  and  her 
bowels  continued  active.  With  continued  severe 
infection  the  patient  became  alarmingly  ill.  There 
was  no  softening  nor  evidence  of  a  collection  of 
pus  for  which  we  could  resort  to  surgical  drainage. 
As  nothing  changed  the  picture  and  the  outcome 
looked  disastrous,  the  roentgenologist  was  consult- 
ed concerning  small  doses  of  x-rays  to  the  pelvis. 
The  roentgenologist  stated  that  this  treatment 
could  no  no  harm.  She  was  immediately  started  on 
100  R  over  the  pelvis  and  the  sulfanilamide  was 
discontinued.  After  the  second  dose  which  was 
given  in  twenty-four  hours  after  the  first,  her  tem- 
perature dropped  to  normal,  and  without  further 
treatment  of  any  kind  she  progressed  to  a  complete 
cure  and  is  well  and  without  symptoms  at  this 
writing. 

Before  the  advent  of  sulfapyridine  the  radiolo- 
gists were  reporting  very  favorable  results  from 
x-ray  therapy  in  pneumonia.  Many  acute  inflam- 
mations have  been  seen  to  subside  following  its 
use,  and  many  conditions  have  shown  as  miracul- 
ous benefits  as  from  sulfonamides.  Although  the 
sulfonamide  drugs  are  supposed  to  be  specific,  one 
wonders  if  their  use  is  not  about  as  empirical  as 
that  of  the  x-rays.  Their  possibilities  have  begun 
to  be  every-day  stand-bys  so  much  so  that,  regard- 
less of  the  nature  of  the  disease,  the  presence  of  a 
high  temperature  immediately  suggests  the  use  of 
these  drugs.  Sometimes  they  fail.  Whether  or  not 
other  remedies  which  have  shown  a  good  result  are 
empirical,  when  the  specifics  do  fail,  we  should  not 
forget  the  possibilities  of  the  other  agents. 


400 


SOUTHERN  MEDICINE  &  SURGERY 


July.   1941 


This  excellent  discussion  was  inadvertently  omitted  jror, 
tr  June  issue — 


DISCUSSION  OF  DR.  NEBLETT'S  PAPER: 

Dr.  M.  D.  Clayton,  Statesville:  Mr.  Chairman,  Ladies 
and  Gentlemen:  It  is  a  pleasure  to  discuss  Dr.  Neblett 's 
paper.  In  the  first  place,  as  you  know,  he  is  one  of  the 
foremost  oculists  in  our  State.  Secondly,  he  activates 
the  highest  ideals  of  the  profession.  Those  of  you  who 
know  him  will  readily  understand  what  I  mean. 

It  has  been  stated  that  glaucoma  is  not  a  disease,  yet 
it  is  a  disease  which  manifests  itself  in  various  ways, 
each  with  a  different  etiological  factor  and  hence,  requir- 
ing different  forms  of  treatment. 

The  first  thing  to  do  in  the  approach  of  any  case  of 
glaucoma  is  to  classify  the  disease.  First,  there  is  pri- 
mary glaucoma,  under  which  we  have  the  uncompensated 
form,   formerly  called  inflammatory   or  congestive. 

Under  the  compensated  form,  we  have  the  acute  or 
chronic,  non-inflammatory,  glaucoma  simplex;  and  finally 
under   primaries   we   have   juvenile. 

It  has  been  stated  that  the  difference  between  primary 
and  secondary  glaucoma  is  a  matter  of  ignorance,  im- 
plying that  we  do  not  know  the  cause  of  secondary 
glaucoma.  Most  any  physician  can  diagnose  an  attack  of 
acute  classical  glaucoma;  hence,  it  is  not  necessary  to 
dwell  on  the  symptoms  of  this  type. 

Given  a  case  of  potential  glaucoma,  my  first  procedure 
is  to  examine  the  patient  from  head  to  foot  in  order  to 
evaluate  the  patient  as  a  whole.  Secondly,  a  careful 
study  of  the  visual  acuity  is  made.  Following  this  re- 
fraction, both  manifest  and  static,  is  done,  which  implies 
the  use  of  a  mydriatic.  Tension  is  taken  before  and 
after  the  use  of  the  mydriatic.  Following  this  a  careful 
study  of  the  visual  fields,  including  both  form  and  color, 
is  done.  Should  there  still  be  a  doubt  as  to  the  diagnosis, 
the  tension  is  taken,  patient  is  placed  in  a  dark  room  and 
the  tension  repeated  every  twenty  or  thirty  minutes  for 
a  time.  Should  the  tension  increase,  glaucoma  is  quite 
possible.  After  these  procedures,  if  one  is  still  in  doubt, 
the  patient  should  be  carefully  observed  from  time  to 
time  until  a  satisfactory  conclusion  is  reached.  Assuming 
that  a  diagnosis  of  glaucoma  is  established,  inasmuch  as  1 
per  cent  of  all  cases  of  eye  disease  is  due  to  glaucoma 
and  as  12  per  cent  of  all  cases  of  absolute  blindness  result 
from  glaucoma,  these  cases  naturally  require  the  utmost  of 
attention.  Such  cases  should  only  be  entrusted  to  those 
who  have  knowledge,  skill,  experience,  and  who  are  skill- 
ed technicians. 

The  statement  has  been  made  that  all  physicians  should 
be  equipped  to  use  the  ophthalmoscope.  This  is  an  ex- 
cellent idea,  but  it  requires  prolonged  training  and  com- 
parative knowledge  to  be  able  to  properly  evaluate  find- 
ings in  the  ocular  fundi.  Not  infrequently  I  see  patients 
who  have  emerged  from  clinics  with  the  statement  that 
the  ocular  fundi  present  nothing  unusual,  yet,  after  a 
careful  study,  findings  are  revealed  which  are  invaluable 
to  the  physician  who  has  the  patient  under  his  care. 

At   this   very   moment,   in   our   State   Capital,   the  non- 
medical  refractionists   are   attempting   to   gain    recognition 
which  would  give  them  equal  privilege  in  the  care  of  the 
eye  with   the  physicians.     The   implication   is   evident. 
A  little  knowledge  is  a  dangerous  thing; 
Drink  deep  or  taste  not  the  Pierian  spring. 

Dr.  J.  G.  Johnston,  Charlotte:  I'd  like  to  say  a  few 
words  if  I  may  in  order  to  emphasize  some  points  in 
Dr.  Neblett's  favor.  I  want  to  say  this—  we  are  all 
likely  to  be  fooled  in  some  cases  of  glaucoma.  I  remem- 
ber when  I  first  began  this  work  I  got  hold  of  an  old 
lady   that   had   glaucoma    and   I    never   saw   anvbodv   dq 


better.  Everything  went  on  as  nicely  as  it  could.  She 
just  bragged  about  it.  I  soon  found  that  it  wasn't  all  such 
easy  plain  sailing  and  I  came  to  the  conclusion  that  the 
thing  you  have  got  to  do  probably  more  than  any  other 
is  the  complete  diagnosis.  Early  diagnosis  can  help  save 
the  sight  in  a  great  many  cases  of  glaucoma,  but  if  you 
wait  and  think  this  and  that  little  attack  is  not  much, 
and  they  get  a  little  worse  and  a  little  worse,  they  go  past 
the  safety  line  and  the  eye  is  badly  crippled,  if  not  entirely 
gone.  Early  diagnosis  is  the  thing  that  we  have  got  to 
undertake,  particularly  in  this  disease. 

One  other  thing  Dr.  Clayton  spoke  of  and  Dr.  Neblett 
implied  also,  and  that  is  this  non-medical  refractionists' 
job.  No  later  than  last  Saturday  a  woman  was  brought 
into  my  office  who  had  been  seen  before  and  told  that 
she  had  beginning  cataract,  but  not  to  do  anything 
about  it,  don't  have  anything  done  yet,  but  a  short  while 
later  on  when  she  couldn't  see,  to  have  it  operated  on. 
Consequently,  she  had  absolute  glaucoma.  She  couldn't 
see.  Her  eyes  were  entirely  lost  beyond  any  hope  at  all 
of  restoring  sight.     Thank  you. 

Dr.  Neblett,  closing:  I  just  want  to  say  one  or  two 
words.  Apropos  what  these  two  gentlemen  said  about 
this  non-medical  refractionist  I  will  just  bring  this  one 
point  to  mind— of  children  of  pre-school  age  and  those 
before  the  age  of  40  or  45,  forty-five  to  fifty  per  cent  are 
medical  cases.  They  have  eye  symptoms,  it  is  true,  but 
most  of  them  are  different  diseases,  stigmata  of  heredity 
or  various  and  sundry  diseases  that  affect  the  human 
body  by  affecting  the  eye,  and  it  takes  all  we  have  in 
medical  knowledge  to  be  able  to  differentiate  these  cases. 
I  don't  dare  say  that  every  man  that  wears  glasses  or 
every  child,  is  always  a  medical  case.  I  do  say  many  are 
medical  cases. 

But  the  question  of  the  use  of  the  opthalmoscope — I 
don't  mean  to  say  that  a  man  should  be  skilled  or  pro- 
ficient to  the  last  word.  I  don't  mean  to  say  he  should 
be  able  to  make  a  diagnosis  of  glaucoma  quickly  and 
clinically  and  know  what  he  is  doing;  but  I  do  say  the 
average  individual  using  the  opthalmoscope  in  general 
practice  can  tell  whether  an  anterior  chamber  is  shallow, 
whether  a  pupil  is  dilated  and  immobile  or  not;  he  can 
tell  whether  the  optic  cup  is  deep  or  normal  provided 
he  keeps  his  opthalmoscope  in  condition.  If  he  does 
that,  plus  getting  a  history  of  the  case,  going  into  it  and 
getting  symptoms,  and  he  bears  glaucoma  in  mind,  he 
is  going  to  do  something  then  and  there  about  that  case. 

I  wish  to  thank  both  of  the  gentlemen  for  their  dis- 
cussion. 


DR.  CROOM'S  WESNOCA  MOVES  TO  AMBLER 
HEIGHTS 

An  institution  designed  to  meet  the  needs  of  patients 
suffering  from  chronic  diseases  or  conditions  wJl  be  opened 
in  the  plant  formerly  occupied  by  the  Ambler  Heights 
Sanitarium,  by  Wesnoca.  Inc..  an  outgrowth  of  an  institu- 
tion established  in  Asheville  by  Dr.  G.  H.  Croom  in  1928, 
and  in  successful  operation  to  the  present. 

Wesnoca  purposes  to  provide  a  type  of  service,  with 
such  accommodations  as  are  needed  and  required  by  the 
host  of  sufferers  with  chronic  degenerative  diseases;  and 
to  provide  facilities  for  teaching  those  not  really  disabled 
the  fundamentals  of  healthful  living,  all  at  a  reasonable 
rate. 

No  patients  will  be  received  for  treatment  for  active 
mental  disease,  drug  habituation  or  tuberculosis. 


July.  1941 


SOUTHERX  MEDICINE  &  SURGERY 


SOUTHERN  MEDICINE  &  SURGERY 

Official  Organ 

TRI-STATE    MEDICAL    ASSOCIATION    OF    THE 

CAROLINAS  AND  VIRGINIA 

James  M.  Northincton,  M.D.,  Editor 


Department  Editors 
Human  Behavior 

James    K.    Hall,   M.D Richmond,   Va. 

Orthopedic   Surgery 
Oscar  Lee  Miller,  M.  D.  ) 
John  Stuart  Gaul,  M.D.  1" Charlotte,  N.  C. 

Urology 

Hamilton  W.  McKay,  M.D.  I  Charlotte,  N.  C 

Robert  W.  McKay,  M.D ) 

Surgery 

Geo.  H.  Bunch,  M.D _ Columbia,  S.  C. 

Obstetrics 

Hxnry  J.  Langston,  M.D Danville,  Va 

Ivan  M.  Procter,  M.D Raleigh,  N.  C. 

Gynecology 

Chas.  R.  Robins,  M.D Richmond,  Va. 

G.  Carlyle  Cooke,  M.D Winston-Salem,  N.  C. 

Pediatrics 

G.  W.  Kutscher,  Jr.,  M.D Asheville,  N.  C. 

General  Practice 

J.   L.   Hamner,   M.D Mannboro,   Va. 

W.  J.  Lackey,  M.D Fallston,  N.   C. 

Clinical  Chemistry  and  Microscopy 

C.  C.  Carpenter,  M.D | 

d    t>    hi  t.  o     »»  »     -wr.    /Wake   Forest,  N.   C. 

R.  P.  Morehead,  B.S.,  M.A.,  M.D.. ) 

Hospitals 

R.  B.  Davis,  M.D Greensboro,  N.   C. 

Cardiology 

Clyde  M.  Gllmore,  A.B.,  M.D Greensboro,  N.  C. 

Public  Health 

N.  Thos.  Ennett,  M.D Greenville,  N.  C 

Radiology 

Wright  Clarkson.  M.D.,  and  Associates.. ..Petersburg,   Va. 

R.  H.  Lajterty,  M.  D.,  and  Associates,     Charlotte,  N.  C. 

Therapeutics 

J.  F.  Nash,  M.  D., Saint  Pauls,  N.  C. 

Tuberculosis 

John    Donnelly,   M.D Charlotte,   N.    C. 

Dentistry 

J.  H.   Guion,  D.  D.  S Charlotte,   N.   C. 

Internal  Medicine 

George  R.  Wilkinson,  M.  D Greenvile,  S.  C. 

Ophthalmology 

Herbert  C.  Neblett,  M.  D., Charlotte,  N.  C. 

Rhino-0 to-  Laryngology 

Clay  W.  Evatt,  M.  D.,  Charleston,  S.  C. 

Proctology 

Russell  von  L.  Buxton,  M.D Newport  News,  Va. 

Insurance  Medicine 
H.   F.    Starr,   M.D.. Greensboro.    N.    C. 

Offerings  for  the  pages  oj  this  Journal  are  requested  and 
given  careful  consideration  in  each  case.  Manuscripts  not 
found  suitable  for  our  use  will  not  be  returned  unless 
author  encloses  postage. 

As  is  true  of  most  Medical  Journals,  all  costs  of  cuts, 
etc.,  for  illustrating  an  article  must  be  borne  by  the  author. 


ROYSTER  RINGS  THE  BELL 

Some  weeks  ago  Dr.  Hubert  A.  Royster  was 
asked  to  supply  material  for  Westbrook  Pegler's 
column  in  an  issue  of  the  Raleigh  Times,  and  right 
nobly  did  he  rise  to  the  occasion. 

Dr.  Royster  has  never  been  one  of  those  I'd- 
rather-cut-than-eat  sort  of  persons,  and  he  has 
always  deplored  the  confusing  on  the  part  of  the 
public  of  the  operator  with  the  surgeon.  Here  was 
an  opportunity  for  telling  the  public  how  different 
are  the  two,  an  opportunity  for  sowing  good  seed 
in  the  hope  that  a  few  would  fall  in  good  ground. 

Well  does  he  protest  against  the  knife  being  re- 
garded as  the  symbol  of  surgery;  and  well  does  he 
picture  the  surgeon  with  forceps,  a  blunt  dissector 
or  a  needle  and  thread — instruments  far  less  grue- 
some, but  more  widely  employed  and  requiring 
greater  ingenuity  in  their  use.  There  are  many 
operations,  he  goes  on  to  say,  done  wholly  without 
the  knife.  The  singling  out  of  this  alarming  instru- 
ment as  the  popular  embodiment  of  surgery  is  but 
a  sign  of  the  fascination  for  most  minds  of  the 
terrifying  and  the  dramatic. 

In  this  message  to  the  general  public  is  carried 
instruction  which  physicians  and  surgeons  will  do 
well  to  take  to  heart.   This,  for  instance: 

The  modern  surgeon  is  much  more  of  a  tailor, 
or  a  plumber,  than  a  butcher.  Cannot  we  get  rid 
of  such  expressions  as  "going  under  the  knife." 
"nothing  but  the  knife  will  do,"  or  "the  horror  of 
the  knife?"  It  is  not  superfluous  to  remind  medi- 
cal men  that: 

The  surgeon's  best  instruments  are  his  brains 
and  his  fingers:  intelligent  coordination  of  these 
twin  faculties  makes  for  the  highest  grade  of  surgi- 
cal performance.  Without  these  agencies,  all  the 
devices  ever  invented  are  vain  and  futile. 

"We  must  not  omit,"  says  this  accomplished  and 
veteran  surgeon,  "but  we  must  emphasize,  the 
moral  perception  involved  in  every  surgical  thought 
and  act.  The  character  of  the  surgeon  shows  in  his 
work.  Looked  upon  as  so  much  slashing,  surgical 
operations  do  but  brutalize  those  who  perform 
them;  viewed  in  th?  light  of  occasions  for  exercis- 
ing skill  and  healing,  they  are  uplifting  and  purify- 
ing. The  heroism  often  exhibited  by  patients  can- 
not but  have  its  effect  upon  the  surgeon's  disposi- 
tion. Who  can  behold  unmoved  a  calm  mental  and 
moral  attitude  toward  physical  suffering?" 

It  is  gratifying  to  see  the  courageous  part  in  th~ 
drama  of  the  surgical  amphitheater  assigned  to  the 
patient.  Many  years  ago,  some  great  surgeon 
(Nicholas  Sen'n  as  it  is  recalled)  dedicated  a  sur- 
gical treatise  "to  the  heroic  man  at  the  point  of 
the  knife." 

This  fine  paragraph  must  be  included: 

Even   from  its  most  unsatisfactory  aspect,  sur- 


402 


SOUTHERN  MEDICINE  &  SURGERY 


July.  1941 


gery  must  be  regarded  as  a  humane  profession.  Its 
aid  is  too  often  invoked  as  a  last  resort.  How 
much  better  if  surgical  assistance  were  made  an 
early  resort,  if  not  a  first  resort,  when  it  is  inevita- 
bly demanded!  Operations  done  too  soon,  if  act- 
ually needed,  are  so  rare  as  to  be  inconsiderable; 
operations  done  too  late  furnish  the  common  op- 
probrium of  our  art. 

No  doctor  needs  to  be  told  this;  it  is  put  into  a 
journal  for  doctors  to  suggest  to  them  that  this  is 
one  of  the  points  on  which  doctors  should  correct 
the  mistaken  opinions  of  a  large  part  of  those 
designated  by  some  disillusioned  individual  as 
them  asses: 

The  mission  of  surgery  is  to  heal,  to  cure,  to 
banish  forever  the  offending  lesion.  Our  motto  is 
to  restore,  if  we  can;  to  remove,  if  we  must.  It 
takes  more  capacity  to  save  an  organ  or  a  limb 
than  it  does  to  sacrifice  one.  Tis  not  all  of  surgery 
to  cut,  nor  all  of  operating  merely  to  master  the 
mechanical  technique.  The  true  surgeon  does  not 
believe  that,  because  an  operation  can  be  done,  it 
ought  to  be  done. 

If  all  of  us  would  avail  ourselves  of  every  op- 
portunity to  take  the  cause  of  Medicine  to  the 
public,  and  present  it  in  the  candid  vet  forceful 
way  Dr.  Royster  has,  the  public  could  be  brought 
to  understand  our  problems  better,  and  to  cooper- 
ate with  us  in  our  efforts  to  thwart  all  attempts  to 
obstruct  the  progress  of  rational  medicine  in  im- 
proving knowledge  of  prevention  and  cure,  and  in 
making  all  such  knowledge  available  to  all. 


RECENT  ADVANCES  IN  THE  DIAGNOSIS 
AND  TREATMENT  OF  HEART  DISEASE 
Every  doctor  would  like,  and  needs,  to  know 
the  best  for  his  heart  patients.  An  important  part 
of  this  is  knowledge  of  the  place  of  the  electro- 
cardiograph in  diagnosis  and  treatment;  other  im- 
portant parts  are  how  best  to  use  digitalis  and 
mercurial  diuretics. 

A  Denver  doctor1  who  has  a  comprehensive 
grasp  of  this  problem  in  an  article  from  which  our 
readers  may  learn: 

In  recent  years  histories  and  physical  examina- 
tions have  come  to  mean  more  to  us.  but  electro- 
cardiography has  done  most  in  segregating  the 
various  types  of  heart  disease.  Indeed  it  is  the 
ecg.  that  has  given  new  meaning  to  the  results  of 
history-taking  and  examination. 

Today  electrocardiographic  patterns  absolutely 
diagnostic  of  six  clinical  entities  have  been  worked 
out: 

1 .  Coronary  thrombosis 

a)  Anterior  left  ventricular  infarction 

b)  Posterior  left  ventricular  infarction 


1.  Douglas  Deeds,  De 


Rock}  Mountain  Med.  .11. ,  June, 


2.  Chronic  left  ventricular  strain 

a)  Hypertension 

b)  Aortic  insufficiency 

c)  Aortic  stenosis 

d)  Congenital  lesions 

3.  Acute  right  ventricular  strain  (acute  cor  pul- 
monale) 

4.  Chronic  right  ventricular  strain  (chronic  cor 
pulmonale) 

5.  Acute  fibrinous  pericarditis 

6.  Chronic  constrictive  pericarditis. 
Coronary  thrombosis  can  be  a  painless  catastro- 
phe recognized  only  by  the  electrocardiograph. 

In  chronic  ventricular  strain  the  left  ventricular 
muscle,  by  reason  of  continued  excess  work,  is  un- 
able to  carry  on  normally.  It  is  a  reversible  pro- 
cess and  is  not  due  to  coronary  sclerosis.  The 
progression  or  lack  of  progression  of  deleterious 
left  ventricular  effects  can  be  followed  with  ac- 
curacy. 

Pulmonary  embolism  is  the  commonest  cause 
of  the  pattern  of  acute  right  ventricular  strain 
present  from  the  instant  the  mechanical  and  vaso- 
spastic pulmonary  resistance  is  created  by  the  em- 
bolus. The  pattern  may  disappear  in  a  few  hours 
or  last  for  weeks  and  even  become  chronic. 

Any  condition  which  causes  acute  fibrinous  peri- 
carditis produces  a  characteristic  electrocardio- 
graphic pattern.  Chronic  constrictive  pericarditis 
may  follow  any  acute  pericarditis,  develop  with 
few  or  no  acute  manifestations,  or  arise  as  a  tuber- 
culous process.  The  changes  constitute  the  chief 
diagnostic  criterion.  There  are  many  other  condi- 
tions in  which  there  are  significant  electrocardio- 
graphic changes. 

Now  to  discuss  digitalis,  the  best  digitalis  is  the 
powdered  whole  leaf.  The  digitalization  dose  for 
an  average  person  is  18  to  21  grains,  if  this  total 
dosage  is  to  be  given  within  a  period  of  four  or  five 
days.  Of  the  "new''  digitalis,  one  cat  unit  per  dav 
is  a  maintenance  dose  only  for  voung  people  with- 
out any  renal  involvement:  for  the  middle-aged  it 
may  be  one  cat  unit  five,  or  at  most  six,  days  a 
week.  If  the  patient  is  older,  if  great  restriction  of 
fluid  is  necessary,  or  if  impairment  of  renal  excre- 
tion is  present,  a  maintenance  dose  of  the  "new" 
digitalis  may  be  one  cat  unit  three  or  four  times 
per  week.  The  earliest  signs  of  over-dosage  are 
unexplained  loss  of  optimism  by  the  patient,  fol- 
lowed quicklv  by  unexplained  loss  of  appetite. 
Nausea  and  emesis  or  frequent  premature  beats 
mean  that  the  valuable  early  signs  of  overdosage 
have  long  been  overlooked  and  serious  digitalis  in- 
toxication exists. 

An  acurate  dailv  record  of  the  total  intake  and 
output  of  water  should  always  be  kept;  usually 
the  total  fluid  intake  should  be  limited  to  one  quart 
per  day  until  it  is  apparent  just  how  much  fluid 


July,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


can  be  handled.  A  salt-free  diet  may  be  impera- 
tive. Fluid  accumulates  in  the  tissues  of  most 
cardiac  patients. 

Mercurial  diuretics  should  be  used  in  the  vein 
as  a  diagnostic  as  well  as  a  therapeutic  procedure. 
If  the  patient  does  not  feel  well,  and  particularly 
if  some  dyspnea  is  present  give  2  c.c.  of  some 
mercurial  diuretic  intravenously  and  watch;  fre- 
quently there  is  a  tremendous  outpouring  of  fluid 
from  hidden  edema.  Mercurial  diuretics  are  used 
to  prevent  reaccumulation,  an  injection  every 
other  day  for  several  weeks  in  severe  cases.  Sixty 
to  90  grains  of  enteric-coated  potassium  nitrate 
per  day  on  alternate  weeks  only  will  often  double 
the  urinary  output  obtained  from  a  single  inject- 
ion of  mercurial.  Albuminuria  is  not,  but  per- 
sistent hematuria  is,  a  contraindication  to  continu- 
ance of  a  mercurial  diuretic. 

Often  the  pain  of  coronary  thrombosis  can  be 
controlled  without  the  use  of  morphine. 

Most  cardiac  patients  need  oxygen  for  control- 
ling cyanosis  and  dyspnea,  and  as  a  means  of  ad- 
ministration nothing  approaches  the  efficiency  and 
economy  of  the  B.  L.  B.  mask.  This  same  mask 
is  likewise  the  best  way  to  administer  to  asthmatic 
patients  a  mixture  of  helium  and  oxygen  which  is 
often  life-saving. 

Subacute  bacterial  endocarditis  has  been  cured 
by  sulfapyridine  to  combat  the  organism,  followed 
by  continuous  intravenous  therapy  with  heparin 
to  soften  the  fibrin  and  thick  plastic  material  cov- 
ering the  vegetations  on  the  heart  valve. 

In  chronic  constrictive  pericarditis  it  is  now 
possible  to  excise  the  constricting  pericardial  sac 
and  effect  a  cure. 

There  are  now  authentic  cases  on  record  in 
which  the  patent  ductus  arteriosus  has  been  at- 
tacked surgically  and  successfully  ligated  with  res- 
toration to  normal  of  the  circulatory  mechanism. 


A  METHOD  OF  RECORDING  AND 
REPRODUCING  HEART  SOUNDS 

For  a  number  of  years  the  matter  of  better  uti- 
lization of  auscultation  in  the  practice  and  teach- 
ing of  diagnosis  has  enlisted  a  good  deal  of  at- 
tention of  the  Tri-State  Medical  Association.  It 
looks  as  though  what  we  sought  has  been  found.1 

The  examining  physician's  impression  of  the 
many  peculiarities  of  human  heart  sounds — normal 
or  abnormal — cannot  long  be  accurately  retained; 
of  how  much  more  value  would  it  be  if  the  heart 
sounds  were  recorded  for  future  reproduction  and 
comparison  with  later  changes  in  the  sounds  over 
the  same  heart? 

Since  the  advent  of  the  crystal  microphone  much 
advanced  knowledge  of  heart  sounds  is  possible  by 
the  following  means:  1 )  the  stethograph  records 
the  heart  sounds  so  they  may  be  accurately  meas- 

1.  A.   L.   Smith,   Lincoln,   Xel> ,  in   Med.   Times,  June. 


ured;  2)  the  cardiophone  amplifies  them  so  they 
may  be  heard  distinctly  by  the  average  ear;  3) 
the  cardiophonograph  accurately  records  them  so 
that  they  may  be  reproduced  at  various  rates  and 
intensities  for  careful  analysis. 

Since  murmurs  do  not  suddenly  burst  into  full 
bloom  without  a  budding  stage,  it  is  thought  that 
the  sub-audible  murmurs  can  be  discovered  by 
these  methods,  that  treatment  for  the  underlying 
lesion  can  be  instituted  earlier  and  that  a  more 
favorable  outcome  may  be  expected. 

The  cardiophonograph  which  I  have  developed 
and  have  been  using  for  three  years  is  built  into  a 
compact  carrying  case  and  the  loud  speaker  is  in 
the  detachable  cover.  A  long  cord  connecting  the 
amplifier  allows  the  speaker  to  be  moved  to  va- 
rious places  in  the  room  or  outside. 

A  four-stage  amplifier  is  placed  between  the 
microphone  and  the  cutting  head  and  has  a  range 
of  120  decibels.  The  three-stage  amplifier  between 
the  pickup  and  the  loud  speaker  for  reproduction 
has  a  range  of  70  decibels.  The  frequency  re- 
sponse is  from  SO  to  10,000  cycles  per  second.  A 
selection  tone  control  for  reproduction  of  either 
low  or  high  frequencies  will  increase  or  decrease 
these  at  the  will  of  the  operator. 

A  monitoring  calibrated  meter  is  used  for  vol- 
ume control  when  recording  and  the  loud-speaker 
is  in  operation  at  the  same  time  so  one  may  select 
exactly  what  one  wishes  to  record. 

The  pickup  is  of  the  crystal  type.  The  input 
impedance  matches  the  crystal  microphone.  The 
microphone  is  placed  over  a  bell  which  is  composed 
of  soft  rubber  and  this  separates  it  from  the  chest 
wall  by  a  chamber  of  air.  The  heart  sounds,  after 
leaving  the  chest  wall,  must  pass  through  this  col- 
umn of  air  before  activating  the  microphone.  The 
loud  speaker  is  of  the  electrodynamic  type  and 
eight  inches  in  diameter. 

For  cutting  records  the  revolutions  of  the  turn- 
table are  78  per  minute;  thus  the  records  can  be 
reproduced  on  any  phonograph.  The  loud-speaker 
being  used  as  a  control,  the  microphone  can  be 
moved  about  on  the  chest  (like  a  stethoscope) 
and,  when  the  most  favorable  position  is  found, 
the  recording  can  begin. 

The  records  are  of  two  sizes,  six  inches  and  10 
inches  in  diameter.  The  smaller  allows  \y2  min- 
utes, the  larger  3'/2  minutes,  playing  time  per  side, 
revolving  at  the  same  rate  as  for  recording.  The 
discs  are  made  of  hard  substance  allowing  a  great 
number  of  auditions  (from  100  to  700  have  been 
tried)  with  little  wear  of  the  record  resulting  even 
when  steel  needles  are  used.  Reproduction  can  be 
tested  immediately  after  cutting  and  if  any  exact 
sounds  wanted  are  not  recorded  another  record  can 
be  cut.   The  amplification  can  be  so  increased  that 


SOUTHERN  MEDICINE  &  SURGERY 


July,   1941 


the  sounds  may  be  heard  clearly  in  a  large  audito- 
rium. 

When  the  heart  sounds  are  picked  up  by  the 
microphone,  the  electrical  impulses  are  carried 
through  the  four-stage  amplifier  directly  to  the 
loud  speaker.  The  microphone  must  be  sealed  to 
the  chest  wall  or  squeals  will  develop.  Recordings 
of  58  fetal  hearts — from  SJ/2  months  to  just  before 
delivery — were  attempted  and  52  were  successful. 
On  one  half  of  the  disc  is  recorded  the  fetal,  on 
the  other  the  maternal  heart  sounds.  One  fetus 
had  a  systolic  murmur  and  six  weeks  after  birth 
the  systolic  murmur  was  again  recorded. 

The  heart  sounds  can  be  amplified  and  audited 
directly  from  the  patient  as  long  as  wished.  The 
recorded  heart  sounds  can  be  reproduced  at  leisure, 
given  careful  study  and  then  filed  for  future  refer- 
ence. Evolution  of  any  heart  disease  can  be  accu- 
rately followed  through  a  series  of  records  and  will 
prove  an  invaluable  source  for  investigative  medi- 
cine. 

Records  of  heart  disease  can  be  accumulated 
and  the  whole  auscultatory  course  can  be  presented 
in  a  short  time.  The  recorded  discs  can  be  audited 
until  the  sounds  are  mastered.  The  heart  sounds 
can  be  broadcast  directly  from  the  patient  to  the 
students.  The  student  can  be  supplied  with  heart 
records — with  proper  notations  on  them — and  in 
the  privacy  of  his  own  room,  without  interference 
from  teacher  or  patient,  he  can  reproduce  the 
heart  sounds  until  he  is  entirely  familiar  with 
them.  Stethograms  of  the  same  patient  will  allow 
one  to  see  as  well  as  hear  these  sounds. 

By  broadcasting  the  fetal  heart  sounds  through 
the  loud-speaker  all  in  the  delivery  room  may  con- 
tinuously follow  the  changes  in  the  fetal  heart. 
By  this  method  the  student  can  learn  the  changes 
in  fetal  heart  sounds  during  delivery. 

The  heart  sounds  of  the  patient  being  operated 
on  can  be  made  audible  in  the  operating  room  and 
each  interested  person  can  interpret  the  condition 
of  the  patient  according  to  his  ability  and  this 
ability  should  constantly  improve. 


be  very  suspicious. 

From  month  to  month  this  Department  will 
will  carry  the  best  of  established  knowledge  in  this 
field,  with  due  notice  of  alleged  additions  to  this 
knowledge,  and  their  evaluation  by  the  Depart- 
ment Editor. 


DR.  BUXTON'S  DEPARTMENT 
Beginning  with  the  issue  for  June  a  Depart- 
ment of  Proctology  was  instituted  with  Dr.  Russell 
Buxton,  of  Newport  News,  Virginia,  as  Editor. 
Dr.  Buxton  does  not  confine  his  work  to  proctol- 
ogy. He  does  general  surgery,  as  did  his  distin- 
guished father.  Dr.  Joseph  T.  Buxton,  until  his 
death  in  1940. 

It  is  in  the  field  of  proctology,  perhaps,  that 
most  inexcusable  errors  of  diagnosis  are  made,  and 
with  gravest  consequences.  The  first  editorial  of- 
fered for  this  Department  elaborates  this  point. 
He  urges  that  on  the  least  suspicion  a  digital  ex- 
amination of  the  rectum  be  made,  and  that  doctors 


PROFESSOR  ALLAN 

Since  his  entry  on  the  study  of  medicine,  Wil- 
liam Allan  has  been  a  research  worker.  This  does 
not  mean  that  he  did  not  develop  into  a  superb 
clinician.  His  decades  as  favorite  consultant  of 
his  section  attest  to  his  distinguished  ability  as 
diagnostician  and  therapist.  For  many  years,  if 
a  doctor  falls  ill  in  Piedmont  Carolina  and  doesn't 
call  for  Dr.  Allan  it  is  because  he  doesn't  think 
he  is  much  sick. 

But  he  has  never  been  content  to  just  practice 
the  best  medicine  of  his  day  by  keeping  up  with 
the  advances  made  by  others.  He  has  wanted  to 
make  his  own  contribution  to  medical  advance- 
ment. And  his  accomplishment  in  this  field  has 
been  large,  notably  as  to  heredity's  influence  and 
as  to  amebic  infestation. 

The  medical  school  Wake  Forest  College  is 
soon  to  open,  recognizing  the  importance  of  the 
factor  of  heredity  in  the  practice  of  medicine,  has 
established  such  a  chair,  and  recognizing  Dr. 
Allan's  eminent  fitness  for  its  occupancy  has  called 
him  to  Winston. 

Dr.  Allan  will  be  happy  in  the  work  nearest 
his  heart,  and  his  ability  will  constitute  a  great 
pillar  of  strength  in  this  medical  school  soon  to 
open  under  such  favorable  auspices. 

All  Charlotte  is  sorry  to  see  him  leave,  yet  glad 
for  him  to  obtain  this  high  recognition  which  he 
so  richly  deserves. 

THE  GENERAL  PRACTITIONER  IX  TUBERCULOSIS 
(Cedric  Xorthop,  San  Haven.  X.  Dak.,  in  Jl.-Lancet.  May) 
Supposing  that  you  have  discovered  a  case  of  active 
pulmonary  tuberculosis  in  a  parent,  and  in  applying  Man- 
toux  tests  and  taking  x-rays  you  And  all  of  the  children 
positive  reactors  and  two  or  three  with  parenchymal  or 
glandular  involvement  by  a  primary  lesion.  Should  they 
be  sent  to  the  sanatorium?  It  was  formerly  believed  all 
over  the  country  that  the  hospitalization  of  patients  with 
childhood  type  of  tuberculosis  was  a  worth-while  proce- 
dure. Considerable  data  prove  that  it  is  money  not  well 
spent  to  hospitalize  first-infection  tuberculosis.  Primary 
tuberculosis  is  for  the  most  part  a  self-limited  disease.  It 
merely  requires  good  hygiene,  adequate  diet,  rest  propor- 
tional to  the  severity  of  the  involvement  and,  most  im- 
portant of  all,  that  the  contact  from  whence  the  youngster 
received  his  infection  be  broken.  Following  out  this 
thought  there  has  been  a  closing  of  preventoria  all  over 
the  country.  My  special  message  to  general  practitioners  is 
make  every  effort  to  locate  and  examine  the  contacts  of 
diagnosed  cases  of  pulmonary  tuberculosis  in  your  com- 
munity. There  are  funds  available  for  the  examination 
and  x-raying  of  all  contacts  of  diagnosed  cases  in  persons 
who  cannot  afford  the  cost  of  such  an  examination.  It  is 
merely  necessary  to  communicate  with  the  local  or  county 
(To   Page   405) 


July,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


A  BIT  ABOUT  CHRISTIAN"  SCIENCE 

CHRISTIAN   SCIENCE   COMMITTEE   ON 
PUBLICATION 

FOR     THE     STATE     OF    NORTH     CAROLINA 
106     GROVE     ARCADE     BLDG. 

ASHEVILLE.   N.   C. 

July  2.  1941 

James  M.  Northington,  M.D., 
Editor  Southern  Medicine  &  Surgery, 
Charlotte,  North  Carolina. 
Dear  Editor: 

Certain  erroneous  conclusions  are  implied  in  the 
June  issue  of  your  Publication,  under  the  caption: 
"AS  PUZZLING  AS  HESS'  TRIP,"  which  asso- 
ciates the  name  of  Mary  Baker  Eddy  with  the 
statement  ".. a  sect  that  denies  the  very  exist- 
ence of  disease  and  obstructs  and  impedes  Medi- 
cine to  the  utmost  of  its  ability "  It  is  kindly 

requested  that  vou  carry  this  short  letter  in  your 
July  number,  which  will  serve  to  clarify. 

Now  it  is  at  once  admitted  that  to  material 
sense  reasoning,  which  without  discrimination  ac- 
cepts man  as  wholly  mortal,  disease  may  appear 
very  real — even  solid  conviction.  Reasoning,  how- 
ever, about  the  Creator  and  His  creation,  man. 
including  his  relationship  to  disease,  in  the  light 
of  Christian  Science,  which  manifestly  is  the  point 
at  issue;  we  are  justified  in  going  direct  to  the 
Christian  Scientist's  denominational  text  books,  the 
Bible,  and  Science  &  Health  with  Key  to  the  Scrip- 
tures, by  Mary  Baker  Eddy.  The  Apostle  John 
affirms  (John  4:24)  "God  is  a  Spirit,"  and  in  Gene- 
sis 1:26,  we  read:  "And  God  said,  Let  us  make 
man  in  our  image,  after  our  likeness:  and  let  them 

have  dominion ".    Meanwhile,  the  author  of 

Science  &  Health,  page  182,  succinctly  declares: 
"To  admit  that  sickness  is  a  condition  over  which 
God  has  no  control,  is  to  suppose  that  omnipo- 
tent power  is  powerless  on  some  occasions." 

Fundamentally,  there  is  no  basis  for  dissension 
between  the  Christian  Scientists  and  those  of  the 
Medical  Fraternity;  neither  are  health  programs 
opposed;  (both  of  which  were  implied)  when  in- 
tended for  those  who  wish  to  avail  themselves  of 
such  ministrations.  One  point,  however,  is  defi- 
nite; that  ambitious  medical  legislation,  designed 
to  bring  all  under  its  arbitrary  restrictions,  and 
to  limit  the  choice  of  treatment  without  respect 
to  convictions,  will  as  usual,  be  opposed,  and  vigor- 
ously; even  until  the  inevitable  conclusion  is  har- 
moniously reached,  that  under  the  provisions  of 
our  blessed  Constitutions  and  Bill  of  Rights,  equal 
privileges  are  vouch-safed  to  all. 

Obviously,  when  Lord  Lothian,  who  in  your 
editorial  is  described  as  "a  disciple  of  Mary  Baker 
Eddy"  approached  the  Rockefeller  Foundation  in 
behalf  of  British  medical  students,  and  was  granted 
the  initial  and  substantial  sum  of  $100,000  toward 


enabling  them  to  complete  their  courses  in  Ameri- 
can and  Canadian  institutions,  he,  as  a  public  serv- 
ant, was  rendering  to  his  beloved  homeland,  an 
unselfish  and  probably  immeasurable  service;  for 
while  none  would  move  to  restrain  his  individual 
liberties,  not  all,  perhaps,  of  his  beleagured  nation, 
shared  his  devout  spiritual  convictions.  Indeed,  an- 
other recent  incident  of  perhaps  parallel  interest 
is  at  this  point  recalled.  A  venerable  woman,  who 
lived  in  New  York  state,  bequeathed  the  bulk  and 
residue  of  her  estate,  ranging  into  some  millions, 
for  the  philanthropic  purpose  of  aiding  in  the  build- 
ing of  Christian  Science  edifices.  A  clause  in  her 
Will  reads  in  part:  "I  desire  to  state  that  I  am 
not  a  member  of  any  Christian  Science  church, 
and  have  never  taken  the  lessons  given  by  the 
authorized  teachers  in  said  church;  but  I  believe 
that  the  people  who  are  studying  the  Bible  in  con- 
nection with  the  teachings  of  Mary  Baker  Eddy, 
are  living  exceptionally  good  lives  .  .  .  and 
by  their  goodness  and  example  are  making  less 
the  evils  that  come  into  the  world  through  sin." 
Manifestly,  the  divinity  of  the  Christ  is  a  potent 
power  in  the  humanity  of  these  times. 

WILLIAM   CARSON   BLACKBURN, 
Christian   Science   Committee   on   Publication. 

(Every  doctor  reader  of  this  journal  knows  how 
disingenuous  this  letter  is.  The  point  is  not  whether 
man  is  wholly  mortal;  it  is  that  in  this  mortal  ex- 
istence he  has  physical  (often  mortal)  diseases. 

There  is  solid  basis  for  Medicine  to  dissent  to 
practically  everything  that  Mary  Baker  Eddy's 
disciples  stand  for. 

As  to  how  worthy  of  credence  "Health  & 
Science"  is  and  as  to  the  activities  of  the  Christian 
Science  Committee  on  Publication,  we  gladly  ten- 
der the  loan  of  a  very  revealing  book,  by  three 
authors:  Woodbridge  Riley,  Ph.D.,  member  of  the 
American  Psychological  Association;  F.  W.  Pea- 
body,  LL.B.,  member  of  the  Massachusetts  Bar; 
and  Chas.  E.  Humiston,  M.D.,  Professor  of  Sur- 
gery, Univ.  of  Illinois.  The  title  is  "The  Faith, 
The  Falsity  and  the  Failure  of  Christian  Science;" 
publisher,  Fleming  H.  Revell  Company,  New 
York.— The  Editor.) 

TUBERCULOSIS— from  Page  404 

chairman  to  that  effect  and  funds  will  be  provided  to 
defray  the  cost  of  the  examination.  These  funds  are  from 
Christmas  Seal  Sales. 

When  patients  are  discharged  from  the  sanatorium  it  is 
our  wish  that  each  and  everyone  should  return  to  the 
physician  who  referred  him  to  the  sanatorium.  Those  pa- 
tients who  need  pneumothorax  refills  should  be  taken  care 
of  by  the  family  physician  if  he  is  familiar  with  this  type 
of  work  and  has  access  to  a  pneumothorax  machine,  and  a 
fluoroscope  or  x-ray  machine,  preferably  all  three.  It  is 
the  legal  responsibility  of  the  county  from  whence  the 
patient  came  to  take  care  of  the  expense  of  these  refills  for 
those  who  are  unable  to  pay. 


SOUTH ER\  MEDICINE  &  SURGERY 


July.  194! 


NEWS 


INTEREST   IN   NORTH   CAROLINA'S  HEALTH 

PROGRAM 
Health  officials  in  Mississippi,  Alabama  and  Tennessee 
are  contemplating  the  establishment  of  programs  patterned 
after  North  Carolina's  school  health  coordinating  services. 
Dr.  John  F.  Kendrick  and  Dr.  John  A.  Ferrell,  both  of 
the  Rockefeller  Foundation,  held  conferences  with  health 
officers  of  the  three  States  early  in  the  month. 


DR.  SANGER  AND  DR.  NEGUS  ADDRESS 
HOMEOPATHS 

Dr.  Desiderio  Roman,  chief  surgeon  of  St.  Luke's  and 
Children's  Homeopathic  Hospital  of  Philadelpria,  Dr.  Wil- 
liam T.  Sanger,  president  of  the  Medical  College  of  Vir- 
ginia, and  Dr.  Sidney  S.  Negus,  Professor  of  Chemistry  at 
the  Medical  College  of  Virginia,  were  the  principal  speak- 
ers at  the  concluding  banquet  of  the  American  Institute  of 
Homeopathy  convention,  June  19th,  at  Old  Point  Comfort. 

Dr.  Roman  is  a  native  of  South  America,  a  graduate  of 
Hahnemann  Medical  College  of  Philadelphia,  a  Fellow  of 
the  American  College  of  Surgeons  and  a  recognized  author- 
ity on  diseases  of  the  thyroid  gland. 


THOMASVILLE  HOSPITAL  FUND  DRIVE  NEARS 

GOAL 
For  the  drive  for  additions  to  the  City  Memorial  Hos- 
pital, Thomasville,  N.  C,  more  than  $16,000  of  the  $18,000 
needed  is  already  raised.  The  drive  is  being  conducted  by 
the  trustees  and  the  members  of  the  medical  staff  of  the 
hospital,  divided  into  eight  groups  as  follows:  Dr.  R.  K. 
Farrington  and  Dr.  O.  R.  Hodgin ;  Dr.  C.  H.  Phillips  and 
Doak  Finch;  Dr  P.  M.  Sherrill  and  T.  Austin  Finch; 
Dr.  R.  L.  MacDonald  and  R.  B.  Eleazer;  Dr.  Joe  Far- 
rington and  D.  A.  Long,  Jr.;  Dr.  J.  C.  Pennington  and 
James  E.  Lambeth,  Sr.;  Dr.  R.  H.  Holliday  and  Dr.  G.  T. 
Alexander;  and  Dr.  R.  G.  Jennings,  Dr.  R.  W.  Crews  and 
Dr.  W.  G.  Smith. 


WAYNESBORO  HOSPITAL  REORGANIZATION 
Dr.  H.  B.  Webb  has  been  made  Physician-in-Charge  of 
the  Waynesboro   (Va.)    Community  Hospital.    In  this  ca- 
pacity he  will  act  as  administrator  and  conduct  his  prac- 
tice of  medicine  and  surgery  with  offices  at  the  hospital. 

In  1937  Dr.  Webb  was  president  of  the  group  which 
organized  and  erected  the  Waynesboro  General  Hospital, 
which  later  was  reorganized  on  a  community  basis  as 
Waynesboro  Community  Hospital.  Since  August  15th, 
1940.  he  has  served  as  president  of  the  hospital  staff.  In 
assumin  gduties  as  physician  in  charge  Dr.  Webb  said  there 
would  be  no  staff  changes — either  medical  or  administra- 
tive^— except  the  addition  of  Miss  Lucile  Menefee  to  the 
administrative  staff.  She  has  heretofore  been  employed  in 
Dr.  Webb's  office  downtown. 


TWO  SOUTH  AMERICANS  STUDY  HEALTH  WORK 
IN  VIRGINIA 
Dr.  Paul  Pena,  Director  of  the  National  Department  of 
Health  of  Paraguay,  and  Dr.  Juan  Antonio  Montoya  of 
Colombia,  recently  completed  courses  in  public  health 
work  at  Johns  Hopkins  University.  Virginia's  State  Health 
Department  was  recommended  to  them  by  Dr.  Hugh  S. 
Cummings,  Director  of  the  Pan-American  Sanitary  Bureau, 
as  a  good  one  to  study  for  practical  application  of  public 
health  methods.  They  will  continue  their  investigations  in 
Richmond  and  in  various  parts  of  the  State,  including  dis- 
trict branch  offices  at  Abingdon  and  Norfolk. 


VIRGINIA  NEGRO  DOCTORS 

The  Old  Dominion  Medical  Society.  Negro,  brought  to 
a  close  its  annual  convention  June  5th  at  Hampton  Insti- 
tute by  naming  Dr.  W.  M.  Hoffier  of  Suffolk  as  president 
and  selecting  other  officers  for  the  year: 

President-elect  for  1942,  Dr.  F.  R.  Trigg.  Norfolk;  first 
vice-president,  Dr.  Henry  W.  Williams,  Petersburg;  second 
vice-president.  Dr.  J.  B.  Blayton,  Williamsburg;  executive 
secretary.  Dr.  W.  P.  Collette  of  Norfolk;  assistant  secre- 
tary. Dr.  Harrison  Franklin,  and  treasurer,  Dr.  A.  B. 
Green,  Sr.,  of  Norfolk. 


The  American  Psychiatric  Association  has  organized 
a  committe  to  prepare  a  history  of  psychiatry  in  the  Unit- 
ed States.  The  Committee  on  the  History  of  Psychiatry  is 
composed  of  Dr.  Gregory  Zilboorg,  Chairman,  New  York; 
Dr.  Earl  D.  Bond,  of  the  Pennsylvania  Hospital,  Depart- 
ment of  Mental  Diseases.  Philadelphia;  Dr.  C.  C.  Fry.  of 
the  School  of  Medicine,  Yale  University;  Dr.  Hugh  Carter 
Henry,  Director  of  State  Hospitals  of  Virginia,  Richmond. 
The  hope  is  entertained  that  the  history  may  be  finished 
against  the  Centennial  meeting  of  the  American  Psychia- 
tric Association  in  Philadelphia  in  1944. 


Dr.  Ralph  Moschella,  for  the  past  two  years  a  mem- 
ber of  the  staff  of  the  H.  F.  Long  Hospital  in  Statesville, 
has  returned  to  Massachusetts,  of  which  State  he  is  a  na- 
tive, to  engage  in  private  practice. 


Dr.  L.  D.  Hacaman  has  been  elected  Director  of  the 
Public  Health  Service  of  the  district  composed  of  Cald- 
well and  Burke  Counties.  Dr.  Hagaman  has  been  engaged 
in  private  practice  at  Boone,  but  he  has  been  assistant 
director  of  the  district  for  a  few  months. 


Dr.  John  H.  Bonner,  since  1938  Public  Health  Officer 
of  the  district  in  Virginia  composed  of  Page.  Warren  and 
Shenandoah  Counties,  has  resigned.  He  will  return  to  his 
native  State  on  September  1st,  and  engage  in  private  prac- 
tice at  Elizabeth  City,  North  Carolina. 


Dr.  R.  Flnley  Gayle,  Jr.,  of  Richmond,  has  been  elect- 
ed to  membership  in  the  American  Neurological  Associa- 
tion. The  other  members  of  the  Association  in  Virginia 
are  Dr.  Beverley  R.  Tucker,  Dr.  Claude  C.  Coleman  and 
Dr.  David  C.  Wilson. 


Dr.  Millard  C.  Hanson  is  the  new  commissioner  of 
health  for  the  city  of  Richmond.  Dr.  Hanson's  background 
of  five  years  of  general  practice,  ten  years  as  health  officer, 
first  of  Mansfield,  later  of  Toledo,  Ohio,  and  one  year  in 
Syphilis  Control  in  Pittsburgh,  promises  well  for  efficient 
work  in  Richmond. 


University  of  Vteginu 

On  May  13th,  Dr.  W.  W.  Waddell.  Jr.,  spoke  before  the 
Mississippi  State  Medical  Association,  meeting  in  Biloxi. 
His  subject  was  Vitamin  K  in  the  Newborn. 

At  the  meeting  of  the  St.  Louis  Medical  Society  on  May 
13th,  Dr.  Vincent  W.  Archer  discussed  X-Ray  and  Gastro- 
intestinal Diagnosis. 

On  May  22nd,  Dr.  J.  M.  Meredith  participated  in  the 
Post-Graduate  Course  in  Medicine  and  Surgery  for  the 
Loudoun  County  Medical  Society  conducted  under  the 
auspices  of  the  Department  of  Clinical  and  Medical  Edu- 
cation of  the  Medical  Society  of  Virginia.  He  spoke  on 
Management  of  Head  Injuries. 

At  the  meeting  of  the  American  Otological  Society  in 
Atlantic  City  on  May  26th,  Dr.  Fletcher  D.  Woodward 
presented  a  paper  on  The  Use  of  a  Temporary  Inexpensive 
Bite    Block    to    Determine    the    Relationship    Between    the 


July,  1941 


SOUTHERX  MEDICINE  &  SURGERY 


Closed  Bite  and  Temporomandibular  Joint  Symptoms. 

Drs.  Fletcher  Woodward  and  Oscar  Swineford.  Jr..  pre- 
sented a  joint  paper  before  the  Oto-Rhino-Laryngological 
Section  of  the  American  Medical  Association  in  Cleveland 
entitled.  Allergic  Rhinitis. 

At  the  recent  meeting  of  the  American  Society  for  the 
Study  of  Allergy  held  in  Cleveland.  Dr.  Oscar  Swineford, 
Jr.,  was  elected  Vice-President  for  the  coming  year. 

Fifty-four  students  were  graduated  with  the  degree  of 
Doctor  of  Medicine  at  the  finals  exercises  on  June  9th. 

The  Second  Post-Graduate  Course  in  Medicine  spon- 
sored by  the  Department  of  Internal  Medicine  of  the  Uni- 
versity of  Virginia  and  the  Department  of  Clinical  and 
Medical  Education  of  the  Medical  Society  of  Virginia  was 
held  at  the  Medical  School  and  Hospital  from  June  16th 
to  21st.  The  guest  speakers  were  Dr.  Warfield  M.  Firor, 
Associate  Professor  of  Surgery  at  Johns  Hopkins  Medical 
School,  who  spoke  on  Sulfaguanidine,  and  Dr.  Walter  O. 
Klingman.  Associate  in  Neurology  at  the  College  of  Physi- 
cians and  Surgeons  in  New  York  City,  who  discussed  Au- 
tonomic Drugs.  The  list  of  those  giving  lectures  and  hold 
ing  clinics  included  thirty  members  of  the  faculty.  Thirty 
one  physicians  registered  for  the  course. 


was  commissioned  major  in  1917  and  served  in  the  World 
War.  He  retired  from  active  duty  in  1928  and  had  made 
his  home  in  Richmond  since  that  time. 


MARRIED 


Dr.  William  L.  Venning,  of  Arlington,  Virginia,  and  Dr. 
Laura  Ross,  of  Charlotte,  North  Carolina,  were  married 
June  13th.    Mrs.  Venning  is  a  daughter  of  Dr.  Otho  Ross. 

Miss  Randolph  MacDonald  Arnold,  talented  Virginia 
artist,  and  Dr.  Otto  Edward  Aufranc,  of  Boston,  were 
married  June  28th  in  the  garden  of  Rose  Terrace,  the 
home  of  Dr.  and  Mrs.  L.  Wilson  Jarman.  Dr.  Jarman  is 
the  president  of  Mary  Baldwin  College,  Staunton,  Va., 
where  Miss  Arnold  has  been  a  member  of  the  faculty  for 
the  past  four  years.  Dr.  Aufranc  was  graduated  from  the 
University  of  Missouri  and  from  the  Medical  School  of 
Harvard  University  and  is  now  assistant  to  Dr.  M.  N. 
Smith  Petersen,  noted  orthopedic  surgeon,  and  is  a  mem- 
ber of  the  staff  of  Massachusetts  General  Hospital. 

Miss  Flora  Phillips  Miller,  of  Ellerson,  Virginia,  and 
Doctor  Thomas  Nathaniel  Jacob,  Junior,  of  Onancock, 
Virginia,  June  21st. 

Dr.  J.  Dent  Summers,  of  Statesville,  North  Carolina, 
and  Miss  June  Rogers,  of  Burlington,  Iowa,  were  married 
on  June  21st.  Dr.  Summers  will  serve  an  interneship  in  a 
hospital  in  Cleveland. 

Dr.  Stanley  H.  Macht.  of  Crewe,  and  Miss  Naomi  New- 
man, of  Danville.  Virginia,  were  married  on  July  1st. 

Dr.  William  Taliaferro  Thompson,  Jr.,  and  Miss  Jessi:- 
Gresham  Baker,  of  Richmond,  were  married  on  June  21st. 

Dr.  Francis  Record  Whitehouse,  of  Lynchburg,  and 
Miss  Doris  Irion,  of  Dallas,  Texas,  were  married  on  June 
21st.    Dr.  Whitehouse  is  a  member  of  the  Mayo  staff. 

Dr.  John  Hansford  Thomas,  Jr.,  of  Greenville,  in  Au- 
gusta County.  Virginia,  and  Miss  Mary  Johnston  Lash. 
of  Staunton,  Virginia,  were  married  on  June  19th. 


DIED 

Major  Allen  J.  Black.  76.  U.  S.  Army  Medical  Corps, 
retired,  died  suddenly  June  25th  at  his  home  in  Richmond, 
of  a  heart  attack.  He  received  his  medical  degree  in  the 
class  of  1884  at  the  Medical  College  of  Virginia;  then 
practiced  his  profession  at  Radford  and  Roanoke  for  sev- 
eral years  before  entering  the  Army.  He  served  as  a  medi- 
cal officer  in  Cuba  during  the  Spanish-American  War  and 
later  in   the  Philippines   during   the  insurrection   there.    He 


Dr.  Richard  Franklin  Slaughter,  Jr.,  of  Augusta,  Ga., 
Head  of  the  Department  of  Neuro-surgery  at  the  Univer- 
sity of  Georgia  Medical  School,  died  at  Johns  Hopkins 
Hospital  July  3d,  after  a  six  months'  illness,  of  a  brain 
ailment.  He  was  a  graduate  of  the  University  of  Virginia, 
and  had  served  on  the  staffs  of  hospitals  in  Baltimore, 
Richmond  and  Boston.  A  native  of  Hampton,  Va.,  before 
going  to  the  University  of  Georgia  four  years  ago,  he 
practiced  in  Norfolk. 


Dr.  Percy  E.  Lilly,  of  Kilmarnock,  Virginia,  died  sud- 
denly of  a  heart  attack  at  his  home,  on  the  15th  of  June. 
He  was  63  years  of  age,  a  graduate  of  the  University  of 
Man-land's  Medical  Class  of  1901. 


Dr.  Thomas  D.  Jones,  a  graduate  of  the  Medical  College 
of  Virginia  Class  of  1906,  died  at  his  home  in  Richmond, 
June  13th.  For  many  years  Dr.  Jones  had  limited  his 
practice  to  pediatrics,  and  in  that  specialty  he  had  estab- 
lished an  enviable  reputation  for  skillful  and  sympathetic 
ministration. 


Dr.  Fred  Brooks,  82,  died  June  21st,  at  the  home  of  a 
patient  he  was  attending.  A  native  of  Popeshead,  Va.,  Dr. 
Brooks  started  his  practice  in  Fairfax  County  in  1883.  He 
was  president  of  the  National  Bank  of  Fairfax  for  more 
than  25  years,  for  10  years  was  chairman  of  the  County 
School  Board,  and  a  founder  of  the  Fairfax  County  Medi- 
cal Society. 


To  be  cut  and  pasted  over  parts  of  Dr.  Elliott's  article 
in  May  issue. 

P     252,    col.    1,    1.    3    to    7— 

Surgery  that  blood  plasma  could  be  used 
as  a  substitute  for  whole  blood,  that  it  could  be 
preserved  for  long  periods,  that  it  could  be  used 
without  typing  and  cross-matching.  Extensive  ex- 
perimentation developed  equipment  for  the  aseptic 

P.    252,   col.    2,   paragraph    3 — 

In  some  diseases  the  intramuscular  and  subcu- 
taneous administration  of  plasma  has  been  found 
to  be  equally  as  effective  as  the  intravenous.  These 
routes  are  particularly  effective  for  transfusion  of 
blood  plasma  into  premature  infants,  babies  and 
small  children  whose  veins  are  difficult  to  enter. 
Patients  of  this  age  who  are  in  dire  need  of  blood 
often  have  normal  red  cell  counts.  Their  need  is 
for  plasma  rather  than  for  red  cells,  and  plasma 
can  be  administered  intramuscularly  in  most  cases 
as  effectively  as  intravenously. 

P.    252,   col.   2     1st  3   lines   of   par.    5— 

Red  cells  do  not  create  colloid  csmotic  pressure 
or  materially  increase  the  effective  blood  volume 
or    pressure,    and    can    not    circulate    effectively. 

P.   253,   col.    1,   line    1  — 

heart     is     merely     a     pumping     and     propelling 

•      P.    253.    col.     I,    lm.  s    10    ami    11  — 

body  could  be       jregated  there.    However,  only  a 
part  nf  the  capillaries  arc  active  at  any  given  time 

P.    253,   col,    1,   par.   2.  line  8— 

vestigal  n       sh  ck;  namely:  (1)  decreased  cardiac 


SOUTHERN  MEDICINE  &  SURGERY 


BOOKS 


FEARFULLY  AND  WONDERFULLY  MADE:  The 
Human  Organism  in  the  Li-ht  of  Modern  Science,  by 
Renee  von  Eulenburg-Wienep,  The  Macmillan  Company, 
New  York.      1939.     $3.50. 

The  author  complains  that,  though  the  material- 
istic viewpoint  no  longer  governs  in  the  field  of 
the  exact  sciences,  it  survives  in  the  field  of  biology. 
In  his  opinion  the  intolerance  of  the  ecclesiastical 
rulers  of  the  Middle  Ages  finds  its  counterpart 
in  the  scientific  dogmatism  of  today. 

That  the  nature  of  the  cell  is  not  fully  under- 
stood, certainly  no  one  is  disposed  to  deny;  but 
the  reasoning  of  the  author  from  that  fact  will 
appear  to  many  to  be  more  ingenious  than  con- 
vincing. 

There  are  chapters  on  the  cell,  human  embry- 
ology, food  and  its  digestion,  the  blood,  on  the 
various  organs  and  systems  and  their  physiology: 
others  on  the  new  physics  and  biology,  energetics 
of  the  living  organism,  th;  different  senses  and 
on  the  human  organism  as  a  whole. 

The  book  has  an  aspect  of  metaphysical  profun- 
dity, and  it  may  have  much  meaning  to  those 
who  can  understand  it,  of  which  number  this  re- 
viewer is  not  one. 


ASAC 

15%,  by  volume  Alcohol 
Each   fl.    oz.   contains: 

Sodium  Salicylate,  U.  S.  P.  Powder 40  grains 

Sodium  Bromide,  U.  S.  P.  Granular 20  grains 

Caffeine,   U.   S.   P 4  grains 

ANALGESIC,    ANTIPYRETIC 
AND    SEDATIVE. 

Average    Dosage 

Two  to  four  teaspoonfuls  in  one  to  three  ounces  ol 
water   as   prescribed   by   the   physician. 

How   Supplied 
In  Pints,  Five  Pints  and  Gallons  to  Physicians  and 
Druggists. 

Burwell  &  Dunn  Company 

Manufacturing    tff^     Pharmacists 
Established    |HH9      m    1SS? 

CHARLOTTE,  N.  C. 


July,  1941 

X-RAY  TREATMENT  OF  CHRONIC  ARTHRITIS 
(Including  the  X-Ray  Diagnosis  of  the  Disease),  by 
Karl  Goldhamer,  M.D.,  Associate  Director.  Quincy  X- 
ray  and  Radium  Laboratories,  Quincy.  111..  Formerly 
Roentgenologist.  University  of  Vienna;  Author.  Atlas  of 
Normal  Anatomy  of  Head  as  seen  by  X-rav ;  with  fore- 
word by  Harold  Swanserg,  B.S.,  M.D..  F.A.C.P.,  Editor 
Mississippi  Valley  Medical  Journal  and  the  Radiologic  Re- 
view, Radiologist,  St  Mary's  Hospital  and  Blessing  Hos- 
pital; Director,  Quincy  X-ray  and  Radium  Laboratories. 
Radiological  Review  Publishing  Co.,  Quincy,  111.  $2.00 
post  paid. 

This  comprehensive  treatise  on  the  x-ray  treat- 
ment of  chronic  arthritis  is  based  on  the  author's 
experience  of  20  years  in  the  treatment  of  this 
disorder  in  Vienna  and  in  this  country.  Clinical 
aspects,  pathology,  roentgen  diagnosis  and  differen- 
tial diagnosis,  history  of  x-ray  therapy  and  how 
x-ray  acts  in  chronic  arthritis,  what  cases  should 
be  treated  by  x-rays,  technic  of  treatment,  report 
of  cases,  and  results — all  these  are  well  covered, 
with  numerous  illustrations  by  the  author  serving 
to  elaborate  the  text. 

A  PRIMER  FOR  DIABETIC  PATIENTS:  Bv  Russell 
M.  Wilder  M.D.,  Ph.D.,  F.A.C.P.,  Professor  and  Chief  of 
the  Department  of  Medicine  of  the  Mayo  Foundation, 
University  of  Minnesota;  Head  of  Section  on  Metabolism 
Therapy,  Division  of  Medicine,  The  Mayo  Clinic.  Sev- 
enth Edtion,  Reset.  184  pages.  Philadelphia  and  London: 
W.  B.  Saunders  Co.,  1941.     $1.75. 

The  author  puts  out  this,  the  seventh  edition 
to  bring  his  primer  right  up  to  our  present  know- 
ledge, particularly  to  describe  an  improved  use  of 


Sample    sent    to    any    physician 
request 


the    U.    S.    on 


SOUTHER.X  MEDICINE  &  SURGERY 


PROSTIGMIN  PREVENTS  ABDOMINAL  DISTENTION  AND  URINARY  RETENTION 


It  is  a  fact  that  about  75^  of  the  general  hospitals  on  our  entire  U.  S.  list  are  regular  buyers 
of  Prostigmin.  This  is  due  to  the  widespread  acceptance  of  Prostigmin  Methylsulfate  'Roche' 
among  surgeons  as  an  effective  preventive  of  postoperative  distention  and  urinary  reten- 
tion. The  recommended  dosage  schedule  consists  of  an  intramuscular  injection  of  1  cc  (1 
ampul)  of  Prostigmin  Methylsulfate  1:4000  solution  immediately  after  operation,  followed 
by  5  similar  1-cc  injections  at  2-hour  intervals.  Additional  injections  may  be  given  if  neces- 
sary; by-effects  from  the  use  of  Prostigmin  in  therapeutic  doses  are  conspicuously  absent. 

HOFFMANN-LA    ROCHE,   INC.    .    ROCHE    PARK    .   NUTLEY,    NEW    JERSEY 

Patronage  of  our  Advertisers  is  u  Mark  of  Friendship  to   the  Journal 


SOUTHERN  MEDICINE  &  SURGERY 


July.   1941 


protamine-zinc  insulin.  Certainly  nobody  knows 
more  about  diabetes  than  does  Dr.  Wilder  and 
certainly  nobody  knows  better  how  to  write  for 
patients. 

ORBITAL  TUMORS:  Results  following  the  Trans- 
cranial Operative  Attack,  by  Walter  E.  Dandy,  Osknr 
Piest,  New   York.      1941.   $5.00. 

To  meet  the  great  need  for  an  improved  tech- 
nique for  removing  tumors  of  the  orbit,  Dr.  Dandy 
has  devised  a  special  transfrontal  method  for  (op- 
erative attack  on  deep-orbit  tumors  and  any  in- 
tracranial extensions.  At  the  Hopkins  tumors  in 
the  anterior  portion  of  the  orbit  and  not  suspected 
of  intracranial  extension  are  operated  on  by  the 
ophthalmologic  surgeon  by  either  the  subconjunc- 
tival or  the  upper  orbital  route;  others  are  re- 
ferred to  the  neurosurgical  service. 

This  book  describes  the  new  operative  tech- 
nique and  the  results  obtained  by  its  use  in  the 
past  several  years  in  the  large  number  of  cases  of 
this  kind  of  tumor  brought  to  the  Johns  Hopkins 
Hospital.  Illustrative  case  reports  and  pictures, 
freely  used,  supplement  the  text.  The  operative 
mortality  has  been  very  low. 

INFANTILE  PARALYSIS:  By  Phillip  Lewln,  M.D., 
F.A.C.S.,  Associate  Professor  of  Bone  and  Joint  Surgery. 
Northwestern  University  Medical  School,  Professor  of 
Orthopedic  Surgery,  Cook  County  Graduate  School  of 
Medicine;  Attending  Orthopedic  Surgeon,  Cook  County 
and  Michael  Reese  Hospitals;  Consulting  Orthopedic 
Surgeon,  Municipal  Contagious  Disease  Hospital,  Chicago. 
Illustrated  by  Harold  Laufman,  M.D.  372  pages  with 
165  illustrations.  W.  B.  Saunders  Company,  Philadelphia 
and  London.     1941.     Price  $6.00. 

The  book  is  written  to  guide  the  student, 
family  doctor,  pediatrician  and  orthopedist  in  the 
early  recognition  and  proper  treatment  of  polio- 
myelitis. The  development  of  our  knowledge  of 
this  is  traced  from  the  earliest  times.  Peculiarities 
of  the  causative  agent,  mode  of  transmission,  re- 
sistance and  immunity  are  briefly  described.  Symp- 
toms, methods  of  examination,  diagnosis  and 
management  in  every  phase  are  detailed. 

Prognosis  depends  to  a  considerable  extent  on 
the  mother  and  the  doctor  who  sees  the  patient 
first. 

Preventive  measures  include  guarding  against 
raw  milk,  fatigue,  flies,  kissing.  Raw  fruits  and 
vegetables  should  be  carefully  selected  and  peeled 
and  cleaned.  Active  immunization,  the  use  of 
convalescent  serum,  nasal  spraying — all  are  of  un- 
certain value.  Active  general  treatment  is  required 
largely  and  frequently  from  many  individuals.  It 
is  advised  that  the  orthopedic  surgeon  be  called 
in  as  soon  as  the  disease  is  suspected. 

The  author  is  fully  conversant  with  the  present 
state  of  our  knowledge  of  poliomyelitis,  and  he 
has  written  a  book  that  contains  that  knowledge, 
which  should  be  known  to  everv  doctor  who  has 


anything   to   do   with   the   care   of   the   health   of 
children. 

THE  AMERICAN  ILLUSTRATED  MEDICAL  DIC- 
TIONARY: A  complete  Dictionary  of  the  terms  used  in 
Medicine,  Surgery.  Dentistry,  Pharmacy,  Chemistry.  Nurs- 
ing, Veterinary  Science,  Biology,  Medical  Biography,  etc. 
By  W.  A.  Newman  Dorlaxd,  A.M.,  M.D.,  F.A.C.S..  Lieut- 
Colonel,  M.R.C.,  U.  S.  Army;  Member  of  the  Committee 
on  Nomenclature  and  Classification  of  Diseases  of  the 
American  Medical  Association,  Editor  of  the  "American 
Pocket  Medical  Dictionary".  With  the  Collaboration  of 
E.  C.  L.  Miller,  M.  D.,  Medical  College  of  Virginia. 
Nineteenth  Editon,  Revised  and  Enlarged.  1647  pages 
with  914  illustrations;  including  269  portraits.  Flexible 
and  Stiff  Binding.  W.  B.  Saunders  Company,  1941. 
Phladelphia  and  London.  Plain  $7.00.  Thumb-index, 
$7.50. 

This  edition  has  received  the  thorough  revis- 
ion of  every  edition  since  the  first;  and  a  great 
many  new  words,  new  tests  and  other  things  new 
have  been  added. 

It  seems  evident  that  there  was  never  a  time, 
since  the  first  dictionary,  in  which  the  so-called 
educated  so  sadly  needed  to  use  dictionaries  assidu- 
ously— and  this  particularly  applies  to  members 
of  the  medical  profession;  and  never  were  such 
good  dictionaries  to  be  had.  The  one  under  review 
is,  in  itself,  a  good  part  of  an  excellent  medical 
library. 


July.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


A  SIMPLE  AND  EFFECTIVE  METHOD  IX  THE 

TREATMENT  OF  ECZEMA 

(Jos.  Ragany.  Trenton,  N.  J.,  in  Med.  Rcc,  June  18th) 

Two  opposing  viewpoints  as  to  the  cause  of  eczema  are 
that  it  is  caused  by  (1)  endogenous  factors  and  systemic 
disorders  and  (2)  exogenous  factors.  Those  holding  the 
first  theory  try  to  explain  skin  disease  as  the  result  of 
faulty  diet,  the  toxic  products  of  metabolism,  or  certain 
nervous  influences,  including  the  menopause,  allergic  con- 
ditions, or  personal  idiosyncrasies.  The  second  school  de- 
nies the  existence  of  internal  causes  and  considers  eczema 
as  a  manifestation  of  purely  external  irritation  or  agents 
affecting  the  skin's  surface.  Neither  is  tenable,  as  the  sole 
causal  agency. 

We  do  know  that  the  chief  underlying  physiological 
change  present  in  eczematous  conditions  is  inactivity  of 
the  sebaceous  glands  of  the  skin. 

Diseased  skins  were  treated  with  various  kinds  of  oil, 
occasionally  oil  packs  for  the  removal  of  scales  and  crusts. 
After  many  trials  the  therapy  was  limited  to  simple  olive 
oil.  having  found  that,  after  a  few  weeks'  constant  appli- 
cation, it  gave  better  results  than  any  of  the  ointments. 

The  eczematous  skin  treated  with  a  continuous  olive  oil 
dressing  was.  after  two  weeks  and  three  months,  respect- 
ively, unable  to  absorb  more  of  the  oil  through  its  surface. 
At  the  same  time,  the  skin  lost  its  dryness  and  the  eczema- 
tous condition  disappeared.  During  the  last  eight  years,  I 
have  tried  this  olive  oil  treatment  on  134  patients,  of 
whom  112  have  been  completely  cured  without  recurrences 
so  far.  The  failures  were  the  result  of  improper  methods 
of  application. 

My  treatment  did  not  include  dietary  measures,  since  I 
have  found  previously  that  these  had  no  effect  upon  the 
disorder  and  did  not  shorten  its  duration. 


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SOUTHERN  MEDICINE  &  SURGERY 


July,   1941 


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and  Allied  Countries 
Need  Your  Help  TODAY! 


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SOUTHERN  MEDICINE  &  SVRGERY 


•      1941      • 

FLORIDA'S  NEWEST  —  FINEST  &  LARGEST 

All-Year  Hotel 


THE      RIVIERA 

Near  Daytona  Beach. 

Ideal  Convention  or  Conference  Headquarters.     Capacity  400. 

The  only  Hotel  Bar  open  all  year  between 
Jacksonville  &  Palm  Beach. 

Radio  and  Fan  in  Every  Room.  Golf  Links  Artesian  Swimming 
Pool  with  Sand  Beach.  Tennis.  Badminton.  Ping  Pong.  Croquet, 
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Hall.    Banquet  Facilities.    Spacious  Gi  ountls. 

COOLEST  SPOT  IN  ALL  FLORIDA.  AT  THE  BIRTHPLACE  OF 
THE  TRADE  WINDS  Where  the  Labrador  (Arctic)  Current 
meets  the  Gulf  Stream,  and  Summer  Bathing  and  Fishing  are 
Superb 

Write  tor  Special  Summer  Rates.  April  to  December. 

Hotel  Riviera,  Box  429.  Daytona  Beach,  Fla. 

MOUNTAINEER,  TAR  HEEL  &  CRACKER 

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PROFESSIONAL    CARDS 


July.   1941 


GENERAL 


Nalla  Clinic   Building 


THE  NALLE  CLINIC 

Telephone— 3-2141    (//  no  answer,  call  3-2621) 


412  North   Church   Street,  Charlotte 


General  Surgery 

BRODIE  C.  NALLE,  M.D. 
Gynecology  &  Obstetrics.. 
EDWARD    R.    HIPP,   M.D. 

Traumatic  Surcery 

PRESTON  NOVVLIN,   M.D. 

Urology 


Consulting   Staff 

DRS.   LAFFERTY,   BAXTER   &   PARSONS 
Radiology 
BARRET   LABORATORY 
Pathology 


General  Medicine 


LUCIUS   G.   GAGE,  M.D. 
Diagnosis 


LUTHER   W.  KELLY,  M.D. 
Cardio-Respiratory   Diseases 


J.  R.  ADAMS,  M.D. 
Diseases  of  Infants  &  Children 


W.  B.  MAYER,  M.  D. 
Dermatology  &  Syphllology 


C— H— M   MEDICAL   OFFICES 

DIA  GNOSIS— SURGER  Y 

X-RAY— RADIUM 

Dr.   G  Carlyle  Cooke — Abdominal  Surgery 

&  Gynecology 
Dr.  Geo.  W.  Holmes — Orthopedics 
Dr.  C.  H.  McCants — General  Surgery 
222-226  Nissen  Bid.  Winston-Salem 


WADE   CLINIC 

Wade  Building 

Hot  Springs  National  Park,  Arkansas 


H.  King  Wade,  M.  D. 
Charles  S.  Moss,  M.D. 
Jack  Ellis,  M.D. 
Frank  M.  Adams,  M.D. 


Urology 

General  Surgery 

General  Medicine 

General  Medicine 


N.  B.  Burch,  M.D.  Eye,  Ear,  Nose  &  Throat 
Raymond  C.  Turk,  D.D.S.  Denial  Surgery 
A.  W.  Scheer  X-ray  Technician 

Etta  Wade  Clinical  Pathology 

Marjorie  Wade  Bacteriology 


INTERNAL  MEDICINE 


ARCHIE  A.  BARRON,  M.  D.,  F.A.C.P. 
INTERNAL  MEDICINE— NEUROLOGY 
Professional   Bldg.  Charlotte 


JOHN  DONNELLY,  M.  D. 

DISEASES  OF  THE  LUNGS 

324H  N.  Tryon  St.  Charlotte 


CLYDE    M.    GILMO^E,    A.  B.,    M.D. 
CARDIOLOGY— INTERNAL    MEDICINE 
Dixie  Building  Greensboro 


JAMES  M.  NORTHINGTON,  M.D. 
INTERNAL    MEDICINE— GERIATRICS 
Medical  Building  Charlotte 


ORTHOPEDICS 


HERBERT   F.   MUNT,   M.D. 
ACCIDENT  SURGERY  &  ORTHOPEDICS 

FRACTURES 
Nissen  Building  Winston-Salem, 


July.   1941 


PROFESSIONAL   CARDS 


415 


NEUROLOGY  and  PSYCHIATRY 


J.  FRED  MERRITT,  M.D. 

NERVOUS  and  MILD  MENTAL 
DISEASES 

ALCOHOL  and  DRUG  ADDICTIONS 

Glenwood    Park    Sanitarium  Greensboro 


EYE,  EAR,  NOSE  AND  THROAT 


H.  C.  NEBLETT,  M.D. 

OCULIST 

Phone   3-58S2 

Professional   Bldg.  Charlotte 


Burlington 


AMZI  J.  ELLINGTON,  M.D. 

DISEASES  of  the 
EYE,  EAR,  NOSE  and  THROAT 

Phones:   Office  992— Residence  761 

North   Carolina 


UROLOGY,   DERMATOLOGY   and   PROCTOLOGY 

THE  CROWELL   CLINIC   of   UROLOGY   and   UROLOGICAL   SURGERY 
Hours— Nine  to  Five  Telephones— 3-7101— 3-7102 

STAFF 

Andrew  J.  Crowell,  M.  D. 

(1911-1938) 

Angus  M.  McDonald,  M.  D.  Claude  B.  Squires,  M.  D. 

Suite  700-711  Professional  Building  Charlotte 


Dr.  Hamilton  W.  McKay 


Dr.  Robert  W.  McKay 


DOCTORS  McKAY  and  McKAY 


Practice  Limited  to   UROLOGY  and  GENITO-URINARY  SURGERY 

Hours  by  Appointment 

Occupying  2nd  Flood  Medical  Arts  BIdg.  Charlotte 


Raymond  Thompson,  M.  D.,  F.  A.  C.  S. 


Walter   E.   Daniel,   A.  B.,   M.  D. 


THE  THOMPSON  -  DANIEL  CLINIC 

o) 

UROLOGY  &  UROLOGICAL  SURGERY 

Fifth   Floor  Professional   Bldg. 


Charlotte 


C.  C.  MASSEY,  M.  D. 

PRACTICE  LIMITED 

TO 

DISEASES   OF    THE   RECTUM 


Professional   Bldg. 


Charlotte 


L.  D.  McPHAIL,  M.  D. 
RECTAL  DISEASES 


Professional    Bldg. 


Charlotte 


WYETT   F.   SIMPSON,   M.D. 

GENITO-URINARY   DISEASES 

Phone   1234 

Hot  Springs  National  Park  Arkansas 


PROFESSIONAL   CARDS 


July.   1941 


SURGERY 


R.   S.   ANDERSON,   M.  D. 

GENERAL  SURGERY 

144  Coast  Line  Street  Rocky  Mount 


R.  B.  DAVIS,  M.D.,  M.  M.  S.,  F.A.C.P. 
GENERAL  SURGERY 

AND 
RADIUM   THERAPY 

Hours  by  Appointment 
Piedmont-Memorial  Hosp.  Greensboro, 


WILLIAM    FRANCIS    MARTIN,   M.D. 
GENERAL  SURGERY 

Professional    Bldg.  Charlotte 


OBSTETRICS  &  GYNECOLOGY 


IVAN  M.  PROCTER,  M.D. 
OBSTETRICS   &    GYNECOLOGY 

133   Fayetteville   Street  Raleigh 


SPECIAL  NOTICES 


THE  EDITING  OF  MEDICAL  PAPERS 

This  journal  has  arranged  to  meet  the  demand  for  the  service  of  editing  and  revis- 
ing papers  on  medicine,  surgery  and  related  subjects,  for  publication  or  presentation 
to  societies.  This  service  is  rendered  on  terms  comparing  favorably  with  those  pre- 
vailing generally  in  other  Sections  of  the  Country. 


SOUTHERN  MEDICINE  &  SURGERY. 


THE  JOURNAL  OF 
SOUTHERN  MEDICINE  AND  SURGERY 

306  North  Tryon  Street,  Charlotte,  N.  C. 

The  Journal  assumes  no  responsibility  for  the  authenticity  o  f  opinion  or  statements  made  by  authors  or  in  communica- 
tions submitted  to   this  Journal  for  publication. 


JAMES   M.   NORTHINGTON,   M.  D.,   Editor 


CHARLOTTE.   N.   C,   AUGUST,   1941 


Forty-Two  Years  of  Appendictis* 

Robert  L.  Gibbon,  M.D.,  Charlotte 


OUR  SECRETARY  seems  to  think  that  I 
belong  to  a  certain  group  from  whom  it 
might  be  interesting  to  have  a  portrayal  of 
Surgery  in  the  early  period  of  what  we  know  as 
Modern  Surgery.  To  have  personally  participated 
in  much  of  this  formative  stage,  a  man  should 
have  received  his  degree  of  Doctor  of  Medicine 
not  later  than  1890.  Obviously  our  friend,  the 
secretary,  was  limited  by  the  ravages  of  time 
and  physical  infirmity,  in  available  material 
from  which  to  make  a  selection.  Under  the  circum- 
stances, let  us  hope  he  did  the  best  he  could. 

The  great  men  who  most  ably  contributed  to 
those  formative  years  of  contemporary  surgery  have 
in  a  great  measure  crossed  the  Great  Divide,  but  a 
minority  are  still  with  us.  The  autobiographies 
of  these  latter  and  the  more  numerous  biographies 
of  the  former,  together  with  the  many  articles  and 
addresses  dealing  with  the  progress  of  our  pro- 
fession, furnished  us  a  broad  as  well  as  a  detailed 
picture  of  the  old  and  of  the  new  in  surgical 
practice. 

I  feel  therefore,  that  any  formal  attempt  at  a 
resume  of  what  has  already  been  so  well  done 
would  be  in  every  aspect  but  vain  repetition.  For 
this  reason  I  shall  confine  my  remarks  to  an  effort 
to  depicit  the  gradual  adoption  of  the  New  Order 
by  the  profession  in  our  small  towns  and  cities,  at 
that  time  far  removed  from  any  of  the  great 
medical  centers  of  teaching  and  hospitals.  From 
all  information  and  observations,  I  am  convinced 
that  there  is  a  remarkable  similarity  in  the  ex- 
perience of  all  these  small  communities  such  as 
was  ours,  in  whatever  part  of  the  United  States 
they  were  situated. 

For  most  of  you  it  is  necessary  to  recall  the  type 

•Presented   to   the    meeting   of   the    Tri-State    Medical    Associatioi 
34th  and   25th. 
•The  Tri-Stati*  Medioal  Association  is  42  years  old. 


of  education  our  medical  schools  were  furnishing 
at  that  time.  In  even  the  best  of  them  the  instruc- 
tion was  almost  entirely  didactic,  and  it  was  possible 
for  a  student  who  had  never  seen  a  case  of  labor 
to  make  a  perfect  mark  on  final  examination  in 
obstetrics.  A  similar  lack  of  clinical  experience 
was  characteristic  of  other  departments.  The  nota- 
ble improvement  in  medical  teaching  is  not  the 
least  of  the  many  changes  that  distinguish  the 
present  era.  As  a  result  of  the  old  system,  the  young 
graduate,  however  well  grounded  in  the  scientific 
theories  of  the  professors  of  that  time  was 
very  poorly  prepared  in  the  art  of  practice. 
Except  for  the  fortunate  few  who  obtained 
one  of  the  rather  scarce  big  hospital  appointments, 
or  who  were  able  to  supplement  their  acquirements 
by  a  visit  to  one  of  the  great  European  universities, 
the  average  young  physician  was  compelled  to  spend 
years  in  actual  practice  before  he  became  reason- 
ably proficient.  Lucky  he  was  if  he  could  make  a 
connection  with  an  older  man,  already  established. 
In  spite  of  these  handicaps,  then  as  always,  where 
there  was  the  will  to  self  improvement  ways  and 
means  could  be  found  to  make  up  what  had  been 
lost  by  a  poor  start. 

The  medical  profession  has  always  had  a  reputa- 
tion for  professional  jealousy.  This  was  particularly 
noticable  in  small  towns.  High  hats  and  gold-headed 
canes  were  still  in  fashion,  as  indeed  were  whiskers 
in  great  variety  of  style  and  profusion.  They 
served  in  conjunction  with  a  certain  pomposity  of 
manner  in  camouflaging  not  a  few  empty  heads. 
Except  for  diseases  of  the  ear,  eye,  nose  and  throat, 
specialism  was  unknown  and  the  general  practi- 
tioner usually  considered  himself  as  proficient  as 
any  colleague  in  all  branches  of  the  curative  art. 

of   the   Carolinas    and    Virginia,    held    at   Greensboro,    February 


FORTY-TWO     YEARS    OF    APPENDICITIS— Gibbon 


August.   1941 


Some  were  even  loth  to  call  a  local  consultant 
unless  forced  bv  the  patient  or  his  friends,  for  fear 
of  diminishing  their  prestige. 

And  then  came  a  flock  of  recent  graduates, 
young  men  with  quite  a  smattering  of  bacteriology 
and  pathology  and  a  surgical  technique  which 
greatly  enlarged  the  boundaries  of  surgery,  and 
greatly  diminished  its  casualties.  They  called  it 
antiseptic  surgery;  and,  although  as  compared  with 
modern  methods  it  was  very  clumsy  and  sloppy, 
the  results  were  far  superior  to  those  of  former 
practice.  Of  course,  its  greatest  advantage  was  that 
it  opened  a  new  field  of  great  promise  and  was 
the  logical  antecedent  to  our  present  aseptic  tech- 
nique. The  surgeons  of  that  day  could  be  distin- 
guished by  their  hands,  discolored  bv  frequent 
immersion  in  various  antiseptic  solutions  ranging 
from  the  odorus  5  per  cent  carbolic  acid,  through  the 
corrosive  mercurv  chloride  1  to  1000,  to  the  lovely 
purple  of  permanganate  of  potash  in  various 
strengths.  The  introduction  of  rubber  gloves  was 
a  great  help  toward  the  solution  of  our  problem  of 
hand  sterilization.  They  also  proved  a  safeguard 
against  infection  of  the  surgeon  himself  while 
handling  infectious  wounds. 

The  small-town  surgeon  had  to  spend  much  time 
and  effort  in  frequent  visits  to  the  great  clinics 
of  the  country,  as  well  as  in  attendance  upon  meet- 
ings of  medical  and  surgical  societies.  Travel  clubs 
were  organized  and  practically  all  the  larger 
hospitals  of  the  United  States  and  Canada  were 
visited.  At  night  we  got  together  and  discussed 
what  we  had  seen  during  the  day.  I  always  felt 
that  the  Mayo  Clinic  at  Rochester,  where  there 
were  no  outside  diversions,  and  where  the  cases  were 
concentrated  in  one  place,  was  a  peculiarly  satis- 
factory place  to  visit.  The  kindly,  approachable, 
helpful  attitude  of  the  distinguished  brothers  was 
not  the  least  of  its  attractions. 

Dr.  Northington  has  given  me  some  extracts  from 
the  writings  of  prominent  surgeons  and  medical 
men  of  those  days,  dealing  with  the  then  contro- 
versial subject  of  appendicitis.  Here  is  illustrated 
how,  out  of  the  discussions  which  raged  for  years, 
our  present  attitude  toward  this  disease  was  grad- 
ually evolved. 

You  will  note  in  the  following  quotations  there 
was  quite  a  variety  of  views  as  to  the  nomencla- 
ture, and  the  etiology,  as  well  as  the  treatment. 

It  seems  remarkable  that  observations  of  the 
fact  that  general  peritonitis  and  death  could  be 
caused  by  inflammatory  destruction  of  the  appen- 
dix were  made  so  long  before  it  was  recognized 
that  appendicitis  is  far  the  commonest  cause  of  this 
disaster.  An  illustrative  case,  in  which  reference  is 
made   to   two   similar  cases,  was   reported  in   the 


territorv  of  this  Association  four-score-and-six  years 
ago. 

"A  case  of  Rupture  of  the  Appendix  Yermifor- 
mis,"  by  F.  M.  Robertson,  M.  D.,  Charleston,  S.  C. 
in  the  Charleston  Medical  Journal,  1853. 

A  stable-boy  the  property  of  the  doctor,  whose  pre- 
vious health  had  been  good,  on  August  29th  had  a 
flight  griping  pain  and  was  given  a  simple  anodyne. 
The  next  day  he  began  attending  the  horses  as  usual.  He 
was  found  lying  on  a  feed  box  having  intermittent  severe  ! 
pains  at  and  below  the  navel.  Told  to  go  to  his  room, 
as  he  was  passing  to  a  stairway  he  was  overcome  with 
violent  agony.  He  was  carried  to  his  room,  given  20 
grains  of  opium,  and  a  mustard  plaster  applied.  Four 
hcurs  later  (at  11:00  a.m.)  he  was  still  suffering  severely 
was  hiccoughing  and  vomiting.  One-half  grain  morphine 
and  a  drachm  of  chloroform  and  a  salt  enema  given.  At 
7:00  p.m.  he  was  in  less  pain,  extremely  tender.  A 
b'ister  7x8.  A  powder  of  5  grains  of  calomel,  1  grain  of 
opium  and  30  grains  of  ipecac  every  2  hours.  The  next 
day  the  boy  was  given  a  wine-glass  of  champagne  every 
half  hour.  He  went  steadily  down  hill,  died  at  2:00  a.m. 
on  September   1st. 

At  postmortem,  4  hours  later,  the  general  peritoneal 
cavity  contained  much  effusion,  an  abscess  was  found  im- 
plicating the  vermiform  appendix  which  was  raptured 
across  completely. 

In  the  present  case  the  caecum  was  perfectly 
healthy. 

This  was  the  third  case  in  the  doctor's  practice 
of  26  years.  The  first  was  reported  in  the  same 
journal,  the  Charleston  Medical  Journal,  in  1847. 

Evidently  the  Doctor  denied  his  slave  bov 
neither  his  assiduous  care  nor  his  treasured  cham- 
pagne. Evidently  it  struck  him  as  odd  that  the 
cecum  was  not  diseased.  His  intellectual  interest 
was  excited.  Here  was  the  opportunity:  but  it  went 
neglected  for  another  thirty  years. 

Gross'  System  of  Surgery  (1882)  makes 
mention  of  appendicitis,  or  even  of  typhlitis.  It 
does  say  that  perityphlitic  abscess  may  arise  from 
cancer  disease  of  the  colon,  or  vermiform  appendix, 
and  that  "the  most  common  cause  is  the  lodgement 
of  some  extraneous  matter  in  the  caecal  appendix." 

For  Pepper's  System  of  Medicine  (1884).  James 
T.  Whittaker,  Professor  of  Medicine  in  the  Medical 
Co'lege  of  Ohio,  writes: 

Tvphilitis,  inflammation  of  or  about  the  head 
of  the  colon,  more  especially  the  vermiform  proc- 
ess, is  a  disease  of  modern  recognition.  It  is  to 
Dupuytren  that  the  credit  is  due  of  having  first 
individualized  this  disease  as  a  separate  affection. 
About  the  same  time  (1827)  Longer  Villermav 
published  his  communications  in  the  Archives  gen., 
t.  v.  246,  on  the  diseases  of  the  vermiform  process. 
Stokes  and  Petrequin  (1837)  wrote  on  the  value 
of  opium  in  the  treatment  of  perforation  of  the 
vermiform  appendix.  Matterstock  (1880)  deserves 
mention  for  having  given  prominence  to  anomalies 
of  the  vermiform  appendix  in  the  etiology  of  the 


FORTY-TWO     YEARS    OF    APPENDICITIS— Gibbon 


affection.  Kraussold  expresses  his  convictions  re- 
garding the  necessity  of  early  evacuation,  by  in- 
cision, of  inflammatory  products,  as  first  practiced 
by  Willard  Parker  in  1843. 

It  is  the  rule  to  discover  in  the  vermiform  ap- 
pendix in  these  cases  either  fecal  concretions  or 
foreign  bodies.  In  cases  of  more  acute  course  the 
lesions  are  often  found  centered  about  the  verm- 
iform appendix.  The  most  various  contortions, 
adhesions,  or  erostions  are  observed  in  this  struc- 
ture. Occasionally  a  constriction  occludes  the 
course  of  the  tube,  while  the  distal  end  is  dilated 
into  a  condition  of  hydrops.  It  may  be  found  per- 
forated in  one  or  in  several  places.  The  cicatrices 
or  agglutinations  of  old  attacks  may  be  encoun- 
tered. 

In  adults  the  disease  begins  as  a  rule  with  vio- 
lent signs:  in  children  there  is  often  a  prodroma- 
tous  stage.  Fever  is  not  a  necessary  factor.  The 
pulse  is  usually  accelerated,  full  and  hard.  Every 
form  of  typhilitis  is  more  fatal  in  childhood  than 
in  adult  life.  The  greater  danger  in  childhood  lies 
in  the  greater  liability  to  peritonitis.  The  mortal- 
ity of  perityphlitis  alone  in  childhood  is  70,  in 
adult  life  30  per  cent. 

The  general  adoption  of  the  opium  treatment 
has  reduced  the  mortality  in  adult  life  from  80  per 
cent,  the  appalling  figure  of  the  older  statistics 
(Volz),  to  30  per  cent,  the  ratio  of  modern  times. 

In  1872.  Bull  of  New  York  had  to  report  67 
cases  of  perityphlitic  abscess  collected  by  him, 
mostly  treated  without  operation,  a  mortality  of 
47J/2  per  cent;  while  10  years  later  (1882)  Noyes 
of  Providence  was  able  to  report  of  100  cases 
treated  by  operation  a  mortality  of  only  IS  per 
cent. 

Since  in  childhood  perforation  has  occurred  in 
insidious  cases  after  so  slight  an  irritation  as  a 
laxative  or  an  enema,  or  even  after  a  bath,  every 
provocation  of  this  kind  should  be  avoided.  In- 
junction is  to  be  put  upon  all  solid  food  in  all 
cases  in  the  inception  as  well  as  throughout  the 
course  of  the  affection,  that  the  element  of  copros- 
tasis  be  not  superadded  to  the  irritation  of  the 
disease.  Many  cases  of  typhlitis  are  aborted  bv 
the  observance  of  absolute  rest  and  abstinence 
from  food  or  rigid  diet  at  the  start.  A  peri-  or 
paratyphlitis  demands  a  treatment  that  shall  put 
the  bowels  at  rest.  Opium  is  called  for  at  the 
start,  with  the  double  view  of  preventing  the  irreg- 
ular, spasmodic,  or  tetanic  contraction  of  the  mus- 
cular coat  and  of  obviating  the  danger  of  peri- 
tonitis. 

"When  a  quick  action  is  required,  morphine  hypo- 
dermicaliy  may  be  preferred. 

Austin  Flint,  in  the  Fifth  Edition  of  his  Practice 
of  Medicine  (1884): 
The  appendix  is  a  part  of  the  caecum,  but  in- 


flammation and  perforation  here  may  occur  inde- 
pendently of  any  affection  of  the  caecum  proper. 
The  term  typhlitis  is  applied  to  inflammation  of 
the  vermiform  appendix  as  well  as  to  caecitis.  Per- 
foration of  the  caecum  is  much  more  infrequent 
than  of  the  appendix.  Acute  inflammation  of  the 
appendix  was  described  by  James  Jackson,  in  his 
"Letters  to  a  Young  Physician" — the  pain  as 
seated  on  a  horizontal  line  connecting  the  anterior 
superior  spinous  processes  of  the  ilia  at  the  point 
where  this  line  intersects  the  right  margin  of  the 
right  rectus  muscle.  Marked  tenderness  on  pres- 
sure exists  within  a  circumscribed  space.  In  sev- 
eral cases  detailed  by  Jackson  the  pain  and  ten- 
derness, together  with  the  tumor,  slowly  disap- 
peared under  treatment  with  cathartics,  leeches,  a 
blister  to  the  part,  and  opium  to  relieve  pain.  I 
have  met  with  cases  corresponding  to  those  which 
he  described,  and  it  seems  to  me  clear  they  are 
cases  of  acute  inflammation  of  the  appendix. 

In  the  cases  which  have  come  under  my  obser- 
vation, the  patients  generally  had  had  uncomfor- 
table sensations  in  the  iliac  region  for  two  or  three 
days,  and  in  many  instances  had  taken  some  ca- 
thartic medicine  thinking  that  they  were  "bilious" 
or  needed  "clearing  out."  Suddenly  a  sharp  pain 
forced  them  to  seek  medical  advice.  In  a  short 
time  were  developed  the  symptoms  of  a  diffuse 
peritonitis  which,  under  these  circumstances, 
proves  fatal  as  a  rule.  At  the  autopsy,  generally, 
within  the  appendix  hard  bodies  are  found,  to 
which  it  is  customary  to  attribute  the  perforation. 

In  the  examination  of  bodies  dead  with  other 
diseases,  old  adhesions  are  frequently  found.  1 
have  seen  a  specimen  in  which  the  appendix  was 
attached  to  the  bladder,  and  perforation  had 
taken  place  causing  a  vesico-intestinal  fistula.  The 
first  evidence  of  this  was  the  appearance  of  a  lum- 
bricoid  worm  at  the  end  of  the  penis.  Pain  or  un- 
easiness referred  to  the  right  iliac  fossa,  without 
other  symptoms  of  disease,  should  always  excite 
apprehension  in  the  mind  of  the  physician.  Rest 
should  be  enjoined  and  cathartics  avoided.  By 
these  precautions,  if  patients  seek  advice  prior  to 
perforation,  its  occurrence  may  perhaps  be  pre- 
vented. 

It  looks  as  though  we  must  credit  the  physicians 
with  being  'way  ahead  of  the  surgeons  in  recogniz- 
ing the  dangers  from  purging  in  the  beginning  of 
an  attack  of  appendicitis. 

In  Pepper's  System  oj  Medicine,  188S,  one  year 
before  Reginald  Fitz  showed  that  typhlitis  is  very 
rare,  appendicitis  very  common,  James  T.  Whit- 
taker,  of  Cincinnati,  Professor  of  Medicine  in  the 
University  of  Ohio,  defined  typhlitis  as  "inflam- 
mation of  or  about  the  head  of  the  colon,  more 
especially  the  vermiform  appendix."  He  said  that 
under  abstinence  from  food  and  complete  rest 
many  recoveries  resulted. 


FORTY-TWO     YEARS    OF    APPENDICITIS— Gibbon 


August,   1941 


The  "History  of  Medicine,"  by  Joh.  Hermann 
Bass,  of  Worms-on-the-Rhine,(1889)  makes  no 
mention  of  appendicitis,  nor  of  Fitz. 

In  Keating's  Cyclopedia  oj  Diseases  of  Chil- 
dren, (1890)  Fenger  writes  on  Perityphlitis.  He  says 
that  Fitz  has  proposed  the  title  appendicitis.  He 
notes  that  a  case  has  been  reported  in  a  girl  of 
seven  weeks,  says  there  was  nothing  typical  in  the 
course  and  that  Morton  insists  that  salines  and 
enemata  be  employed  in  the  early  stages,  that 
Pepper  recommends  citrate  of  magnesia  at  frequent 
intervals  and  that  the  diet  in  the  acute  stage  must 
be  liquid. 

From  Flint's  Practice  oj  Medicine,  17th  Edition 
(1894): 

The  term  typhlitis  is  applied  to  inflammation  of 
the  vermiform  appendix  as  well  as  to  caecitis.  Per- 
foration of  the  caecum  is  much  more  infrequent 
than  of  the  appendix. 

Keep  in  bed  with  ice  bag  to  the  abdomen.  If 
constipated  give  calomel.  Surgical  treatment  is  in- 
dicated for  urgent  symptoms. 

Deaver  put  out  his  Treatise  on  Appendicitis  in 
1896.  There  he  advised  removing  the  appendix  as 
soon  as  the  diagnosis  has  been  made,  and  said  it 
is  difficult  to  differentiate  between  nephritic  colic 
and  appendicitis.  A  number  of  other  renal  and 
ureteral  conditions  are  mentioned  in  the  differen- 
tial diagnosis. 

When  expectant  treatment  is  the  only  alternative 
he  recommended  "the  judicious  administration  of 
laxatives,  restricted  diet  and  alleviation  of  pain. 
Medical  treatment  consists  chiefly  in  the  adminis- 
tration of  laxatives:  "In  most  cases  castor  oil  should 
be  given."  "I  am  perfectly  familiar  with  the  un- 
favorable opinion  upon  the  advisability  of  the 
administration  of  laxatives  in  appendicitis  ...  .1  do 
not  hesitate  to  offer  it  as  sound  and  rational 
therapeutics." 

Beaten  eggs,  pancreatized  milk  or  buttermilk 
were  allowed. 

In  cases  of  chronic  appendicitis  the  patient 
should  eat  sparingly  and  avoid  all  foods  that  will 
overload  the  bowels  with  residue. 

In  abscess  it  requires  skillfull  manipulation  to 
remove  the  appendix  without  infecting  the  general 
peritoneal  cavity. 

The  patient  should  be  isolated  after  operation, 
giving  no  morphine  and  absolutely  nothing  by 
mouth  for  the  first  4  hours,  no  food  for  the  first 
18  hours. 

For  the  relief  of  pain  asafoetida  suppositories 
or  enemata. 

A  close  observation  of  over  500  of  his  own 
operative  cases  forms  the  basic  of  these  earnest 
convictions. 


From  the  American  System  of  Practical  Medi- 
cine, 1898,  for  which  the  Edinburgh  surgeon,  W.  F. 
McNutt,  writes  the  Chapter  on  Appendicitis: 

We  do  not  believe  that  the  word  typhlitis  is 
doomed  to  disappear  and  give  place  to  the  term 
appendicitis.  On  the  contrary,  we  hope  that  in  the 
near  future  we  will  be  able  to  as  readily  and 
clearly  differentitate  between  caecitis  and  appen- 
dicitis as  we  now  diagnose  bronchitis  from  pneu- 
monia. 

When  boys  arrive  at  the  fighting,  \\Testling, 
climbing  age  they  develop  more  cases  of  appendi- 
citis than  do  girls  of  the  same  age. 

Any  occupation  that  produces  violent  contrac- 
tions of  abdominal  muscles  predisposes  also  to  any 
infectious  disease,  including  syphilis. 

Constipation  as  a  cause  is  much  overestimated. 
Nothing  is  more  certain  than  the  influence  of  a 
previous  attack  in  predisposing  a  person  to  appen- 
dicitis. Once  a  person  has  an  attack,  he  is  never 
safe  while  the  appendix  remains  unless  the  lumen 
becomes  obliterated,  which  it  occasionally  does 
from  repeated  attacks. 

Reaction  has  set  in  against  the  belief  that  foreign 
bodies  are  the  only  cause.  Some  say  only  4  or  5  per 
cent,   Fowler  that   they  are  rarely   the  cause. 

Blows,  falls,  lifting  heavy  weights  cause  a  goodly 
number. 

Inflammation  of  the  caecum  readily  invades  the 
appendix  by  extension. 

Some,  especially  in  England,  attribute  many 
cases  to  rheumatism  and  gout. 

Varieties  of  Appendicitis  are: 

1.  Catarrhal  or  medical  appendicitis. 

2.  Mural  or  parietal  appendicitis — may  terminate 
in  appendicitis  obliterans. 

3.  Acute  or  subacute  perforating  appendicitis  may 
properly  be  called  surgical  or  suppurative 
appendicitis.  Other  forms  may  require  surgical 
aid  but  this  variety  demands  it. 

4.  Periappendicitis,  circumscribed  or  general 
peritonitis  without  rupture  of  appendix. 

5.  Relapsing. 

6.  Recurrent. 

It  is  a  protean  disease.  Many  cases  do  not  fit 
accurately  into  any  of  these  classes.  The  tempera- 
ture is  usually  101-2,  sometimes  subnormal.  The 
cases  of  perforation  that  result  from  complete 
strangulation  of  the  appendicular  artery  are  free 
from  pain  until  perforation  has  taken  place. 

It  is  only  to  those  prone  to  be  negligent  in 
regard  to  current  literature  that  appendicitis  is  an 
obscure  disease.  Xot  more  than  five  per  cent  of 
the  cases  are  difficult  of  diagnosis. 

The  writer  has  learned  to  reserve  his  diagnosis 


August.   1941 


FORTY-TWO    YEARS    OF    APPENDICITIS— Gibbon 


in  some  cases  of  abdominal  disease  until  he  gets 
his  hand  into  the  cavity,  and  there  are  some  which 
can  not  be  decided  then. 

Pain  may  be  over  the  anomalous  position  of  the 
appendix. 

In  the  first  meeting  of  this  Association,  held  at 
Charlotte  in  1899,  Dr.  Chas.  B.  McAnally,  of 
Madison,  had  a  paper  on  "The  Medical  Treatment 
of  Appendicitis."  He  gave  calomel  followed  by 
salts,  morphine,  spirits  of  turpentine  and  warm 
applications. 

'As  we  see  no  more  than  5  per  cent  of  our  cases 
of  appendicitis  till  the  3rd  or  4th  day"  he  conclud- 
ed, "there  is  little  chance  for  early  operation." 

In  Park's  Surgery,  by  American  Authors,  (1901) 
Maurice  H.  Richardson  contributes  the  chapter  on 
Appendicitis.  He  says  the  diagnosis  is  rightly  re- 
garded as  easy;  but  at  times  it  is  impossible. 
Further  that  no  more  difficult  question  can  arise 
than  when  to  operate.  He  operates  at  once  in  all 
severe  cases  seen  early  unless  there  is  some  defi- 
nite contraindication,  also  at  any  time  unless  the 
patient  is  certainly  improving.  He  says  nothing 
about  purgation  or  pain  relief. 

In  Surgery  by  American  Authors  (1901),  Mau- 
rice H.  Richardson  gives  his  opinions: 

Prognosis  in  a  given  case  cannot  be  accurately 
determined  even  by  the  most  experienced.  An 
examination  of  the  blood — white  cell  count — may 
have  little  bearing,  at  times  be  of  great  value.  Pain 
is  at  first  paroxysmal,  later  constant.  The  temper- 
ature is  moderate.  The  pulse  is  a  better  index. 
Strangulation  of  Meckle's  diverticulum  is  to  be 
differentiated. 

Best  treatment  in  first  few  hours  of  disease  is 
immediate  operation.  Also  in  all  severe  cases  un- 
less unmistakably  improving,  and  in  all  cases  in 
which  it  is  clear  that  disease  is  limited  to  the  ap- 
pendix. The  appendix  should  be  removed  when- 
ever it  is  possible  to  do  so  without  infecting  the 
abdominal  cavity.  The  author  has  used  this 
method  in  400  consecutive  cases  without  a  death. 

The  first  volume  of  Hemmeter's  Diseases  oj  the 
Intestines  (1902)  is  dedicated  to  Reginald  Fitz 
and  says  Fitz's  original  contribution  was  published 
in  The  American  Journal  oj  Medical  Sciences  in 
1886. 

Hemmeter  forbade  foDd  for  24  hburs,  later 
giving  only  albumen  water.  For  severe  pain  l/8th 
to  1  6th  gr.  morphine.  He  gave  enemas  and  if 
they  were  unsuccessful,  purges  "even  at  the  risk 
of  aggravating  the  inflammation."  "In  chronic 
relapsing  appendicitis",  said  he  "it  is  always 
idvisable  to  consult  with  an  experienced  surgeon". 
He  advised  operation  in  case  the  symptoms  did  not 
improve  within  two  days. 

From  Hare's  Practice  oj  Medicine  (1905): 
In  a  case  of  acute  appendicitis  the  first  thing  for 


the  physician  to  do  is  to  call  in  a  surgeon  "as 
a  consultant,  not  as  an  operator."  He  forbids  all 
food  and  drink  and  purgatives,  and  says  nothing 
should  be  given  for  pain  unless  it  is  very  severe. 
By  the  end  of  36  hours,  if  symptoms  are  not 
rapidly  subsiding,  he  advises  operation. 

It  is  evident  from  the  foregoing  extracts  and 
quotations  derived  from  a  really  massive  literature 
dealing  with  this  disease,  that  the  adjustment  of 
the  problems  confronting  the  profession  at  that 
period  awaited  a  clear  recognition  of  the  symptoms, 
and  of  the  realization  by  the  public  generally  of 
the  importance  of  early  surgical  interference. 

Many  an  ambitious  young  surgeon  of  those  days 
suffered  a  devastating  blight  to  his  surgical  repu- 
tation by  having  unloaded  upon  him  a  series  of 
last-stage  cases  of  appendicitis  with  resulting 
heavy  morality  rate. 

It  has  been  truly  said  that  in  scientific  investiga- 
tion, the  solution  of  one  problem  uncovers  others 
of  like  or  greater  complexity,  and  so  the  field 
of  knowledge  broadens  far  beyond  an  ever-expand- 
ing horizon.  It  is  to  the  everlasting  credit  of  our 
profession  that  we  maintain  a  free  interchange 
of  scientific  information;  that,  with  us,  nothing 
is  allowed  to  interfere  with  the  dissemination  of 
knowledge  of  recently  discovered  facts  and  recently 
developed  methods. 

The  modern  surgeon  operates  against  a  high  per- 
centage of  operative  success.  Less  and  less  are 
baneful  results  attributed  to  the  act  of  the  Al- 
mighty and  more  and  more  to  the  doctor.  The 
personal  strain  is  greater,  the  responsibility  for 
adequate  provision  against  possible  contingencies 
and  the  necessity  for  meticulous  care  in  execution 
are  ever  present  with  us. 

The  profession  owes  a  vast  debt,  not  only  to  the 
illustrious  men  of  medicine  of  the  immediate  and 
remote  past  whose  legitimate  legatees  we  are,  but 
to  the  great  advance  during  the  last  half  century 
of  related  branches  of  science  whose  brilliant 
achievements  have  broadened  our  knowledge  and 
provided  means  and  instruments  of  precision 
wholly  absent  before.  We  are  "debtors,  therefore. 
both  to  the  Greeks  and  to  the  Barbarians"  for  our 
progress,  for  all  scientific  knowledge  is  akin. 

There  is  here  no  ground  on  which  to  base  a 
superiority  complex,  or  indulge  ourselves  in  any 
personal  delusions  of  grandeur.  The  spirit  of  our 
greatest  scientists  has  always  been  one  of  humility. 
That  great  British  surgeon,  Lord  Berkeley  Moy- 
nihan.  was  fond  of  saying,  "I  have  gathered  a 
posie  of  other  men's  flowers;  nothing  but  the 
thread  that  binds  them  is  mine  own." 

Discussion 

Tine  Skcretary:  Dr.  Foy  Robinson  was  called  to  Dur- 
ham   on    account   of    a    terrible    automobile    accident.    He 


FORTY-TWO    YEARS    OF    APPENDICITIS— Gibbon 


August,  1941 


called  me  on  the  phone  to  ask  that  I  tell  Dr.  Gibbon  and 
the  meeting  how  sorry  he  is  that  he  cannot  be  here  to 
discuss  this  paper. 

Later  he  supplied  the  following  discussion: 

Dr.  Roberson:  Mr.  President,  gentlemen  of  the  Tri- 
State  Medical  Association:  I  enjoyed  Dr.  Gibbon's  paper 
immensely.  In  his  usual  charming  and  delightful  way 
he  has  presented  a  picture  of  appendicitis  as  it  was  seen 
by  surgeons  of  other  years.  These  men  spoke  of  typhlitis, 
para-typhlitis,  peri-typhlitis  etc.  They  were  absolutely 
right — because  the  condition  they  saw  had  passed  beyond 
what  might  be  termed  appendicitis  and  was  never  recog- 
nized by  them  as  such,  because  the  early  spmptoms  of 
appendicitis  as  we  know  them  today  were  not  known  to 
the  men  of  that  generation. 

They  called  it  indigestion,  cramp  colic  etc.,  and  even  to 
day  those  same  signs  and  symptoms  are  misinterpreted 
and  typhlitis  develops.  After  an  appendix  has  ruptured 
appendicitis  ceases  to  exist  per  se,  complications  and  se- 
quelae take  charge.  Appendicitis  exists  when  the  very 
mildest  symptoms  or  signs  first  began — maybe  in  infancy — 
on  through  suppuration  and  gangrene:  but  when  the  ap- 
pendix ruptures,  or  even  before,  complications  and  se- 
quelae are  too  far-reaching  to  be  classified  as  appendici- 
tis. What  I  am  attempting  to  bring  out  is  that  we 
should  think  of  appendicitis  only  in  terms,  as  the  appendix 
itself  is  involved,  from  the  very  mildest  to  the  most 
severe  type,  before  rupture.  One  could  expostulate,  ad 
infinitum,  on  this  subject  alone,  but  let  it  go  at  that; 
beyond  this  stage  the  condition  becomes  far  more  grave  and 
should  no  longer  be  called  appendicitis. 

Modern  knowledge  and  methods  make  it  possible  to 
diagnose  appendicitis  when  it  is  appendicitis.  The  men  to 
whom  Dr.  Gibbon  referred,  accomplished  though  they 
were,  saw  typhlitis,  not  appendicitis.  Let  us  hope  that 
Dr.  Gibbon's  paper  will  so  impress  this  group  that  we 
shall  do  all  within  our  power  to  recognize  and  treat  ap- 
pendicitis while  it  is  appendicitis  and  render  typhlitis  ex- 
tinct.      Thus  the  mortality  will  become  practically  nil. 

And  Dr.  T.  C.  Bost,  Charlotte,  this: 

Dr.  Bost:  This  subject,  appendicitis,  which  Dr.  Gib- 
bon has  so  ably  discussed  is  perhaps  the  most  important 
which  has  been  discussed  in  this  meeting:  first, 
because  of  the  frequency  of  the  disease;  second,  because 
health  and  life  are  so  much  at  stake;  third,  because  the 
disease  is  so  easily  cured  if  seen  early  and  promptly  dealt 
with  surgically,  while  delay  may  and  frequently  does 
result  in  death. 

It  must  be  a  profound  sense  of  satisfaction  to  Dr.  Gib- 
bon to  have  lived  and  practiced  surgery  for  the  past  half 
century,  to  have  seen  and  to  have  contributed  to  the 
evolution  of  means  of  dealing  with  appendicitis,  and  to 
practice  the  art  as  it  is  done  today  as  contrasted  with  the 
early  days  when  there  was  so  little  knowledge  of  the 
disease  and  so  uncertain  was  the  outcome.  In  going 
through  this  long  and  trying  evolutionary  period  and  ar- 
riving at  our  present  state  of  knowledge,  Dr.  Gibbon 
has  had  a  vast  experience  over  a  long  period  of  years 
and  he  has  applied  it  in  such  a  scientific  way  as  to  further 
our  knowledge  and  assist  materially  in  standardizing  the 
surgical  principles  of  appendicitis  as  we  know  them  today. 

As  extensive  as  Dr.  Gibbon's  work  has  been  in  appendi- 
citis, I  might  say  that  he  has  not  yet  removed  my  appen- 
dix, but  several  years  ago  he  adequately  dealt  with  my 
acutely  inflamed  gallbladder;  and  after  his  removal  of 
this  offending  organ  I  made  a  prompt  and  perfect  re- 
covery and  was  soon  back  in  the  surgical  field  in  friendly 
competition  with   this  master-hand,  and  I  hope  that  we 


both  will  be  able  to  keep  this  up  for  a  long  time  without 
either  having  to  again  operate  on  the  other. 


FAVORABLE  TYPES  OF  BRAIN  TUMOR  AND  THE 
RESULTS   OF  THEIR  OPERATIVE   REMOVAL 

(Gilbert  Horrax,  Boston,  in  New  England  Jl  of  Med.,  Feb.). 

This  study  concerns  the  present  status  of  224  patients 
who  were  considered  to  have  favorable  brain  tumors 
out  of  a  total  series  of  400  verified  tumors  of  all  types. 

These  224  may  be  classed  as:  Meningiomas,  80;  acous- 
tic neuromas,  33;  pituitary  adenomas,  30;  gliomas  (most- 
ly cystic),  29;miscellaneous  (angimoas,  hemangiomatous 
cysts,  colloid  cysts  of  the  third  ventricle,  craniopharyn- 
giomas and  pinealomas,  cholesteatomas  and  unclassified 
tumors)    52. 

Among  the  224  favorable  tumors  there  were  27  operative 
deaths,  a  majority  of  12%.  Of  the  197  survivors,  10  have 
died  subsequently,  leaving  a  final  figure  of  187  patients 
who  are  living  and  whose  tumors  I  believe  have  been 
wholly  eradicated.  Twenty-seven  of  these  survivors  have 
major  disabilities  or  handicaps  that  prevent  them  from 
living  useful  lives.  Thus  160  (71%)  of  the  original  224 
with  favorable  tumors,  have  survived  for  periods  varying 
from  1  to  8  years  and  are  leading  useful  lives  with  little 
or  no   functional  loss. 

The  meningiomas  are  the  most  common  of  the  favor- 
able types  of  brain  tumors.  Acoustic  neuromas,  the 
sedond  type  of  favorable  growths,  may  almost  always  be 
recognized  from  the  tinnitus  and  increasing  deafness  on 
one  side,  followed  by  numbness  of  the  same  side  of  the 
face,  staggering,  headaches  and  in  the  later  stages  failing 
vision  due  to  choked  disk.  I  always  remove  these 
tumors  completely  at  the  primary  operation,  mortality 
under  10%.  The  inevitable  facial  paralysis,  this  can  be 
overcome  largely  by  a  spinofacial  anastomosis. 

Pituitary  adenomas  may  be  diagnosed  by  optic-nerve 
atrophy,  partial  or  complete  bitemporal  hemianopsia  and 
an  enlarged  sella  turcica — mortality  of   5%. 

Benign  gliomas  are  commoner  in  the  cerebellum  and 
most  frequent  in  children.  Intermittent  bouts  of  head- 
ache and  vomiting,  and  cerebellar  signs  and  symptoms 
are  as  a  rule  outspoken. 


THE  SIGNIFICANCE  OF  THE  TONSILS  IN  THE 
DEVELOPMENT  OF   THE   CHILD 

(A.  D.  Kaiser,  Rochester,  N.  Y  ,  in  Jl  A.  M.  A.    Oct.  5th) 

About  50%  of  children  are  subjected  to  this  procedure. 
It  is  our  opinion  that  only  some  20%  of  children  possess 
tonsils  which  should  be  removed. 

We  have  studied  a  group  of  4.400  children,  half  of 
whom  were  subjected  to  tonsillectomy.  The  other  half 
were  advised  to  be  operated  upon,  but  for  various  reasons 
did  not  accept. 

Our  statistics  are  derived  from  a  10-year  period  of  ob- 
servation. 

Sore  throat  or  tonsillitis — 38%  of  the  4,400  children  had 
tonsillitis  (at  least  two  febrile  attacks  a  year)  during  the 
first  7  years  of  life.  In  the  2,200  children  operated  upon 
the  incidence  of  sore  throat  was  decidedly  less  during  the 
first  3  years,  then  increased  in  the  next  seven  years;  but 
the  trend  was  decidedly  downward.  In  the  group  in  which 
the  operation  was  not  done,  attacks  of  tonsillitis  recurred 
with  only  slight  decrease  in  frequency.  The  incidence  of 
the  common  cold  was  the  same  for  the  two  groups. 

It  seems  probable  that  the  removal  of  adenoids  was 
of  distinct  benefit  to  the  younger  children  who  were 
subject  to  ear  infections.  The  tonsils  have  no  constant 
relation  to  infections  in  the  ear  . 


August,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


Unnecessary  Cancer  Dissemination* 

Wright  Clarkson,  M.D. — Hilmar  Schmidt,  M.D. — -Edith  Miller,  M.D. 
Petersburg,  Virginia 


WE  ARE  MINDFUL  of  the  truth  of  the 
ancient  adage,  ''To  err  is  human";  still 
we  wonder  if  physicians  fully  realize 
how  frequently  mistakes  in  handling  cancer  cases 
cause  a  needless  loss  of  life.  We  should  bear  in 
mind  the  great  truth  spoken  by  Confucius,  "To 
know  what  we  know  and  to  know  what  we  do  not 
know,  that  is  wisdom." 

It  is  impossible  for  any  one  physician  to  become 
fully  capable  in  every  branch  of  medicine  and  a 
physician  who  does  not  fully  realize  his  limitations 
is  indeed  a  dangerous  practitioner. 

In  this  presentation,  there  is  no  personal  ele- 
ment. We  are  not  trying  to  hurt  anyone,  but  we 
want  to  bring  to  your  attention,  through  a  series 
of  case  reports,  the  gross  errors  that  are  frequently 
being  made  in  the  treatment  of  cancer.  Everyone 
makes  mistakes,  but  we  should  profit  by  these  mis- 
takes, and  we  hope  that  the  errors  shown  here  will 
help  you  to  avoid  similar  errors  in  your  work. 

Somehow,  physicians  frequently  forget  the  me- 
chanics of  cancer  dissemination  which,  in  reality, 
is  quite  similar  to  an  infection.  It  begins  locally 
and  spreads  through  the  circulating  fluids  of  the 
body  to  distant  and  vital  parts.  We  should  keep 
this  fact  constantly  before  us  whenever  we  attempt 
the  examination  or  treatment  of  a  lump  or  an  ulcer 
that  may  possibly  be  malignant. 

These  reports  must  necessarily  be  very  brief,  but 
we  hope  that  they  will  be  sufficiently  illustrative  to 
make  all  of  us  fully  cognizant  of  some  needless 
errors. 

The  first  case  that  we  wish  to  discuss  is  that  of 
a  man  who  called  at  our  office  not  long  ago  with  a 
small  elevated  shiny  white  lesion  on  his  chest.  It 
was  very  hard,  but  the  patient  said  it  had  caused 
him  no  discomfort  and  that  it  was  not  growing,  so 
far  as  he  could  tell.  When  he  first  came  to  us 
everyone  had  left  for  the  day  except  the  clinical 
photographer.  She  made  a  photograph  and  gave 
the  patient  an  appointment  to  see  us  the  next 
morning.  We  heard  nothing  more  about  the  case 
until  five  months  later,  when  he  came  in  for  a 
roentgen  study  of  his  chest.  This  showed  multiple 
sarcoma  metastases  throughout  both  lungs.  On 
questioning  the  patient,  we  learned  that  his  family 
physician,  who  had  recently  bought  a  high-fre- 
nuency  machine,  had  coagulated  the  lesion.  Post- 
mortem examination  showed  that  the  tumor  was 
nrie:nally  encapsulated  and  it  proved  that  the  lung 
metastases  were  identical  with  the  original  lesion. 


We  should  always  remember  that  a  tumor  cap- 
sule is  nature's  protective  measure  and  the  enuclea- 
tion of  tumors  or  their  partial  destruction  is  dan- 
gerous therapy,  yet  these  things  are  being  done 
daily  in  physicians'  offices  throughout  the  country. 

Our  lantern-slides  today  show  also  three  cases  of 
mixed  tumor  of  the  parotid  gland  enucleated  by 
three  recent  graduates  in  medicine  in  their  re- 
spective offices.  Two  of  these  have  already  result- 
ed in  the  death  of  the  patients  and  the  outcome 
of  the  third  remains  uncertain.  All  of  our  medical 
schools  should  establish  a  chair  on  oncology  and 
pay  more  attention  to  the  training  of  students  in 
this  subject. 

Such  errors  are  far  too  common  in  our  profes- 
sion. The  group  of  cases  here  reported  include 
gross  errors  made  by  recent  graduates  in  medicine, 
by  professors  of  several  medical  schools  and  by 
members  of  various  state  boards  of  medical  exam- 
iners. A  neurogenic  sarcoma,  for  instance,  is  shown 
in  this  group.  It  was  on  the  front  of  a  woman's  leg, 
and  was  enucleated  in  the  office  of  a  member 
of  a  State  Board  of  Medical  Examiners,  with  a 
prompt  return  of  this  very  dangerous  lesion. 

We  are  showing  metastases  in  the  axilla,  in  the 
supraclavicular  regions  and,  in  fact,  all  over  the 
body  surface  of  a  patient  who  a  very  few  months 
ago  happened  to  be  visiting  his  wife,  a  patient  of 
a  professor  in  one  of  the  foremost  medical  schools 
of  this  country.  The  professor,  a  specialist,  had 
performed  a  very  successful  operation  upon  the 
wife  and  the  husband  happened  to  ask  the  doctor 
about  a  mole  on  his  back.  It  had  been  there  all 
of  his  life  and  had  given  him  no  trouble  up  to  that 
.  ime.  The  professor  walked  up  to  the  dresser  and 
picked  up  a  string  and  tied  it  tightly  about  this 
pedunculated  blue  mole.  The  undertaker  did  the 
rest  for  the  patient  in  about  ninety  days.  The 
specialist  did  an  excellent  piece  of  work  with  the 
man's  wife  because  he  was  working  in  his  special 
field,  but  melanomas  are  something  that  he  ob- 
viously knew  nothing  about. 

Not  long  ago  we  saw  a  case  of  bone  sarcoma,  in 
which  we  advised  immediate  amputation,  but  an- 
other radiologist  attempted  to  cure  this  case  by 
irradiation.    The  patient  died. 

During  the  past  year  a  prominent  radiologist 
has  been  treating  a  skin  cancer  that  involved  the 
mandible.  It  is  hard  to  understand  this  since,  so 
far  as  we  know,  there  is  no  possibility  of  curing  by 
irradiation  an  epidermoid  carcinoma  in  bone,  and 


meeting    at    tlic    Tri-Slate    Medical    As 


of    the    Carolina 


nd    Virginia,    held    at   Grecnsbor 


SOUTHERN  MEDICINE  &  SURGERY 


August,  1941 


surgery  at  a  reasonably  early  stage  gives  these  pa- 
tients a  chance  for  recovery. 

On  the  other  hand,  a  very  fine  surgeon  removed 
a  malignant  wart  on  the  back  of  a  patient's  hand 
three  times,  at  about  sixty-day  intervals.  The 
metacarpal  bone  finally  became  involved  and  the 
patient  had  to  lose  part  of  his  hand.  Irradiation 
proved  that  the  lesion  was  quite  radiosensitive  and 
the  patient  has  now  been  well  for  many  years. 

Perhaps  there  is  no  branch  of  medicine  that 
requires  such  intensive  training,  such  expensive 
equipment  and  so  many  years  of  experience  as  that 
which  we  call  oncology.  Merely  to  be  a  good  sur- 
geon or  a  good  radiologist  does  not  qualify  one  to 
deal  with  cancer. 

Most  of  our  states  have  now  been  successful  in 
running  out  cancer  quacks:  but  during  the  past 
few  months  we  have  had  two  patients  with  a  his- 
tory of  having  been  treated  with  an  arsenic  paste 
at  the  hands  of  an  old  woman  who  has  a  wide- 
spread reputation  for  "curing  cancer,"  according 
to  the  patients.  One  of  these  has  succumbed  with 
an  osteomyelitis  of  the  lower  jaw,  the  other  has 
needlessly  lost  the  entire  lower  lip  and  part  of  the 
mandible. 

For  many  years  we  have  been  stressing  the  fact 
that  improper  radium  therapy  is  permitting  more 
patients  to  die  than  good  radium  therapy  is  curing, 
and  this  is  because  only  a  very  small  percentage 
of  these  patients  are  being  treated  by  qualified  ra- 
diologists. 

Improper  treatment  by  radium  of  carcinoma  of 
the  cervix  accounts  for  most  of  this  mortality,  but 
in  this  series  we  are  showing  a  patient  who  lost  his 
eye  and  eventually  his  life  from  the  improper  use 
of  radium,  and  another  patient  who  has  lost  his 
nose  from  the  same  cause. 

We  are  showing  a  patient  with  a  very  large 
atrophied  malignant  scar  on  his  cheek  resulting 
from  an  x-ray  burn  at  the  hands  of  one  of  Amer- 
ica's leading  dermatologists;  and  a  malignant  bone 
tumor  diagnosed  as  osteomyelitis  by  a  general  prac- 
titioner who  had  recently  bought  an  x-ray  machine. 
The  tumor  was  operated  upon  on  this  diagnosis 
and  curetted.  The  patient  died. 

Speaking  of  bone  tumors,  one  must  remember 
that  not  even  the  best  radiologist  can  be  absolutely 
positive  in  all  cases  and  we  believe  that  wherever  a 
malignant  bone  tumor  is  suspected,  a  tourniquet 
should  be  placed  on  the  extremity  well  above  the 
tumor  and  a  frozen  section  made  of  the  growth.  If 
it  is  found  to  be  malignant,  a  second  tourniquet 
should  be  applied  above  the  first  and  the  limb 
amputated  between  the  two  tourniquets.  If  thisi 
procedure  were  universally  followed,  we  would  saver 
a  very  much  larger  percentage  of  the  patients  who) 
have  malignant  bone  tumors. 

Unfortunately,  one  of  the  rarest  things  in  med- 


icine is  a  good  surgical  pathologist,  and  we  are 
showing  a  large  number  of  cases  improperly  diag- 
nosed even  after  the  tissue  had  been  examined  by 
hospital  pathologists  in  various  sections  of  several 
states.  We  venture  to  say  that  the  pathologists  in 
this  country  are  not  getting  a  square  deal.  Most 
of  them  are  on  salaries  so  small  as  to  destroy  their 
incentive  to  build. 

The  pathologist,  however,  is  not  always  the 
cause  of  the  wrong  diagnosis,  for  frequently  the 
biopsy  is  taken  improperly.  We  have  shown  lan- 
tern-slides here  to  demonstrate  the  vast  difference 
in  the  microscopic  pathology  by  taking  numerous 
biopsies  on  the  same  tumor  at  different  levels.  If 
the  pathologist  is  to  diagnose  the  nature  of  the 
lesion,  you  must  be  sure  to  submit  a  fair  sample  of 
the  involved  tissue. 

It  is  impracticable  to  record  here  all  of  the  cases 
that  are  shown  by  the  lantern  slides  in  this  lec- 
ture. We  want,  however,  to  stress  the  importance 
of  intense  irradiation  five  days  every  biopsy.  We 
will  end  with  a  case  report  that  seems  to  us  to 
illustrate  the  kind  of  problem  that  we  are  facing 
almost  daily  in  our  work. 

The  patient  is  a  woman  who  went  to  see  her 
family  physician  in  June  of  1940  because  of  exces- 
sive uterine  hemorrhage.  She  was  given  hypo- 
dermic injections  of  a  pituitary  growth-stimulating 
hormone  over  a  period  of  months,  with  a  continu- 
ous increase  instead  of  a  cessation  of  the  hemor- 
rhage. On  October  24th  she  was  referred  to  a  sur- 
geon who  coagulated  her  cervix  without  taking  tis- 
sue for  a  biopsy.  She  returned  to  the  same  sur- 
geon a  month  later,  because  she  was  still  bleeding. 
At  that  time  he  made  a  biopsy  and  received  report 
of  a  very  malignant  squamous-cell  epithelioma. 
The  patient  was  then  referred  to  another  surgeon 
who  has  some  radium  and  this  surgeon  proceeded 
to  give  her  radium  therapy  on  three  occasions  at 
thirty-day  intervals.  The  amount  of  each  treat- 
ment was  inadequate,  and  the  radium  therapy  was 
spread  over  a  too  great  length  of  time ;  so  the  tumor 
naturally  became  radioresistant  and  incurable. 

We  do  not  believe  that  we  are  going  to  get  far 
in  the  reduction  of  the  mortality  rate  from  cancer 
as  long  as  patients  are  being  so  mistreated. 

We  hope  that  you  will  take  these  case  reports  in 
the  spirit  in  which  they  are  given.  No  names  will 
ever  be  ca'led  in  these  cases,  for  we  realize  that  we 
too  make  errors.  We  want  to  repeat  here  that  we 
are  not  trying  to  hurt  anyone.  We  know  that  phy- 
sicians are  not  fully  aware  of  the  seriousness  of 
their  errors  in  oncology,  and  we  know  that  the 
only  way  to  reduce  the  mortality  from  cancer  is  to 
i analyze  our  mistakes  and  to  profit  by  them. 

Discussion 
Dr.  Barker:     I  have  nothing  to  add.  only  to  thank  Dr. 
(Parsons  for  his  discussion. 

Dr.  Clarkson:     I  have  nothing  to  say  except  to  com- 


August,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


425 


pliment  Dr.  Barker  on  the  very  excellent  work  he  is  doing. 
I  feel  close  to  him  as  he  was  once  associated  with  me.  He 
is  doing  a  marvelous  piece  of  work  in  Roanoke.  I  want 
to  compliment  him  for  the  good  work  he  is  doing  .  I  wish 
we  could  build  up  a  group  of  young  men  really  specializ- 
ing in  this  field.  If  we  do  that  and  get  these  cases  re- 
ferred to  this  group,  we  will  make  progress. 

Dr.  P.  B.  Parsons,  Charlotte:  The  time  is  so  short 
that  I  just  want  to  say  a  hearty  amen  to  both  of  these 
papers.  I  have  greatly  enjoyed  hearing  this  very  per- 
tinent topic  discussed  with  such  frankness  and  such  ability. 

Just  one  point  I'd  like  to  bring  up  there  in  the  treat- 
ment of  superficial  tumors  and  the  possible  treatment  of 
deep  tumors.  I  always  try  to  get  biopsies  on  the  tissues. 
I  have  found  it  best  to  follow  them  through  from  that 
standpoint  on  the  various  types  of  basal-cell  tumors,  us- 
ually either  basal-cell  or  squamous-cell  is  to  be  recogniz- 
ed. 

It  is  as  a  lesson  rather  than  as  a  reproach  that  these 
melancholy  facts  are  recited.  It  is  a  life-saving  matter; 
and  often  a  matter  of  saving  from  months,  even  years, 
of  such  torture  as  to  make  welcome  Death's  coming  to 
bring  relief. 

Such  cases  as  have  been  presented  here  come  within 
the  experience  of  every  surgeon  and  every  radiologist  who 
sees  many  patients.  If  all  of  us  join  with  these  es- 
sayists in  reporting  such  experience,  inevitably  these  tragic 
occurrences,  these  unnecessary  deaths,  will  be  reduced  to 
a  minimum. 


SURVIVALS  OF  FIVE  TO  NINE  YEARS  OF  PATIENTS 

TREATED  FOR  CANCER 

(From   Dept.    of   Cancer,   Med.    Times,    July) 

The  New  York  State  Committee  of  the  American  So- 
ciety for  the  Control  of  Cancer  concluded  that  knowledge 
that  the  physicians  practicing  in  the  communities  of  the 
State  were  able  to  diagnosticate  cancer  and  to  provide 
suitable  treatment  when  the  patient  applied  for  examina- 
tion before  hopeless  metastases  had  developed,  would  tend 
to  relieve  the  defeatist  attitude  on  the  part  of  the  pro- 
fession as  well  as  the  laity.  The  first  report,  made  in 
1930,  from  the  six  active  hospitals  in  Monroe  County 
showed  that  43  patients  with  cancer  had  survived  the  five- 
year  period.  The  microscopic  slides  were  studied  by  three 
pathologists,  one  from  each  of  three  hospitals,  and  all  had 
concurred  in  the  original  diagnosis.  The  reports  have 
been  made  annually  since  to  a  total  of  365  cases. 

This  year  we  are  reporting  81  additional  cases,  which 
brings   the  total   number  of  five-year  survivals  to   446. 


SUDDEN  HEART  DEATH 
(P    W.  Morgan,  Emporia,  in  Jl.  Kansas  Med.  Soc,  July) 

Laymen  suspect  sudden  death  as  a  likelihood  whenever 
any  heart  abnormality  is  diagnosed.  The  lay  coroner 
does  not  hesitate  to  name  heart  disease  as  the  cause 
of  death  when  a  sudden,  unexpected  death  occurs;  only 
4%  of  all  heart  deaths  are  sudden  It  is  important  that 
physicians  be  possessed  of  the  facts  on  the  subject. 
Cardiac  sudden  death  though  accounting  for  only  4% 
of  heart  deaths  is  the  commonest  cause  of  sudden  death. 

Coronary  sclerosis  with  heart  pain  in  persons  who  have 
had  coronary  occlusion  is  the  combination  most  fre- 
quently seen  in  sudden  heart  death.  Up  to  33%  of  these 
have  died  suddenly. 

Sudden  death  in  luetic  aortitis  is  common  up  to  33%. 
Aortic  stenosis  is  the  only  valvular  abnormality  in  which 
sudden   death   is   a   threat. — 11    to    14%. 

Toxic  myocarditis  may  cause  sudden  death.  Rest  dur- 
ing infections  and  in  convalescence  is  valuable.     All  diag- 


nostic criteria  should  be  used  to  establish  the  fact  that  the 
"activity"  of  an  infection  is  over  before  allowing  patients 
up  and  about. 

Non-penetrating  wounds  of  the  heart  have  been  follow- 
ed by  sudden  death  in  21%  of  a  reported  series. 

The  definition  of  angina  pectoris  should  include  the 
phrase  ''Liable  to  die  suddenly."  There  are  therapeutic 
sudden  deaths  in  heart  disease. 


COBRA  VEN'  ANALGESIA  IN  SURGERY 

(P.    E.   Craig,  Coffeyvile,  Kan.,  in  Jl  Kansas  Med.,  July) 

Abdominal  operations  are  ordinarily  followed  by  con- 
siderable pain;  when  cobra  venom  was  employed  the 
total  dosage  and  the  number  of  injections  of  the  opiates 
were  greatly  reduced. 

Cobra  venom  exerted  no  unfavorable  action  on  the 
bowel  and  paralytic  ileus  was  not  experienced  in  any  of 
the   abdominal   operations   reported. 

Cobra  neurotoxin  when  given  to  38  surgical  patients 
helped  prevent  and  relieve  postoperative  pain..  The 
full  effect  of  the  venom  was  manifested  48  to  72  hours 
after  its  use  in  cases  prepared  two  or  three  days  for 
surgery.  Increased  dosage  on  the  day  of  operation  proved 
effective  inasmuch  as  fewer  narcotic  injections  were  re- 
quired. The  venom  is  synergic  with  the  opiates  and 
enhances  their  analgestic  properties  without  making  the 
patient  stupid.  As  a  whole,  those  patients  who  received 
injections  of  venom  were  brighter,  slept  better,  suffered 
less  from  gas  pains  and  retained  better  appetities  than  those 
who  had  been  narcotized  for  two  or  three  days  following 
surgery. 

Cobra  neurotoxin  has  cumulative  action  which  lasts 
several  days  after  injections  are  discontinued,  thereby  ex- 
tending the  postoperative  analgesia.  Its  recipient  does 
not  complain  of  blurred  vision. 

Cobra  venom  was  given  to  16  patients  three  days  preop- 
eratively,  to  14  patients  one  day  prior  to  surgery  and  to 
eight  patients  on  the  day  of  operation.  In  all  three 
groups  the  injections  were  continued  for  two  to  three 
days  after  operation. 

In  Group  I — Eight  of  the  16  needed  narcotics  for  the 
relief  of  pain. 

In  Group  II — Ten  of  the  14  required  supplemental  nar- 
co.ic   analgesia. 

In  Group  III — Each  of  the  eight  was  given  opiates 
for  the  control  of  pain;  but  in  three  instances  the  dosage 
needed  was  half  the  amount  usually  given. 

Cobra  venom,  although  slower  in  its  action  than  the 
narcotics,  produces  a  sustained  analgesia  after  the  third  or 
fourth  injection. 

It  does  not  inhibit  intestinal  peristalsis  or  narrow  the 
field  of  vision.  It  is  not  habit-forming  and  does  not  de- 
press the  patient — on  the  contrary  it  improves  the  psyche 
and   stimulates  the   appetite. 

It  is  safe  and  highly  effective  when  given  in  therapeu- 
tic doses. 

The  writer  believes  that  cobra  venom  is  a  valuable 
addition  to  the  armamentarium  of  drugs  used  by  the 
surgeon  in  his  office  and  hospital  practice. 


SNUFF-TAKING  REVIVAL 
(Editorial  in  Med.  Times,  July) 
The  tobacco  shortage  in  England  has  resulted  in  a  re- 
sort to  snuff.  The  snuff-sniffing  habit  is  encouraged  by 
three  factors:  cigarettes  are  scarce;  there  are  many  regula- 
tions against  smoking,  as  in  airplane  and  munitions  fac- 
tories;   the   blackout   prohibits   outside   lights. 

Shops   for   the   sale   of   snuff   are   increasing   in   number 
daily,  with  perfumed  brands  for  women. 


SOUTHERN  MEDICINE  &  SURGERY 


August,  1941 


CO2  Culture  Method  in  the  Diagnosis  of  Gonorrhea  and 
Undulant  Fever 

J.  M.  Feder,  M.D.,  Anderson,  South  Carolina 
Director  of  Laboratories,  Anderson  County  Hospital 


INFORMATION  gained  by  detailed  investiga- 
tion has  been  sufficiently  impressive  to  war- 
rant the  belief  that  inadequate  use  is  being 
made  of  cultural  methods  in  the  diagnosis  of  gon- 
orrhea and  undulant  fever. 

The  failure  of  routine  laboratory  workers  to 
make  these  valuable  diagnostic  aids  more  generally 
available  can  be  explained  on  the  ground  that  to 
most  of  these  the  involved  technical  procedures 
previously  described  have  appeared  almost  beyond 
the  scope  of  the  average  laboratory.  Lack  of  a 
satisfactory,  commercially  available  outfit  for  pro- 
duction of  a  suitable  carbon  dioxide  atmosphere 
has  also  been  a  factor  contributing  to  this  neglect. 

The  necessity  of  making  cultures  in  cases  of 
suspected  gonorrhea  when  slide  smears  are  negative 
has  been  amply  proven.  Leahy  and  Carpenter1 
report  that  cultural  methods  result  in  the  discovery 
of  10  per  cent  more  cases  of  gonorrhea  than  are 
discovered  by  slide  examinations  alone.  They  also 
report  that  IS  per  cent  more  cultures  were  positive 
when  an  atmosphere  reinforced  by  10  per  cent  car- 
bon dioxide  was  employed. 

Technic  for  Preparing  Media  and  Identifying  the 
Gonococcus 

Bacto-Proteose  No.  3  Agar  and  Bacto-Hemo- 
globin  prepared  by  Difco  Laboratories  were  used 
exclusively  in  our  work.  By  means  of  these  an 
entirely  satisfactory  chocolate  agar  plate  can  be 
prepared. 

Nine  grams  of  Bacto-Proteose  Agar  is  weighed 
and  suspended  in  100  c.c.  of  distilled  water  and 
two  grams  of  Bacto-Hemoglobin  is  dissolved  at  the 
same  time  in  100  c.c.  of  distilled  water  at  50°  C. 
When  solution  is  nearly  complete,  filter  through 
moistened  gauze  to  remove  coarse  particles.  Ster- 
ilize both  flasks  at  15  pounds  pressure  for  20  min- 
utes. Remove  from  autoclave  and  cool  both  flasks 
to  between  50  and  60°  C.  Mix  under  aseptic  con- 
ditions and  pour  into  petri  dishes,  being  careful  not 
to  produce  air  bubbles. 

Culture  of  Specimen 
Swabs  are  made  from  the  suspected  area  and  at 
once  immersed  in  test-tubes  containing  about  1  c.c. 
of  sterile  broth  ( Proteose-Peptone  is  very  satisfac- 
tory). It  is  essential  that  they  be  kept  moist. 
Drying  will  kill  the  gonococcus  very  rapidly. 
Plates  are  streaked  with  these  moist  swabs  and 
placed  in  the  C02  jar  under  10  per  cent  carbon 
dioxide  atmosphere  and  incubated  36  to  48  hours 
at  usual  bacteriological  incubator  temperature. 


DIFFERENTIAL    IDENTIFICATION    OF    COLONIES 

The  gonococcus  grows  on  chocolate  agar  in  typi- 
cal, convex,  transparent  colonies  1  to  3  mm.  in 
diameter  having  undulating  edges.  Inspection  alone 
is  not  sufficiently  accurate  to  warrant  its  use  espe- 
cially in  the  presence  of  mixed  bacterial  growths 
nearly  always  present  in  chronic  gonorrhea. 

The  plate  should  be  flooded  with  an  oxydase 
reagent  to  further  facilitate  identification.  This  is 
carried  out  by  making  a  1  per  cent  aqueous  solu- 
tion of  dimethyl-paraphenylene-diamine-hydrochlo- 
ride  obtainable  from  Eastman  Kodak  Company, 
Rochester,  N.  Y.  After  flooding,  the  plate  is  gently 
rotated  and  an  exsess  of  fluid  poured  off.  Obser- 
vations should  be  made  every  few  minutes  and 
specimens  should  not  be  reported  as  negative  until 
fifteen  minutes  of  such  study  has  discovered  no 
organisms.  Subcultures  should  be  made  on  carbo- 
hydrate media  (dextrose,  maltose,  saccharose  and 
lactose).  Positive  oxydase  reactions  are  noted  by  a 
change  of  color  of  the  colonies  under  investigation 
from  pink  through  various  stages  to  metallic  black. 
It  is  essential  that  subcultures  be  made  on  the  car- 
bohydrates as  soon  as  a  colony  turns  pink.  If  one 
waits  until  it  turns  black  the  cells  are  usually  dead 
and  will  not  grow. 

Confirmation  of  Identity  of  Organisms 
A  gram-stained  slide  in  the  hands  of  a  competent 
observer  is  usually  sufficient  for  routine  purposes. 
A  gram-negative  diplococcus  or  diplobacillus  is  re- 
ported by  Thompson  that  has  all  of  the  cultural 
characteristics  of  the  gonococcus  and  can  be  dif- 
ferentiated only  by  its  carbohydrate*  reaction.12 
The  minimum  requirement  from  a  medico-legal 
standpoint  is  in  our  opinion  the  isolation  of  organ- 
isms that  ferment  dextrose,  as  shown  by  the  fol- 
lowing chart,  and  that  will  not  grow  upon  plain 
agar.  It  is  to  be  noted  that  faint  growths  of  some 
strains  of  the  gonococcus  can  be  obtained  on  plain 
agar.  It  is  highly  essential  that  the  subcultures 
also  be  exposed  to  10  per  cent  dioxide  atmosphere. 

Carbohydrate  Cultural  Behavior  of  Some  of  the  Commoner 
Gram-Negative  Dipococci   (Acid  Formation) 

Microorganism  Dextrose     Maltose    Sacchrose    Lactose 

N.   gonorrhea  Positive    Negative  Negative  Negative 

N.  intracellulars  Positive  Positive  Negative  Negative 
N.    catarrhalis  Negative  Negative  Negative  Negative 

N.  sicca  Positive    Positive    Positive    Negative 

Bruceliosis,  Technic  for  Preparing  Media  for  Making 
Cuitures  From  Blood  and  Subcultures 
The  procedure  recommended  by  Huddleson3  for 
preparing  a  suitable  medium  follows: 


August,  1941 


CO*  CULTURE  METHOD— Feder 


427 


Figure  1 

1.     The  loaded,   sealed  jar   ready   for  incubation. 

2  Rack  containing  petri  dishes,  flasks  for  blood  cultures  and  test-tubes  for  subcultures.  Technician  is 
placing  acid  and  alkali  in  respective  compartments  of  mixing  tray.  (Acid  is  1-30  dilution  of  concentrated 
sulphuric  acid  and  alkali  is  an  8.4  per  cent  solution  of  sodium  bicarbonate.  Each  c.c.  of  this  will  liberate 
22.4  c.c.  of  carbon  dioxide  )  .  ».     ■       , ,  j 

3.  After  the  medium  racks  have  been  loaded  and  the  acid  and  alkali  placed,  the  jar  is  tightly  sealed 
and  tilted  gently  to  mix  the  solution,  thus  liberating  the  gas. 


Bacto-Tryptose  2.0  gram 

Sodium  Chloride  0.5  gram 

Sodium   Citrate  1.0  gram 

Distilled  Water  to  100.0  c.c. 

This  broth  is  distributed  into  SO-c.c.  cotton- 
stoppered  flasks,  allowing  20  c.c.  to  each  flask. 
The  flasks  are  inoculated  by  drawing  S  c.c.  of 
blood  from  the  patient  and  introducing  it  directly 
into  the  flask.  One  may  use  the  rubber-capped 
vials  recommended  by  Huddleson  if  C02  is  placed 
directly  into  them.  We  have  found  that  the  gas  will 
not  enter  if  one  places  a  cotton-protected  needle 
through  the  cap  while  incubating.  In  view  of  our 
desire  to  adapt  the  technic  to  the  container  de- 
scribed, cotton-plugged  flasks  have  been  substitut- 
ed for  the  capped  bottles  described  by  the  author. 
(3a.) 

The  vials  are  incubated  at  37°  C.  for  four  days 
and  subcultures  are  then  made  upon  petri  dishes 
or  slants  of  Tryptose  Agar.  These  subcultures  are, 
of  course,  incubated  in  the  C02  jar.  Recent  advice 
seems  to  point  to  the  desirability  of  having  a  25 
per  cent  gas  atmosphere  rather  than  a  10  per  cent 
when  Brucella  is  being  grown. 

Cultural  Differentiation  of  the  Various  Strains  of 
Brucella 
Huddleson  has  established  the  differentiation  of 
Brucella  types  by  their  behavior  in  the  presence 
of  certain  bacteriostatic  dyes.  Bacto-Tryptose  Agar 
can  be  employed  very  effectively  as  a  base  for  the 
thionin  and  basic  fuchsin  media  used  by  Huddle- 
son, but  the  dye  content  of  these  media  must  be 
less  than  that  employed  for  liver  infusion  agar. 
Thionin  (C.  1.920)  is  employed  in  1/200,000  dilu- 


tion (0.5  c.c.  1  per  cent  solution  of  Bacto-Thionin 
per  liter),  and  basic  fuchsin  in  1/100,000  dilution 
(dissolve  0.1  gram  Bacto-Basic  Fuchsin  (DF-4)  in 
100  c.c.  distilled  water  at  70°  C,  add  10  c.c.  per 
liter  of  medium).  The  plates  should  be  inoculated 
within  24  hours  after  pouring,  as  the  dyes  become 
reduced  in  the  medium  on  standing.  The  bacterio- 
static action  of  the  dyes  in  the  concentration  in 
tryptose  agar  is  in  every  way  comparable  with 
that  previously  described  by  Dr.  Huddleson.  Upon 
thionin  tryptose  agar,  Brucella  melitensis  and  B. 
suis  will  grow,  while  B.  abortus  is  inhibited;  upon 
basic  fuchsin  tryptose  agar,  B.  melitensis  and  B. 
abortus  develop  and  B.  suis  is  inhibited.  For  dif- 
ferentiation of  the  Brucella  types  on  the  basis  of 
hydrogen  sulfide  production  it  is  recommended  that 
Bacto-Tryptose  Agar  be  dissolved  in  a  fresh  liver 
infusion  prepared  from  %  pound  fresh  liver  per 
liter  of  distilled  water.  Differentiation  of  the  three 
Brucella  species  by  means  of  their  hydrogen  sulfide 
production  is  not  clearly  defined  when  distilled 
water  alone  is  used  in  preparing  the  medium.  For 
a  more  complete  discussion  of  Brucellosis  reference 
should  be  made  to  Dr.  Huddleson's  text,  "Brucel- 
losis in  Man  and  Animals." 

Description  and  Mechanization  of  Standardized  C02 
Jar 

Our  search  for  a  suitable  device  for  this  purpose 
started  several  years  ago  and  in  January,  1940,  a 
preliminary  description  was  presented.4  Since  that 
time,  further  improvements  have  been  made  until 
a  rather  versatile  container  has  been  devised,  pos- 
sessing sufficient  flexibility  to  meet  most  routine 
laboratory  requirements. 

The  appliance  consists  essentially  of  two  parts: 


428 


SOUTHERN  MEDICINE  &  SURGERY 


August,  1941 


1.  An  ordinary  screw  top  museum  jar. 

2.  A  rack  made  of  acid-resisting  metal  and  con- 
structed along  lines  that  will  snugly  fit  container. 

The  model  made  by  us  consists  of  two  shelves 
at  top  fitted  to  accommodate  two  ordinary  petri 
dishes.  Around  the  mid  portion  of  the  rack,  a 
metal  band  has  been  placed  bearing  clips  to  which 
test-tubes  can  be  fastened.  We  have  included  six 
clips  of  this  type.  Two  inset  clamps  on  perfor- 
ated floor  of  appliance  snugly  support  two  SO  c.c. 
flasks.  The  petri  dishes  are  used  with  chocolate 
agar  for  culture  of  the  gonococcus  and  the  test- 
tubes  containing  suitable  carbohydrate  media  as 
shown  in  above  chart  are  used  to  determine  the 
fermentation  reaction  of  colonies  isolated  from  the 
plates. 

The  flasks  are  used  for  blood  cultures  using 
technic  described  above  and  both  plates  and  tubes 
can  be  used  for  their  subculture  and  group  iden- 
tification. 

A  sliding  shelf,  divided  in  the  center,  has  been 
placed  immediately  beneath  the  flooring.  When 
medium  containers  have  been  loaded,  this  shelf  is 
withdrawn,  an  amount  of  sodium  bicarbonate  so- 
lution sufficient*  to  produce  the  required  CO2  vol- 
ume is  placed  in  one  compartment,  in  the  other  an 
equal  amount  of  1-30  dilution  of  concentrated  sul- 
phuric acid  is  introduced.  The  shelf  is  replaced 
and  the  rack  introduced  into  the  jar.  After  sealing 
the  lid,  the  two  solutions  are  mixed  by  gentle  rota- 
tion. Incubation  is  then  carried  out  in  the  usual 
manner. 

Summary 

1.  A  standardized,  simplified  technic  is  present- 
ed for  cultural  identification  of  gonococcus  and 
Brucella  in  a  carbon-dioxide  atmosphere. 

2.  Bacteriological  elaboration  has  been  purpose- 
ly eliminated  as  this  presentation  deals  essentially 
and  primarily  with  an  appliance  for  aiding  in  the 
work  rather  than  the  fine  points  of  differential 
diagnosis  encountered  after  growth  has  taken 
place. 

3.  By  using  the  methods  outlined,  no  difficulty 
should  be  encountered  in  growing  and  identifying 
the  organisms  under  discussion  by  any  clinical  lab- 
oratory, regardless  of  its  size. 

References 

1.  Leahy,  Alice  D.,  and  Carpenter,  Charles  M.:  Amer. 
Jour,  of  Syph.,  Gon  &  Ven.,  Dis.,  Vol.  20,  No.  4,  July, 
1936 

2.  Thompson,  Luther:  Jour,  oj  Inject.  Dis.,  Sept. -Oct., 
1937,  Vol.  61. 

3.  Isolation  and  Cultivation  of  Brucella  on  Bacto-Tryptose 
^gar.     Difco  Bulletin,  88,  1938. 

3a.  A  New  and  Simplified  Blood  Culture  Technic.  Feder, 
J.  M.:  Jour.  Lab.  &  Clin.  Med.,  Vol.  22,  No.  8,  May, 
1937. 

4.  Essentials  oj  Applied  Medical  Laboratory  Technic,  Fe- 
der.   Charlotte  Medical  Press,  1940,  pp.  187-191. 


*Dr.  Luther  Thompson  of  Mayo  Clinic  has 
shown  that  each  c.c  of  8.4  per  cent  sodium  bicar- 
bonate solution  will  yield  22.4  c.c.  of  carbon  diox- 
ide when  treated  with  an  equal  amount  of  1-30 
concentrated  sulphuric  acid.  Making  use  of  this 
formula,  we  have  found  that  the  museum  jar  has 
a  capacity  of  2S00  c.c.  In  view  of  the  fact  that 
extreme  accuracy  in  volume  is  not  required  and 
expediency  favors  dealing  in  round  numbers,  we 
use  10  c.c.  of  each  solution  for  culturing  for  gon- 
ococcus infections.  This  gives  an  atmosphere  ap- 
proximating 10  per  cent,  sufficiently  close  for  prac- 
tical purposes.  In  view  of  the  recommendation 
that  Brucella  grows  best  in  a  25  per  cent  replace- 
ment, we  use  25  c.c.  of  each  solution  when  that 
organism  is  being  sought. 

Experimental  work  was  carried  out  with  tubes, 
flasks  and  petri  dishes,  using  lime  water  as  an  in- 
dicator and  the  evidence  afforded  conclusively 
demonstrated  the  free  passage  of  carbon  dioxide 
into  the  containers. 

Footnote  1. — Acknowledgement  is  hereby  made  of  the 
work  of  Dr.  Luther  Thompson  of  Mayo  Clinic  and  Dr.  R. 
S.  Spray  of  the  University  of  West  Virginia.  The  device 
described  is  built  largely  upon  the  foundation  of  their 
original  investigation  without  which  it  could  not  have  been 
possible. 

Footnote  2. — We  wish  to  express  our  gratitude  to  the 
Difco  Laboratories  of  Detroit,  Michigan,  for  their  friendly 
counsel  and  also  for  supplying  the  several  items  of  culture 
media  in  carrying  out  this  work. 


ELECTRO-SHOCK  THERAPY 

(J.  L.  Fetterman,  Cleveland,  in  Ohio  State  Med.  Jl.,  July) 

At  the  meeting  of  the  American  Psychiatric  Association 
held  in  Richmond  in  May  considerable  attention  was  de- 
voted to  the  new  method  of  treating  certain  types  of  men- 
tal disease  by  inducing  coma  and  convulsions  through  elec- 
tricity. 

The  electro-shock  method  is  a  step  forward  in  the  ther- 
apeutic use  of  coma  and  convulsions  for  the  relief  of  men- 
tal disease.    In  principle  and  results  it  resembles  metrazol. 

As  a  rule,  an  alternating  current  delivering  a  voltage  of 
between  80  and  200  volts  is  applied  for  a  time  interval  of 
0.1  to  0.5  of  a  second.  Such  "treatments"  are  given  two  to 
three  times  a  week  in  a  series  of  six  to  12  coma  reactions. 

The  results  of  treatment  have  been,  in  the  main,  satis- 
factory. The  severe  melancholias  have  responded  well.  The 
consensus  was  that  this  method  had  a  remarkable  value  in 
the  affective  illnesses.  As  regards  schizophrenia,  it  might 
bring  about  an  improvement  in  the  early  cases,  but  there 
was  doubt  about  its  value  in  the  more  chronic  cases.  Sev- 
eral psychiatrists  had  had  a  patient  with  schizophrenia  of 
years'  standing  ''recovered"  after  a  series  of  12  or  so  such 
treatments.  The  complications  have  been  decidedly  less 
than  those  with  the  previous  shock  methods. 

The  freedom  from  discomfort  is  such  that  most  patients 
accept  the  treatment  willingly. 


Fallacies  ln  Mortality  Reports. — It  must  be  pointed 
out  that  part  of  the  difference  in  the  total  life  expectancy 
in  different  countries  is  due  to  the  methods  of  birth  re- 
porting. Since  immediate  registration  of  birth  is  not  re- 
quired in  some  countries,  an  infant  dying  during  the  first 
few  weeks  of  life  may  not  become  counted  as  a  live  birth. 
— H.  G.  Hadley  in  Jl  of  Med. 


August,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


Sudden  Death  From  Natural  Causes*** 

E.  B.  Save,  M.D.,  Spartanburg,  South  Carolina 


THE  END  of  life  may  come  with  startling 
suddenness,  in  any  one  of  the  seven  ages 
allowed  to  man1;  may  come  during  conva- 
lescence from,  or  at  the  very  inception  of,  serious 
illness;  and  may  even  come  to  one  in  apparent 
health,  without  warning  symptom  and  without  clin- 
ical sign  that  could  easily  be  detected.  Such  catas- 
trophe, we  call  sudden  death  from  natural  causes, 
if  not  produced  by  suicidal  or  homicidal  effort, 
and  if  it  has  not  resulted  from  the  introduction  of 
extraneous  poison  or  from  accident.  It  will  be 
understood,  I  am  sure,  that  I  apply  the  word 
death  only  to  the  complete  cessation  of  the  human 
vital  functions.  For  I  trust  that  you  may  share 
with  me  the  conviction  long  ago  voiced  by  the 
psalmist,  'My  flesh  and  my  heart  faileth;  but  God 
is  the  strength  of  my  heart,  and  my  portion 
forever.'2 

The  precise  mechanism  of  death  from  any 
cause  remains  unfathomed.  Physicians  regular- 
ly certify  the  causes  of  death,  implying  only  that 
pathological  conditions  which  they  believe  to  be 
sufficient  to  account  for  the  fact  of  death  were 
present  in  their  patients.  It  is  the  purpose  of  this 
paper  to  review  the  post-mortem  findings  that  are 
most  frequent  in  cases  of  sudden  death  from 
natural  causes,  and  to  comment  upon  a  few  that 
may  be  perplexing. 

It  is  generally  accepted  that  thorough  autop- 
sies, made  by  competent  examiners,  are  desirable, 
not  only  to  improve  mortality  statistics,  but  also 
continually  to  increase  the  diagnostic  acumen  of 
the  clinician.  The  autopsy  worth  while  is  more 
than  technique;  it  is  the  translation  into  practice 
of  an  acquaintance  both  with  pathological  process- 
es and  with  the  clinical  aspects  of  medicine.  In 
cases  of  sudden  death,  autopsies  are  almost  indis- 
pensable. They  may  serve  to  remove,  although 
sometimes  to  confirm,  the  suspicion  of  foul  play. 
Whether  an  accident,  such  as  a  fall,  precipitated 
fatal  illness  or  was  itself  the  result  of  internal 
disease,  may  sometimes  be  determined.  Questions 
of  compensation  for  workmen,  or  of  the  extent 
of  insurance  liability,  may  be  affected  by  the  out- 
come of  the  examination.  Every  practicing  path- 
ologist has  records  of  examinations  that  have  help- 
ed to  solve  each  of  these  problems  for  families,  in- 
surance companies,  or  courts  of  law. 

The  postmortem  is  seldom  an  easy  method  of 
diagnosis.     The  establishment  of  new  disease  en- 


*From    the    Pathological    Laboratory,    Spartanburg    Gen- 
eral Hospital,  Spartanburg,  S.  C. 

"Read    before    the    South    Carolina    Medical    Association     Green. 


tities  has  increased  the  responsibility.  The  want 
of  a  reliable  history  of  the  last  illness  is  an  occa- 
sional handicap.  Chemical  analyses  of  the  blood, 
useful  in  the  study  of  the  living  patient,  are  un- 
profitable when  applied  to  the  cadaver.  Microscopic 
investigation  is  sometimes  essential.  There  are, 
morever,  diseases  that  leave  no  characteristic 
structural  changes,  either  gross  or  microscopic. 
Such  clinical  conceptions  as  shock  and  paralytic 
ileus  can  never  be  verified  by  post-mortem  ap- 
pearances. In  a  small  proportion  of  cases,  no 
matter  how  thorough  the  investigation,  the  cause 
of  death  will  have  to  be  recorded  as  undetermined. 
Many  instances  have  been  reported  of  sudden 
death  from  various  causes,  some  of  them  unusual 
or  rare.  There  is  general  agreement  as  to  what 
conditions  are  ordinarily  responsible,  although 
opinion  varies  as  to  the  order  and  frequency  of 
their  occurrence.  It  is  useful  for  the  practitioner 
to  bear  in  mind  the  lesions  commonly  found,  since 
it  is  he  who  is  summoned  first  when  death  im- 
pends or  when  it  has  occurred  unexpectedly. 

Common  Causes  op  Sudden  Death 
In  Adults,  the  usual  causes  of  sudden  death 
(crime,  accidents  and  anesthesia  excluded)  are: 
acute  cardiac  failure,  often  associated  with  disease 
of  the  coronary  arteries;  massive  visceral  hem- 
orrhage, notably  that  from  a  ruptured  aneurysm 
of  the  aorta  or  from  a  cavity  in  a  tuberculous 
lung;  asphyxia  from  an  obstructive  lesion  of  the 
upper  part  of  the  respiratory  passages;  pneumonia; 
and,  if  the  postoperative  state  be  included,  pul- 
monary embolism  and  peritonitis. 

In  Children,  acute  infectious  diseases,  parti- 
cularly of  the  respiratory  organs;  intracranial 
hemorrhage;  asphyxia  from  obstruction  of  some 
portion  of  the  respiratory  tract;  and  visceral 
hemorrhages  in  the  newborn. 

The  main  deductions  in  this  paper  are  based 
upon  data  which  I  have  obtained,  during  the 
past  10  years,  from  the  examination  of  26  adults 
and  19  children  who  had  died  unexpectedly.  The 
45  cases  are  taken  from  the  records  of  548  con- 
secutive autopsies  which  were  made  at  the  Macon 
(Georgia)  Hospital  and  at  the  Spartanburg  (S. 
C.)  Genera]  Hospital.  The  series  comprises:  371 
white  persons,  and  177  negroes;  346  men  and  boys, 
and  212  women  and  girls;  413  persons  more  than 
10  years  old,  and  145  children  in  the  first  decade 
of  life.  The  analysis  includes  a  relatively  large 
proportion   of   cases   in   infancy   and   early   child- 

ville,    S.    C,    April    16th,    1941 


430 


SUDDEN    DEATH   FROM    NATURAL    CAUSES— Saye 


August,  1941 


hood.  The  results  are  set  forth  in  Table  I.  When- 
ever, reference  is  made  to  these  cases,  the  adult 
group  will  be  called  Group  A,  and  the  childhood 
group,  Group  C. 

In  the  26  adults,  the  principal  lesions  involved: 
the  circulatory  system  in  16  instances,  of  which 
8  were  of  cerebral  hemorrhage,  and  8  diseases  of 
the  heart  or  aorta;  the  lungs  or  adjacent  medias- 
tinal tissues,  in  4;  the  digestive  organs,  in  3;  the 
reproductive  organs,  in  2;  and  the  brain,  without 
conspicuous  alteration  of  the  bloodvessels,  in  but 
one  instance. 

That  these  results  accord  essentially  with  those 
of  other  workers  is  evinced  by  two  recent  pub- 
lications; one,  from  a  neighbor  institution;  and  the 
other,  from  England. 

Pund,3  of  the  University  of  Georgia,  found 
that,  in  the  cases  of  105  adults  who  had  died  sud- 
denly, the  causes  of  death  were:  diseases  of  the 
circulatory  organs,  75  times,  six  of  which  were  of 
hemorrhage  into  the  brain  or  meninges:  pulmon- 
ary diseases,  21;  brain  tumor,  1;  ruptured  tubal 
pregnancy,  1 ;  and  other  or  unknown  causes,  7 
times. 

Bedford4  reviewed  the  post-mortem  diag- 
noses in  the  cases  of  198  persons  (all  but  6  of  them 
beyond  the  first  decade  of  life)  who  were  already 
dead  when  they  arrived  at  the  Leeds  General  In- 
firmary. The  principal  lesions  were  found  in  the 
following  organs:  heart  and  aorta,  144  times,  with 
22  instances  of  aneurysm  of  the  aorta  among  the 
144;  organs  of  respiration,  19;  region  of  the 
brain,  15;  digestive  organs,  4;  urinary  bladder,  1; 
and  demonstrable  lesion  in  no  organ,  15  times. 

Heart  failure  stands  preeminent  among  the 
causes  of  sudden  death.  In  the  majority  of  cases 
atheromatous  or  sclerotic  narrowing  of  the  coronary 
arteries  may  be  demonstrated,  often  with  a  branch 
occluded  by  a  thrombus,  and  usually  with  recent 
or  older  areas  of  infarction,  or  other  secondary 
changes,  in  the  myocardium.  Coronary  throm- 
bosis was  the  cause  of  death  of  5  of  the  26  adults 
in  Group  A,  with  hemopericardium  from  rupture 
of  a  ventricle  in  3  of  the  five.  Nathanson5 
found  coronary  thrombosis  in  39  of  142  persons 
who  had  died  suddenly  of  coronary  artery  disease, 
and  rupture  of  the  heart  in  7  of  the  39.  He  con- 
cluded that  the  mechanism  of  death  from  coronary 
artery  disease  is  usually  physiologic  rather  than 
structural.  According      to     Levine,6      besides 

rupture  of  the  heart  or  aorta,  3  intrinsic  cardiac 
conditions  can  account  for  instantaneous  death: 
complete  heart  block,  ventricular  fibrillation,  and 
very  rarely,  cardiac  standstill,  which  phenomenon 
may  possibly  be  the  manifestation  of  an  over- 
active carotid  sinus  reflex.  Ruptured  aortic  aneu- 
rysm explained  2  of  the  16  deaths  from  cardio- 
vascular causes  in  Group  A.     Except  for  the  ane- 


urysm cases,  evidence  of  syphilis  was  noted  only 
once.  Hamman",  who  based  his  opinion  upon 
the  combined  statistics  from  several  sources, 
thought  that  syphilis  of  the  aorta  occurred  in  20 
per  cent  of  all  cases  of  sudden  death.  Chronic 
valvular  disease  probably  owes  its  seriousness 
mainly  to  the  accompanying  myocardial  impair- 
ment. The  single  case  in  Group  A  attributed 
to  valvular  disease  was  one  of  aortic  stenosis,  at- 
tended also  with  sclerosis  of  the  aorta  and  coron- 
ary arteries.  Death  was  sudden  in  6  of  Cabot's" 
28  cases  of  aortic  stenosis.  Congestive  heart  fail- 
ures should  not,  I  believe,  find  place  in  any  tabula- 
tion of  sudden  deaths.  They  represent  the  gradual, 
even  though  rapid,  development  of  imbalance  be- 
tween the  systemic  and  the  pulmonary  circulation, 
and  are  the  mode  of  termination,  not  only  of  some 
cardiac  diseases,  but  of  other  illnesses  as  well. 

Hemorrhage  commands  a  foremost  position  in 
every  statistical  study  of  the  causes  of  sudden 
death.  It  was  observed  in  18  of  the  26  cases  in 
Group  A;  8  times,  in  the  brain;  5,  in  diseases  af- 
fecting the  cardiovascular  organs;  twice,  in  gas- 
trointestinal viscera;  twice,  in  the  uterus;  and 
once,  in  a  tuberculous  lung. 

Cerebral  hemorrhage,  it  is  generally  believed 
seldom  causes  sudden  death.  Such  was  Osier's9 
opinion.  Lambert10  said  'Sudden  death  from  apo- 
plexy is  rare  indeed.'  However,  in  29  to  42  cases 
of  cerebral  hemorrhage  summarized  by  Pieczar- 
kowski,11  death  befell  instantaneously.  The  out- 
come was  rapidly  fatal  in  the  8  cases  in  Group  A; 
in  4  of  these,  massive  bleeding  into  a  lateral  ven- 
tricle had  disrupted  the  contiguous  cerebral  tissues. 
Lobar  pneumonia,  with  certain  atypical  fea- 
tures, is  illustrated  by  one  case  in  Group  A.  A 
negro  laborer,  61  years  of  age,  able  to  be  at  work 
in  the  afternoon,  entered  the  Macon  Hospital, 
comatose,  late  in  the  evening,  and  died  soon  after 
midnight,  of  whit  the  resident  physician  suspect- 
ed to  be  an  apoplectic  stroke.  The  ignorant  rel- 
atives who  supplied  the  history  held  the  ground- 
less belief  that  the  man  had  been  poisoned.  Well 
advanced  consolidation  of  a  lobe  of  one  lung 
was  revealed  at  autopsy.  Canavan12  found  lobar 
pneumonia  to  be  the  sole  cause  of  death  in  several 
cases  that  had  been  diagnosed  as  cerebral  hemor- 
rhage, and  emphasized  the  fact  tha  tpneumonia 
might  simulate  apoplexy  in  onset  and  symptoms. 
According  to  Osier,13  sudden  death  from  lobar 
pneumonia  occurs  most  commonly  in  the  stage  of 
gray  hepatization. 

The  restrictive  title  of  this  paper  forbids  full 
consideration  of  a  few  conditions  that  may  speed- 
ily bring  about  death.  One  of  these,  massive 
pulmonary  embolism,  it  was  stated  by  Crawford 
and  Mohler14,  usually  causes  death  in  less  than  15 
minutes.   The  lesion  often  follows  thrombophlebitis 


August,  1941 


SUDDEN    DEATH    FROM    NATURAL    CAUSES— Saye 


of  a  vein  in  the  pelvis  or  leg,  which  disease  is  itself 
usually  secondary  to  surgical  operation  upon  the 
abdomen,  to  childbirth,  or  to  local  trauma. 

In  acute  peritonitis,  Bedford4  has  reminded  us, 
death  may  ensue  almost  without  warning. 

Alcoholism  is  by  no  means  a  negligible  direct 
cause  of  death.  Apart  from  the  contribution  it 
makes  to  suicide,  homicide  and  accidental  death, 
the  mortality  rate  from  alcoholism  throughout  the 
registration  area  of  the  Nation  was  2  per  100,000 
in  1938,  the  lowest  figure  since  1921.  Assistant 
Surgeon  General  Kolb,15  of  the  U.  S.  Public 
Health  Service,  said,  'It  is  well  known  that  the 
number  of  recorded  deaths  is  much  lower  than 
the  actual  number  due  to  this  cause'.  In  the  U. 
S.  Army,  in  1939,  of  51  officers  and  enlisted  men 
who  died  in  the  States  suddenly  from  other  than 
accidental  causes  (The  mean  average  daily 
strength,  that  is,  population  was  141,523),  upon 
all  of  whom  autopsies  were  made,  acute  alcohol- 
ism was  assigned  as  the  cause  of  death  4  times.16 

Occasional  accounts  of  sudden  death  from  anal- 
gesics,17 or  from  anesthetics  given  by  skilled 
hands,18  remind  us  of  the  vigilant  care  that  is  nec- 
essary in  order  to  minimize  the  ever-present  danger 
of  anesthesia. 

Childhood  Deaths 

In  early  life,  sudden  death  is  produced  by  fac- 
tors different  from  those  which  bring  it  about 
in  later  years.  With  the  exception  of  in- 
frequent serious  malformations  of  the  heart,  and 
of  myocarditis  induced  by  such  agents  as  the 
diphtheria  toxin,  lesions  of  the  heart  are  uncom- 
mon. Hemorrhages  in  children  are  of  a  differ- 
ent order  from  the  gross  ruptures  of  large  vessels 
seen  in  adults.  Death  may  occur,  especially  in 
the  early  months  of  life,  from  apparently  mild 
illness;  and  the  marks  of  disease  post-mortem  may 
be  slight  and  vague. 

The  principal  lesions  noted  at  autopsy  in  the 
19  cases  in  Group  C  were  the  following:  pneu- 
monia, 5  times,  four  of  which  were  of  the  bron- 
chial variety;  intracranial  hemorrhage,  4  times; 
asphyxia,  2,  one  of  which  was  from  a  retropharyn- 
geal abscess;  diphtheria,  2;  congenital  hydrocepha- 
lus, 2 ;  meningitis,  also  with  aspirated  vomitus  in 
the  lungs,  1 ;  spontaneous  intraabdominal  hemor- 
rhage,  1;   and,  in  2  instances,  undertermined. 

There  is  a  paucity  of  reports  concerned  solely 
with  the  post-mortem  findings  in  cases  of  sudden 
death  in  childhood;  the  subject  yet  offers  a  ripe 
field  for  inquiry.  Summaries  of  recent  statistics 
by  Polish,  Canadian  and  English  investigators 
may  be  offered  for  comparison  with  the  data  just 
presented. 

Pieczarkowski11  analyzed  148  cases  of  sudden 
death  in  children  whose  ages  ranged  from  birth  to 
14  years.    He  found,  by  post-mortem  examination, 


causes  of  fatality  in  the  following  organs:  respira- 
tory organs,  66  times;  alimentary  viscera,  18;  both 
respiratory  and  digestive  structures,  27  times;  gen- 
eralized infectious  diseases,  16  circulatory  organs, 
6  times;  brain  and  meninges,  6;  and  other  organs, 
or  undetermined,  9  times. 

The  report  of  Goldbloom  and  Wiglesworth,10 
who  examined  at  autopsy,  30  children  two  years  old 
or  younger,  may  be  epitomized  thus:  pneumonic 
changes,  21;  asphyxia  from  aspirated  milk,  2;  in- 
tracranial hemorrhage,  2;  enteritis,  1;  appendicitis, 
1 ;  other  causes,  3. 

Simpson20  gave  as  the  main  post-mortem  diag- 
noses, in  the  cases  of  12  infants  who  had  died  sud- 
denly, the  following:  bronchopneumonia,  3  times; 
asphyxia,  2 — one  of  which  was  from  inhalation  of 
vomitus;  intracranial  hemorrhage,  1;  enteritis,  1; 
acute  tuberculosis,  1 ;  atresia  of  ureters,  1 ;  unde- 
termined cause,  3  times. 

Respiratory  tract:  Infection  and  obstructive 
lesions  of  the  respiratory  organs  exceed  other 
causes  of  sudden  death  in  children.  Farber21  has 
called  attention  to  the  hemolytic  streptococcus 
as  a  cause  of  fulminating  infections  in  the  young. 
He  encountered  a  large  number  of  cases  in  which 
the  patient  was  said  to  have  been  perfectly  well 
until  fatal  illness  set  in.  At  autopsy,  early  bron- 
chopneumonia and  edema  of  some  of  the  nerve 
tissues  were  found. 

Aspiration  of  food  or  vomitus  by  a  weakened 
infant  may  be  immediately  fatal. 

Diphtheria,  notwithstanding  the  effort  that  has 
been  made  to  eradicate  it,  continues  to  exact  a  toll 
of  young  life.  Two  deaths  from  diphtheria  are  re- 
corded in  Group  C. 

Another  impressive  case  in  the  Childhood  Group 
is  that  of  the  infant  whose  asphyxial  death  resulted 
from  the  presence  of  a  large  retropharyngeal  ab- 
scess. 

Next  in  importance  to  the  group  of  respiratory 
affections  is  that  of  hemorrhage.  Four  instances 
of  intracranial  hemorrhage  are  entered  in  Group  C, 
all  of  which  had  probably  originated  from  tears  of 
inelastic  structures  incurred  during  delivery.  Soon 
after  birth  hemorrhages,  other  than  intracranial, 
may  occasion  loss  of  life.  These,  designated  by 
Holt22  as  visceral  hemorrhages  in  the  newly  born, 
are  the  spontaneous  leakages  of  blood  which  occur 
typically  in  some  of  the  intraabdominal  and  retro- 
peritoneal organs  and  tissues.  They  seem  to  de- 
pend upon  congenital  instability  of  the  bloodves- 
sels, therein  differing  from  hemorrhagic  disease  oj 
the  newborn,  which  disease  is  characterized,  John- 
son23 has  said,  by  a  deficiency  of  prothrombin  in 
the  blood  coupled  with  a  lack  of  vitamin  K. 

Trivial  factors  seem  to  engender  death  more 
easily  in  childhood  than  in  later  life.  Koppisch24 
has  reported  the  case  of  a  6-year-old  child,  with 


SUDDEN    DEATH    FROM    NATURAL    CAUSES— Saye  August,  1941 

TABLE  /.—AUTOPSY  DIAGNOSES  IN 


ORGAN 

CHIEFLY 

INVOLVED 

Case 

Number 

Age 

Race 

Sex 

Principal 
Lesion 

ADULT  GROUP 

1 

56 

White 

Man 

Thrombosis   of   coronary   artery   Left   descending 

2 

55 

White 

Man 

Thrombosis   of  coronary   artery   Left   descending 

Heart  and  Aorta 
(8  Cases) 

3 
4 
5 
6 

54 
52 
54 
26 

White 

Negro 
White 

Negro 

Man 
Man 
Man 
Man 

Hemorrhage  from  ruptured 
coronary  artery 
Hemorrhage  from  ruptured 
coronary  artery 
Hemorrhage  from  ruptured 
coronary  artery 
Hemorrhage  from  ruptured 
aneurysm  of  arota 

7 
8 

47 
70 

Negro 
White 

Man 
Man 

Hemorrhage  from  ruptured 
dissecting  aneurysm  of  aorta 
Stenosis  of  aortic  valve 

9 

80 

White 

Man 

Hemorrhage,  cerebral 

10 

64 

White 

Man 

Hemorrhage,  cerebral 

11 

45 

White 

Woman 

Hemorrhage,  cerebral 

12 

53 

Negro 

Man 

Hemorrhage,  cerebral 

Brain 
(9  Cases) 

13 

14 

50 
37 

Negro 
Negro 

Man 
Woman 

Hemorrhage,  cerebral 
Hemorrhage,  cerebral 

15 

65 

Negro 

Man 

Hemorrhage,  cerebral 

16 

51 

White 

Man 

Hemorrhage,  cerebral 

17 
18 

16 
61 

White 

Negro 

Woman 
Man 

Tumor  of  Brain 

Lobar  pneumonia 

Lungs  & 
Mediastinum 
(4  Cases) 

19 
20 
21 
22 

62 
35 
26 
43 

White 
Negro 
Negro 
White 

Man 
Man 
Man 
Man 

Bronchopneumonia 

Acute  suppurative  mediastinitis 
and  pericarditis 
Hemorrhage,  massive 
pulmonary 
Perforated  gastric  ulcer 

Stomach,  Esophagus, 
&  Pancreas 
(3  Cases) 

23 

24 

37 
30 

Negro 
White 

Woman 
Man 

Hemorrhage  from  ruptured 
varicose  esophageal  veins 
Acute  hemorrhagic  pancreatitis 

Uterus 
(2  Cases) 

25 
26 

38 
22 

Negro 
White 

Woman 
Woman 

Hemorrhage  from  abruptio 

placentae 

Hemorrhage  from  rupture 

of  uterus 

CHILDHOOD   GROUP 

27 

2  mo. 

White 

Girl 

Hemorrhage,  intracranial 

28 
29 

1  day 
1  mo. 

Negro 

Negro 

Boy 
Girl 

Hemorrhage,  intracranial 
Hemorrhage,  intracranial 

August.  1941  SUDDEN    DEATH   FROM   NATURAL    CAUSES— Saye 

45  CASES  OF  SUDDEN  DEATH  (*)    (**) 


ORGAN 

Site  of 

Associated 

SYSTEM 

Principal 

Lesions 

Comment 

PRIMARILY 

Lesion 

INVOLVED 

(26  Cases) 

branch 

Recent  infarct  of 
myocardium 

None 

branch 

Old  myocardial  infarcts. 
Sclerosis  of  aorta,  and  other 
branches  of  coronary  artery 

None 

L.  descending  branch 

Recent  infarct  of 
myocardium 

None 

Right  branch 

Syphilis  and  atheroma 

Syphilis 

of  aorta 

complicating 

Right  branch 

Hemopericardium 

None 

(intraaortic) 

Descending  aorta 

Massive  intraabdominal 
hemorrhage 

Syphilis 

Thoracic  aorta 

Mediastinal  hemorrhage 

Syphilis 

Aortic  valve 

Sclerosis  and  calcification  of 

None 

Circulatory 

aorta.  Sclerosis  of  coronary 

(16  Cases) 

arteries 

Region  of  left  basal 

Sclerosis  of  aorta  and 

None 

ganglia 

cerebral  arteries 

Region  of  L.  basal  ganglia 

Atheroma  and  sclerosis 

None 

L.  lenticulostriate  artery 

Region  of  right  basal  ganglia 

Left  lateral  ventricle 

Right  lateral  ventricle 

Rt.  lateral  ventricle 

Rt.  lateral  ventricle 

Left  cerebellar  hemisphere 
Lower  lobe,  right  lung 

Middle  and  lower  lobes, 

rt.  lung  (lobar  distribution) 

Neck,  mediastinum, 

pericardium 

Upper  lobe,  right  lung 

Lesser  curvature  of  stomach 
prepyloric 
Gastro-esophageal  region 

Pancreas 

Uterus 

Scar  of  previous*  cesarean 
section 

(19  Cases) 

Diffuse  meningeal 

Region  of  falx  cerebri 
Diffuse  meningeal 


of  cerebral  arteries 
Sclerosis  of  aorta  and 
cerebral  arteries 
Generalized  arteriosclerosis. 
Nephrosclerosis 
Atheroma     and     sclerosis     of 
cerebral  arteries 
Sclerosis  of  cerebral 
arteries 

Sclerosis  of  aorta  and 
cerebral  arteries 
Atheroma   and  sclerosis  of 
cerebral  arteries 
None 

Sclerosis  and  atheroma 
of  aorta 
None  remarkable 

Tonsillitis  (Vincent's 

organisms  demonstrated) 

Chronic  pulmonary 

tuberculosis 

Early  acute  peritonitis 

Atrophic  cirrhosis  of  liver 

Necrosis  and  hemorrhage  in 
pancreas.      No    fat    necrosis 
Extreme  anemia 

Extreme  anemia 


Partial    atelectasis   of    lungs 

None 

Hemorrhages  in  region  of 
cardiac  interventricular 
septum,  L.  kidney,  and  peri- 
cardium. Partial  atelectasis 
of  lungs 


None 

None 

Massive 

hemorrhage 

Massive 

hemorrhage 

Massive 

hemorrhage 

Massive 

hemorrhage 

Medulloblastoma 

Gray  hepatization 

Recent  attack  of 
influenza 

Ambulant  few  hrs. 
before  death 
None 

None 

None 

Alcoholic    history 

Massive  intrauterine 
hematoma 
Intraabdominal 
hematoma 


Recent,  and  old 
bleeding 

Recent  hemorrhage 
Recent  hemorrhage 


Nervous 
(1  Case) 


Respiratory 
(4  Cases) 


Gastrointestinal 
(3  Cases) 
Genital 
(2  Cases) 


SUDDEN    DEATH    FROM    NATURAL    CAUSES— Saye 


August,   1941 


ORGAN 

CHIEFLY 

INVOLVED 

Case 

Number 

Age 

Race 

Sex 

Principal 
Lesion 

Intracranial 

30 

26  hrs. 

White 

Girl 

Hemorrhage,  intracranial 

Structures 

31 

4  mo. 

Negro 

Boy 

Hydrocephalus,  internal 

(7  Cases) 

32 

11  mo. 

White 

Boy 

Hydrocephalus,  Rt.  internal 

33 

6  wk. 

White 

Girl 

Acute  suppurative  meningo- 
encephalitis  (pneumococcus) 

34 

15  mo. 

Negro 

Girl 

Bronchopneumonia 

35 

1  mo. 

White 

Boy 

Bronchopneumonia 

36 

8  days 

White 

Boy 

Bronchopneumonia 

37 

5  days 

Negro 

Boy 

Bronchopneumonia 

Lungs,  Larynx,  and 
Retropharynx 

38 

5  yrs. 

Negro 

Girl 

Lobar  pneumonia 

(9  Cases) 

39 

4  yrs. 

White 

Girl 

Diphtheria 

40 

18  mo. 

Negro 

Girl 

Diphtheria 

41 

3  mo. 

Negro 

Boy 

Abscess,  retropharyngeal 

42 

lyr 

Negro 

Boy 

Papilloma  of  larynx  (pedunculated, 
fibroepithelial,  0.8  cm.  in  diameter) 

Ovary 
(1  Case) 

43 

1  day 

Negro 

Girl 

Hemorrhage,  massive 
intra-abdominal 

Undetermined 

44 

8  yrs. 

White 

Girl 

Undetermined  (Carbon 
tetrachloride  therapy) 

(2    Cases) 

45 

6  wk. 

Negro 

Girl 

Undetermined 

"Deaths  from   trauma,  poisoning,  anesthesia,  and  postoperative  conditions  excluded 

#From  series  of  548  consecutive  autopsies,   10-year  period,  at  Macon,  Ga.,  Hospital,  and  at  Spartanburg,    S    C,  Gi 


hookworm  disease,  whose  sudden  death  followed 
the  administration  of  oil  of  chenopodium.  I  recall 
two  similar  deaths  from  chenopodium  given  to 
little  children,  at  the  Milledgeville  (Georgia)  State 
Hospital,  several  years  ago.  In  Group  C,  there  is 
mentioned  the  case  of  an  8-year-old  girl  whose 
death  supervened  soon  after  she  had  taken  a  dose 
of  carbon  tetrachloride,  which  had  been  prescribed 
for  the  cure  of  uncinariasis.  The  inability  of  un- 
dernourished children  to  withstand  the  toxic  effects 
of  vermifuges  appears  to  be  due,  not  to  anemia 
alone,  but  to  a  need  of  additional  calcium  in  the 
blood  as  well.  Atkinson25  has  found  that  both 
deficiencies  may  be  overcome  by  giving  calcium 
and  iron  before  the  anthelmintic  treatment  is 
begun.  Iron,  he  has  learned,  acts  efficiently  in 
these  cases  as  a  hematinic  even  before  the  parasites 
are  eliminated. 

The  relationship  between  enlargement  of  the 
thymus  and  sudden  death  is  unsettled.  Hyper- 
plasia of  the  organ  may  be  present  with  few  or 
no  symptoms;  at  other  times  it  seems  to  accelerate 
death  from  some  concomitant  infectious  disease. 
Status  thymic o-lymphatkus  is  no  longer  regarded 
as  a  syndrome  adequate  to  account  for  sudden 
death.  My  faith  in  this  status  as  a  cause  of  death 
was  rudely  shaken  long  before   the   British   com- 


mittee26 decided  positively  that  the  lymphatic 
constitution  is  not  a  definite  unit  of  disease.  I 
witnessed  an  autopsy  upon  a  child  who  had  died 
suddenly,  in  which  the  single  abnormality  discov- 
ered was  an  enlarged  thymus.  Influenced  by 
articles  which  I  had  read,  I  was  persuaded  that  I 
had  seen  a  case  of  status  lymphaticus.  A  few 
days  later,  the  chemist  returned  3  grains  of  stry- 
chnine which  he  had  recovered  from  the  viscera 
of  the  lad. 

Conclusion 
If  this  brief  review  shall  contribute  to  a  better 
understanding  of  what  the  usual  antecedents  of 
sudden  death  are,  the  object  of  my  endeavor  will 
have  been  attained. 
DEATH,    be    not    proud,    though    some    have    called    thee 

Mighty  and  dreadful,  for  thou  art  not  so  .  .  . 
One  short  sleep  past,  we  wake  eternally, 

And   DEATH   shall  be  no  more   .   .   . 

— English  lyric,  Death,  by  John  Donne. 

References 
1     Shakespeare,  W.:  As  You  Like  It,  Act  2,  Scene  VII. 

2.  The   Bible,   Psalm   73,   Verse   26. 

3.  Pund,  E.  R.:  The  Pathology  of  Sudden  Death.  J.M.A. 
Ga.   24:252-258    (July)    1935. 

4.  Bedford,   T.H.B.:    The   Pathology   of   Sudden   Death, 
/.  Path  &  Bac.  36:333-347    (May)    1933. 

5.  Nathanson,    M.    H.:    Pathology    and    Pharmacology 
of   Cardiac   Syncope   and   Sudden    Death,   Arch.   Int. 


August.  1Q41 


SUDDEN    DEATH    FROM    NATURAL    CAUSES— Saye 


ORGAN 

Site  of 

Associated 

SYSTEM 

Principal 

Lesions 

Comment 

PRIMARILY 

Lesion 

INVOLVED 

Tentorium  cerebelli 

Partial  atelectasis  of  lungs 

Recent  hemorrhage 

Nervous 

Lateral  ventricles 

None 

Cengenital 

(7  Cases) 

Rt.  corpus  callosum, 

Extensive  defects  of 

Congenital  exencephaly, 

Rt.  lateral  ventricle 

cranial  bones 

region  of  nasion 

Brain  and  meninges 

Aspirated  vomitus  in  lungs. 

Aspiration   of  vomitus 

No  inflammatory  reaction. 

probably  agonal 

Lungs 

None 

None 

Lungs 

Partial  atelectasis,  both  lungs 

None 

Lungs 

None 

None 

Lungs 

None 

None 

Middle  and  lower  lobes, 

Acute  fibrinous  pleuritis 

None 

Respiratory 

Rt.  lung 

(9  Cases) 

Tonsillar  region 

Asphyxial   changes,   lungs 

Toxemia 

Region  of   uvula   and  fauces 

Asphyxial  changes  in  lungs 

Pseudomembrane 

Retropharyngeal  region 

Asphyxia 

Pneumococcus  abscess 

Larynx 

Asphyxia.  Thymus  large 

Possibly  pasms  of 
glottis.    No  noteworth} 
edema 

Region  of  Rt.  ovary 

None 

Spontaneous  visceral 

Vascular 

hemorrhage  in  newborn  ( 1  Case) 

No  lesion 

Slight  anemia 

Death  soon  after 

Lungs,  slight  changes 


Edema  and  early 
congestion  of  lungs 


hookworm  treatment      Undetermined 
None  ("2    Cases) 


Med.  58:685-702   (Oct.)   1936. 

Levine,    S.    A.:     Clinical    Heart    Disease,    page    226, 
Philadelphia,  W.   B.  Saunders  Co.,   1936. 
Hamman,   L.:    Sudden    Death,   Bull.    Johns   Hopkins 
Hosp.  55:387-415   (Dec.)    1934. 

Cabot,  R.  C,  quoted  by  Marvin,  H.  M.  and  Sulli- 
van, A.  G.:   Clinical  Observations  upon  Syncope  and 
Sudden   Death    in    Relation    to    Aortic    Stenosis,   Am. 
Heart  J.  10:   705-734   (Aug.)    1935. 
Osler,  W.   and  McCrae,  T.:    Modern  Medicine,   Ed. 
3,  Vol.  I,  page  224,  Lea  and  Febiger,   1925. 
Lambert,  A.:   Cardiac  Pain  and  Sudden   Death,  Am. 
J.   Med.  Sci.   182:769-784    (Dec.)    1931. 
Pieczarkowski,  M.  and  Olbrycht,  J.:   La  mort  nat- 
urelle    subite    chez    les    adultes    et    les    mineurs    entre 
1900  et  1930,  /.  de  Med.  de  Lyon  16:731-738   (Nov. 
20)    1935. 

Canavan,  M.  M.:  Hemiplegias  without  Visible  Brain 
Lesions  in  Pneumonias  of  Insane,  Am.  J.  Psyckiat. 
3:81-91    (Jury)    1923. 

Osler,  W.  and  McCrae,  T.:  Modern  Medicine,  Ed. 
3,  Vol.  6,  page  362,  Philadelphia,  Lea  and  Febiger. 
1925. 

Crawford,  B.  L.  and  Mohler,  H.  K.:  Clinical  and 
Pathologic  St^idy  of  Acute  Pulmonary  Embolism 
and  Thrombosis, Venn.  M.  J.  40.'  1020-1026  (Sept.) 
1937. 

Kolb,    L.:     Alcoholism     and    Public    Health,    Public 
Health    Reports    56:485-498    (Mar.    14)    1941. 
Meehan,  J.  W.:   Personal  Communication. 
Montgomery,  T.  L.:   Analgesia  with   Barbituric  Acid 
Derivatives  and  its  Relationship  to  Sudden  Death  in 
Labor,  Am.  J.  Obs.  &  Gyn.  33:745-750  (May)   1937. 


Cohn,  I.:  And  Sudden  Death,  Tex.  S.  J.  Med.  33:- 
689-693    (Feb.)    1938. 

Goldbloom,  A.  and  Wiglesworth,  F.  W.:  Sudden 
Death  in  Infancy,  Canad.  M.  A.  Jour.  38:119-129 
(Feb.)    1938. 

Simpson,  C.  K.:  Sudden  Death  from  Natural  Causes 
in  Youth,  Guy's  Hosp.  Gaz.  50:83-90  (Feb.  29)  1936. 
Farber,  S.:  Fulminating  Streptococcus  Infections  in 
Infancy,  N.  Eng.  J.  Med.  211:154-159  (July  26)  1934. 
Holt,  L.  E.  and  Howland,  J.:  Diseases  of  Infancy 
and  Childhood,  Ed.  10,  New  York,  D.  Appleton-Cen- 
tury   Co.,   1933. 

Johnson,  G.  D.:  The  Use  of  Vitamin  K  in  the  New- 
born, S.  C.  Med.  Assn.  Jour.  36:336-337  (Dec.)  1940. 
Koppisch,  E.:  Sudden  Death  in  Puerto  Rico,  Puerto 
Rico  J.  Pub.  Health  &  Trap.  Med.  9:328-345  (Mar.) 
1934. 

Atkinson,   H.    C:    Personal   Communication. 
Young,  M.  and  Turnbull,  H.  M.:  Analysis  of  Data 
Collected  by  Status  Lymphaticus  Investigation  Com- 
mittee, J.  Path  &  Bac.  34:213-258   (Mar.)    1931. 


SULFAGUANIDINE 
(Edi  in  Minn.  Med.,  July) 
Now  that  sulfaguanidinc  has  been  accepted  for  general 
use  by  the  medical  profession,  further  evaluation  in  a  larger 
number  of  cases  is  permitted.  One  is  warranted  in  prescrib- 
ing the  compound  in  acute  bacillary  dysentery.  The  results 
of  therapy  in  patients  with  typhoid  and  paratyphoid  fever, 
cholera,  and  chronic  ulcerative  colitis  will  be  awaited  with 
interest,  as  well  as  the  treatment  of  carriers  of  the  typhoid 
bacillus. 


SOUTHERN  MEDICINE  &  SURGERY 


DEPARTMENTS 


HUMAN  BEHAVIOUR 

James   K.   Hall,  M.  D.,  Editor,   Richmond,   Va. 

DOCTOR  WILLIAM  G.  SPILLER--A  MEMOIR 

I  have  become  possessed,  in  the  form  of  a  re- 
print, of  a  copy  of  the  Memoir  of  Dr.  William  G. 
Spiller,  by  my  friend,  Dr.  James  William  Mc- 
Connell.  The  brief  sketch  of  Dr.  Spiller's  life 
with  a  highly  condensed  statement  of  him  as  a 
pioneer  medical  scientist  was  read  to  the  College 
of  Physicians  of  Philadelphia  on  December  4th, 
of  last  year.  Dr.  Spiller  had  died  in  the  hospital 
of  the  University  of  Pennsylvania  on  the  previous 
18th  of  March.  Dr.  McConnell  is  peculiarly  fitted 
to  write  about  Dr.  Spiller  and  the  meaning  of  his 
life  to  scientific  medicine  in  the  domain  of  neuro- 
psychiatry. I  believe  that  Dr.  MeConnell  is  a 
nephew  of  the  late  Dr.  Charles  K.  Mills,  the 
father  or  the  founder  of  neurology  in  the  United 
States.  Dr.  McConnell  breathed  the  air  of  neurolo- 
gy, from  his  very  infancy,  and  his  earliest  years 
were  spent  in  a  deeply  thoughtful  medical  atmos- 
phere, in  which  he  soon  became  conscious  of  the 
revolutionary  changes  that  were  around  the  corner 
in  medicine. 

Some  years,  but  not  enough  of  them  to  put  Dr. 
Spiller  in  one  era  and  Dr.  McConnell  in  another 
era,  separated  the  two  in  age.  Each  witnessed 
the  growth  of  the  other  and  each  helped  to  make 
possible  the  growth  of  the  other.  Since  his  grad- 
uation from  the  Medical  School  of  the  University 
of  Pennsylvania  about  fifty  years  ago  Dr.  Mc- 
Connell has  observed  and  has  participated  in  the 
development  of  neurology  and  of  neurohistopath- 
ology  in  this  country. 

Every  young  man  who  is  contemplating  the 
study  of  medicine  should  read  the  McConnell 
Memoir  of  Dr.  Spiller.  Although  Dr.  Spiller  must 
have  acquired  an  international  reputation  as  a 
profound  medical  scientist  many  years  before  his 
death,  he  did  not  take  to  medicine  from  his  mother's 
breast,  and  there  is  no  evidence  that  he  felt  called, 
in  ecclesiastical  language,  into  medicine.  It  would 
seem  that  he  did  not  know  what  he  was  to  attempt 
to  make  of  his  life  until  his  wife  discovered  him 
and  revealed  him  to  himself.  Dr.  Spiller's  father, 
a  cloth  merchant  of  Baltimore,  was  a  native  of 
King  William  County  in  Virginia.  He  had  married 
Miss  Anne  Augusta  Maltby,  probably  in  1840-odd. 

Dr.  Spiller,  whom  Dr.  McConnell  memorializes, 
was  born  in  Baltimore,  in  the  darkest  days  of  the 
Civil   War,   on    September    13th,    1863,   less   than 


three  months  after  Gettysburg.  Before  the  lad 
who  was  to  become  the  eminent  physician  had 
reached  the  age  of  eight  years  his  mother  was 
dead;  his  father  married  again,  and  the  father,  too, 
was  dead  before  his  son  was  fifteen.  The  lad  had 
been  placed  by  his  father  in  the  Cheltenham  Mili- 
tary School,  at  Ogontz,  in  Philadelphia,  and  his 
guardian  continued  him  there  after  his  father's 
death.  Young  Spiller's  early  days  at  home,  where 
he  soon  became  both  motherless  and  fatherless. 
were  probably  not  happy.  But  he  had  a  happy 
and  a  popular  roommate  at  the  military  school  for 
whom  his  friendship  was  so  strong  that  he  followed 
him  to  Dakota.  There  young  Spiller,  city-bred, 
purchased  a  ranch  and  spent  six  years  in  growing 
wheat.  Good  fortune  brought  him  as  a  wife  his 
former  roommate's  sister,  Miss  Helen  C.  New- 
bold.  She  participated  with  him  in  the  ranching 
and  agricultural  life  for  two  or  three  years.  But 
she  was  evaluating  him,  and  her  analysis  convinced 
her  that  her  husband  was  neither  a  stockman  nor 
a  wheat-grower.  She  sensed  his  appreciation  of 
the  beautiful,  his  fondness  for  Shakspere,  for 
rhythm,  and  his  love  of  poetry  and  of  good  litera- 
ture. Even  while  living  on  the  arid  plains  of  Da- 
kota he  would  occasionally  indulge  himself  in 
writing;  verse.  Perhaps  it  was  there,  on  the  bound- 
less plains,  that  he  learned  the  art  of  concentra- 
tion. He  could  and  he  did  learn  bv  heart  long 
passages  from  Shakspere  and  from  other  poets. 

His  wife  observed  his  interest  in  the  cause  of 
of  things.  She  encouraged  him  to  study  medicine. 
He  entered  as  a  medical  student  the  University 
of  Pennsylvania  in  1889,  at  the  age  of  twenty- 
six,  and  was  graduated,  a  gold-medalist,  at  the 
top  of  his  class  in  1892,  lacking  one  year  of  being 
thirty  years  of  age. 

But  he  had  not  found  himself:  his  wife  sensed 
that.  He  had  found  his  profession  but  not  the 
particular  domain  in  it  in  which  he  belonged.  He 
was  somewhat  asocial,  certainly  a  trifle  shy,  and 
he  did  not  commingle  easily  and  joyously  with  the 
crowd.  His  wife  dissuaded  him  on  account  of 
those  traits  from  taking  an  interneship  as  a  step 
in  the  direction  of  internal  medicine. 

With  her  encouragement,  both  of  them  went 
abroad  for  his  further  study,  and  in  search  of  his 
inner  self.  A  few  months  were  spent,  perhaps  not 
profitably,  in  London;  a  year  almost  in  Berlin, 
profitably,  where  he  learned  the  language;  but  he 
found  the  medical  niche  in  which  he  wished  to 
spend  his  medical  life.  In  Vienna,  in  Obersteiner's 
laboratory,  his  interest  in  neuropathology  was 
aroused:  and  in  the  clinics  he  studied  the  reflect- 
ed symptomatology  of  the  underlying  neurologi- 
cal pathology. 


August.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


Dr.  Spiller  had  travelled  far — from  his  broad 
wheat  fields  on  the  plains  of  the  Dakotas,  through 
the  University  of  Pennsylvania,  to  London,  to 
Berlin,  to  Vienna,  and,  at  last,  to  Paris,  to  the 
celebrated  clinic  of  Dr.  J.  J.  Dejerine  and  his  wife, 
also  a  neurologist.  There  he  probably  said  to  him- 
self for  the  first  time  in  his  busy  and  somewhat 
adventurous  and  unsettled  life:  eureka,  I  have 
found  myself  and  my  life  work. 

While  Dr.  Spiller  was  abroad,  immersed  in 
study,  the  Pepper  Clinical  Laboratory  had  been 
founded  by  William  Pepper,  the  Provost  of  the 
University  of  Pennsylvania.  The  Provost  was 
anxious  that  research  in  nervous  diseases  be  un- 
dertaken in  the  new  institution,  and  the  Dean  of 
the  Medical  School  suggested  that  the  young,  un- 
known Dr.  Spiller  be  called  to  take  charge  of  that 
activity.  But  Dr.  Spiller  was  lost  to  the  authori- 
ties of  the  University  of  Pennsylvania.  At  last 
Dr.  Henrv  W.  Cattell  found  him  in  the  Dejerines' 
Laboratory  in  Paris,  and  from  there  he  was  prompt- 
ly and  without  fanfare  brought  to  the  member- 
ship of  the  faculty  of  the  School  of  Medicine  and 
placed  in  charge  of  the  research  work  in  neurology. 
In  that  field  he  laboured  unremittingly,  wherever 
he  might  be  and  in  whatever  position  he  might 
occupy — in  the  laboratory,  in  the  ward,  in  his 
private  office.  He  was  forever  in  search  of  the 
cause  of  the  deflection  from  health  and  normality 
in  the  domain  of  the  neurologic. 

Dr.  McConnell  tells  of  the  first  visit  of  Dr. 
Spiller  to  Charles  K.  Mills  on  his  return  from 
Paris,  in  1896,  to  assume  his  new  duties  and  to 
direct  the  new  investigative  work  in  the  Pepper 
Laboratory.  That  meeting  of  Dr.  Spiller  and  Dr. 
Mills,  at  which  Dr.  McConnell  was  present,  con- 
stituted an  event  in  American  neurology;  it  mark- 
ed the  beginning  of  scientific  neurology  in  the 
United  States. 

Soon  Dr.  Spiller  was  at  the  head  of  the  clinic 
in  nervous  diseases  in  the  Polyclinic  Hospital,  on 
Lombard  Street  at  Nineteenth.  It  was  there,  in 
my  interneship  days,  that  I  came  to  know  Dr. 
Spiller,  and  to  develop  an  appreciation  of  his 
zeal,  his  enthusiasm,  and  his  insistent  search  for 
the  causes  of  things.  The  most  inert  interne  was 
quickened  by  the  vigor  and  the  directness  with 
which  Dr.  Spiller  investigated  the  condition  of 
his  patients  in  the  clinic.  We  sensed  that  he  was 
forever  trying  to  find  out  in  understandable  terms 
the  causes  of  the  conditions  that  brought  the 
patients  to  his  clinic. 

Dr.  Spiller  was  tallish,  thin,  stooped,  never  ruddy 
nor  robust-looking,  and  we  would  wonder  how 
such  somatic  sparseness  could  elaborate  so  much 
physical  and  intellectual  vigor.  There  was  never 
a  dull,  static,  or  prosaic  moment  where  he  was.  We 
felt  that  he  was  ceaselessly  impelled  by  a  scientific 


curiosity  that  would  permit  no  rest  of  body  or  of 
mind  until  the  truth  had  been  uncovered.  In  the 
Polyclinic  Hospital  of  the  University  of  Pennsyl- 
vania, in  the  Philadelphia  General  Hospital  (Old 
Blockley),  he  did  most  of  his  work  from  1896  until 
the  roll  of  the  years  had  brought  him  into  a  state 
of  inactivity  only  a  little  while    before  his  death. 

I  recall  the  interest  displayed  by  Dr.  Spiller  in 
pellagra  as  soon  as  that  disease  fell  with  such 
pestilential-like  fury  upon  certain  regions  of  the 
South.  I  had  gone  in  mid-summer,  1905,  directly 
from  my  interneship  in  the  Polyclinic  Hospital  to 
the  Medical  Staff  of  the  State  Hospital  at  Mor- 
ganton.  There  in  mid-summer,  1906,  I  had  wit- 
nessed the  death  of  a  young  man  from  a  condition 
that  I  knew  I  had  not  seen  before.  I  examined 
him  carefully,  I  made  copious  notes,  but  the  intrac- 
table diarrhea,  the  inflamed  gastro-intestinal  canal, 
the  blistered  hands,  and  the  associated  delirium, 
which  steadily  lessened  his  strength,  all  defied  my 
efforts,  and  he  sunk  down  into  the  grave  of  exhaus- 
tion. I  did  not  know  his  malady.  I  knew  that  I 
did  not  understand  his  ailment.  A  year  later,  when 
I  read  in  the  Journal  oj  the  American  Medical  As- 
sociation's issue  for  July  6th,  1907,  the  report  by 
Dr.  George  H.  Searcy  of  the  presence  of  pellagra 
in  the  State  Hospital  in  Alabama,  I  remarked 
aloud  to  myself:  why,  that  is  what  killed  the  Ward 
boy  last  summer.  Within  a  few  minutes  I  had 
asked  Dr.  Isaac  M.  Taylor,  who  had  sent  the  pat- 
ient to  the  State  Hospital,  if  he  had  read  the  re- 
port of  Dr.  Searcy.  He  replied  that  he  knew  Dr. 
Searcy  well,  and  that  as  soon  as  he  could  read  the 
report  he  would  call  me.  When  Dr.  Taylor  called, 
less  than  an  hour  later,  his  remark  was  that  he 
and  I  should  have  written  Dr.  Searcy's  report  a 
year  earlier.  I  had  never  before  seen  pellagra,  but 
Dr.  Taylor  told  me  that  during  his  sixteen  years 
of  service  in  the  State  Hospital  he  had  seen  death 
come  to  patients  after  months  of  wasting  away 
from  diarrhea,  eczema  on  the  backs  of  the  hands, 
sore  mouth  and  delirium.  The  clinical  records  of 
the  State  Hospital  at  Morganton  recorded  such 
symptoms  long  before  the  outbreak  of  pellagra 
in  that  region  soon  after  1900. 

Dr.  P.  V.  Anderson,  my  present  associate,  came 
also  from  the  Polyclinic  Hospital  to  the  State  Hos- 
pital at  Morganton,  a  little  later  than  I,  and  in 
1910  Dr.  Spiller  asked  Dr.  Anderson  if  he  could 
not  be  supplied  with  certain  tissue  for  study  from 
patients  dying  of  pellagra.  The  man  patient,  from 
whom  material  for  study  was  sent  to  Dr.  Spiller. 
died  in  January,  1910:  the  woman  from  whom 
tissue  was  sent  to  Dr.  Spiller  died  in  May,  1910. 
Dr.  Anderson  furnished  Dr.  Spiller  the  clinical 
notes  on  the  woman's  condition;  I  supplied  him 
with  such  data  about  the  man  dead  of  pellagra. 
The  woman  had  been,  at  the  time  of  her  death    a 


SOUTHERN  MEDICINE  &  SURGERY 


August,  1941 


patient  in  the  State  Hospital  for  only  four  or  five 
months;  the  man  had  been  living  in  the  Hospital  in 
quiet  dementia  for  more  than  twenty  years.  Dr. 
Spiller  presented  the  study  of  the  two  patients 
to  the  meeting  of  the  College  of  Physicians  of 
Philadelphia  on  Dtcember  7th,  1910.  In  the 
American  Journal  of  the  Medical  Sciences  for  Jan- 
uary, 1911,  the  situation  was  presented  in  full 
under  the  caption: 

Pellagra  with  a  Report  of  Two  Cases  with  Necropsy 

By  Paul  V.  Anderson,  M.D. 

Morganton,  N.  C. 

and 

William  G.  Spiller,  M.D. 

of 

Philadelphia 

Dr.  Anderson  and  I  have  always  been  proud  of 
our  association  with  Dr.  Spiller  in  that  pioneer 
work  in  pellagra.  I  made  the  necropsies  and  selected 
the  tissue  and  prepared  it  and  sent  it  to  Dr. 
Spiller.  He  told  us,  when  he  asked  for  the  ma- 
terial, that  he  could  not  find,  even  in  1910,  any 
report  of  a  necropsy  made  on  a  pellagrous  patient 
in  this  country;  and  that  so  far  as  he  knew  I  had 
the  unique  experience  of  making  in  the  United 
States  the  first  post-mortem  following  death  from 
pellagra,  and  that  he  had  examined  for  the  first 
time  in  this  country  pathologic  pellagrous  tissue. 

The  names  of  Dr.  Searcy  and  of  Dr.  Spiller 
are  seldom  heard  or  seen  in  these  days,  only  thirty- 
four  years  after  Dr.  Searcy  reported  the  first  cases 
of  pellagra  in  the  United  States,  in  spoken  or  writ- 
ten statements  about  pellagra.  Yet  the  observa- 
tions and  the  work  of  these  two  were  primal  in 
pellagra. 

We  students  and  internes  thought  of  Dr.  Spiller 
as  the  student,  impelled  by  eager  yearning  to 
know,  and  ever  to  know  more  and  more  and  more. 
He  knew  no  rest,  perhaps  because  he  was  always 
so  busy  that  he  had  no  opportunity  for  thought 
about  himself.  We  thought  of  him  as  a  student — 
a  term  indicative  not  only  of  the  desire  to  know 
but  of  the  determination  also  to  find  out.  We 
heard,  too,  we  students,  that  Dr.  Spiller  was  a 
man  of  substance,  and  that  it  was  not  necessary 
for  him  to  labour.  But  as  the  years  rolled  and  I 
came  to  know  him  better  I  realized  that  for  him 
incessant  work  was  rest. 

I  think  of  Dr.  Spiller  as  the  scientist  in  medi- 
cine. He  had  no  thought  of  publicising  himself. 
Any  such  suggestion  would  have  been  painful  to 
him. 

Medical  students  and  doctors  should  read  Dr. 
McConnell's  Memoir  of  Dr.  Spiller.  It  is  splendid- 
ly done.  Why  should  it  not  be  well  done?  Dr. 
McConnell  is  a  distinguished  neurologist;  the  spe- 


cialty courses  through  his  blood;  for  almost  forty 
years  he  was  Dr.  Spiller  s  chief  of  clinic;  they 
worked  side  by  side  and  each  added  to  the  other. 

Dr.  Spiller 's  life  constitutes  a  contribution  to 
the  dignity  of  labour  in  a  learned  profession.  In 
no  other  way  can  valid  and  lasting  achievement 
come,  and  in  no  other  way  should  it  come.  By 
directed,  zealous  activity  Dr.  Spiller  came  from 
the  Dakota  wheat  fields  to  a  position  of  the  high- 
est eminence  in  scientific  medicine. 

He,  through  his  father,  came  out  of  Virginia. 
Dr.  S.  Weir  Mitchell,  another  distinguished  phy- 
sician wrho  did  much  for  the  fame  of  Philadelphia 
as  a  medical  center,  likewise  came  from  Virginia- 
born  parents.  Dr.  W.  S.  Forbes,  of  the  Chair  of 
Anatomy  at  Jefferson  in  my  day,  told  me  that  he, 
too,  was  Virginia-born,  though  he  added,  some- 
what sublingually,  that  he  was  taken  to  Philadel- 
phia in  his  infancy,  and  that  he  was  Grant's  medi- 
cal chief  during  the  Vicksburg  siege. 

But  I  have  never  known  another  physician  who 
impressed  me  as  being  so  solely  interested  in  the 
search  after  truth  as  William  Gibson  Spiller.  He 
*-as  long  in  finding  himself,  but  when  he  had  found 
out  what  he  would  do  nothing  deflected  or  stayed 
him  until  the  Boatman  came. 


THERAPEUTICS 

J.  F.  Nash,  M.  D„  Editor,  Saint  Pauls,  N.  C. 


OFFICE  GYNECOLOGY 

If  we  would  onlv  equip  our  offices  respectably 
and  keep  them  neat  and  clean,  with  an  intelligent 
attendant,  we  could  take  care  adequately  of  90  per 
cent  of  our  gynecology  practice,  and  have  most  of 
these  patients  come  to  the  office. 

The  examination  of  anv  patient  with  a  gynecol- 
ogical complaint  includes  a  urinalysis.  The  patient 
need  only  cleanse  the  genitalia,  plug  the  vaginal 
atrium  with  dry  cotton,  and  then  urinate,  in  order 
to  obtain  a  clean  specimen.  If  a  clean  specimen 
is  desired  at  the  time  of  examination  do  an  office 
catheterization. 

Insure  an  empty  bladder  prior  to  a  pelvic  exam- 
ination. This  is  particularly  true  as  to  a  young 
person  in  whom  only  a  rectoabdominal  examination 
is  possible. 

Visualize  the  vagina  and  cervix  by  the  use  of  a 
vaginal  speculum.  Specula  must  be  available  in 
assorted  sizes  and  shapes. 

Very  valuable  and  much  neglected  is  a  test  of 
the  competency  of  the  levator  ani  carried  out  as 
follows:  One  or  two  fingers  are  placed  on  the 
posterior  wall  of  the  vagina,  palms  downward,  the 
patient  being  in  lithotomy  position.     She  is  told 

1.     J.   L.   Baer,   Chicago,  in  Neb.  State  Med.  Jl,  Aug 


August.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


to  squeeze  the  finger  or  pull  in,  at  the  same  time 
tapping  the  buttocks  with  the  thumb  to  indicate 
where  the  pull  is  to  be  exerted.  A  voluntary  con- 
traction of  the  levator  is  accompanied  by  an  ele- 
vation of  the  patient's  chest  which  can  serve  as  an 
index  that  she  understands  what  you  mean.  The 
contracted  levator  can  then  be  explored  in  its  en- 
tirety by  the  vaginal  finger.  This  reveals  even 
minor  injuries  sustained  in  childbirth,  or  as  the 
result  of  poor  episiotomy  reconstruction. 

After  parturition  gaping  exposes  the  labia  min- 
ora completely  due  to  destruction  of  the  most  an- 
terior fibers  of  the  levator.  This  is  the  normal 
after  parturition.  Further  separation  or  non- 
union of  the  levator  results  in  rectocele  of  varying 
degrees. 

The  sedimentation  rate  is  a  more  reliable  and 
delicate  for  the  presence  of  infection  and  progno- 
sis than  is  the  white  count. 

Neglect  to  examine  the  breasts  may  be  over- 
looking the  early  stage  of  a  carcinoma.  In  the 
presence  of  chafing,  ectropion,  erosions  of  all  de- 
grees and  discharge,  microscopic  examination  is 
essential.  Examination  of  a  drop  in  saline  solu- 
tion without  staining  is  indicated.  Trichomonas 
vaginalis  is  readily  detectable  when  present  in  any 
number,  also  monilia  budding  forms  are  charac- 
teristic. 

In  trichomonos  vaginitis  almost  immediate  relief 
of  the  most  severe  itching  and  burning  is  given  by 
daily  use  of  glycerine  tampons.  For  eradication  of 
the  infection  best  results  from  Floraquin  (Searle) 
powder  insufflation  and  Floraquin  tablets  for  home 
use.  In  case  resistant  streptococci  are  demonstrat- 
ed, combine  the  use  of  the  streptococcus  vaccine 
with  the  local  therapy. 

Monilia  infection  yields  very  promptly  to  careful 
painting  of  the  entire  vaginal  tract  with  1  per  cent 
gentian  violet. 

If  there  are  intracellular  gram-negative  diplo- 
cocci  in  typical  clusters,  the  diagnosis  of  gonorrhea 
is  made.  Here  the  sulfonamides  have  proved  their 
worth.  The  omission  of  bed  rest  in  a  fresh  gon- 
orrheal infection  is  a  serious  error. 

Non-specific  vaginitis  responds  readily  to  careful 
painting  of  the  vaginal  tract  with  2  per  cent  mer- 
curochrome  solution.  Senile  vaginitis  likewise  re- 
sponds to  this  treatment,  but  the  results  can  be 
accelerated  by  hypodermic  injections  of  large  doses 
of  one  of  the  estrogen  preparations. 

Pruritus  vulvae  requires  examinations  of  the 
urine  and  blood  for  sugar.  In  the  presence  of  a 
normal  carbohydrate  metabolism  treat  by  10  to 
50,000  units  of  estrogen  (hypo.)  and  a  bland  anti- 
pruritic ointment.  These  patients  eventually  re- 
quire vulvectomy. 

Of  abnormal  bleeding  from  the  genitals  caruncle 
may  be  the  source — cauterize  under  local  anesthe- 


sia. The  bleeding  of  cervical  erosion — cure  of  the 
erosion  by  cautery  stops  the  bleeding.  It  is  a 
simple  office  procedure  which  can  usually  be  car- 
ried out  in  one  sitting.  The  practice  of  hospitaliz- 
ing patients  for  cervical  cauterization  is  just  as  un- 
necessary as  the  tendency  to  do  cauterizations  in 
multiple  sittings,  sometimes  through  a  whole  year. 
Cauterize  to  a  dry  black  eschar  over  the  entire 
exposed  erosion  area.  The  cervical  canal  is  cauter- 
ized in  two  or  four  longitudinal  axes.  Preliminary 
to  the  cauterization,  the  entire  cervix  including  the 
canal  should  be  rendered  free  of  mucus  by  dusting 
with  Caroid  powder  to  liquefy  the  mucus,  which 
can  then  be  wiped  off.  Do  not  let  the  patient  leave 
too  quickly,  as  occasionally  there  may  arise  a  de- 
layed syncope.  Insert  a  tampon  with  enough  mer- 
curochrome  ointment  to  cover  the  entire  area.  The 
patients  report  weekly  at  which  time  mercuro- 
chrome  ointment  tampons  are  inserted  for  24  hours. 
The  patients  are  instructed  to  counteract  the  odor 
(when  the  destroyed  tissue  begins  to  discharge) 
by  using  Amolin  or  Quest  deodorant  powders  on 
the  valvar  pads,  shortly  after  a  mensis. 

A  cervix  which  shows  anything  other  than  a 
typical  erosion  should  have  a  microscopic  examina- 
tion. I  have  found  the  iodine  test  unreliable  for 
the  differential  diagnosis  of  benign  and  malignant 
lesions. 

A  case  history  may  expose  the  cause  of  the  ster- 
ility. Examination  should  include  pelvic  viscera, 
breasts,  hair  distribution,  basal  metabolism,  two 
specimens  of  the  husband's  semen — the  first  in  a 
washed  condom,  the  second  spermatozoa  recovered 
from  the  cervix  and  posterior  fornix.  Await  the 
next  menstruation,  patient  to  return  without  hav- 
ing had  coitus.  For  tubal-patency  test  rarely  is  it 
necessary  to  grasp  the  cervix  with  a  vulsellum,  nor 
do  I  sound  the  uterine  cavity  to  determine  the 
direction  of  the  canal.  If  the  insufflation  is  success- 
ful the  patient  is  instructed  to  have  coitus  that 
night  and  thereafter  during  the  fertile  week.  If 
unsuccessful,  it  is  tried  at  a  subsequent  time  and 
the  patient  is  given  atropine  just  preceding.  Thy- 
roid administration  serves  well  in  many  cases,  and 
care  for  the  husband  if  the  spermatozoa  are  ab- 
sent, few,  inactive,  or  deformed. 

The  adolescent  may  show  amenorrhea,  infantile 
genitalia,  abnormal  secondary  sex  characteristics 
and  B.  M.  R.  Rontgen  study  of  the  sella  turcica 
and  the  epiphyses  of  the  long  bones  may  show  need 
for  hormones.  I  have  chosen  to  lag  behind  in  the 
use  of  these  preparations. 

Massive  doses  of  synthetic  estrogen  followed  by 
progestin  is  a  satisfactory  method  of  establishing 
a  normal  menstrual  rhythm.  Thyroid  therapy  is 
positive,  whereas  utilization  of  gonadotropic  and 
ovarian  hormones  is  still  fallible. 


SOUTHERN  MEDICINE  &  SURGERY 


August,  1941 


In  the  treatment  of  the  symptoms  of  the  meno- 
pause the  synthetic  estrogens  are  much  more  effi- 
cacious.   Stilboesterol  is  potent  but  toxic. 

The  woman  with  a  retrodisplacement  who  is 
fitted  with  a  pessary  and  her  backache  is  relieved, 
and  if  on  the  removal  of  the  pessary,  the  symp- 
toms return,  the  cause  of  the  backache  is  plain. 

In  the  field  of  prolapse  the  pessary  is  required 
for — those  who  are  too  old  for  surgery,  those  who 
refuse  surgery,  and  those  in  whom  surgery  is  con- 
traindicated  because  of  various  diseases.  The  in- 
flated round  rubber  pessary  is  the  most  generally 
satisfactory.  The  Gellhorn,  available  in  two  sizes, 
very  often  succeeds  when  the  round  type  produces 
discomfort.  In  a  small  group  with  no  perineal  sup- 
port the  cup-and-stem  pessary  held  in  place  by 
perineal  straps  is  best. 

The  symptomless  movable  retrodis placed  uterus 
requires  no  treatment.  This  kind  of  uterus  is  to 
have  frequent  examination  to  guard  against  a  pos- 
sible incarceration. 

Most  of  the  low  backaches  complained  of  by 
women  and  old  are  skeletal  in  their  origin.  A  retro- 
displaced  uterus,  with  varicosities  of  the  broad  lig- 
aments and  passive  congestion.,  will  canuse  low 
backache.  A  therapeutic  test  with  a  properly  fitted 
Smith  or  Hodge  pessarv  will  make  the  diagnosis. 
Thereafter  the  treatment  in  general  is  surgical. 

Chronic  infection  of  the  endocervix  frequently 
involves  the  uterosacral  ligaments,  makes  them  ten- 
der to  the  touch  and  causes  pain  when  the  cervix 
is  displaced  anteriorly.  The  endocervicitis  is  usual- 
ly curable  by  cauterization.  The  residium  usually 
takes  care  of  itself.  When  this  is  low,  prolonged 
hot  irrigation  at  low  pressure  twice  daily  hastens 
the  recovery. 

For  advanced  cancer  of  the  cervix  or  corpus, 
palliation  by  irradiation,  perhaps  division  of  the 
presacral  plexus  or  both. 

Premarital  advice  is  more  and  more  becoming  a 
part  of  the  duty  of  the  family  physician.  It  is 
unusual  to  come  across  a  dyspareunia  which  is 
mechanical  in  origin.  These  patients  require  in- 
struction and  reassurance.  Rarely  is  it  necessary 
to  perform  a  discission  of  the  posterior  commissure 
to  establish  normal  marital  relationships. 

Ureteral  stricture  symptoms  are  readily  relieved 
by  gradual  and  repeated  dilatation. 

Sharply  localized  trigonitis  is  not  uncommon  in 
the  presence  of  cystocele.  Cystoscopic  examination 
reveals  the  condition.  It  is  possible  to  reach  the 
same  conclusions  by  palpation  of  the  base  of  the 
bladder  through  the  anterior  vaginal  wall.  Instilla- 
tion of  %.  to  1  per  cent  mercurochrome  solution  is 
curative. 

In  pyelitis  urinalysis  establishes  the  diagnossi. 
Edema  or  blockade  in  the  ureter  may  keep  pus 


cells  from  the  bladder  urine.    The  punch  test  over 
the  costo-vertebral  angle  is  useful. 

COTTON  SICKNESS 

It  has  been  the  lot  of  numerous  doctors  in  var- 
ious localities  where  cotton  was  being  made  into 
mattresses  to  observe  an  unusual  acute  illness 
among  some  of  the  workers.  This  sickness  atack- 
ed  only  those  who  were  in  close  contact  with  the 
cotton  and  handled  it  intimately,  i.  e..  the  beaters 
and  fluffers.  It  was  not  observe  damong  males 
for  the  workers  were  all  women  of  35  to  55  years 
of  age.  One  group  showed  20  white  women  affect- 
ed, another  group  8  or  10  colored  women. 

This  disease  was  not  seen  where  ventilation  was 
ample,  nor  where  the  work  was  done  out  of  doors. 
The  onset  was  usually  3  to  5  hours  after  intimate 
contact  and  exposure  to  the  dust  of  the  cotton.  It 
was  ushered  in  with  a  headache,  fever  nad  generally 
nausea,  and  occasionally  vomiting.  The  aching  in- 
creased fairly  rapidly  and  fever  was  noted  to  103  to 
104°.  In  one  or  two  there  was  diarrhea.  The 
fever  and  aching  persisted  for  3  or  4  days — in  a 
few  as  long  as  10  days.  All  symptoms  gradually 
subsided. 

Except  that  there  was  no  respiratory  involve- 
ment the  cases  presented  all  symptoms  of  influen- 
za, especially  the  aching.  The  patients  showed 
that  they  had  been  sick — had  lost  weigh  and  color, 
and  claimed  to  be  very  weak.  Those  that  re- 
turned to  the  same  work  did  not  have  a  recurrence, 
due  probably  to  the  recent  active  immunization. 

The  cotton  came  from  a  southwest  state  and 
was  of  low  grade;  yellow  color  and  full  of  dust. 
One  bale  showed  evidence  of  moisture  and  smelled 
sour  and  moldlv. 

The  School  of  Public  Health  in  Bethesda,  Mary- 
land has  investigated  this  cotton  sickness  and  en- 
deavored to  isolate  an  organism  causing  the  malady. 
They  have  found  a  flagellated,  encapsulated  bacil- 
lus in  the  cotton  and  in  the  nasal  cultures  as  long 
as  6  weeks  after  onset.  Blood  cultures  and  cultures 
from  nasal  smears  are  going  through  the  laboratory 
now,  and  perhaps  they  will  be  able  to  tell  us  more 
about  this  sickness  before  many  months.  At  any 
rate  the  disease  is  annoying,  but  doesn't  seem  to 
be  fatal. 


SPIDER  BITE 

(Z.   B.   Noon.  Xogales.  Ariz.,  &  W.  L.  Minear.   Patagonia    Ariz  , 
in  Southwestern  Med.,  June) 

Untreated  or  symptomatically  treated  cases  of  bite  of 
the  black  widow  spider  usually  have  a  long  period  of  mor- 
bidity and  a  possible  mortality. 

Treatment  with  specific  antivenin  (Latrodectus  mactans) 
results  in  minimal  morbidity  and  no  mortality.  The  earlier 
the  antivenin  is  given  the  more  prompt  is  the  relief. 

It  is  possible  that  by  giving  double  the  usual  dose  of  the 
antivenin  in  the  severe  cases  and  when  time  is  a  factor  (a 
long  period  having  elapsed  after  the  bite)  more  prompt 
relief  would  result. 


SOUTHERN  MEDICINE  &  SURGERY 


INSURANCE  MEDICINE 


TIME  AS  A  FACTOR  IX  MEDICAL 

SELECTION 

For  this  issue  Albert  Seaton,  M.  D.,  Indianapolis 
Medical    Director,    American    United    Life    Insurance    Company 

Time  is  a  measurement  of  duration.  Life  in- 
surance contracts  are  built  upon  time  and  the 
classification  of  applicants  for  life  insurance  in 
an  attempt  to  predict  their  duration  of  life.  Such 
an  attempt  can  only  be  predicted  upon  experiences 
based   upon  large  groups  and  accurate  statistics. 

The  duration  of  the  human  race  changes  the 
environment  in  which  human  life  exists  and  these 
changes  modify  the  prognostic  value  of  these  ex- 
periences. With  the  passage  of  time  come  changes 
in  the  duration  of  human  life.  Mortality  trends 
modify  mortality  statistics.  Grandpa  may  have 
been  killed  by  a  runaway  horse.  Grandson's  life 
may  be  saved  by  the  serum  of  a  descendant  of 
that  horse.  The  mortality  experience  of  human 
life  is  based  upon  the  number  of  deaths  occurring 
while  the  earth  moves  in  its  orbit — rather  a  gross 
and  remotely  related  thing  with  which  to  measure 
a  series  of  biological  events,  but  still  having  an 
effect  as  shown  by  seasonal  mortality  fluctuations. 

Some  day  a  biological  unit  may  be  developed 
for  the  measurements  of  human  life  which  will  be 
an  improvement  upon  the  astronomical  incident 
of  a  year  among  the  events  of  eternity  .  What 
such  a  unit  of  biological  capacity  might  be  can 
only  be  left  to  the  imagination.  It  would  be  a 
composite  of  many  factors.  The  process  of  risk 
classification  is  an  attempt  to  correlate  the  factors 
which  affect  longevity  as  shown  by  experience  so 
that  a  definite  estimate  of  the  duration  of  life 
may  be  attained. 

The  physical  examination  and:  environmental 
investigation  of  a  risk  for  life  insurance  are  prac- 
tical applications  of  definite  units  of  biological 
measurements  in  an  effort  to  arrive  at  a  measure- 
ment of  life  duration.  Time  is  essential  to  most 
functional  tests,  from  taking  the  pulse  rate  to 
performing  the  most  elaborate  laboratory  proce- 
dure. An  estimation  of  the  heart's  efficiency  or 
the  diagnosis  of  valvular  defects  cannot  be  made 
without  giving  consideration  to  the  factor  of  time. 
Time  as  a  measurement  of  longevity  shows  in 
the  family  tree.  The  biometric  studies  of  Raymond 
Pearl  indicate  that  the  total  immediate  ancestral 
longevity  (Tial)  is  as  definite  a  biological  at- 
tribute as  height.  Build  is  a  factor  affecting 
longevity,  but  time  added  to  overweight  leaves 
but  few  old  fat  men. 

Statistics  have  accumulated  to  indicate  that 
many  physical  impairments  show  definite  rates  of 
mortality  and  can  be  so  classified.  Time  is  a  factor 
in  our  National  Vital  Statistics,  which  are  modified 


as  increased  areas  come  under  registration  laws, 
and  death  reports  conform  to  the  advancements 
in  medical  diagnosis.  Statistics  are  hard  to  ac- 
cumulate and  more  difficult  to  interpret  when 
modified  by  the  passage  of  time.  They  are  a  con- 
stant demonstration  that  nothing  is  constant  ex- 
cept change.  Time  has  recorded  the  changed  meth- 
ods of  treatment  and  prognosis  of  physical  im- 
pairments, and  the  elimination  of  many  indus- 
trial and  occupational  hazards.  New  occupations 
and  environments  bring  new  life  hazards.  Time 
again  is  a  factor  in  risk  classification.  Hours  of 
flight  and  duration  of  training  help  determine  the 
ratings  for  aviators.  The  consideration  of  time 
in  medical  examination  reports  is  often  neglected, 
not  because  of  the  examiner's  indifference  but 
because  of  the  applicant's  attitude.  Time  deter- 
mines the  rating  given  or  other  action  taken  upon 
most  physical  impairments.  When  they  occurred 
is  just  as  important  as  what  they  were.  Risk  in  a 
case  giving  a  history  of  passing  a  kidney  stone  im- 
proves with  age.  Dates,  duration  and  number  of 
attacks  of  any  impairment  history  mean  definite 
sums  in  premium  dollars.  Accurate  time  records 
mean  equitable  and  fair  treatment  of  applicants 
and  company. 

The  older  I  grow,  the  more  I  respect  the  appli- 
cant who  by  sacrifice  and  self-denial  carries  or 
drags  insurance  premiums  through  the  years.  The 
premiums  should  be  equitable.  If  a  record  is 
made  of  a  physical  impairment,  the  element  of 
time  is  as  important  as  the  physical  diagnosis. 

In  my  opinion,  the  best  examiner  writes  the  best 
time  records  of  personal  and  family  histories.  Time 
means  money  in  risk  classifications.-  Inaccurate 
ratings  based  upon  inaccurate  records  result  in 
losses  and  lapses,  and  defeat  the  objectives  of  life 
insurance. 

If  one  thought  only  could  be  carried  to  the  ex- 
aminer when  physical  examinations  are  made,  in 
my  opinion  that  thought  would  be  the  thought  of 
time.  Time,  the  constant  in  a  world  of  change. 
Time,  a  definite  in  a  nebulus  of  indefinites.  Time, 
the  panacea  and  corrector  of  judgment.  Remem- 
ber the  jingle  about  Mr.  Jenkins  and  give  accurate 
records  of  time  in  medical  reports  to  save  us  from 
his  fate. 

Mr.   Jenkins   had   a   brink 

Where  he  used  to  sit  and  think 

Of  the  stars  above,  and  the  earth  below, 

And  why  the  world  was  thus  and  so. 

There  is  no  better  place  to  think 
Great  thoughts  than  on  a  quiet  brink, 
But  Mr.  J.'s  became  so  vast 
So  supercosmic,  that   at  last 

Pondering  on   what   God  had  wrought 
He  was  completely  lost  in   thought. 
He  disappeared  without  a  sound 
And  since  that  time  he's  ne'er  been  found. 


SOUTHERN  MEDICINE  &  SURGERY 


August,  1941 


UROLOGY 

Raymond  Thompson,  M.  D.  Editor,  Charlotte,  N.  C. 


THE  HEART  IN  UROLOGY 

In  taking  over  the  Department  of  Urology, 
we  wish  for  this  issue  to  abstract  rather  fully,  a 
recent  excellent  paper  by  Dr.  Edwin  P.  Maynard, 
Jr1.,  of  Brooklyn. 

The  author  first  calls  attention  to  the  fact  that 
as  a  class  patients  with  heart  disease  are  not  bad 
risks  for  major  surgical  procedures.  He  reports 
the  work  of  Drs.  Butler,  Feeny,  and  Levine,  who 
studied  this  question.  In  418  patients  comprising 
the  whole  group  the  unexpected  mortality  was  6.3 
per  cent.  On  the  other  hand  when  120  patients 
with  rheumatic  heart  disease  were  studied  separate- 
ly, the  unexpected  mortality  was  2.1  per  cent.  In  35 
patients  with  coronary-artery  disease  and  angina 
there  were  3  unexpected  deaths,  a  mortality  of  7.7 
per  cent.  Fifty  operations  were  performed  on  as 
many  patients  with  congestive  heart  failure.  There 
were  7  unexpected  deaths,  a  mortality  of  17.1 
per  cent. 

Death  of  cardiac  patients  during  operations  is 
rare.  The  unexpected  mortality  is  the  result  of 
the  same  complications  that  beset  patients  with- 
out heart  disease — postoperative  pulmonary  com- 
plications, shock  and  infections.  Congestive  heart 
failure  and  coronary  thrombosis  are  relatively  rare 
causes  of  unexpected  death.  Pulmonary  embolism 
is  a  little  more  common. 

Patients  with  rheumatic  heart  disease  and  le- 
sions of  the  kidney  or  bladder  belong  to  the  younger 
age-group,  and  usually  stand  surgery  rather  well. 
Patients  with  prostatism  belong  to  the  older  group 
and  have  hypertensive  heart  disease,  arteriosclero- 
sis of  the  coronary  arteries  with  anginel  syndrome 
and  cardiovascular  syphilis.  If  the  coronary  ar- 
teries are  involved  as  evidenced  by  angina  pectoris 
the  risks  of  surgery  are  increased.  Cardiovascular 
syphilis  in  its  early  stage  of  uncomplicated  aortitis 
increases  the  dangers  of  major  operation  greatly. 

First  the  physician  must  diagnose  the  kind  of 
heart  disease  the  patient  has;  next  he  must  as- 
certain how  the  patient  stands  the  physical  activi- 
ties required  by  his  customary  duties.  If  he  can 
be  active  in  business  or  do  physical  labor  without 
distress  he  can  stand  a  major  operation.  On  the 
other  hand,  if  the  patient  has  had  a  previous  epi- 
sode of  congestive  heart  failure,  auricular  fibril- 
lation,   or    coronary    arteriosclerosis    with    anginal 


1.  Cardiac  and  Pulmonary  Complications  of  Genito-Urinary 
Surgery,  Brooklyn  Hospital  Journal  for  July  read  before  the 
Section  of  Genito-urinary  Surgery  of  the  New  York  Academy 
>f    Medicine,    March    19th,. 


syndrome,  the  physician  and  surgeon  must  weigh 
the  importance  of  the  operation  against  the  dang- 
ers to  be  incurred. 

It  is  amazing  how  well  the  damaged  heart  will 
stand  an  operation.  Patients  with  heart  disease 
should  not  be  digitalized  routinely.  Just  as  in 
ordinary  medical  practice,  the  rule  holds  that 
digitalis  should  be  used  only  to  treat  heart  failure 
or  chronic  auricular  fibrillation.  The  surgeon  should 
plan  the  operation  so  that  it  will  be  as  short  as 
possible  and  so  that  only  essential  maneuvers  will 
be  carried  out.  Surgical  shock  is  especially  hazar- 
dous for  the  cardiac  patient. 

The  kind  of  operation  should  determine  the  type 
of  anesthesia.  In  cardiac  patients  it  is  especial- 
ly necessary  to  avoid  excitement,  struggling  and 
cyanosis  and  the  best  quarantee  against  these  haz- 
ards is  skillful  administration  of  the  anesthetic. 

There  is  much  that  the  surgeon  can  do  to  pre- 
vent postoperative  pulmonary  complications.  Gen- 
tle and  meticulous  technique  will  do  much  to  pre- 
vent postoperative  pulmonary  embolism  and  in- 
farction. Beck  cautions  against  the  use  of  tight 
dressings  across  the  upper  abdomen  and  lower 
thorax  that  may  interfere  with  respiratory  move- 
ments. In  genito-urinary  surgery  this  may  apply 
to  the  application  of  dressings  after  operations  on 
the  kidney. 

To  minimize  the  danger  of  pulmonary  embolism 
during  the  postoperative  period  it  is  important 
to  encourage  the  patient  to  move  his  legs  about  in 
bed  and  to  exercise  the  calf  muscles  by  flexing 
the  feet  and  toes.  The  deep  veins  of  the  legs  are 
favorite  sites  for  the  formation  of  thrombi  and 
every  effort  should  be  made  to  keep  the  blood  flow 
brisk. 

In  conclusion,  we  congratulate  the  author  upon 
this  work  and  agree  heartily  in  his  stressing  that 
each  case  should  be  studied  carefully  by  an  in- 
ternist, particularly  regarding  the  type  of  heart 
disease  and  disturbance  of  function.  We  believe 
that  a  large  factor  in  our  low  mortality  in  prosta- 
tic surgery  has  been  the  careful  study  of  these 
cases  by  a  capable  internist. 

HERPES  OF  THE  BLADDER 

I  have  been  able  to  find  only  four  cases  of  herpes 
vesicalis  reported.  My  case1  is  that  of  a  white  man, 
45,  with  no  skin  lesion  or  urinary  symptoms,  who 
was  riding  in  a  car  when  he  was  seized  with  urgent 
desire  to  urinate.  The  urine  "looked  like  blood," 
but  there  were  no  clots  and  he  had  no  difficulty 
with  his  stream.  In  a  few  minutes  he  again  felt  a 
burning  desire  to  urinate;  which  returned  about 
every  30  minutes,  with  severe  hematuria,  and  with 

1.  J  .R    Rinker,   Fort  Worth,   in  Southwestern  Med..  June. 


August,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


increasing  pain,  maximum  at  the  end  of  urination 
and  burning  in  the  penis.  Symptoms  began  to  sub- 
side after  24  hours  bed  rest. 

Examination  was  negative  except  for  a  temper- 
ature of  99.6°  on  admission,  thereafter  afebrile. 
Cystoscopy  revealed,  from  the  internal  urethral 
orifice  at  9  o'clock  backward  to  the  post-trigonal 
region,  an  area  covered  by  vesicles,  the  largest  6 
mm.  in  diameter.  Scattered  among  the  clear  vesi- 
cles were  a  few  large  yellow  vesicles,  flat-topped. 
Urine  from  either  kidney  was  negative  for  cellu- 
lar elements  and  on  culture.  Phenolsulphonphtha- 
lein  appeared  in  four  minutes  on  both  sides.  Pyelo- 
grams  normal. 

Acute  symptoms  referable  to  the  bladder  had 
subsided  by  the  fourth  day  without  treatment  other 
than  bed  rest.  The  only  treatment  thereafter  was 
a  0.5%  silver  nitrate  instillation  every  third  day. 
By  the  11th  day  the  patient  was  symptom-free;  16 
days  after  the  first  cystoscopy  the  lesion  had  dis- 
appeared except  for  a  few  reddish  areas  which  were 
covered  by  smooth  bladder  mucosa. 


RADIOLOGY 


cases  were  operable  than  of  the  cases  in  the  older 
age  group.  As  the  location  was  more  frequent  in 
the  distal  part  of  the  stomach  and  pylorus,  resec- 
tion was  possible  in  many  cases. 

Prognosis  naturally  is  not  good.  But  it  is  more 
favorable  than  in  the  older  group.  Among  the  oper- 
able cases  there  is  an  immediate  mortality  of  25 
per  cent.  Of  the  remaining  cases  20  per  cent  of 
those  afflicted  lived  three  years  without  evidence  of 
disease,  and  in  16  per  cent  of  the  resectable  cases 
there  was  a  survival  of  five  years. 

In  this  article  McNeer  proves  the  fallacy  of  the 
old  rule  of  thumb,  "this  cannot  be  cancer  because 
of  the  youth  of  the  patient."  More  and  more  cases 
of  proven  cancer  in  the  young  are  being  recorded 
as  we  become  more  and  more  conscious  of  the 
possibility  or  even  the  probability  of  cancer  being 
the  explanation  of  the  symptom-complex  in  an 
ever-increasing  number  of  the  cases  coming  for 
diagnosis  and  treatment.  This  does  not  apply  to 
gastric  cancer  only  but  also  to  the  cancer  of  other 
organs. 


CANCER  OF  THE  STOMACH  IN  THE 
YOUNG. 

Hilmar  Schmidt,  M.D.,  Editor,  Petersburg,  Va. 

"A  high  index  of  suspicion  is  necessary  in  the 
case  of  any  youthful  subject  who  presents  symp- 
toms presumptive  of  a  diagnosis  of  gastric  carci- 
noma in  older  patients."  Thus  concludes  an  article 
by  McNeer1  on  cancer  of  the  stomach  in  the 
young. 

It  is  a  common  error  to  suppose  that  carcinoma 
is  excluded  because  of  the  youth  of  the  subject. 
The  author  has  collected  five  hundred  cases  for  his 
analysis.  True,  these  do  not  all  emanate  from  one 
clinic,  but  they  present  a  sufficient  array  to  place 
this  disease  among  the  differential  possibilities. 

All  but  4  per  cent  of  the  group  were  between 
fifteen  and  thirty  years  of  age. 

Oddly  enough,  there  was  a  slight  preponderance 
of  females,  and  of  these  many  cases  were  observed 
during  pregnancy.  This  combination  seems  espe- 
cially serious,  as  in  all  of  these  cases  death  ensued 
rapidly  from  the  disease. 

As  vomiting  and  pain  were  the  most  prominent 
symptoms,  it  made  the  question  of  differential  diag- 
nosis from  ulcers  unusually  difficult.  The  roentgen- 
ologist must  be  especially  wary  in  this  respect. 

The  distinctive  findings  were  an  abdominal  mass, 
achlorhydria  and  very  late  cachexia.  This  late  ap- 
pearance of  cachexia  is  one  of  the  pitfalls  that 
must  be  guarded  against.  In  view  of  the  later 
cachexia,  he  finds  that  a  larger  percentage  of  the 


GENERAL  PRACTICE 


of   the   Stomach    in   the    Young,  by   Cordon    McNeer. 
of  Roentgenology,   April,    1941. 


Walter  J.  Lackey,  M.D.  Editor,  Fallston,  N.  C. 

MORE  INDICATIONS  FOR  SULFONAMIDES 
The  field  of  usefulness  of  the  sulfonamide  group 
of  drugs  grows  bigger  all  the  time.  For  some  time 
we  have  known  the  benefits  of  sulfapyridine  and 
sulfathiazole  in  pneumonias  and  gonococcus  infec- 
tions, sulfanilamide  in  treating  streptococcus  in- 
fections, sulfathiazole  for  staphylococcus  infections 
etc.  A  member  of  this  group  of  drugs  is  being  used 
now  very  successfully  in  treating  colitis,  especially 
in  children.  Sulfathiazole  seems  to  be  the  drug  of 
choic?  in  diarrhea  and  its  prompt  action  in  stop- 
ping the  diarrhea  with  blood  and  pus  in  the  stools 
is  amazing.  Many  babies  with  diarrhea  are  now 
being  saved  during  the  summer  months  and  their 
illness  cut  short  by  giving  sulfathiazole  by  mouth. 
Some  medical  men  give  larger  doses  than  others.  I 
usually  give  about  the  same  dosage  as  I  would  in 
treating  pneumonias.  It  is  not  uncommon  to  see  a 
difference  in  the  stools  after  4  or  5  doses  are  given 
and  the  child  usually  will  be  well  in  a  few  days. 

The  powdered  drug  is  now  being  used  with 
much  success  in  surgery.  From  sulfanilamide  or 
sulfathiazole  powder  in  the  peritoneal  cavity  dur- 
ing operation,  for  localized  abscesses  or  generalized 
peritonitis,  surgeons  are  reporting  excellent  results. 
The  high  concentration  of  the  drug  locally  seems 
to  be  more  beneficial  than  by  giving  it  some  other 
way. 

Local  abscesses  anywhere  in  the  body  after  in- 
cision and  drainage  are  usually  helped  by  local 
applications  of  either  powdered  sulfanilamide  or 
sulfathiazole. 


SOUTHERN  MEDICINE  &■  SURGERY 


August,  1941 


In  repairing  lacerations  of  the  perineum  follow- 
ing childbirth  a  small  amount  of  the  powder  ap- 
plied in  the  wound  helps  keep  off  infection  and 
thus  keeps  many  repairs  from  breaking  down. 

A  5  per  cent  solution  of  sulfathiazole  seems  to 
work  well  used  as  a  spray  in  cases  of  sinusitis  and 
sore  throat. 

The  field  of  rectal  surgery  has  almost  been  rev- 
olutionized recently  by  using  the  powdered  drug 
in  the  wounds  during  operations.  Infected  fistulous 
tracts  are  now  being  dissected  out  and  powdered 
sulfanilamide  or  sulfathiazole  applied  and  the 
wound  closed  with  sutures  allowing  prompt  healing 
in  many  cases  instead  of  leaving  the  tract  open 
to  take  many  weeks  for  the  healing  process.  Dur- 
ing hemorrhoidectomy  and  the  excision  of  fissure- 
in-ano  the  drug  is  used  with  much  success. 

In  treating  dirty  lacerated  wounds  seen  in  so 
many  accident  cases  it  will  be  found  that  the  local 
application  of  the  powdered  drug  will  prevent  many 
wounds  from  becoming  infected. 

OBSTETRIC  ANESTHESIA  IN  THE  HOME 

Here1  we  have  a  sensible,  practical  discussion  of 
a  subject  which  concerns  most  of  us. 

It  is  questionable  whether  first-stage  analgesia  is 
ever  desirable  in  the  multipara  in  the  home ;  but,  in 
the  primipara,  especially  in  prolonged  labor,  mor- 
phine is  sometimes  indicated.  Give  very  small 
doses  of  morphine,  repeating  until  the  desired  an- 
algesia is  obtained,  but  stopping  short  of  cyanosis 
or  great  slowing  of  the  respiratory  rate.  Scopola- 
mine given  with  morphine  increases  the  respiratory 
rate,  counteracting  to  a  degree  the  effect  of  mor- 
phine; excitement  may  be  avoided  by  beginning 
with  small  doses  and  repeating.  The  proper  pro- 
portion is  usually  1  part  scopolamine  to  25  parts 
morphine. 

In  the  second  stage  ether  is  fairly  satisfactory 
when  there  is  no  danger  from  lamps  or  a  stove  in 
the  room,  by  the  open  method  on  any  simple  mask. 
At  the  beginning  of  the  pain,  45  to  50  drops  of 
ether  are  poured  on  the  mask,  the  patient  breathes 
deeply  of  this  2  or  3  times;  a  few  more  drops  are 
added,  the  patient  again  inhales  and  the  mask  is 
removed.  This  is  repeated  with  each  pain.  The 
patient  is  never  unconscious.  For  surgical  anesthe- 
sia in  the  home,  ether  is  the  only  safe  agent. 
Chloroform  is  useful  and  safe  in  the  second  stage 
for  analgesia  with  each  pain  where  the  second  stage 
is  short,  and  it  is  often  the  only  pain-relieving  drug 
used  during  the  entire  labor  if  prolonged  or  deep 
anesthesia  is  not  needed. 

If  the  fetus  is  at  all  times  assured  of  adequate 
oxygen,  a  reasonable  prolongation  of  labor  is  un- 
important.    The   fetal  heart   tone  should  be  fre- 


quently examined  in  order  to  relieve  with  pure  oxy- 
gen any  alteration  in  fetal  heart  rate. 

Schreiber  has  found  by  examination  of  the  rec- 
ords of  mentally  defective  children  in  whom  there 
was  no  history  of  inherited  defect,  infection,  or 
trauma  associated  with  birth  a  definite  relationship 
between  fetal  oxygen  want  and  the  later  neurologic 
defect. 


SURGERY 

Geo.  H.   Bunch,  M.  D.,  Editor,   Columbia,   S.   C. 


(P.   V.   Moore,   Io 


THE  TREATMENT  OF  CONTAMINATED 

WOUNDS  WITH  SULFATHIAZOLE 

POWDER 

The  word  chemotherapy  has  acquired  new  sig- 
nificance since  the  discovery  of  sulfanilamide.  Clin- 
icians are  only  beginning  to  appreciate  the  effec- 
tiveness of  this  group  of  drugs  when  used  in  the 
prevention  and  in  the  treatment  of  infection.  Their 
applicability  has  become  so  general  that  the  prob- 
lem in  the  individual  case  is  now  largely  one  of 
selection.  Members  of  the  group  vary  in  toxicitv 
and  in  potency. 

A  phase  of  chemotherapy  of  particular  interest 
to  surgeons  is  the  local  application  of  the  powdered 
drug  in  wounds  that  are  either  grossly  or  poten- 
tially infected.  Orthopedic  surgeons  early  reported 
encouraging  results  from  the  local  use  of  sulfan- 
ilamide powder  in  the  treatment  of  compound  frac- 
tures. Because  it  is  more  effective  against  staphylo- 
cocci, we  have  used  sulfathiazole  powder  in  a  series 
of  contaminated  operative  wounds  with  surpris- 
ingly beneficial  effect.  In  a  case  of  acutely  perfor- 
ating peptic  ulcer,  in  five  cases  of  gangrenous  rup- 
tured appendix,  in  a  case  of  ruptured  gallbladder, 
in  a  case  of  strangulated  inguinal  hernia  there 
have  been  noticeably  smoother  convalescence  and 
better  wound  healing. 

We  have  not  used  the  drug  within  the  peritoneal 
cavity  although  others  have  done  so  and  recent 
experiments  on  animals  show  that  neither  func- 
tional nor  anatomical  injury  is  caused  by  its  direct 
application  to  the  brain. 

The  powder  has  no  hemostatic  effect  and  bleed- 
ing should  be  carefully  controlled  before  it  is  ap- 
plied. When  it  comes  into  contact  with  the  tissues 
enough  soon  goes  into  solution  to  gloss  the  surface 
and  to  change  the  color.  This  makes  differentiation 
difficult,  so  tissue  planes  should  first  be  identified 
for  suture.  To  provide  for  the  escape  of  the  serous 
exudate  which  forms  in  grossly  infected  wounds 
they  should  be  drained  even  though  the  drug  is 
used. 

During  the  first  world  war  frequent  irrigations 
of  Dakin  solution  were  used  in  wounds  to  prevent 
infection.    This  necessitated  constant  nursing  care 


August,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


and  the  frequent  change  of  dressings.  The  use  of 
sulfathiazole  powder  in  wounds  has  many  obvious 
advantages  over  this.  Dressings  do  not  have  to  be 
changed  frequently.  Wound  discharge  not  increas- 
ed but  lessened.  The  local  antiseptic  effect  of  the 
drug  is  exerted  in  the  tissues  of  the  wound  con- 
tinuously so  that  infection  and  suppuration  are  in- 
hibited. For  liberal  application  in  a  wound,  we 
use  one  or  two  teaspoonfuls  of  sulfathiazole  pow- 
der. Absorption  of  the  drug  continues  for  the  sev- 
eral days  of  the  incubation  period  of  infecting  or- 
ganisms so  that  the  patient  during  this  vulnerable 
time  is  also  protected  against  the  hazard  of  bac- 
teremia just  as  effectively  as  though  administration 
had  been  by  mouth.  We  have  observed  no  harmful 
reaction  either  local  or  general  in  our  cases  and 
the  blood  concentration  of  the  drug  has  always 
been  within  safe  therapeutic  limits.  By  this  method 
the  patient  is  spared  nausea  and  the  nuisance  of 
oral  or  hypodermic  administration  during  the  first 
trying  postoperative  days. 

Xo  doubt  other  members  of  the  sulfanilamide 
group  will  in  time  be  discovered.  Their  therapeu- 
tic effects  will  also  vary  so  that  the  indications 
for  the  use  of  any  individual  drug  will  have  to  be 
learned  from  experience.  Certainly  the  possibilities 
of  this  form  of  chemotherapy  are  just  beginning  to 
be  understood. 


GENERAL  PRACTICE 


James    L.    Hamner,    M.  D.,    Editor,    Mannboro,    Va. 

TREATMENT  OF  CHRONIC  ULCERS  OF 

THE  LEGS  WITH  THE  USE  OF 

UNNA'S  PASTE  BOOT 

This1  is  the  description  of  the  method  of  treating 
ulcers  that  is  best  of  all. 

Unna's  paste  boot  acts  as  a  supporting  bandage 
and  as  an  antiseptic  dressing. 

The  ingredients  for  a  10  kg.  batch  are  1  kg.  zinc 
oxide  (C.P.),  1  kg.  good  gelatin,  3  kg.  water,  4  kg. 
Glycerine  (C.  P.) 

Gelatin  placed  in  cold  water  until  soft  and  swol- 
len, then  firmly  squeezed  out,  contains  the  4  kg.  of 
water.  It  is  placed  in  a  water-bath  and  stirred  until 
dissolved.  At  the  same  time  the  zinc  oxide  is  stirred 
up  with  1  liter  (1  kg.)  of  water,  forming  a  thick 
paste,  which  is  then  mixed  with  glycerine  by  vigor- 
ous shaking.  The  mixture  is  now  poured  into  the 
prepared  gelatin  and  again  well  shaken.  Then  the 
mixture  is  poured  out  into  a  shallow  vessel.  After 
1  or  2  hours  it  has  solified  into  a  white  jelly. 

Slices  of  the  prepared  paste,  enough  to  make 
a  boot,  are  placed  on  a  water-bath  until  the  paste 
has  completely  dissolved.  The  leg  is  cleaned  with 
soap  and  water  and  dried.     The  ulcer  is  cleaned 


1.  L.  B.  Greentree  &  L.  F.  Gallardo,  in  Philippine  Med.  Assn. 
71.,  21-   31,    1941) 


with  any  antiseptic  solution  and  a  thin  coating 
of  any  ointment  is  applied  over  it.  A  thin  sterile 
dressing  is  then  applied  over  this.  The  Unna 
paste  melted  and  cooled  to  a  t.  which  will  be 
tolerated  is  then  painted  on  the  leg  with  a  large 
brush  from  just  below  the  knee  to  just  above  the 
toes.  While  it  is  still  moist,  the  leg  is  enveloped 
in  a  carefully  applied  single-layer  gauze  bandage. 
A  second  coat  of  Unna's  paste  is  applied  and  over 
this  a  second  layer  of  gauze  bandage.  Frequently 
this  suffices  but  when  more  support  is  needed  a 
third  and  a  fourth  layer  of  bandage  and  paste 
may  be  applied.  The  more  the  patient  walks  with 
the  leg  thus  bandaged,  the  more  quickly  will  the 
ulcer  heal.  The  boot  is  left  on  for  from  7  to  10 
days,  after  which  time  it  is  removed  by  cutting 
through  with  scissors.  On  removal,  usually  the 
ulcer  is  healed.  If  not  yet  healed  another  boot  is 
applied  and  kept  on  for  a  week  or  two.  In  the 
cure  of  very  extensive  ulcers  3  or  even  4  applica- 
tions may  be  necessary.  The  principal  indications 
for  its  removal  and  reapplication  are  soiling  of 
the  boot  and  such  reduction  in  the  swelling  that 
the  boot  no  longer  provides  support.  Discontinu- 
ing the  use  of  the  boot  too  soon  may  result  in 
recurrence.    No  windows  or  doors  shall  be  cut. 

TREATMENT  OF  DIABETES  IN  THE  AGED 

Old  diabetics  should  not  be  neglected.  Here1  is 
given  a  satisfactory  outline. 

Therapy  must  be  as  simple  as  the  oldster  desires, 
and  no  attempt  should  be  made  to  change  the  hab- 
its of  a  lifetime.  The  practice  of  permitting  older 
patients  to  have  an  elevated  blood  sugar  so  that 
they  will  feel  better  must  be  severely  condemned. 

Extra-diabetic  complications,  responsive  to  prop- 
er therapy,  will  be  successfully  treated  in  the  dia- 
betic. 

Avoid  radical  changes  in  diet  or  insulin.  Shocks 
are  serious;  glycogen  stores  in  heart  muscle  should 
be  guarded.  Arteries  are  fragile.  The  structures 
of  the  eye  and  nervous  system  cannot  resist  rapid 
chemical  changes. 

Reasonable,  firm  discipline  must  be  maintained. 
Routine  visits  for  blood  sugar  estimations  are 
necessary. 

Do  not  take  any  physical  condition  for  granted. 
Examine  the  feet,  eyes,  and  heart.  It  may  take 
the  patient  months  to  get  the  courage  to  speak 
of  a  sore  toe  or  failing  vision. 

Senile  diabetes  is  gentle  enough  to  use  a  house- 
hold measured  diet  as  routine.  Vitamin  deficien- 
cies and  mineral  shortages  must  be  foreseen  in  the 
original   diet  prescription. 

Many  older  patients  will  be  able  to  enjoy  better 
health  and  have  larger  and  more  varied  diets  from 
the  use  of  protamine  zinc  insulin  daily. 

1.     J.    W.    Mitchell,    Pittsburgh,    in  Perm.    Med     Jl.    May 


SOUTHERN  MEDICINE  &■  SURGERY 


August,  1941 


RESUSCITATION  OF  THE  NEWBORN 

Mouth-to-mouth  insufflation  remains  a  method 
of  distinct  value,  while  awaiting  materials  for 
trachael  intubation,  a  procedure  whcih  often  proves 
unnecessary  by  the  time  it  is  available.  Mouth-to- 
mouth  insufflation  should  be  employed  very  cau- 
tiously because  of  the  danger  of  rupturing  the  al- 
veoli. A  small  catheter  should  be  passed  into  the 
stomach  to  evacuate  the  gas  bubble. 

In  immersing  in  hot  and  cold  water  alternately, 
asepsis  is  impossible,  and  the  position  in  which 
the  infant  is  held  prevents  drainage  of  the  bron- 
chial tree;  physical  shock  is  excessive,  and  the 
method  offers  no  advantages  over  maintenance 
of  body  heat  by  warm  blankets  with  occasional 
sensory  stimulation  by  slapping  the  buttocks  or 
soles  of  the  feet. 

Carbon  dixoide-oxygen  therapy  richly  deserves 
the  wide  usage  which  it  enjoys. 

For  tracheal  catheterization  the  catheter  is 
aspirated  full  of  fluid,  removed,  the  contents  blown 
out  and  the  catheter  reinserted  very  quickly.  With 
the  catheter  in  place,  carbogen  or  oxygen  is  intro- 
duced at  will,  care  being  taken  to  use  pressures 
that  do  not  exceed  4  to  5  mm.  Hg. 

Alpha-lobeline  is  helpful  in  increasing  the  depth 
and  frequency  of  respirations,  once  spontaneous 
respirations  have  been  established. 

Intracardiac  injection  of  adrenalin,  resorted  to 
in  desperation  on  a  number  of  occasions,  in  only 
two  instances  seemed  to  help  in  the  least. 

The  authors  have  had  no  experience  with  the 
various    mechanical    respiration    apparati. 


The  rowing  method  adapts  itself  to  use  under  any  con- 
dition where  artificial  respiration  is  necessary,  except  in 
the  case  of  removing  an  electric  shock  victim  from  a  pole, 
where  an  anterior-basal  chest-squeeze  is  used  while  de- 
scending the  pole. 


1.  W.     B.    Thompson    &    E.    J      Krauhulik,    Los    Angele 
Western  Jl  of  Surg.   Obs.  &  Cynec.,  49:   169,   1941 


ROWING   METHOD   OF   ARTIFICIAL   RESPIRATION 

(M.  C.  Rosekrans,  Neillsville,  in  Wise.  Med.  Jl  July) 
With  the  patient  supine,  place  yourself  at  the  patient's 
head.  Grasp  the  patient's  arms  at  the  wrists  and  firmly 
extend  his  arms  above  his  head,  to  raise  the  chest,  keep- 
ing them  there  long  enough  for  air  to  enter  the  chest ; 
then  rapidly  drop  the  arms  back  toward  the  patient's  chest, 
leaving  them  there  long  enough  for  air  to  rush  out  of 
the  chest.       Repeat  10  to  12  times  per  minute. 

No  pressure  is  brought  to  bear  upon  the  body  at  any 
point.  With  the  patient  in  a  comatose  state,  being  re- 
laxed as  he  is,  the  chest  is  raised  with  very  little  effort. 
One  operator  is  able  to  carry  on  this  rowing  motion  for 
two  hours  or  more  with   perfect  ease. 

Only  one  of  the  many  methods  of  artificial  respiration 
has  survived — prone  pressure.  This  method  is  not  en- 
tirely  satisfactory   for    the    following    reasons: 

(1)  It  requires  several  persons  to  keep  the  operation 
going   continuously. 

(2)  It  often  produces  trauma  to  the  ribs  and  other  tis- 
sues. 

(3)  It  cannot  be  used  upon  a  patient  supine  on  an 
operating  table. 

(4)  It  does  not  readily  adapt  itself  to  convenient  ob- 
servation and  care  of  the  patient. 

(5)  The  procedure  is  that  of  an  entirely  negative  phase 
of  respiratory  mechanism  throughout,  and  admits  only  a 
minimum  of  aeration. 


DERMATOLOGY 

J.  Lamar  Calloway,  M.D.,  Editor,  Durham,  N.  C. 


THE  MANAGEMENT  OF  DERMATOPHYTO- 
SIS  ' 

Dermatophytosis  (athlete's  foot),  one  of  the 
commonest  and  sometimes  one  of  the  severest  of 
all  dermatoses,  is  caused  by  several  common  fungi 
and  is  often  difficult  to  cure.  Bacteria  (Staphlo- 
coccus,  Streptococcus)  often  complicate  the  infec- 
tion with  serious  sequelae.  About  seventy-five  per 
cent  of  all  adults  have  the  infection  either  in  a 
latent  or  active  phase.  The  latent  phase  is  charac- 
terized by  scaling,  Assuring  and  maceration  be- 
tween the  toes  and  the  toe  webs,  and  by  an  occa- 
sional small  vesicle  over  sole  and  dorsum.  Fortu- 
nately for  these  carriers,  the  disease  is  essentially 
asymptomatic  and  causes  few  or  no  serious  com- 
plications. 

The  latent  phase  can  be  successfully  treated  in. 
the  majority  of  instances  by  careful  drying  between 
the  toes  after  each  bath  plus  massage  to  get  all  of 
the  dead  skin  out  from  between  the  toes.  The 
patient  should  be  instructed  to  avoid  walking  bare- 
footed on  bathroom,  shower,  gymnasium,  swim- 
ming pool,  locker  room,  or  other  floor.  Fingers 
should  be  kept  away  from  infected  areas.  Infec- 
tions to  other  parts  of  the  body  are  sometimes 
spread  in  this  way.  Socks  should  be  changed  daily. 
Cotton  socks  should  be  worn  so  that  they  can  be 
boiled  after  each  day's  wear.  It  is  sometimes  nec- 
essary to  fumigate  the  shoes  since  shoes  frequently 
harbor  spores  of  the  fungi  which  serve  as  a  source 
of  reinfection.  A  powder  such  as  is  detailed  below 
dusted  between  the  toes  and  over  the  soles  of  the 
feet  each  morning  will  as  a  rule  control  this  latent 
phase. 

Rx    Thymol  iodide  0.6 

Salicylic   acid   1.8 

Camphor   1.8 

Talcum  30.0 

Zinc  oxide  30.0 

Sig:  Use  locally  as  dusting  powder. 

When  the  disease  becomes  more  active,  espe- 
cially with  the  development  of  secondary  infection, 
lymphangitis  and  lymphadenitis,  sometimes  with 
erysipelatous  spread,  the  patient  should  be  imme- 
diately taken  off  his  feet,  placed  at  bed  rest,  given 
warm  wet  compresses  using  either  saline,  boric  acid 
solution,  or  1:4000  potassium  permanganate.  Me- 
chanical debridement  should  be  done,  all  the  vesi- 
cles and  bullae  being  clipped  and  all  of  the  crust- 
ing and  dead  skin  cleaned  away.  In  some  instances 
sulfathiazol  or  other  of  the  sulfonimids  are  neces- 
sary to  help  control  the  secondary  infection. 


August,  1941                                               SOUTHERN  MEDICINE  &  SURGERY  447 

After  all  the  secondary  infection  is  cleared  up  an  Acute  abscess  of  the  lung  is  divided  into  the  more 

ointment  mav  be  used  locally  at  night  followed  by  frequent  putrid  or  anaerobic  abscess,  and  the  less 

the  application  of  a  dusting  powder  such  as  de-  frequent  non-putrid  or  aerobic  form.    The  acute 

tailed  above  the  following  morning.    A  simple  yet  putrid  abscess  is  a  superficial  solitary  monolocular 

Satisfactory  ointment  is  this:  lesion  within  a  pulmonary  lobe,  with  a  thin  and 

soft  overlying  shell,  which  is  compressed  and  avas- 

Rx    Thymol  iodide  0.6  cuJar     Thg  surfac€  of  the  iung  over  suc}j  an  abscess 

Benzoic  acid    ... '.'.'.'....".....................    3.6  is  always  attached  to  adjacent  structures  by  adhe- 

Boric  acid  ointment 60.0  sions  which  may  bind  the  surface  of  the  abscess  to 

Sig:  Apply  locally  each  night.    Remove  an  adjacent  pulmonary  lobe,  to  the  mediastinum, 
excess  in  morning  and  apply  dusting  or  tQ  ^  diaphragm.  Such  abscesses  usually  have  a 
pow  limited  amount  of  pneumonitis  around  them  and 
Other  complications,  dermatophytides,  the  use  of  limited  changes  in  the  bronchi  except  in  the  imme- 
x-ray  therapy,  desensitization,  vaccine  therapy,  and  diate  area  of  the  abscess.   A  chronic  putrid  abscess 
other  special  measures  should  be  used  only  by  one  has  stiff  walls,  is  multilocular,  and  there  is  exten- 
especially  trained  in  the  care  and  treatment  of  the  sjve  pulmonary  infiltration  with  fibrosis  and  exten- 
sion, sive  changes  in  the  bronchi. 

■  The  pathology  of  acute  aerobic,  non-putrid  ab- 

TUBERCULOSIS  scess  is  more  variable  than  that  in  putrid  abscess. 

,   _                ,,  _.     „ ...       ,,.     ,  „„   M    r  It  may  be  in  the  midst  of  an  area  of  broncho- 

J.  Donnelly,  M.  D.,  Editor,  Charlotte,  N.  C.  J     . 

pneumonia,  or,  although  the  abscess    may    be    a 

prominent  part  of   the  lesion,  extensive  broncho- 

TREATMENT  OF  PULMONARY  ABSCESS  £neum0Ilia  may  also  be  present.  Features  of  putrid 

The  observations  in  this  article  concerning  the  pulmonary  abscess  are  sometimes  seen  in  the  non- 
proper  treatment  of  pulmonary  abscess  of  the  acute  putrid  type,  the  latter  being  usually  unilocular  and 
type  are  derived  from  a  discussion  of  the  subject  of  considerable  size.  The  author  states  that  recov- 
by  Harold  Neuhof  in  a  recent  issue  of  Diseases  oj  ery  from  non-putrid  abscess  under  conservative 
the  Chest.  The  author  notes  that  treatment  of  this  treatment  often  occurs,  and  that  this  may  account 
serious  complication  is  principally  conservative;  for  the  many  cures  under  conservative  treatment, 
and  that  the  condition  is  not  considered  surgical  the  aerobic  cases  being  combined  with  the  anaero- 
by  most  men  in  its  acute  stage,  surgical  treatment  bic  m  the  reports. 

being  employed  only  for  urgent  complications,  or  The  author  has  arrived  at  the  conclusion  that 

when  bronchoscopic  and  postural  drainage,  drugs  practically  all  cases  of  putrid  pulmonary  abscess 

and  bed  rest  fail  to  benefit.   The  arguments  against  are  amenable   to  surgical   treatment  in  the  acute 

surgery  are  reports  of  spontaneous  cure  and   the  stage,  but  only  exceptional    cases    of    non-putrid, 

assumption  that  pulmonary  abscess  is  a  pneumonic  aerobic  abscess  should  have  surgical  interference, 

lesion  in   the  beginning.    The  author  admits  that  and  that  there  is  no  reason  for  setting  any  certain 

the  occurrence  of  spontaneous  cure  is  not  rare,  but  time  for  observation   before  surgical  treatment  is 

notes  that  the  reported    incidence    of    such    cure  instituted. 

ranges  from  10  to  90  per  cent,  which  indicates  con-  The  indications  for  operation  are  given  as  fol- 

siderable  discrepancy  in  results.   He  says  that  such  lows:   (1)  no  evidence  of  subsidence  of  the  process 

discrepancy  in  figures  may  be  due  to  a  difference  in  during  observation;    (2)   an  unsatisfactory  clinical 

follow-up  and  a  difference  in  the  criteria  by  which  course;    (3)   a  pulmonary    abscess    more    than    2 

cures   are  judged.    He   contends   that  with   strict  inches  in  diameter;  (4)  x-ray  evidence  of  extensive 

criteria  of  cure   (freedom   from  symptoms,  disap-  pleural  reaction,  suggesting  danger  of  perforation 

pearance  of  cavity  and  pulmonary  infiltration)  and  of  the  abscess;    (5)   clinical  or  bronchoscopic  evi- 

complete  follow-up,  the  percentage  of  cures  from  dence    of    interference    with    adequate    bronchial 

conservative  treatment  is  low,  and  that  the  argu-  drainage;    (6)   fluctuating,  remitting  or  stationary 

ment  for  a  high  percentage  of  cures  by  non-opera-  course;    (7)    increase   in    the   size   of   the   abscess 

tive  procedures  is  fallacious.  during  the  period  of  observation;    (8)   potentially 

It  is  also  the  opinion  of  this  author  that  "the  dangerous  location  of  the  abscess,  as  in  the  cardiac 

assumption  that  widespread  pneumonic  infiltration,  lobe  or  at  the  mediastinum. 

occupying  more  or  less  ill-defined  pulmonary  zones  A  properly  planned  operation  must  be  based  on 
characterizes  the  pathology  of  acute  abscess  of  the  ( 1 )  the  fact  that  an  acute  abscess  is  solitary,  super- 
lung"  is  based  on  the  interpretation  of  the  x-ray  ficial,  with  overlying  pleural  adhesions,  and  (2)  the 
film  and  is  not  a  fact.  exact  localization  by  x-rays  of  the  site  of  contact 

There  follows  a  discussion  of  the  pathology  of  between   the  abscess  and   the   thoracic  wall.    The 

acute   pulmonary   abscess,   on    which,    the    author  author  claims   that   errors   in   localization   can   be 

states,  his  advocacy  of  surgical  treatment  is  based,  caused  only  by  error  in  x-ray  interpretation  or  in 


448 


SOUTHERN  MEDICINE  &  SURGERY 


August,  1941 


counting  of  the  ribs  at  the  time  of  operation.  The 
method  of  choice  for  spot  localization  is  that  of 
Rabin — the  injection  of  a  small  amount  of  methy- 
lene blue  and  lipiodol  at  the  predetermined  site  of 
contact  of  abscess  with  chest  wall,  followed  by  a 
series  of  films  taken  in  different  positions.  The  re- 
lationship between  the  lipiodol  and  the  abscess  will 
be  shown,  and  the  methylene  blue  in  the  intercostal 
space  will  designate  the  rib  to  be  removed  at  opera- 
tion. 

The  operation  is  a  one-stage  procedure,  the  ab- 
scess being  entered  through  overlying  pleural  ad- 
hesions, unroofed,  and  packed.  The  author  prefers 
local  anesthesia,  in  most  instances  the  removal  of  a 
portion  of  one  rib  is  sufficient.  After  inadequate 
operation  continuation  of  symptoms  and  extension 
of  the  abscess  may  be  expected.  An  adequate 
operation  usually  results  in  subsidence  of  the  symp- 
toms. 

Cases  operated  on  by  the  author  and  his  asso- 
ciate in  the  last  15  years  number  109.  There  were 
four  deaths  following  operation,  a  mortality  of  3.6 
per  cent.  Several  other  deaths  occurred  months  or 
years  after  the  abscess  had  healed,  due  to  unrelated 
causes.  One-third  of  the  cases  were  of  the  severe 
acute  type,  and  three  of  the  four  deaths  occurred 
in  this  group.  According  to  these  results  acute 
putrid  pulmonary  abscess  is  a  surgical  disease, 
the  results  of  precisely  performed  operative  proce- 
dures excellent  and  the  mortality  low.  The  author 
further  states  that  "the  menace  of  subacute  and 
chronic  abscess  will  disappear  only  when  the  prob- 
lem is  squarely  faced  and  adequately  solved  in 
the  acute  phase." 


INTERNAL  MEDICINE 

George   R.   Wilkinson,   M.  D.,   Editor,    Greenville,   S.   C. 


FACTORS   INFLUENCING   IMMEDIATE 
MORTALITY  RATE  FOLLOWING 
ACUTE  CORONARY  OCCLUSION 

The  common  occurrence  of  attacks  of  coronary 
artery  disease  makes  it  incumbent  on  all  doctors  to 
know  all  they  can  about  this  kind  of  seizure.  What 
to  tell  the  patient  or  family  as  to  the  outlook  is 
an  important  part  of  this  knowledge. 

The  number  of  cases  seen  and  carefully  studied 
at  the  Mayo  Clinic  afford  pertinent  and  reliable 
information.1 

One  hundred  and  twenty-eight  cases  of  acute 
coronary  occlusion  were  taken  at  random. 

The  mortality  within  six  weeks  of  the  acute  at- 
tack for  the  32  patients  less  than  SO  years  of  age 
was  28.1%;  for  all  between  50  and  59  years  of 
age,  41.7%;  for  those  between  60  and  69,  57.1  % 


1.  R.   M.   Woods  &  A.   R.    Barnes.   Rochester,   Minn., 
Staff  Meetings   Mayo   Clinic,    May  28th. 


and  for  those  70  years  of  age  or  more,  84.6%.  The 
rate  for  men  in  this  series  of  cases  was  41.7%,  as 
compared  with  75'  [   for  women. 

The  incidence  of  previous  angina  pectoris  was 
39.7%  in  the  group  of  patients  who  lived  and  40% 
in  the  group  who  died  within  the  immediate  period. 
Of  the  group  of  patients  who  had  acute  coronary 
occlusion  and  survived,  19.1%  gave  clinical  of 
electrocardiographic  evidence  or  both  of  having 
had  an  attack  of  coronary  occlusion  in  the  past. 

Pulmonary  edema  occurred  in  33.3%  of  the 
deaths  within  the  immediate  period,  not  observed 
among  the  patients  who  survived;  congestion  of 
the  liver  in  15%  of  the  cases  in  which  death  oc- 
curred, not  present  in  any  cases  in  which  death  did 
not  occur;  15%  of  the  patients  who  died  and  2.9% 
of  those  who  survived  the  acute  attack  had  cere- 
bral thrombosis.  Pericarditis  was  recognizable  in 
10' c  of  the  cases  in  which  death  occurred  and  in 
1.5%  of  the  other  cases. 

Ventricular  extrasystoles  following  acute  coro- 
nary occlusion  are  ominous. 

Massive  pulmonary  embolism  was  the  immedi- 
ate cause  of  death  of  10%  of  all  patients  who  died 
within  the  immediate  period  but  did  not  occur 
among  the  patients  who  survived.  The  source  of 
these  pulmonary  emboli  was  not  the  mural  thrombi 
in  the  heart  but  thrombi  in  the  iliac  vessels.  The 
decrease  in  b.  p.  which  follows  acute  coronary  oc- 
clusion and  the  complete  rest  in  bed  and  inactivity 
on  the  part  of  the  patient  facilitate  the  formation 
of  thrombi,  particularly  within  the  iliac  veins. 

Fifteen  of  the  60  patients  who  died  gave  clini- 
cal and  pathologic  evidence  of  severe  myocardial 
failure  after  the  onset  of  the  acute  coronary  occlu- 
sion and  myocardial  infarction.  In  10  there  was 
passive  congestion  of  the  lungs.  In  the  other  five 
cases  clinical  and  pathologic  evidences  of  pulmo- 
nary and  hepatic  congestion  were  present. 

Cerebral  thrombosis  brought  about  fatal  termi- 
nation in  four  cases.  Rupture  of  the  heart  with 
cardiac  tamponade  accounted  for  the  death  of  two. 

DIAGNOSIS  AND  TERATMENT  OF 
GASTRIC  DISEASE 

Stomach  trouble  troubles  us  all.  The  English 
still  stick  by  the  term  dyspepsia,  and  we  all  may 
get  back  to  it  just  as  we  have  to  gastritis — al- 
though it  would  be  interesting  to  know  how  many 
cases  of  gastritis  any  one  of  us  has  ever  seen. 

Here  is  abstracted  a  helpful  discussion1  of  com- 
mon stomach  troubles. 

The  three  common  affections  of  the  stomach: 
gastritis,  cancer  and  peptic  ulcer  are  discussed. 

Gastritis,  outcast  from  respectable  medical  so- 
ciety for  many  years,  has  now  returned  to  style. 

1.  W    L.   Palmer,   Chicago,   in  Miss.   Valley  Med.  Jl.     July. 


August.   1941 


SOUTHERN  MEDICINE  &  SURGERY 


The  clinical  diagnosis  of  gastritis  can  be  made  only 
by  gastroscopv.  Hypertrophic  gastritis  is  found 
not  infrequently  in  patients  with  peptic  ulcer  and, 
at  times,  in  patients  with  a  peptic-ulcer  syndrome 
but  without  an  ulcer.  Usually  the  symptoms  are 
relieyed  by  medical  ulcer  management  even  though 
the  gastritis  itself  as  seen  by  gastroscope  persists. 
Superficial  gastritis  does  not  produce  symptoms,  so 
no  treatment  is  indicated.  Atrophic  gastritis  is  the 
most  important  type.  The  author  questions  the 
presence  of  specific  symptoms.  The  condition  is 
invariably  present  in  pernicious  anemia.  Under 
appropriate  therapy,  the  gastric  mucosa  may  re- 
gain an  almost  normal  appearance.  It  is  present 
as  a  rule  in  severe  iron-deficiency  anemia,  with 
achlorhydria.  In  other  deficiency  states,  such  as 
pellagra,  gastritis  seems  to  be  incidental  to  the  dis- 
ease. Cancer  develops  in  an  abnormal  mucosa — 
often;  perhaps  usually,  but  certainly  not  always. 
Periodic  gastroscopic  and  x-ray  examinations  of 
the  stomach  for  all  individuals  known  to  have 
atrophic  gastritis  are  recommended. 

Cancer  of  the  stomach  must  be  suspected  in  all 
adults  with  indigestion.  The  distress  of  gastric 
cancer  is  unreliable.  The  physical  examination 
usually  reveals  no  significant  positive  findings. 
Anemia  may  or  may  not  be  present.  Free  HC1 
may  or  may  not  be  present  in  the  gastric  juice. 
Occult  blood  is  usually  present  in  the  stool.  A 
positive  or  a  negative  x-ray  diagnosis  of  cancer  is 
usually  correct;  x-ray  evidence  may  be  inconclu- 
sive. Gastroscopy  is  helpful.  Operation  should  be 
urged  in  all  cases  unless  distant  metastasis  has 
been  proved.  Whether  an  ulcer  is  benign  or  malig- 
nant is  often  difficult  and  at  times  impossible  to 
know.  Failure  of  the  ulcer  to  heal  within  a  few 
weeks  on  an  adequate  medical  regimen  is  presump- 
tive evidence  of  cancer,  as  is  the  continued  pres- 
ence of  occult  blood  in  the  stool.  In  patients  with 
carcinoma,  medical  management  may  completely 
relieve  the  pain  and  the  patient  may  gain  in 
weight.  Only  rarely  does  the  blood  in  the  stool  dis- 
appear and  only  very  rarely  does  the  crater  of  the 
ulcer  diminish  in  size.  The  ulcer  can  never  be 
assumed  to  be  benign  until  it  has  proved  itself  to 
be  so  .  Cancerous  gastric  ulcers  should  be  treated 
by  resection.  Benign  ulcers  mav  be  treated  by  re- 
section very  effectively. 

Peptic  ulcer  occurs  at  some  time  or  other  in  the 
lives  of  12%  of  all  persons.  As  a  rule  the  diagnosis 
is  easy;  gnawing  or  aching,  relieved  by  food,  may 
be  extremely  atypical.  Constipation  may  dominate 
the  picture,  or  intermittent  attacks  of  severe  pain 
with  profuse  vomiting,  simulating  biliary  colic  or 
tabetic  crisis.  Vomitus  is  always  acid  and  usually 
contains  little  or  no  bile.  Pain  mav  be  absent  and 
the  lesion  manifest  itself  by  bleeding  only,  or  bv 
acute   perforation,   or   by   obstruction.    Moynihan 


wrote,  "In  peptic  ulcer,  the  anamnesis  is  every- 
thing, the  physical  examination  nothing."  The  lab- 
oratory examination  is  unimportant  when  negative, 
as  it  usually  is.  In  chronic  benign  ulcer,  acid  gas- 
tric juice  is  invariably  present,  although  one  or 
more  histamine  tests  may  be  required  to  find  it. 
The  diagnosis  of  benign  ulcer  should  not  be  made 
if  one  is  unable  to  find  acid  in  the  gastric  content. 
The  amount  of  acid  varies  greatly  from  time  to 
time  and  any  patient  with  acid  gastric  juice  may 
have  an  ulcer,  regardless  of  the  amount  present  in 
the  test  meal.  X-ray  examination  should  be  in- 
cluded in  the  routine  examination  of  all  patients 
with  abdominal  distress.  Difference  of  opinion  as 
to  treatment  is  due  in  large  part  to  the  tendency 
of  most  ulcers  to  heal  and  recur  spontaneously. 

Two  or  three  weeks  of  relative  bed  rest  are  indi- 
cated, and  as  much  mental  relaxation  as  possible. 
In  some  cases  ambulatory  treatment  may  be  suffi- 
cient. Sippy's  milk-and-cream  and  powder  pro- 
gram is  satisfactory.  Calcium  carbonate,  30  grains 
hourly,  is  a  very  efficient  antacid.  Magnesium 
oxide,  73^  grains,  or  magnesium  carbonate,  30 
grains,  may  be  substituted  for  the  calcium  as  often 
as  is  needed  for  proper  regulation  of  the  bowels. 
Atropine  (gr.  1-60  or  1-120)  at  6  and  10  p.  m. 
helps  to  control  the  night  secretion.  The  routine 
aspiration  of  the  stomach  at  9:30  p.  m.  should  be 
continued  until  the  amount  obtained  is  regularly 
less  than  3  ozs.  The  progress  of  healing  should  be 
indicated  by  the  prompt  cessation  of  pain,  disap- 
pearance of  the  occult  blood  from  the  feces,  and 
by  roentgenologic,  and  in  the  case  of  gastric  ulcer, 
gastroscopic,  evidence  of  decrease  in  the  size  of 
the  crater  followed  in  time  by  its  complete  disap- 
pearance. Treatment  in  a  modified  form  should  be 
continued  for  months  and  years  in  order  to  prevent 
if  possible  the  recurrence  of  the  lesion. 

Acute  perforation  occurs  almost  exclusively  in 
males  (98%)  and  should  be  treated  by  immediate 
operation.  Massive  hemorrhage  occurs  in  both 
sexes  and  is  best  treated  by  means  of  bed  rest, 
with  starvation  if  vomiting  is  present.  After  vom- 
iting has  ceased,  milk  at  hourly  or  two-hourly  in- 
tervals day  and  night  until  the  stools  are  free  of 
occult  blood.  Blood  transfusions  are  indicated  if 
the  b.  p.  falls  below  100  or  if  the  red  blood  count 
falls  below  3  million,  or  the  pulse  rises  above 
120.  In  certain  cases  of  recurring  massive  hemor- 
rhage, subtotal  gastrectomy  may  be  indicated 
when  the  patient  is  clinically  well.  Repeated  at- 
tacks of  massive  hemorrhage  occur  before  and  after 
various  types  of  operations. 

The  most  frequent  complication  of  ulcer  requir- 
ing surgical  treatment  is  obstruction,  diagnosed  by 
continued  vomiting  and  gastric  retention,  and  by 
the  roentgenologic  demonstration  of  a  channel  less 
than  3  mm.  in  diameter.    The  standard  procedure 


SOUTHERN  MEDICINE  &  SURGERY 


August,  1941 


in  these  cases  is  posterior  gastroenterostomy  or  gas- 
troduodenostomy.  The  incidence  of  recurrent  ulcer 
formation  following  these  operations  is  approxi- 
mately the  same,  40%.  Subtotal  gastrectomy  is 
becoming  more  popular,  though  it,  too,  is  followed 
at  times  by  recurrent  ulcer  formation.  The  medical 
and  surgical  treatment  of  such  recurrent  jejunal 
ulcers  is  extremely  difficult.  In  a  few  cases  we 
have  had  excellent  success  from  roentgen  irradia- 
tion aimed  at  the  fundic  portion  of  the  stomach 
and  designed  to  inhibit  the  secretion  of  acid  gastric 
juice. 


HOSPITALS 

R.  B.  Dams,  M.D.,  Editor,  Greensboro,  N.  C. 


THE  SCARCITY  OF  THE  GRADUATE 
NURSE 

As  far  as  I  have  been  able  to  learn  practically 
all  hospitals  not  running  training  schools  are  hav- 
ing difficulty  in  procuring  graduate  nurses.  If  this 
be  true  the  nursing  profession  is  standing  on  the 
brink  of  a  precipice.  Sick  people  require  nursing. 
They  are  nursed  by  either  their  relatives  and 
friends,  or  by  practical  nurses  or  graduate  nurses. 
In  hospitals  nursing  by  relatives  and  friends  is  not 
practicable, 

Hospital  operators  all  over  the  country  have 
been  slow  to  accept  practical  nurses.  In  order  to 
make  it  most  unattractive  for  these  individuals, 
hospitals  have  chosen  to  call  them  nurse  maids  in 
many  instances.  All  this  means  that  the  hospitals 
have  been  very  loyal  to  the  nursing  profession. 
They  educate  a  young  woman  by  making  it  possi- 
ble for  her  to  work  her  way  through  school.  They 
create  in  her  a  new  life  and  a  new  determination 
to  serve  mankind.  Nowhere  else  can  the  same 
amount  of  education  be  obtained  for  so  little  cost. 
In  no  profession  under  the  sun  ercept  in  the  nurs- 
ing profession  does  yesterday's  graduate  obtain  the 
same  fees  as  does  the  girl  who  graduated  ten  years 
ago.  [My  observation  is  that  family  doctors  grad- 
uated yesterday  obtain  larger  fees  than  do  family 
doctors  graduated  ten  years  ago. — /.  M.  N.] 

Sick  people  have  demanded  graduate  nursing 
service  in  most  instances.  Many  times  they  have 
strained  their  pocketbooks  to  keep  a  registered 
nurse  on  when  a  practical  or  undergraduate  nurse 
could  have  filled  her  place,  but  because  she  was 
loyal  and  appreciative  of  the  tender  and  profes- 
sional care  during  the  very  sick  days  the  patient 
kept  the  graduate  nurse.  These  considerations  lay 
a  responsibility  upon  the  graduate  nursing  profes- 
sion of  producing  sufficient  graduate  nurses  to 
nurse  the  sick  people  in  each  community. 


If  the  graduate  nursing  profession  is  to  meet  the 
challenge  of  an  adequate  nurse  supply  it  must  be- 
gin now — it  should  have  begun  several  years  ago. 
Instead  of  discouraging  hospitals  to  open  training 
schools  it  should  encourage  all  hospitals  which 
have  an  adequate  staff  and  a  reasonable  number  of 
patients,  and  which  are  approved  by  the  American 
College  of  Surgeons  and  the  American  Medical  As- 
sociation, to  open  training  schools  at  once.  The 
Army  and  Navy  are  rapidly  depleting  the  present 
supply  of  graduate  nurses.  A  goodly  supply  of 
these  will  never  reenter  the  profession  for  the  rea- 
son that  they  will  meet  attractive  young  men  who 
are  now  serving  in  the  defense  of  the  country,  and 
will  marry  them.  A  reasonable  number  will  remain 
in  the  Army  or  Navy.  We  are  now  graduating  far 
less  nurses  than  we  did  ten  years  ago.  The  demand 
for  nurses  is  far  greater  than  it  was  ten  years  ago. 

If  the  graduate  nursing  profession  does  not  sup- 
ply the  sick  population  of  our  Country  with  their 
services  then  it  will  take  practical  nurses  in  their 
stead.  If  they  take  practical  nurses  many  of  these 
will  remain  in  the  field  at  a  lower  fee  but  will  sat- 
isfy a  large  proportion  of  the  people.  At  least 
those  who  have  never  had  graduate  nurse  service 
will  not  be  capable  of  judging  the  value  of  that 
service  in  comparison  with  that  which  they  are  get- 
ting from  the  practical  nurse.  We  cannot  speak  too 
plainly  upon  this  matter.  Sufficient  urging  must  be 
brought  to  bear  so  that  the  leaders  in  the  nursing 
profession  will  realize  what  a  grave  mistake  they 
are  making  in  attempting  to  reduce  the  number  of 
graduates  each  year. 


HISTORIC  MEDICINE 


THE  MEDICAL  ASPECTS  OF  SAINT-SIMON'S 

MEMOIRES 

J.  D.  Rolleston,  in  Proc.  Royal  Soc.  Med. 

Louis  de  Rouvroy,  Due  de  Saint-Simon,  was 
born  at  Versailles,  1675,  and  died  1755.  The  Me- 
moires  cover  the  period  1694  to  1723,  contain  num- 
erous passages  of  medical  interest. 

Smallpox  is  by  far  the  most  frequent  of  all  the 
diseases  mentioned  by  Saint-Simon,  over  50  cases 
being  noted,  a  large  proportion  fatal.  The  victims 
included  Saint-Simon  himself,  his  two  sons,  the 
Queen  of  Spain,  and  the  Due  de  Noailles  who  re- 
covered, and  the  Emperor  Joseph  I  of  Austria, 
the  Old  Pretender's  daughter,  Saint-Simon's 
mother  and  sister  and  Monseigneur. 

Since  Jenner's  discovery  the  disease  has  been 
almost  unknown  in  the  upper  classes  among  whom 
objectors  are  rare.  Sequelae  were  facial  disfigure- 
ment of  the  Queen  of  Spain,  Pontchartrain,  and 


August.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


Sieur  de  Xeufchatel,  loss  of  one  eye  or  both  eyes 
of  Phelypenaux  and  Normoutiers  and  dementia  in 
Mme  Desmarets. 

Seven  cases  of  death  in  child-bed  among  the 
court  ladies  are  mentioned,  With  the  exception 
of  the  Duchesse  de  Melun,  whose  death  was  due 
to  post-partum  haemorrhage  attributed  by  Saint- 
Simon  to  her  refusal  to  be  held  in  pregnancy,  there 
is  nothing  to  indicate  whether  the  deaths  were  due 
to  infection  or  not. 

Malaria  was  prevalent  at  Versailles  and  Marly. 
Louis  XIV  was  attacked.  M.  de  Bauvilliers,  Saint 
Simon  says,  was  killing  himself  with  cinchona  to 
arrest  an  obstinate  fever  accompanied  by  a  trouble- 
some diarrhoea,  a  condition  which  may  well  have 
been  typhoid  fever. 

Several  references  are  made  to  the  great  epide- 
mic of  plague  which  occurred  at  Marseilles  in  1720, 
spread  over  a  large  part  of  Provence,  and  did  not 
come  to  en  end  until  1722.  In  1723  the  barriers 
were  removed,  commerce  was  reestablished  with 
all  foreign  countries  and  thanksgivings  were  of- 
fered in  all  the  churches  of  the  kingdom. 

Among  chronic  infections  mentioned,  syphilis 
under  the  name  of  verole  holds  first  place.  Particu- 
larly severe  attacks  of  bone  syphilis  occurred  in 
the  cases  of  the  Due  de  Vendome  and  Jiis  brother 
the  Grand  Prior.  Both  the  Duke  and  another 
eminent  soldier,  M.  de  Vaudemont  underwent  the 
"grand  remedy"  which  produced  abundant  sali- 
vation. Louis  XIV,  though  he  was  doubtless  often 
exposed  and  undoubtedly  contracted  gonorrhoea, 
there  is  no  evidence  in  the  Memoires  or  elsewhere 
that  he  acquired  syphilis. 

Cardinal  Dubois,  one  of  the  most  profligate  men 
of  a  licentious  age.  and  the  subject  of  genito-urinary 
disease  for  which  he  was  operated  on  by  the  fam- 
ous surgeon  La  Peyronie,  was  probably  also  an- 
other subject  of  gonorrhoeal  infection. 

The  Duchesse  de  Berwick  died  of  "Consomption" 
at  Montpellier,  where  her  husband  had  taken  her 
for  a  change  of  air.  The  Due  de  Caderousse  who 
had  long  been  very  ill  with  his  chest  made  a  per- 
fect recovery  under  the  treatment  by  Caretti,  a 
well-known  quack,  while  Pere  Valois,  a  celebrated 
Jesuit,  and  the  Marquis  de  Saint-Simon,  the  oldest 
member  of  the  writer's  family,  both  died  of  a 
"chest  disease",  and  "phthisie"  carried  off  the  Span- 
ish Due  de  Liria.  The  most  remarkable  case  was 
that  of  Mme  de  Clerambault:  "When  young  she 
almost  died  of  a  chest  disease  and  was  strong-mind- 
ed enough  to  pass  a  whole  year  without  uttering 
a  word."  It  may  not  be  generally  known  that  an 
Honorary  Felilow  of  this  Society  and  a  former 
President  of  this  Section  when  sufferinc;  from  laryn- 
geal tuberculosis  also  adopted  this  silent  regimen 
and  made  a  complete  recovery. 


An  example  of  King's  Evil  is  afforded  by  Mme. 
de  Soubise  and  several  of  her  children  who  were 
all  touched  by  Louis  XIV  but  without  success. 
Another  instance  of  the  King's  Evil  was  that  of 
the  Queen  of  Spain.  It  did  not,  however,  prevent 
her  uxorious  husband  from  sleeping  with  her  until 
a  few  days  before  her  death. 

Leprosy  is  mentioned  once,  the  patient  being  M. 
de  Lavardin,  lieutenant  general  of  Brittany,  who 
is  said  to  have  inherited  the  disease  from  the  Ros- 
taing  family  to  which  his  mother  belonged. 

Among  the  most  eminent  of  about  40  sufferers 
of  gout  mentioned  were  Louis  XIV  himself  who 
had  numerous  protracted  attacks,  the  Prince  de 
Conti.  M.  de  Boufflers  and  the  Due  de  Vendome. 

Half  a  dozen  cases  of  cancer  were  mentioned. 
In  one  of  them  (Mme.  de  Vieuville)  it  is  stated 
kept  the  cancer  secret  until  two  days  before  death, 
and  only  her  maid  knew  about  it  and  dressed  it, 
while  in  the  other  (Mme.  Bouchu)  the  breast  was 
amputated  and  the  patient  died  many  years  later 
of  pneumonia.  The  only  case  of  cancer  in  a  man 
was  that  of  the  Due  de  Lauzun,  in  whom  the 
mouth  was  the  seat  of  the  lesion. 

About  40  cases  of  apoplexy  are  mentioned,  the 
most  notable  subjects  being  La  Bruyere,  the  Duch- 
esse de  Bouillon,  and  the  Duke  of  Marlborough, 
of  whom  Saint-Simon  relates  that  for  more  than 
three  years  he  was  no  longer  capable  of  anything. 

Tics,  examples  of  which  were  noted  in  Mme.  de 
Nemours,  tic  of  the  shoulderr;  Duchesse  de  Cha- 
tillon,  facial  tic;  Peter  the  Great,  facial  tic;  and 
Don  Michel  Guerra — "In  spite  of  good  healtth  he 
showed  a  strange  ailment;  his  head  turned  con- 
vulsively to  the  left  side.  Usually  this  was  slight 
but  almost  continuous  with  little  jerks.  Afterwards 
it  increased  and  its  violence  was  sometimes  so  great 
that  his  chin  passed  over  his  shoulder  for  a  few 
moments,  several  times  in  succession.  He  did  not 
get  any  considerable  or  long-standing  relief  except 
in  the  baths  at  Bareges. 

An  example  of  toxi-infective  psychosis  was  the 
case  of  the  Marquis  de  Maulevrier,  who  committed 
suicide  by  throwing  himself  out  of  a  window  during 
a  maniacal  attack  in  the  course  of  pulmonary  and 
laryngeal  tuberculosis.  Mme.  Desmarets  became 
demented  after  an  attack  of  smallpox.  The  Duch- 
esse de  Charoste  died  at  the  age  of  51  after  more 
than  10  years'  illness  without  being  able  to  be 
moved  from  her  bed,  see  any  light,  hear  the  slight- 
est sound,  utter  more  than  two  words  consecutively 
or  change  her  linen  more  than  two  or  three  times 
a  year,  and  always  demanding  extreme  unction 
after  such  effort. 

The  mysterious  condition  known  as  "vapours," 
first  described  by  the  Abbe  Testu,  appears  to  have 
been  a  sort  of  neurasthenia.  It  is  mentioned  as 
occurring  in  seven  other  persons  beside  the  Abbe, 


SOUTHERN  MEDICINE  &  SURGERY 


August,   1941 


all  but  one  of  whom  were  men;  viz.,  Chamillart, 
Pontchartrain,  Louis  XIV,  the  King  of  Spain,  the 
Due  de  Noailles,  Mme.  de  Chevry,  and  the  Due 
de  Veragua. 

.  Cannan  remarks  that  "there  was  nothing  to  do 
at  Versailles  except  to  contemplate  the  King's  ma- 
jestic person  from  morning  to  night."  The  most 
notorious  example  of  collective  alcoholism  at  this 
time  was  furnished  by  the  suppers  of  the  Duke  of 
Orleans  which  were  attended  by  his  mistresses, 
and  other  society  ladies  of  easy  virtue,  army  offi- 
cers and  others  whose  pleasure  lay  in  deep  drink- 
ing, blasphemy  and  licentious  talk. 

Of  a  total  of  13  operations  mentioned  in  the 
Memoires  those  for  stone  in  the  bladder  numbered 
five.  The  first  was  performed  on  Fagon,  the  King's 
physician,  by  Mareschal.  Marechal  de  Lorges  was 
operated  on  by  the  itinerant  lithotomist  Frere 
Jacques,  who  refused  any  other  help  or  advice  but 
that  of  Milet,  a  surgeon  major  in  De  Lorges'  body- 
guard. The  Comte  de  Toulouse  was  successfully 
operated  on  by  Mareschal,  and  made  an  uninter- 
rupted recovery.  Dangeau,  who  also  wrote  Me- 
moires, in  addition  to  operation  for  fistula  in  ano 
underwent  two  lithotomies. 

The  Memoires  contain  brief  indications  of  three 
diseases  long  before  they  were  described  in  scien- 
tific medicine.  They  have  not  received  any  mention 
in  this  historical  account  of  the  diseases  in  ques- 
tion. The  first  of  these,  which  seems  to  be  a  de- 
scription of  achondroplasia,  was  that  of  the  Abbe 
de  Baudrun  who  presented  the  following  appear- 
ance: "Being  an  absolute  dwarf  and  extremely 
lame  he  joined  the  Church.  In  spite  of  his  twisted 
legs  and  enormous  head  he  was  nevertheless  very 
enterprising  with  women  for  winning  whose  favours 
he  possessed  great  talents."  This  Abbe  thus  closely 
resembles  the  patient  named  Anatol  described  by 
Pierre  Marie,  who  emphasizes  the  erotic  tendencies 
of  achondroplasics.  The  next  case,  which  seems  to 
be  one  of  spondylitis  deformans,  is  that  of  Joyeux, 
Governor  of  Meudon,  of  whom  Saint-Simon's  de- 
scription is  as  follows:  "His  back  remained  flat, 
but  it  seemed  to  be  broken  down  below  where  it 
stuck  out  and  Joyeux  walked  as  if  he  was  folded 
in  two."  Lastly  the  case  of  the  Comte  de  Beuvron, 
"who  died  very  young,  losing  his  blood  by  the  pores 
of  his  skin,  a  disease  about  which  very  little  is 
known  by  doctors,"  was  obviously  an  example  of 
haemophilia  which,  according  to  Bulloch  and  Fildes 
was  "entirely  undescribed  as  a  distinct  morbid  en- 
tity before  the  beginning  of  the  19th  century." 

A  centenarian,  the  Marquis  de  Mancera,  a  gran- 
dee of  Spain,  had  the  pecularity  of  never  eating 
bread  or  anything  in  its  place  and  retained  his 
health  and  mental  faculties  until  the  end. 

The  18th  century  was  the  age  of  sexual  athletes, 
the  example  being  set  by  Louis  XIV,  whose  powers 


in  this  respect  even  at  an  advanced  age  made  Mme. 
de  Maintenon  complain  to  her  confessor.  The 
palm,  however,  must  be  given,  even  if  allowance 
oe  made  for  exaggeration,  to  the  Abbe  de  Grandpre, 
of  whom  Saint  Simon  gives  the  following  descrip- 
tion: "He  was  a  kind  of  imbecile  and  behaved  just 
like  one.  .  .  .  His  body,  however,  was  not  like  his 
mind,  and  women  had  given  him  the  name  of  Abbe 
Quatorze." 

Against  the  Marquis  de  Santa  Cruz  action  was 
brought  by  his  wife  and  divorce  granted  on  the 
grounds  of  impotence.  The  wife  was  allowed  to 
marry  again.  Shortly  afterwards  a  girl  brought  an 
action  against  him  for  being  the  father  of  her  ille- 
gitimate child,  and  gained  her  case,  so  that,  as 
Saint-Simon  remarks,  he  was  not  lucky  in  his  law 
suits. 

One  of  the  dark  sides  of  the  resplendent  age  of 
Louis  XIV  was  the  frequency  of  real  or  suspected 
cases  of  poisoning,  of  which  Saint-Simon  reports 
numerous  examples.  Arsenic  and  perchloride  of 
mercury  were  the  drugs  usually  employed.  On  two 
occasions  snuff  was  the  vehicle  in  which  the  poison 
was  administered.  One  case  was  that  of  the  Comte 
d'Aguilar,  a  grandee  of  Spain,  who  was  accused  of 
having  poisoned  the  father  of  the  Due  d'Ossone  by 
this  means.  The  other  was  that  of  the  Due  de 
Noailles  who  gave  a  snuff-box  containing  excellent 
Spanish  snuff  to  the  Dauphine  who  died  after  a  few 
days'  illness. 

Salazat  poisoned  his  wife,  just  as  the  Due  de 
Popoli  did  his,  so  that  it  was  facetiously  said  in 
the  Spanish  court  that  to  have  poisoned  one's  wife 
was  a  necessary  condition  for  achieving  distinction. 
Ferdinand  of  Spain  was  suspected  of  having  pois- 
oned his  son-in-law  Philip  the  Handsome.  In  Spain 
the  Comtesse  de  Soissons  poisoned  the  queen,  the 
poison  being  conveyed  in  milk.  The  death  of 
Madame,  Henrietta  of  England,  the  first  wife  of 
Monsieur,  was  ascribed  without  hesitation  to  pois- 
oning. Saint  Simon  states  that  no  one  ever  had  any 
doubt  about  it.  Subsequent  investigations,  notably 
by  Littre,  Cabanes  and  Nass,  and  Funck  Brentano 
among  others,  indicate  that  her  death  was  due  to 
acute  peritonitis  from  perforation  of  a  peptic  ulcer. 

Louis  XIV  was  born  with  two  teeth,  which  had 
the  effect  of  lacerating  his  nurses'  nipples,  and  at 
an  early  age  suffered  from  dental  caries.  Loss  of 
his  teeth  caused  the  king  considerable  discomfort 
of  which  he  complained  one  day  during  dinner  to 
the  Cardinal  d'Estrees.  "Teeth!"  replied  the  tactful 
ecclesiastic,  "who  has  any  nowadays?" 


De  Lee  is  credited  with  having  said  that  in  the  birth  of 
a  child  the  pain  has  been  greatly  exaggerated.  It  might  be 
worth  while  to  lake  the  testimony  of  doctors  who  have 
borne  children.  Then,  maybe  the  women  doctors  would 
scout  the  idea  that  a  kick  in  the  testicles  is  painful. 


August,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


OPHTHALMOLOGY 

HmintT  C.  Nulitt,  M.  D.,  Editor,  Chirlotte,  N.  C. 

COLOR  OF  THE  EYES  AND  PUBERTY 

The  color  of  the  eyes  is  due  to  the  pigmenta- 
tion of  the  iris,  which,  in  50  per  cent  of  persons, 
changes  its  color  several  times  during  the  early 
period  of  puberty. 

Most  children  are  born  with  a  deep  blue  iris  and 
its  color  changes  in  the  early  years  of  life.  At 
birth  the  iris  stroma,  its  anterior  layer,  contains 
but  little  pigment  and  is  very  thin,  while  the  pos- 
terior or  retinal  pigment  layer  is  seen  through  it 
giving  the  eye  a  bluish  look.  This  is  due  to  the 
same  phenomenon  that  causes  a  dark  background 
to  appear  blue  when  seen  through  a  more  or  less 
opaque  medium.  As  age  increases  the  stroma  be- 
comes thicker  and  thicker  and  if  its  pigment  does 
not  increase  the  eye  becomes  light  blue  or  gray, 
conversely  if  the  pigment  of  the  stroma  increases 
the  color  of  the  eye  becomes  brown.  Should  there 
be  no  pigment  either  in  the  iris  stroma  or  in  its 
retinal  layer  the  iris  is  then  translucent  and,  on 
account  of  its  many  blood  vessels,  has  a  delicate 
grayish-red  color.  This  condition  is  a  part  of  a 
partial  or  complete  albinism. 

Normally,  the  color  of  the  iris  is  proportionate 
to  the  pigmentation  of  the  rest  of  the  body,  hence 
dark  races  always  have  a  dark  iris.  Heterochromic 
eyes — one  blue,  the  other  brown — are  occasionally 
seen  and  a  chronic  cyclitis  with  deposits  on  the 
cornea  and  cataract  is  more  apt  to  develop  in  the 
blue  eye.  Why  this  predilection  for  disease  of  the 
lighter  eye  is  not  known. 

Since  the  iris  is  formed  by  two  concentric  circles 
diversely  colored,  and  the  colors  are  distributed  in 
the  form  of  striae,  specks,  stippling  and  rays  on  a 
colored  background,  these  appear,  disappear  and 
are  transformed  from  one  into  another,  until  a 
more  or  less  complete  change  in  the  primary  color- 
ation of  one  or  both  of  the  zones  is  often  brought 
about.  This  evolution  generally  ends,  without  fol- 
lowing any  fixed  rules,  in  a  color  lighter  than  the 
original  color  in  both  girls  and  boys. 

Light  eyes  and  delayed  puberty  are  often  ac- 
companied by  numerous  changes.  A  judicial  expert 
finds  herein  the  key  of  the  problem  that  develops 
when  a  delinquent  aged  17  years  no  longer  has  the 
blue  eyes  recorded  in  his  anthropometric  chart 
made  at  age  IS. 

ADDITIONAL  NOTE  ON  INCLUSION 
BLENNORRHEA 
The  Editor  of  this  Department  wishes  to  con- 
gratulate Department  Editor  Nash  on  his  clear, 
concise  and  timely  discussion  of  Inclusion  Blennor- 
rhea in  the  July  issue  of  this  Journal.  It  should 
be  of  special  interest  to  all  men  doing  obstetrics 
and  pediatrics  and  it  is  hoped  it  will  be  read  and 


digested  by  many  of  those  therein  engaged.  Prompt 
diagnosis  of  the  disease  obviates  censure  and  em- 
barrassment to  the  physicians  concerned,  to  the 
hospital  where  the  delivery  was  made  and  to  the 
parents  of  the  baby.  Not  infrequently  the  writer, 
when  such  a  case  was  presented  to  him,  has  had 
to  prove  the  existence  of  the  disease,  in  contra- 
distinction to  gonococcal  infection,  and  thereby 
relieve  the  censure  imposed  by  the  parents  upon 
the  physician  or  the  hospital. 

I  wish  to  add  a  few  remarks  to  what  Dr.  Nash 
has  so  well  said. 

The  mucous  membrane  of  the  mouth  of  the  cer- 
vix is  identical  in  structure  to  that  of  the  eye  sac 
and  in  this  particular  area  in  the  birth  canal  only 
is  this  so.  Here  the  inclusion  bodies  lie.  In  order 
to  prove  the  origin  of  the  infection  in  the  mother 
epithelial  scrapings  must  be  procured  from  this 
area.  The  inclusion  bodies  will  not  be  found  in  the 
vaginal  secretions,  or  obtained  from  any  part  of  the 
vaginal  mucous  membrane.  Epithelial  scrapings 
from  the  eye  sac  are  better  procured  and  more 
safely  by  the  use  of  some  type  of  small  semi-sharp 
curette.  A  specimen  of  the  discharge  from  the  sac 
will  be  negative.  A  blennorrhea  developing  from 
the  Sth  to  7th  day  after  birth  is  strong  evidence 
against  gonococcal  infection.  However,  further 
proof  is  mandatory. 

As  an  adjunct  to  treatment  for  control  of  ciliary 
spasm  atropine  in  0.25  per  cent  aqueous  solution, 
1  drop  every  other  day  in  each  eye  sac  during  the 
first  10  days  of  the  disease,  is  strongly  indicated. 


JEFFERSON    ON    ALCOHOL    AS    A    BEVERAGE.    ON 
NOT   HUMORING   HIS   STOMACH,   AND   ON 
HARD  STUDY 
Monticello,  December   13th,   1818 
To  M.  de  Neuville 

I  rejoice,  as  a  moralist,  at  the  prospect  of  a  reduction 
of  the  duties  on  wine,  by  our  national  legislature.  It  is  an 
error  to  view  a  tax  on  that  liquor  as  merely  a  tax  on  the 
rich.  It  is  a  prohibition  of  its  use  to  the  middling  classs 
of  our  citizens,  and  a  condemnation  of  them  to  the  poison 
of  whiskey,  which  is  desolating  their  houses.  No  nation  is 
drunken  where  wine  is  cheap;  and  none  sober,  where  the 
dearness  of  wine  substitutes  ardent  spirits  as  the  common 
beverage.  It  is,  in  truth,  the  only  antidote  to  the  bane  of 
whiskey.  Fix  but  the  duty  at  the  rate  of  other  merchan- 
dise ,and  we  can  drink  wine  here  as  cheap  as  we  do  grog ; 
and  who  will  not  prefer  it?  Its  extended  use  will  carry 
health  and  comfort  to  a  much  enlarged  circle.  Every  one 
in  easy  circumstances  (as  the  bulk  of  our  citizens  are)  will 
prefer  it  to  the  poison  to  which  they  are  now  driven  by 
their  government.  And  the  treasury  itself  will  find  that  a 
penny  apiece  from  a  dozen,  is  more  than  a  groat  from  a 
single  one. 

I  have  been   blessed  with   organs  of 

digestion  which  accept  and  concoct,  without  murmuring, 
whatever  the  palate  chooses  to  consign  to  them,  and  I 
have  not  yet  lost  a  tooth  by  age.  I  was  a  hard  student 
until  I  entered  on  the  business  of  life,  the  duties  of  which 
leave  no  idle  time  to  those  disposed  to  fulfill  them;  and 
now,  retired,  and  at  the  age  of  seventy-six,  I  am  again  a 
hard  student. 


SOUTHERN  MEDICINE  &  SURGERY 


August,  1941 


SURGICAL  OBSERVATIONS 


OF  THE  STAIF 

DAVIS  HOSPITAL 
States  ville 


SPINAL  ANESTHESIA 

Of  the  many  kinds  of  anesthetics  available, 
spinal  anesthesia,  after  many  years,  has  been  found 
very  satisfactory  when  properly  given.  Persons  not 
informed  about  anesthetics,  and  who  have  had  an 
operation,  will  sometimes  attribute  certain  subse- 
quent symptoms  or  some  complication  to  the 
spinal  anesthesia.     This  is  seldom  justified. 

Spinal  anesthesia  merely  blocks  the  nerves  and 
prevents  pain  impulses  reaching  the  brain,  in  other 
words  prevent'  the  patient  being  operated  upon 
from  suffering  pain.  Many  nervous  individuals 
cannot  bear  the  thoughts  of  being  operated  upon 
while  they  are  awake.  A  patient  who  is  being 
operated  upon  under  spinal  anesthesia  usually  has 
far  less  disturbance  than  does  one  being  operated 
upon  under  ether  or  some  other  general  anesthetic. 

Sometimes  people  are  told  that  paralysis  and 
nervous  symptoms  or  insanity  follow  spinal  anes- 
thesia. In  our  experience  with  more  than  20,000 
cases  we  have  never  known  a  case  in  which  paraly- 
sis, nervousness  or  any  disturbance  ot  consequence 
developed  after  spinal  anesthesia. 

Spinal  anesthesia  is  preferable  for  many  reasons. 
Among  them: 

1)  Freedom   from   pain  during   the  operation. 

2)  Easily  administered. 

3)  No  bad  after  effects. 

There  are  no  after  effects  that  amount  to  any- 
thing. There  is  no  danger  to  the  heart,  lungs,  liv- 
er, kidneys  or  central  nervous  system.  In  other 
words,  spinal  anesthesia,  properly  given,  will  cause 
no  damage  whatsoever  to  any  part  of  the  body. 
The  mortality  in  surgery  is  less  under  spinal  than 
under  general  anesthesia  because  of  the  face  there 
is  no  irritation  of  the  lungs.  There  is  no  strain 
thrown  upon  the  heart,  and  complications  after 
the  operation  are  far  less  frequent  with  spinal  than 
with  any  other  anesthesia. 

Patients  who  come  to  us  can  have  any  form 
of  anesthesia  they  wish,  provided  it  is  something 
that  will  be  detrimenta  lto  them.  However,  for 
the  majority  of  abdominal  operations,  spinal  an- 
esthesia is  far  preferable  to  any  other  form  of 
anesthesia  now  available,  and  certainly  there  is  no 
harm  or  damage  to  the  body  following  its  use. 

Patients  should  not  listen  to  the  vague  objec- 
tions of  unqualified  persons  ready  to  condemn 
something  which  they  know  nothing  about. 


THE  TREATMENT  OF   SIMPLE   EMPYEMA 
OF  THE  THORAX 

Many  methods  of  treating  empyema  of  the 
thorax  have  been  devised.  Many  of  them  are  good; 
some  are  impractical. 

The  treatment  of  empyema  should,  of  course, 
begin  with  an  accurate  diagnosis  and  location  of 
the  pus  and  a  carefully  planned  treatment.  One 
of  the  first  things  is  an  aspiration  to  determine  the 
nature  of  the  fluid.  If  it  is  purulent,  surgical 
treatment  should  not  be  undertaken  until  at  least 
three  aspirations  have  been  done  on  each  of  three 
successive  days. 

During  the  World  War,  a  number  of  inexper- 
ienced surgeons  attempted  to  do  rib  resections  in 
early  empyema  before  the  pus-cavity  was  wall- 
ed off  and  before  infiltration  of  the  walls  or  media- 
stinum had  occurred.  Naturally,  this  resulted  in 
many  deaths.  So  great  was  the  number  of  bad 
results  that  a  general  order  then  was  issued  that 
no  rib  resection  and  drainage  of  an  empyema 
cavity  should  be  performed  until  three  successive 
aspirations  had  been  done.  This  order  immediately 
brought  the  mortality  within  normal  limits. 

In  simple  empyema  in  which  there  is  a  large 
pocket  of  thick,  yellow  pus,  and  often  coagulated 
material,  when  this  is  once  well  walled-off  and  at 
least  three  aspirations  have  been  done  and  the 
patient  is  in  condition  for  the  resection,  a  simple 
rib  resection  with  drainage  s;ives  far  better  re- 
sults than  any  other  method  of   treatment. 

To  resect  a  rib  at  the  point  which  will  insure 
freest  drainage  and  prevent  the  formation  of  a 
pocket  of  pus  below  the  opening  will  give  the  best 
results.  A  rib  resection  carefully  done  and  the 
cavity  made  so  that  it  will  tend  to  close  up  in 
due  time  gives  gratifying  results. 

We  do  not  use  rubber  tubing  for  drainage  in 
empyema,  but  we  use  a  rubber-tissue  tubular  drain, 
which  is  soft  and  does  not  irritate  the  parts  with 
which  it  comes  in  contact — or  at  least  the  irrita- 
tion is  the  very  minimum. 

Another  important  factor  to  keep  in  mind  is  the 
fact  that  aspiration  at  the  time  nf  o^cntion  is  of 
great  help.  Rib  resection  should  be  sufficient  to 
allow  the  large  pieces  of  coagulated  material  to 
be  removed  through  the  opening.  This  is  impor- 
tant. By  aspirating  all  the  purulent  material  and 
removing  as  much  of  the  coagulated  material  as 
possible,  we  not  only  hasten  healing  but  we  make 
the  patient  far  more  comfortable  and  fewer  dress- 
ings will  be  required.  To  make  a  simple  open- 
ing, insert  a  drain  and  apply  a  large  dressing,  means 
a  copious  flow  for  days,  often  with  soiling  of  the 
bed  and  sometimes  the  floor,  making  a  very  dis- 
agreeable experience  for  patient,  nurses  and  order- 
lies. 


August,   1941 


SOUTHERN  MEDICINE  &■  SURGERY 


Where  the  proper  kind  of  suction  is  used,  just 
as  soon  as  the  rib  is  resected  and  the  chest  open- 
ed, the  purulent  material  can  be  removed.  Fol- 
lowing this,  the  cavity  may  be  mopped  out  with 
gauze  and  the  large  pieces  of  coagulated  material 
removed.  The  drain  is  then  inserted  and  held  in 
place  with  silkworm-gut  sutures.  This  drain  should 
be  left  in  the  proper  length  of  time  and  when  this 
is  removed  the  drainage  will  continue  until  the  in- 
fection has  cleared  up  and  the  cavity  is  gradually 
filled  by  the  expanding  lung. 

It  must  be  remembered  that  every  patient  with 
empyema  is  a  sick  person.  The  greatest  care  is 
necessary  in  preparing  him  for  operation.  Every 
possible  aid  should  be  given.  Blood  transfusions 
should  be  used  freely.  Where  there  is  a  pneu- 
monic organism  present,  the  proper  serum  may  be 
given.  Sulfanilamide  and  sulfapyridine,  or  other 
such  preparations,  may  be  used  with  good  results, 
especially   in   streptococcic   infection. 

We  must  remember,  however,  that  in  all  these 
cases  there  is  an  interference  with  the  respiration 
due  to  the  partial  collapse  of  the  lung  on  one  side, 
and  any  drug,  such  as  sulfanilamide,  should  be 
used  with  caution.  Lung  exercises  during  con- 
valescence are  very  helpful. 

THE  TREATMENT  OF  SYPHILIS 

Every  case  of  syphilis  should  be  treated  in  a 
careful,  methodical  way.  First,  a  careful  history 
should  be  taken  and  every  possible  bit  of  infor- 
mation that  will  be  helpful  in  deciding  just  ex- 
actly what  the  condition  is  should  be  obtained. 
Following  this,  serological  tests  should  be  made. 
They  should  be  repeated  if  necessary. 

Both  a  Kahn  test  and  a  Wassermann  test  should 
be  done.  While  it  is  true  that  these  tests  do  not 
always  exactly  agree,  each  gives  helpful  informa- 
tion, important  in  determining  the  course  of  treat- 
ment, and,  above  all,  enables  us  to  foretell,  to 
some  extent,  what  the  outcome  will  be. 

Then  a  detailed  systematic  schedule  of  treat- 
ment, to  be  followed  closely,  each  treatment  re- 
corded and  the  reaction,  if  any,  noted.  Serological 
tests  should  be  made  and  recorded  at  regular  in- 
tervals, and  a  spinal  fluid  test  should  be  made  at 
the  proper  time.  These  tests  enable  us  to  gauge 
the  progress  of  the  treatment  and  they  afford  great 
encouragement  to  the  patient. 

One  of  the  most  difficult  things  in  the  treatment 
of  syphilis  is  getting  the  patient  to  understand 
the  importance  of  keeping  to  a  regular  schedule 
and  continuing  treatment  until  the  doctor  discharges 
the  patient.  So  often  we  see  a  patient  who  has 
had  a  course  of  treatment  with  the  disappearance 
of  the  initial  lesion,  or  secondary  lesions,  and  th^ 
patient  feels  that  he  is  well  and  will  have  no  fur- 
ther trouble;  and  years  later  this  patient  develop 


a  central  nervous  system  condition  due  to  syphilis, 
which  is  always  a  tragedy.  The  patient  should 
be  made  aware  of  this  possibility,  if  there  is  a 
tendency  to  carelessness  in  carrving  out  the  treat- 
ment exactly  as  prescribed.  The  present  educa- 
tional campaign  throughout  the  United  States  has 
done  much  to  impress  upon  the  average  citizen 
the  importance  of  this,  and  each  year  the  treat- 
ment is  followed  better  by  the  patient  than  ever 
before.  This  is  a  hopeful  sign  and  we  hope,  as 
times  goes  on,  that  patients  will  be  even  more 
anxious  to  follow  the  prescribed  course  of  treat- 
ment and  continue  this  until  the  doctor  discharges 
them. 

There  should  be  a  spinal  fluid  test  at  the  com- 
pletion of  treatment  in  every  case.  This  is  one 
of  the  most  important  things  in  determining  the 
presence  of  an  infection  in  the  central  nervous 
system.  If  the  spinal  fluid  is  positive,  treatment 
should  certainly  be  continued.  Another  problem 
that  has  come  up  is  just  what  treatment  should 
be  given  a  patient  who  is  in  a  position  where 
human  lives  depend  upon  his  ability  to  perform 
certain  duties,  such  as  driving  a  truck,  car  or  bus. 
These  patients  should  be  most  carefully  studied 
from  every  angle.  Before  they  are  allowed  to  re- 
turn to  their  usual  occupation,  it  should  be  deter- 
mined whether  or  not  there  is  any  danger  of  the 
development  of  a  central  nervous  system  lesion, 
which  might  be  the  cause  of  a  tragedy  later  on. 

As  a  rule,  a  patient  who  has  an  occupation 
of  this  kind  should  have  treatment  until  there 
is  no  danger  of  infecting  others.  Following  this, 
a  spinal  fluid  test  should  be  made,  and  also  sero- 
logical tests  of  the  blood.  If  the  spinal  fluid  test 
is  negative,  the  patient  may  be  returned  to  work 
early  provided  treatment  is  continued  at  regular  in- 
tervals, taking  the  treatment  on  the  days  he  is  off 
duty.  By  following  this  plan,  he  can  continue 
to  work  and  earn  a  living  and  at  the  same  time 
take  the  necessary  treatment  and  obtain  the  best 
possible  results. 

The  use  of  alcohol  during  the  treatment  of 
syphilis  should  never  be  permftted  under  any  cir- 
cumstances. Every  patient  should  be  warned  of 
this  and  told  just  exactly  what  he  may  expect  if 
he  continues  to  use  alcohol  while  the  treatment  is 
being  given.     Tobacco  also  should  be  forbidden. 

The  patient's  confidence  must  be  won.  Let 
the  patient  know  that  you  know  what  you  are 
about  and  just  what  should  be  done.  Let  the 
patient  understand  just  what  you  want  him  to  do 
and  that  you  expect  him  to  do  it,  and,  as  a  rule, 
vou  will  get  this  cooperation.  Let  the  patient  know 
about  the  progress  he  is  making  from  time  to  time. 
That   will   encourage   him   to   continue   treatment. 

The  public  dissemination  of  information  about 
syphilis  by  the  Public  Health  Services  and  other 


SOUTHERN  MEDICINE  &  SURGERY 


August,  1941 


departments  of  the  Government,  and  other  forms 
of  publicity,  has  done  much  to  bring  this  subject  to 
the  minds  of  the  people  and  has  done  much  to 
cause  patients   to   take  thorough   treatment. 

It  is  possible  that  the  importance  of  this  has  been 
overstressed  in  comparison  with  other  diseases  that 
do  more  damage  but  are  less  publicized.  Any"way 
the  public  has  been  made  conscious  of  the  preva- 
lence of  this  disease  and  the  importance  of  proper 
treatment  is  known  to  practically  every  one  who 
reads  newspapers  or  magazines. 

RADICAL  AMPUTATION  OF  THE  BREAST 

This  operation  presumably  includes  removal  of 
the  pectoral  muscles  and  a  careful  dissection  of 
the  axilla  with  removal  of  the  glands  and  the  fatty 
tissue  in  the  axilla.  Radical  mastectomy  is  rarely 
indicated.  If  cancer  cells  have  metastasized  be- 
yond the  original  growth  in  the  breast,  the  chances 
are  that  no  radical  axillary  dissection  will  remove 
all  of  the  glands  and  lymphatic  vessels  that  contain 
cancer  cells.  At  least  it  will  not  do  any  more  good 
than  a  simple  mastectomy  plus  simple  x-ray  treat- 
ment. 

Palpable  metastatic  growths  should  be  remov- 
ed but  a  radical  dissection  removes  the  fatty  and 
other  tissue  from  around  the  vessels  and  nerves  of 
the  axillary  region  so  that  when  healing  takes  place 
there  is  a  constriction  and  pressure  upon  the  veins 
causing  a  chronic,  passive  congestion  of  the  arm 
on  that  side.  In  addition,  pinching  of  the  nerves 
causes  a  painful  condition.  Sometimes  patients 
prefer  death  to  the  agony  which  even  morphine 
does  not  relieve.  Over  a  period  of  years  of  dealing 
with  a  large  number  of  cases,  I  am  convinced  that 
better  results  are  obtained  in  the  vast  majority  of 
cases  by  a  simple  mastectomy  followed  by  deep  x- 
ray  therapy. 

Deep  x-ray  therapy  may  be  given  before  opera- 
tion with  good  results,  especially  in  blocking  the 
lymph  channels  and  destroying  the  cancer  cells 
which  are  radio-sensitive,  especially  those  in  the 
lymphatics  and  those  on  their  way  to  points  distant 
from  the  original  growth.  In  carcinoma  of  the 
breast,  an  early  diagnosis  and  a  simple  mastectomy 
supplemented  by  deep  x-ray  treatment  gives  excel- 
lent results. 

While  sometimes  cures  are  effected,  even  in  cases 
where  there  is  apparently  no  hope,  the  fact  remains 
that  in  the  vast  majority  of  cases  of  carcinoma 
with  axillary  involvement  the  patient  will  succumb 
to  this  disease,  no  matter  what  treatment  is  given. 

Early  diagnosis  and  early  operation  are  the  only 
hopes  of  obtaining  a  cure  in  these  cases.  Even  in 
spite  of  educational  campaigns  as  to  the  danger 
of  lumps  in  the  breast  and  advice  to  the  laity  as  to 
just  what  to  do,  many  women  come  in  with  a  tu- 
mor in  the  breast,  knowledge  of  which  they  have 


concealed  from  their  own  family,  but  which  they 
suspected  from  the  first  might  be  cancer.  During 
the  delay  the  growth  has  extended  beyond  the 
stage  where  a  cure  was  definitely  possible.  Even 
though  enlightened  upon  this  subject,  a  good  many 
will  delay  seeking  medical  advice.  This  is  one  of 
the  peculiarities  of  human  nature  which  must  be 
kept  in  mind. 


A  CASE  OF  DIAPHRAGMATIC  HERNIA  IN  A 
CHILD  ELEVEN  MONTHS  OF  AGE 

A  little  girl  eleven  months  of  age  was  recently 
admitted  to  the  hospital  with  a  history  of  prolong- 
ed vomiting  of  food  and  a  steady  loss  of  weight — 
going  down  from  22  pounds  to  11  pounds.  The 
vomiting  was  not  of  the  projectile  type,  such  as 
found  in  pylorospasm  and  pyloric  stenosis. 

The  general  appearance  was  that  of  hunger  and 
starvation.  The  general  examination  did  not  reveal 
a  great  deal  of  trouble  except  for  the  emaciation 
and  weakness.  As  soon  as  food  was  taken  a  part 
or  practically  all  of  it  would  be  immediately  re- 
gurgitated. This  condition  persisted  and  it  was 
thought  advisable  to  give  the  child  barium  and 
make  a  fluoroscopic  examination.  This  demon- 
strated that  a  large  part  of  the  stomach  was  in  the 
left  pleural  cavity — a  typical  diaphragmatic  her- 
nia. 

It  was  evident  that  surgical  treatment  of  some 
kind  was  necessary  in  order  to  save  the  child's  life, 
but  it  was  so  weak  that  any  surgery  was  extremely 
hazardous.  Several  blood  transfusions  and  glucose 
and  saline  were  given  and  preparing  as  rapidly  as 
possible  for  operation. 

Under  general  anesthesia,  through  a  high  left- 
rectus  incision,  the  abdomen  was  opened  and  the 
stomach  was  brought  down  from  the  left  thoracic 
cavity  into  the  abdomen.  Careful  exploration  re- 
cealed  an  opening  in  the  diaphragm  of  considerable 
size  just  to  the  left  of  the  point  where  the  esopha- 
gus comes  through.  This  opening  was  carefully 
closed  with  four  interrupted  sutures.  The  abdom- 
inal incision  was  closed  immediately  and  the  child 
returned  to  its  room  in  good  condition.  The  oper- 
ation lasted  only  a  few  minutes. 

The  patient  was  allowed  to  take  liquids  soon 
after  operation  and  made  a  rapid  recovery  and 
was  allowed  to  return  home  on  the  eighteenth  day. 
Diaphragmatic  hernia  occurs  oftener  than  is  sus- 
pected and  this  case  illustrates  the  importance  of 
x-ray  examination  of  the  stomach,  even  in  infants, 
where  there  is  prolonged  vomiting.  This  also  illus- 
trates the  importance  of  blood  transfusions  and 
intravenous  fluids  to  restore  the  fluid  balance  of 
the  body  before  any  surgery  is  done. 

Surgery  in  infants,  especially  those  weakened  by 
starvation  from  inability  to  retain  food,  is  extreme- 
ly hazardous,  but  the  hazard  can  be  greatly  reduc- 


August,  1941 


SOUTHERN  MEDICINE  &  SVRGERY 


4S7 


ed  by  giving  repeated  blood  transfusions  and  other 
fluids  by  vein. 

In  surgery  in  children  the  greatest  possible 
speed  in  operating,  so  far  as  is  compatible  with 
good  surgery,  should  be  kept  in  mind,  as  infants 
do  not  stand  anesthesia  and  shock  from  operation 
very  well;  however,  where  an  operation  of  this 
kind  can  be  done  in  a  few  minutes  there  is  a  mini- 
mum of  shock  and  a  rapid  recovery  which,  of 
course,  is  hastened  by  the  fact  that  the  child  can 
take  nourishment,  retain  it,  and  digest  it  in  the 
usual  way. 


CLINIC 

Conducted  By 
Frederick    R.   Taylor,   B.S.,    M.D.,   F.A.C.P. 


HYPOGONADISM 
(Earl   Floyd,   et  al,   Atlanta     in  //  Med.   Asso.    Ga.   July) 

A  white  boy,  16,  with  non-productive  cough  of  two 
weeks'  duration,  had  asthma  for  past  five  years.  At  6  he 
was  found  to  have  left  inguinal  hernia  and  a  weakened 
ring  on  the  right,  a  bilateral  truss  has  been  worn  almost 
continuously  since. 

Secondary  male  sex  characteristics  failed  to  appear,  voice 
remained  high  pitched,  gentials  infantile,  penis  3.5  cm.  in 
length,  no  pubic  hair,  development  of  extremities  poor 
and  gait  and  mannerisms  effeminate. 

X-ray  examination  showed  a  small  sella  turcica,  bony 
development  that  of  9  to  10  years.  Weight  76  pounds; 
height  61  inches;  chest  circumference  (expanded)  2&y2 
inches. 

Another  physician  had  given  a  series  of  injections  of 
antuitrin  S,   no  favorable   response. 

He  was  given  a  high-calorie  general  diet  and  vitamin  B 
complex  for  a  few  days.  The  vitamin  B  was  then  omitted 
so  we  could  judge  the  effects  of  the  hormone.  Sept.  17th 
synthetic  testosterone  propionate,  25  mg.,  was  given  intra- 
muscularly three  times  a  week  and  4  mg  by  injunction  each 
night.  On  the  26th  definite  change  in  the  pitch  of  his 
voice ;  the  testes  were  slightly  larger ;  the  penis  now  5  cm. 
in  length.  He  was  having  frequent  erections  but  no 
emissions.  He  had  gained  9  pounds  in  9  days.  On  the 
28th  there  was  a  beginning  growth  of  hair  over  the  upper 
lip  and  pubic  region,  discharged  from  hospital  on  the 
29th,  kept  on  the  same  treatment,  continued  erections, 
never  troublesome.  On  Oct.  8th  had  his  first  emission. 
On  Jan.  18th,  1941,  the  intramuscular  dosage  was  re. 
duced  to  25  mg.  twice  weekly,  the  inunction  still  to  be  ap- 
plied  nightly. 

During  the  five  months  of  treatment  he  received  a  total 
of  1450  mg.  of  hormone  by  intramuscular  injection  and 
450  mg.  by  inunction.  His  weight  gain  was  30  pounds, 
muscular  development  much  improved,  height  has  in- 
creased 2'4  inches,  chest  circ.  5  inches.  Increased  calci- 
fication of  the  bones  but  no  evidence  of  premature  epi- 
physeal closure,  as  has  been  reported  by  some  observers. 

During  the  past  winter,  for  the  first  time  in  five  years, 
the  patient  had  no  asthmatic  attacks.  No  treatment,  other 
than   testosterone   propionate   has   been   given. 

The  penis  has  increased  from  3.5  to  9.5  cm.  The  pros- 
tate has  developed  to  normal  size  for  age.  We  have 
not  been  able  to  demonstrate  spermatozoa;  testes  normal 
in  size,    good  growth  pubic  hair. 

We  are  now  gradually  reducing  the  dosage  of  the  hor- 
mone  and   are   working   toward   a   maintenance    dose. 


Skin    Disease. — In   any   case   inquire   what   drugs   have 
been  taken  recently. 
Asthma. — All  wheezing  is  not  asthma. 


CORRESPONDENCE  ANENT  THYROID 
CANCER 

Dear  Northington: 

This  letter  with  enclosure  is  for  publication  as 
the  next  material  for  The  Clinic  in  S.  M.  &  S. 
Meanwhile  I'm  off  for  the  biggest  vacation  since  I 
started  practice,  to  the  Pacific  Coast,  from  Los 
Angeles  to  Vancouver.  My  good  friend  McKnight 
took  what  appears  to  be  well-grounded  exception 
to  certain  remarks  of  mine  in  the  last  number  of 
THE  CLINIC  in  S.  M.  &  S.  I  enclose  his  letter 
with  the  request  that  you  publish  it,  and  my  reply. 

Here  is  a  copy  of  my  reply  to  McKnight's  letter: 
Dr.  R.  B.  McKnight, 
Dear  Mac: 

Thanks  a  million  for  your  valuable  criticism.  I 
wish  more  of  it  came  my  way.  I  must  have  slipped 
a  cog — yea,  two  or  three  cogs!  I  confess  I  have 
practiced  medicine  over  26  years  and  have  recog- 
nized just  two  cases  of  cancer  of  the  thyroid,  and  I 
did  not  realize  its  frequency.  Granting  it  is  as  fre- 
quent as  you  say,  why  don't  we  hear  of  more  peo- 
ple dying  of  it?  Anyway,  I'm  forwarding  your 
splendid  letter  to  Northington  with  the  request  that 
he  publish  it  along  with  a  copy  of  this  letter,  as  the 
next  outburst  in  THE  CLINIC.  Meanwhile,  I'm 
off  for  a  real  vacation  to  the  Pacific  Coast  for  the 
month  of  August. 

More  than  ever  your  friend. 

(Signed)      Fred. 

Publication  of  this  letter  may  stir  up  more  inter- 
est in  this  subject  and  be  of  considerable  value. 

As  ever,  your  friend, 

Taylor. 
Dr.  Frederick  R.  Taylor, 
High  Point,  N.  C. 
Dear  Fred: 

A  statement  of  your  appearing  on  page  381  of 
the  July  issue  of  Southern  Medicine  &  Surgery: 
The  last  paragraph  of  the  first  column  contains  the 
following  words:  "a  non-toxic  adenoma  of  the  thy- 
roid   Let  the  goiter  alone  unless  it  begins  to 

cause    pressure    symptoms    or    develop    toxicity. 
Should  it  do  either,  consult  a  surgeon." 

Please  note  the  remarks  in  my  address  before  the 
Section  on  Surgery  at  the  recent  Pinehurst  meeting 
of  the  Medical  Society  of  the  State  of  North  Car- 
olina. It  will  appear  in  the  next  issue  of  the  Jour- 
nal. I  have  never  seen  a  cancer  of  the  thyroid, 
metastases  excepted,  develop  in  the  thyroid  except 
in  a  non-toxic  or  mildly  toxic  adenoma!  Oh,  some- 
times it  does  occur  in  all  likelihood,  but  it  is  ex- 
tremely rare.  The  percentage  of  carcinoma  in  such 
goiters  is  between  5  and  12%,  with  the  weight  of 


SOUTHERN  MEDICINE  &  SURGERY 


August,  1941 


evidence  in  favor  of  the  latter  figure.  All  nodular 
goiters  are  surgical  problems — I  cannot  compro- 
mise that  statement.  (There  may  be  the  occasional 
case  where  operation  is  extremely  hazardous  due 
to  some  other  physical  condition.)  I  think  such 
advice  as  was  given  this  woman  is  entirely  in  error 
and  extremely  dangerous  and  that  its  publication  is 
worse!  Now,  maybe  we  can  get  into  an  argument 
and  both  of  us  learn  something! 

My  very  best  wishes  and  highest  esteem. 
Sincerely  yours, 

Roy  McKnight. 


TREATMENT  OF  BURNS 

Burns  make  up  part  of  the  practice  of  all  regu- 
lar doctors.  Pain  makes  their  victims,  pass  up  the 
cults.     Read  this  abstract1  and  treat  burns  better. 

There  still  is  a  large  number  of  doctors  who  show 
their  credulity  in  favoring  complicated,  expensive, 
and  sometimes  harmful  methods,  and  their  pre- 
judice by  resisting  any  attempt  to  simplify  and 
improve  their  plan  of  treatment.  In  the  treat- 
ment of  extensive  burns  it  may  be  necessary  to 
combat  shock,  to  supply  liquids,  to  counteract 
toxemia,  to  prevent  infection  and  to  heal  the  de- 
nuded areas.  These  ends  are  met  by  bed,  mor- 
phine sufficient  for  pain,  heat  by  means  at  hand, 
and  fluid  by  mouth,  subcutaneously  or  intraven- 
ously. Nothing  else  should  be  done  to  the  burns 
until  the  shock  has  subsided. 

Prior  to  1925  the  author  had  used  several  un- 
satisfactory plans  of  treating  burns.  Too  many 
of  the  cases  had  to  be  hospitalized,  dressings  were 
painful,  infection  was  too  frequent,  convalescence 
protracted,  death  rate  too  high.  This  plan  of  treat- 
ment is  based  upon  the  local  application  of  a  sat- 
urated solution  of  tannic  acid  in  alcohol.  The  solu- 
tion does  not  deteriorate  with  time.  The  cost  is  13 
cents  an  ounce. 

Burning  bestows  relative  sterility,  no  scrubbing, 
no  antiseptic  except  the  alcoholic  tannic  acid  solu- 
tion. A  coat  of  solution  quickly  wiped  over  the 
surface,  causes  severe  stinging  which  begins  to 
subside  within  few  seconds,  gone  within  two  min- 
utes. 

The  film  is  allowed  to  dry  for  five  minutes,  then 
a  second  coat  which  dries  in  15  to  20  minutes,  cov- 
ered by  loose  sterile  pauze  held  in  position  with 
bandage  or  adhesive  tape.  If  the  case  does  not 
require  dehydration,  send  home  and  have  return 
in  two  days  for  dressing.  Gauze  adhering  to  the 
thin  eschar  over  the  burn,  leave  in  place.  If  some 
of  the  burned  area  is  weeping,  another  coat  of  tan- 
nic acid  solution  is  applied,  allowed  to  dry,  and 
dressed  as  before. 

Dress  every  two  or  three  days  until  exfoliation 
occurs.    When  the  eschars  separate,  a  clean,  heal- 


thy, granulating  surface  is  left  in  contrast  to  ex- 
uberant gran,  following  aqueous  tan.  acid  treat- 
ment. Shorten  healing  process  by  use  of  adhesive 
strips.     Skin  grafting  as  necessary. 

The  physician  is  able  to  carry  in  his  emergency 
bag  all  the  material  necessary — alcoholic  tannic 
acid  solution,  cotton,  forceps,  scissors,  gauze  dress- 
ing, bandages,  and  adhesive.  He  can  dress  an  ex- 
tensive burn  in  20  to  30  minutes  and  be  his  way. 
It  is  economical  to  the  patient  not  to  have  to  pay 
for  hospitalization  or  special  nurses. 

The  burning  renders  the  area  relatively  sterile, 
and  the  alcohol  in  the  tannic  acid  solution  is  suffi- 
cient. Blebs  are  not  opened  unless  on  the  palms 
or  soles  where  they  cause  pain.  No  skin  is  re- 
moved, no  milking  resorted  to. 

Chilblains — Our  method  is  to  apply  one  or  two 
coats,  give  the  patient  a  bottle  of  the  mixture 
to  take  home  and  applv  when  necessary.  He  never 
has  to  call  on  us  again  for  help  for  that  ailment. 


A    CASE    OF    STROXGYLOIDES    STERCORALIS 
INFESTATION 

(G    R.   Bodon,  Rochester,  X.  Y.  in  //  Lab.  &  Clin.  Med..  July) 

A  45-year-old  woman  born  in  Italy  migrated  20  years 
ago.  Since  that  time  she  has  lived  in  East  Rochester.  A 
long  history  of  uncertain  abdominal  pain,  vomited  at  times. 
In  1933  cholecystectomy  and  appendectomy,  in  1935  and 
again  in  1938  exploration  for  adhesions.  Operations  show- 
ed negative  findings.  One  blood  count  in  1933  showed  an 
eosinophilia  of   10%. 

On  admission,  Jan.  30th,  1940,  she  complained  of  colicky 
pain,  starting  in  the  right  upper  quadrant  and  sweeping 
across  the  abdomen  to  the  left  side,  pain  in  the  back, 
vomited  bloody  material.  Examination  negative  except  that 
pressure  in  the  left  lower  quadrant  produced  pain  in  the 
epigastrium. 

There  was  a  slight  hypochromic  anemia,  white  count 
6,000  to  8,000,  25%   eosinophiles. 

First  stool  examination  did  not  show  any  parasites, 
but  a  large  number  of  Charcot-Leyden  crystals;  stool  ex- 
amination after  saline  laxative  showed  numerous  wrig- 
gling nematodes,  200  to  300  microns  long,  the  first  rhab- 
ditoid  larva  of  Strongyloides  stercoralis.  In  the  incuba- 
tor the  larvae  developed  into  the  strongyloid  forms.  On 
repeated  stool  examinations  larvae  were  always  found.  A 
skin  test  with  trichinella  antigen  was  positive  in  1:1,000 
dilution. 

Treatment  was  duodenal  lavage  and  gentian  violet  tab- 
lets, 1  grain  three  times  daily.  The  patient  was  not  co- 
operative ;  she  left  the  hospital  and  repeated  stool  ex- 
aminations still  show  the  presence  of  the  parasite. 

The  parasite  was  found  in  the  husband's  stool.  Husband 
had  eosinophilia  of  10% ;  he  did  not  show  any  other 
symptoms  which  could  be  related  to  the  presence  of  the 
parasite.. 

D.  H.  Nisbet  reported1  a  case  in  which  the  worm  caused 
obstructive  jaundice. 

A  case  of  an  Italian  immigrant  woman  is  presented  in 
which  the  stool  examinations  revealed  rhabditoid  larvae 
of  Strongyloides  stercoralis.  It  may  be  assumed  that  the 
parasite  caused  uncertain  abdominal  symptoms  for  which 
the  gallbladder  and  the  appendix  were  removed.  Later 
two  laparotomies  were  performed  for  the  persistence  of 
symptoms  thought  to  be  due  to  postoperative  adhesions. 
All  operations  resulted  in  negative  findings. 


1.  R.    T.    Richards,    Salt    Lake    City,    in   Ry.    Mt.    Med.    Jl,    July         1.     Southern  Medu 


Surgery,   vol.    94,    (1932) 


August,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


459 


SOUTHERN  MEDICINE  6r  SURGERY 

Official  Organ 

TRI-STATE    MEDICAL    ASSOCIATION    OF    THE 

CAROLINAS  AND  VIRGINIA 

James  M.  Northington,  M.D.,  Editor 


Department  Editors 
Human  Behavior 

James   K.   Hall,   M.D Richmond,  Va. 

Orthopedic  Surgery 
Oscar  Lee  Miller,  M.  D.  I 
John  Stuart  Gaul,  M.D.  > Charlotte,  N.  C. 

Urology 
Raymond    Thompson,    M.D Charlotte,   N.    C. 

Surgery 
Gro.  H.  Bunch,  M.D _ Columbia,  S.  C. 

Obstetrics 

Hxnry  J.  Langston,  M.D Danville,  Va. 

Ivan  M.  Procter,  M.D Raleigh,  N.  C. 

Gynecology 

Chas.  R.  Robins,  M.D Richmond,  Va. 

G.  Carlyle  Cooke,  M.D Winston-Salem,  N.  C. 

Pediatrics 

G.  W.  Kutscher,  Jr.,  M.D _ Asheville,  N.  C 

General  Practice 

J.  L.  Hamner,  M.D Mannboro,  Va. 

W.  J.  Lackey,  M.D Fallston,  N.   C. 

Clinical  Chemistry  and  Microscopy 

C.  C.  Carpenter,  M.D | 

d    t>    w  „.     „  .     „.    /..Wake  Forest,  N.  C. 

R.  P.  Morehead,  B.S.,  M.A.,  M.D..  J 

Hospitals 

R.  B.  Davis,  M.D Greensboro,  N.   C. 

Cardiology 

Clyde  M.  Gelmore,  A.B.,  M.D Greensboro,  N.  C. 

Public  Health 

S.  Thos.  Ennett,  M.D Greenville,  N.  C. 

Radiology 

Wricht  Clarkson,  M.D.,  and  Associates.. ..Petersburg,  Va. 

R.  H.  Lapferty,  M.  D.,  and  Associates,     Charlotte,  N.  C. 

Therapeutics 

J.  F.  Nash,  M.  D., Saint  Pauls,  N.  C. 

Tuberculosis 

John    Donnelly,   M.D Charlotte,   N.    C. 

Dentistry 

J.  H.   Guion,  D.  D.  S Charlotte,   N.   C. 

Internal  Medicine 

George  R.  Wilkinson,  M.  D Greenville,  S.  C. 

Ophthalmology 

Herbert  C.  Neblett,  M.  D., Charlotte,  N.  C. 

Rhino-Oto- Laryngology 

Clay  W.  Evatt,  M.  D.,  Charleston,  S.  C. 

Proctology 

Russell  von  L.  Buxton,  M.D Newport  News,  Va. 

Insurance  Medicine 
H.   F.   Starr,   M.D., Greensboro,   N.    C. 

Offerings  for  the  pages  oj  this  Journal  are  requested  and 
given  careful  consideration  in  each  case.  Manuscripts  not 
found  suitable  for  our  use  will  not  be  returned  unless 
author  encloses  postage. 

As  is  true  of  most  Medical  Journals,  all  costs  of  cuts, 
etc.,  for  illustrating  an  article  must  bt  borne  by  the  author. 


A  THREAT  OF  AUTOCRACY 

Several  months  ago  the  editor  learned  of  what 
looked  suspiciously  like  autocratic  action  on  the 
part  of  the  American  Board  of  Surgery.  About  the 
same  time  it  was  noted  that  from  a  good  many 
directions  were  coming  recommendations  and 
prophecies  that  after  a  while  the  diploma  of  this 
Board  would  be  a  requisite  to  hospital  surgical  staff 
membership.  At  the  time  we  decried  such  a  pro- 
gram as  high-handed  and  impracticable. 

This  Board  is  self-constituted  and  self-perpet- 
uating. A  number  of  first-class  surgeons  may  be 
found  among  those  who  got  together  and  said,  Let 
there  be  a  Board,  and  there  was  a  Board.  A  great 
many  first-class  surgeons  have  been  given  the 
stamp  of  approval  of  the  few  who  made  the  Board 
by  fiat.  Many  first-class  surgeons  have  shown  no 
interest  in  the  Board,  one  way  or  another.  Some 
surgeons  have  been  denied  the  accolade,  who,  ac- 
cording to  general  repute  among  profession  and 
laity,  are  better  surgeons  than  a  good  many  to 
whom  it  has  been  said,  Enter  Brother  and  abound. 

And  in  some  instances  the  Board  has  been  ex- 
tremely vague  in  answering  the  question,  very  re- 
spectfully put:  In  what  way  does  my  record  fail 
to  meet  your  requirements? 

We  have  no  idea  but  that  the  main  purpose  of 
the  organizers  of  this  Board  was  the  laudable  one 
of  improving  the  quality  of  the  surgery  practiced 
in  this  Country;  neither  do  we  doubt  that  consid- 
erable quantities  of  pomposity  and  joy  in  being 
exclusive — [excludo=l  shut  out]  might  be  found 
could  one  analyze  the  motivation. 

Back  in  April,  in  reply  to  this  statement:  "Ulti- 
mately every  one  intending  to  do  major  surgery, 
to  be  eligible  for  staff  appointment  in  an  accred- 
ited hospital,  will  have  to  be  certified  by  the  Board," 
we  ventured  this  opinion: 

How  ridiculous  it  would  be  for  this  Board  to 
attempt  to  keep  a  first-class  surgeon  off  the  staff 
of  a  hospital  on  the  vote  of  a  third-class  surgeon! 
Besides  all  the  first-class  surgeon  would  have  to  do 
would  be  to  go  into  court  and  force  the  hospitals 
to  accord  him  his  rights  in  them. 

Practitioners  of  medicine  can  get  on  pretty  well 
without  hospitals.  Practitioners  of  surgery,  though 
they  could  do  much  more  of  their  work  than  they 
do  in  their  offices  to  the  advantage  of  their  patients, 
must  have  hospitals  for  many  of  their  patients. 

It  is  within  the  bounds  of  possibility  that  the 
States  may,  one-by-one,  erect  boards  in  surgery  and 
the  other  specialties,  and  require  examination  at 
the  hands  of  these  law-erected  tribunals  of  those 
who  would  set  up  as  specialists.  It  is  incredible 
that  any  such  exercise  of  authority  on  the  part  of  a 
self-constituted  and  self-perpetuating  body  would 
ever  be  tolerated. 


460 


SOUTHERN  MEDICINE  &  St/RGERY 


August,   1941 


An  Editorial  in  Southwestern  Medicine's  issue 
for  June  has  this  to  say: 

In  a  report  to  The  House  of  Delegates  at  the 
recently  concluded  session  of  The  American  Med- 
ical Association,  the  Reference  Committee  on  Mis- 
cellaneous Business — 

evidence  of  unnecessary  irritation 

among  the  rank  and  file  is  becoming  evident.  It  is 
hoped  that  the  House  of  Delegates  will  not  feel 
that  this  reference  committee  is  exceeding  its  func- 
tions if  it  suggests  that  the  Council  on  Medical 
Education  and  Hospitals  may  have  made  a  mis- 
take in  permitting  the  specialty  boards  to  slip  out 
from  under  the  control  and  jurisdiction  of  the 
American  Medical  Association.  Perhaps  it  is  not 
too  late,  by  proper  contact  methods,  to  reestablish 
such  control. 

Justified  or  not,  unfavorable  criticism  of  the 
conduct  of  certain  Specialty  Boards  is  becoming 
widespread.  Many  young  men  feel  that  those 
already  certified  by  these  boards  have,  in  some 
cases,  promulgated  an  unnecessarily  high  standard 
of  requirements  to  be  met  by  today's  candidate — 
standards  that  have  in  no  case  been  met  by  those 
now  possessed  of  the  magic  certificate.  This  accu- 
sation leads  to  the  charge  that  a  few  men  in  high 
places  are  attempting  to  set  up  closed  guilds  in 
their  fields.  Substantiation  of  this  charge  is  said  to 
be  indicated  by  the  moves  of  certain  boards  to  ob- 
tain Government  regulations  allowing  only  their 
own  members  to  do  certain  work  for  Government 
agencies.  This  is  privilege-seeking,  says  the  current 
comment,  and  is  held  to  be  contrary  to  all  notions 
of  democracy  in  medicine. 

In  self-defense  of  an  inherently  splendid  concep- 
tion of  the  duty  owed  the  public  by  the  specialists 
of  this  country,  it  would  seem  that  the  Specialty 
Boards  would  welcome  a  reassessment  of  their  con- 
duct by  the  only  competent  authority — The  Amer- 
ican Medical  Association.  These  acts  of  a  few  zea- 
lots could  easily  destroy  the  delicately  based  confi- 
dence now  reposed  in  the  Specialty  Boards  by  the 
public  and  the  medical  profession  at  large.  Such  a 
happening  would  be  regrettable. 

A  highly-educated  doctor,  a  member  of  the  Na- 
tional Board  of  Medical  Examiners  and  at  that 
time  Dean  of  a  Medical  School,  was  heard  to  say 
that  he  could  not  gain  entrance  on  credits  and 
could  not  possibly  make  a  passing  mark  on  the  ex- 
amination required  for  entrance  on  the  study  of 
medicine  in  his  own  school. 

Of  course,  schools  can  require  whatever  they 
choose;  but,  once  the  medical  student  becomes  a 
Doctor  of  Medicine  in  due  form,  the  State  decides 
as  to  his  qualifications  for  the  practice  of  medicine 
as  a  whole  or  in  any  of  its  parts,  and  as  to  his 
duties  and  rights  therein. 


Privilege  seeking?  Certainly,  and  on  all-fours 
with  John  L.  Lewis'  demand  that  nobody  be  given 
a  job  who  is  not  a  paying  member  of  his  union. 


FALLACIES   IN   THE   TREATMENT   OF 
HEART  DISEASE 

The  people  and  the  doctors  are  being  given  a 
lot  of  information  and  a  lot  of  misinformation 
about  disease  in  general. 

Dr.  Paul  White'  writes  to  correct  a  good  many 
items  of  misinformation. 

When  things  are  not  going  well  in  the  face  of 
much  drug  or  other  therapy,  try  a  rest  day  or  two 
or  three  without  any  medicines  at  all.  Do  not 
use  many  vigorous  agents  at  one  time. 

Heart  disease  itself  is  not  the  cause  of  palpita- 
tion in  the  large  majority  of  cases.  Common 
causes  are  fatigue,  nervous  strain,  overeating,  cof- 
fee, tobacco,  alcohol,  thyrotoxicosis.  Reassurance 
is  in  order.  For  frequent  recurrence,  quinidine 
sulphate  three  or  four  times  a  day  is  usually  far 
better  than  digitalis. 

Do  not  give  digitalis  to  a  person  simply  because 
he  is  short  of  breath. 

Precordial  pain  is  in  the  majority  of  instances 
not  due  to  heart  disease.  Do  not  put  persons 
with  heartache  to  bed  or  give  them  morphine 
unless  you  are  very  sure  they  need  it. 

Substernal  oppression  is  often  not  angina  pec- 
toris but  due  to  spasm  of  stomach  or  esophagus, 
to  be  treated  by  belladonna  and  diet  rather  than 
by  rest  and  nitroglycerine.  Also  in  such  cases 
omit  tobacco  and  nerve  strain,  and  give  large 
doses  of  reassurance. 

Syncope  and  faintnes  sare  most  likely  to  be  due 
to  vasomotor  instability. 

All  these  various  symptoms  in  one  person  mean 
neurocirculatory  asthenia. 

Cyanosis  is  commonly  due  to  pulmonary  disease 
rather  than  heart  disease.  Fast  pulses  do  not  re- 
quire digitalis,  unless  they  result  from  auricular 
fibrillation,  or  flutter.  A  slow  pulse  rate,  even  in 
the  forties,  requires  no  treatment  per  se,  even  if 
heart  block  is  present;  only  if  the  block  is  un- 
stable with  pulse  dropping  low  enough  to  threaten 
the  patient  with  syncope  (a  very  rare  occurrence) 
is  treatment  needed.  Otherwise  a  slow  pulse 
is  a  decided  asset. 

Low  blood  pressure,  even  systolic  constantly  near 
100,  is  an  asset.  If  the  pressure  has  dropped  from 
200  to  100  one  has  another  situation,  but  even  so, 
such  low  pressure  is  not  to  be  treated  unless  com- 
plicated by  symptoms  or  other  signs. 

Edema  of  the  legs  is  in  the  minority  of  cases  due 
to  heart  failure.  It  is  most  commonly  the  result 
of  local  circulatory  fault,  with  or  without  varicose 

!.     P.  D.  White,  Boston,  in  New  Orleans  Med.   &  Surg.  31,   May 


August.   1941 


SOUTHERN  MEDICINE  &  SURGERY 


461 


veins,  phlebitis,  or  marked  obesity  . 

Twice  as  many  patients  receive  digitalis  as 
need  it,  twice  as  much  as  necessary  is  given  to 
many  of  those  who  do  need  it. 

Give  only  enough  morphine  to  cardiac  patients, 
even  with  coronary  thombosis  or  acute  pulmonary 
edema,  to  dull  the  pain  or  dyspnea.  Morphine  and 
its  allies,  pantopon  and  dilaudid,  often  cause  de- 
pressing or  nauseating  effects  which  can  be  harm- 
ful. 

Do  not  rush  to  try  every  new  remedy  suggested 
in  the  treatment  of  coronary  disease  with  insuffi- 
ciency. None  of  them  is  of  great  value — either 
drugs,  or  surgery,  or  x-radiation.  The  old  stand- 
bys  of  rest  and  the  nitrites  are  still  the  best,  al- 
though in  a  few  instances  aminophyllin  and  nerve 
injections  seem  to  help.  Radical  measures  like 
total  thyroidectomy  and  implantation  of  new  blood 
supply  have  not  proved  their  worth,  nor  has  radia- 
tion of  the  adrenal  glands. 


SAVE  GASOLINE  AND  LIVES 

The  Government  is  asking  all  its  citizens  to 
use  gasoline  more  economically;  this  as  a  feature 
of  defense  of  our  liberties,  of  our  very  existence  as 
a  Nation. 

Over  many  years  this  journal  has  urged,  as  a 
means  of  returning  to  us  the  liberty  to  use  our  own 
highways  in  reasonable  safety,  and  of  continuing 
our  existence  as  individuals  and  families  for  the 
normal  expectancy,  a  measure  which  would,  as  a 
by-product  to  the  saving  of  life  and  limb  and  auto- 
mobiles and  horses  and  buggies  and  wagons,  save 
more  gasoline  than  Mr.  Ickes  says  there  is  need 
for  us  to  save. 

Murder  and  robbery  by  wholesale  has  become 
commonplace  in  our  large  cities;  yet  the  perpetra- 
tors go  scatheless,  so  long  as  they  pay  into  the 
United  States  Treasury  as  income  tax  the  lawful 
percentage  of  said  unlawfully,  murderously  acquir- 
ed income.  Mayhap  our  very  noble  and  approved 
good  masters  and  rulers  will  be  moved  to  adopt, 
as  a  means  of  saving  gasoline,  a  measure  for  saving 
both  gasoline  and  life,  in  which  they  showed  no 
interest  so  long  as  only  the  life-saving  feature  was 
emphasized. 

I 

Everybody  above  the  mental  age  of  five  knows 
that  the  chief  element  in  automobile  killings  is 
fast  driving,  and  that  much  more  gasoline  (and 
oil)  per  mile  is  consumed  at  high  speeds  than  at 
reasonable  speeds. 

On  the  7th  day  of  the  past  June  a  peaceful  citi- 
zen, with  his  wife  and  daughter,  was  driving  quietly 
along  on  his  own  side  of  an  excellent  highway  35 
miles  from  Charlotte.  At  a  point  where  the  road 
had  no  horizontal  curve  for  miles  in  either  direc- 
tion, where  there  was  no  intersection,  no  farm  or 


home  road  from  which  he  should  be  on  the  lookout 
for  vehicle  or  pedestrian,  as  he  came  to  the  top  of  a 
slope — gentle  from  his  side,  steep  from  the  killers' 
side — two  brothers,  both  in  their  twenties,  racing 
at  75  to  90  m.  p.  h.,  side-by-side,  and  filling  the 
whole  road,  crashed  into  him  and  each  other.  This 
law-abiding  citizen,  riding  on  his  own  highway  on 
a  peaceful  mission,  exercising  every  precaution 
against  accident,  awakened  days  later  in  a  hospital 
to  learn  that  his  wife  and  daughter  had  been 
buried. 

Within  the  present  month  a  good  citizen  of 
Union  County  driving  in  his  buggy  along  the  high- 
way near  his  home  was  foully  done  to  death  by  the 
fast,  reckless  driving  of  a  biped  without  feathers  in 
the  uniform  of  the  United  States  Army.  The  ex- 
cuse was  that  he  "came  over  a  little  rise"  and 
couldn't  stop  before  crashing  into  the  rear  of  the 
good  farmer's  buggy  and  killing  man  and  horse. 
This  slaying  occurred  at  about  1  p.  m.,  when  there 
could  be  no  possibility  of  "sun  in  my  eyes,"  or  "his 
lights  blinded  me."  The  road  is  straight  on  and 
the  "slight  rise"  is  slight  indeed,  so  slight  that,  if 
he  had  been  looking,  the  driver  could  have  seen 
the  buggy  a  half-mile  away.  The  other  occupant  of 
this  deadly-weapon  Government  car  was  a  Lieuten- 
ant U.  S.  A. 

According  to  the  papers  two  lieutenants  were  re- 
cently sentenced  to  a  year  or  so's  imprisonment  for 
swooping  down,  in  a  Government  plane,  over  an 
Alabama  turnip-patch  and  cutting  off  the  head  of 
a  farmer's  wife,  working  in  her  own  field.  Others 
working  with  her  saved  themselves  by  dropping 
flat  on  the  ground.  The  idea  of  these  jolly,  care- 
free lads  was  to  "give  the  rubes  a  scare."  What  a 
horrible  crime!  And  how  absurdly  inadequate  the 
punishment!  It  is  to  be  hoped  that  the  widower 
will  bring  a  civil  action  against  these  wanton  mur- 
derers and  get  enough  to  educate  his  children  and 
to  make  it  unnecessary  that  he  and  his  go  out  in 
the  field  to  be  exposed  to  decapitation  to  afford 
entertainment  to  city  slickers.  If  the  culprits  do 
not  have  sufficient  property  to  satisfy  a  heavy 
judgment,  the  Government  should  supply  the  dif- 
ference. 

Not  even  in  a  man's  own  field  are  he  and  his 
family  safe  from  speed  maniacs. 

Instances  of  wanton  speed  killing  Inight  be 
multiplied  almost  indefinitely. 

It  is  not  recommended  that  airplanes  be  equip- 
ped with  governors.  The  plane  incident  is  cited  as 
an  illustration  of  what  the  speed  mania  developed 
on  the  ground,  in  automobiles,  leads  to. 

What  is  this  simple,  inexpensive,  efficient  means 
of  saving  gasoline  and  life?  A  speed  governor 
which  will  not  allow  a  car  to  travel  faster  than  the 
rate  at  which  it  is  set.  Cities  and  towns  can  pass 
ordinances  at  any  time,  awaiting   the  meeting  of 


SOUTHERN  MEDICINE  &  SURGERY 


August,  1941 


State  legislatures.  If  every  car  found  in  any  incor- 
porated place  in  any  State,  without  a  governor, 
were  confiscated,  there'd  be  precious  few  60-  to 
90-mile-an-hour  boys  and  girls  on  our  highways  a 
month  from  now. 

Somebody  will  say:  But  what  about  a  car's 
ability  to  go  up  a  hill  when  it  has  a  governor  at- 
tached? The  answer  is:  a  governor  does  not  come 
into  action  until  the  speed  at  which  it  is  set  is 
reached,  whether  travelling  on  level  ground,  going 
up-hill  or  going  down-hill. 
II 
In  May,  1927,  this  journal  carried  this  edito- 
rial: 

SAFER  SWIMMING 

As  summer  advances  we  may  confidently  look  for  a 
rising  tide  of  death  by  drowning.  Some  of  these  accidents 
will  occur  in  the  surf,  and  some  in  rivers  and  creeks;  but 
the  majority  of  the  drownings  will  be  in  artificial  pools. 

Many  deaths  in  water,  ascribed  to  drowning,  come 
about  in  other  ways.  There  is  little  reason  to  believe  that 
being  in  water  will  materially  affect  the  tendency  to  loss 
of  consciousness  which  is  conspicuous  on  land. 

In  the  last  month  a  fourteen-year-old  school  girl  lost 
her  life  in  a  swimming  pool  at  High  Point;  two  years  ago 
a  young  man  was  taken  from  the  Charlotte  Y  pool  dead; 
five  or  sLx  were  drowned  in  pools  in  the  vicinity  of  Char- 
lotte in  the  past  summer. 

Some  months  ago,  while  passing  a  near-by  pool,  the 
editor  conceived  the  idea  that  a  net  could  be  spread  on  the 
bottom  of  such  a  pool — in  sections  if  size  makes  this  nec- 
essary— with  attachment  by  ropes  to  windlasses  for  imme- 
diately bringing  up  any  one  who  has  gone  under.  In  the 
car  with  me  was  a  doctor  who  enjoys  the  water  immensely 
despite  the  fact  that  he  is  but  an  indifferent  swimmer. 
Immediately  he  said  he  thought  it  an  excellent  idea  and 
entirely  practicable;  adding,  "I  know  I  would  feel  a  whole 
lot  more  comfortable  in  swimming  if  I  knew  there  was 
such  a  net  under  me." 

The  cost  of  such  paraphernalia  would  not  be  prohibitive, 
and  it  is  reasonable  to  assume  that  the  additional  patronage 
induced  by  the  removal  of  the  element  of  danger  would 
far  more  than  pay  for  the  outlay.  Then  there  is  always 
a  chance  of  suits  to  be  defended  and  probably  judgments 
paid.  Finally,  the  most  important  consideration  is  the 
saving  of  life. 

Will  anything  be  done  along  this  line?  We  do  not 
expect  it.  Will  the  papers  carry  their  usual  summertime 
narratives  of  the  drownings  of  men,  women  and  children? 
We  confidently  predict  that  they  will. 

There's  not  a  reader  of  these  words  who  cannot 
recall  a  number  of  instances  since  they  were 
written  in  which  life  would  have  been  saved  by 
the  adoption  of  this  recommendation. 

A  case  in  point  is  quoted  from  the  Rutherjord 
County  News,  of  July  27th: 

Ray  Hollifield,  15,  and  Charles  Bradley,  17,  lost  their 
lives  Sunday  night  in  the  swimming  pool  at  the  Club 
House  here. 

It  was  reported  that  the  boys  had  been  caddying  on 
the  golf  course  and  took  a  swim  about  7:45  p.  m. 

Hollifield  was  reported  to  have  had  an  attack  of  cramps 
while  swimming  and  Bradley,  who  already  had  gotten  out 
of  the  pool  and  dressed,  jumped  in  with  his  clothes  on  in 
an  attempt  to  save  his  chum.  However,  Hollifield  pulled 
him  under. 


Several  other  boys  who  were  present,  including  Paul 
Lee,  a  half-brother  of  Hollifield,  Bud  Moore  and  Yates 
Ledbetter,  attempted  to  rescue  the  drowning  youths  with- 
out success. 


Large  crowds  attended  both  funerals.  Both  were  buried 
in  the  city  cemetery.  Both  graves  were  covered  with 
beautiful  flowers. 


This  tragedy  cast  a  cloud  of  sadness  over  the  commu- 
nity and  is  a  warning  to  all  to  be  "careful." 

How  pathetic?    How  resigned!    How  futile! 

When  Dr.  J.  P.  Matheson  was  beautifying  his 
place  out  on  the  Concord  road  his  lawyer  told  him 
he  must  put  a  strong  fence  about  the  lake;  or,  if 
trespassers  went  swimming  there  and  lost  their 
lives,  he  would  be  actionable  for  "Creating  an  At- 
tractive Nuisance."  Matheson  said  that  it  was 
news  to  him  that  he  could  be  made  to  pay  for  what 
might  happen  accidentally  to  one  who  trespassed 
on  his  property,  not  only  without  his  consent,  but 
despite  being  warned  to  stay  off. 

Since  such  is  the  law,  it  would  seem  that,  since 
the  owners  and  operators  of  such  attractions  have 
been  informed  in  detail  of  a  cheap  and  ready 
means  of  assuring  against  such  tragedies,  an  action 
would  lie  against  any  club,  resort,  amusement  park 
or  swimming-pool  which  did  not  install  such  equip- 
ment and  keep  it  in  good  working  order. 

We  are  being  constantly  told  that  this  is  the  dav 
of  Preventive  Medicine,  that  it  is  the  duty  of  pri- 
vate practitioners,  as  well  as  health  officials  paid 
out  of  our  taxes,  to  save  people  from  sickness,  in- 
jury and  death. 

Here  is  another  of  my  own  efforts  along  this 
line,  this,  too,  backed  by  the  same  quality  of  faith 
as  that  held  by  the  one  who  prayed:  "Lord,  I  be- 
lieve; help  thou  mine  unbelief." 


HOLMES   A   PRECURSOR    OF  FREUD 

(C.  P.  Oberndorf,  New  York,  in  Bull,  N.  Y.  Academ. 
of  Med.,  May) 
''There  are  thoughts  that  never  emerge  into  conscious- 
ness, which  yet  make  their  influence  felt  among  the  per- 
eptible  mental  currents,  just  as  the  unseen  planets  sway 
he  movements  of  those  which  are  watched  and  mapped 
by  the  astronomer.  Old  prejudices  that  are  ashamed 
to  confess  themselves,  nudge  our  talking  thought  to  utter 
.heir  magisterial  veto.  In  hours  of  languor,  as  Mr.  Lecky 
!  as  remarked,  the  beliefs  and  fancies  of  obsolete  condi- 
lions  are  apt  to  take  advantage  of  us.  We  know  very 
little  of  the  contents  of  our  minds  until  some  sudden  jar 
brings  them  to  light,  as  an  earthquake  that  shakes  down 
a  misei  s  house  brings  out  the  old  stockings  full  of  gold, 
r.nd  all  the  hoards  that   have  been  hid  away  in  holes  and 


SUDECK'S  ACUTE  BONE  ATROPHY 

(A.  J.  Mourot,  Washington,  in  Med  .Aim.  D.  C,  July) 
In  a  very  small  percentage  of  cases  acute  osteoporosis 
cccurs  within  a  short  time  following  injury.  It  may  follow 
a  slight  injury  and  is  most  common  in  the  bones  of  the 
wrist,  hand,  ankle  and  foot.  The  predominant  symptom 
is  pain.  Typical  x-ray  findings  clinch  the  diagnosis.  The 
pathology  is  obscure.  Treatment  consists  of  deep  x-ray 
therapy,  or  periarterial  sympathectomy,  supplemented  by 
physiotherapy.     Recovery  requires  many  months. 


August,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


BOOKS 


COLLECTED  PAPERS  OF  THE  MAYO  CLINIC 
AND  THE  MAYO  FOUNDATION,  edited  by  Richard  M. 
Hewitt,  B.A.,  M.A.,  M.D.;  Harky  L.  Day,  Ph.B.,  M.D.; 
James  R.  Eckman,  A.B.;  A.  B.  Nevling,  M.D.;  John  R. 
Miner,  B.A.,  Sc.D.,  and  M.  Katharine  Smith,  B.A.  Vol. 
XXXII— 1940.  1190  pages  with  210  illustrations.  W.  B. 
Saunders  Company,  Philadlephia  and  London,  1941.  Price 
$11.50. 

Not  all  the  papers  published  by  members  of  the 
Mayo  Clinic  in  the  previous  year  are  republished 
in  the  Annual  Collected  Papers.  Many  of  the  total 
are  in  abstract,  some  included  by  title  only,  others 
not  at  all. 

Nowhere  may  be  found  in  one  volume  a  better 
presentation  of  the  best  medicine  of  the  year. 


THE  MARCH  OF  MEDICINE:  New  York  Academy 
of  Medicine  Lectures  to  the  Laity,  1940.  Columbia  Uni- 
versity Press,  Morningside  Heights,  New  York.  $2.00. 
Essays  deal  with  some  of  the  important  aspects 
of  the  history  of  medicine;  the  development  of 
care  of  the  mentally  sick  or  inadequate;  bronchos- 
copy; what  we  know  about  the  blood  and  its  dis- 
ease conditions;  about  the  wonderful  working  out 
of  the  successful  use  of  chemicals  in  defending  our 
patients  against  thhe  attacks  of  some  of  the  dead- 
liest bacteria. 


The  number  of  scientific  and  historical  data 
studied  and  interpreted  to  the  public  is  enormous. 
It  is  shown  that  doctors  and  other  medical  men, 
now,  as  in  all  previous  times,  are  laboring  prodigi- 
ously to,  in  the  words  of  Oliver  Wendell  Holmes, 
"to  promote  the  best  earthly  interest  of  mankind;" 
and  that  these  labors  are  being  eminently  success- 
ful. 

Contents:  Preface:  1.  The  Inheritance  of  Men- 
tal Disease,  by  Abraham  Myerson,  M.D.;  2.  Chem- 
ical Warfare  against  Disease,  by  Perrin  H.  Long, 
M.D.;  3.  The  Story  of  Our  Knowledge  of  the 
Blood,  by  Paul  Reznikoff,  M.D.;  4.  The  Story  of 
Viruses,  by  Thomas  M.  Rivers,  M.D.;  5.  The 
Ascent  from  Bedlam,  by  Richard  H.  Hutchings, 
M.D.;  6.  The  Romance  of  Bronchoscopy,  by  Chev- 
alier Jackson,  M.D.,  and  Chevalier  L.  Jackson, 
M.D.;   Index. 


NECROPSY:  A  Guide  for  Students  of  Anatomic  Path- 
ology, by  Bela  Halpert,  M.D.,  Assistant  Professor  of 
Pathology  and  Bacteriology,  Louisana  State  University 
School  of  Medicine.  The  C.  V.  Mosby  Company,  St. 
Louis.     1941.     $1.50. 

First  is  described  the  external  examination,  then 
examination  of  the  different  organs  and  systems 
in  situ,  then  removal  and  examination  of  the  dif- 
ferent organs.  Examination  of  the  base  of  the 
skull,  of  the  tympanic  and  nasal  cavities  and  the 
sinuses  is  included. 


ASAC 

15%,  by  volume  Alcohol 
Each  fl.   oz.   contains: 

Sodium  Salicylate,  U.  S.  P.  Powder 40  grains 

Sodium  Bromide,  U.  S.  P.  Granular 20  grains 

Caffeine,   U.    S.   P 4  grains 

ANALGESIC,    ANTIPYRETIC 

AND    SEDATIVE. 

Average    Dosage 
Two  to  four  teaspoonfuls  in  one  to  three  ounces  of 
water   as   prescribed   by   the   physician. 

How   Supplied 
In  Pints,  Five  Pints  and  Gallons  to  Physicians  and 
Druggists. 

• 

Burwell  &  Dunn  Company 

Manufacturing    tfsE9     Pharmacists 
Established    IBS?      <»    <**7 

CHARLOTTE,  N.  C. 


iple    sent    to    any    physician 
request 


the    U.   S.    on 


SOUTHERN  MEDICINE  &  SURGERY 


August,  1941 


This  75-page  booklet  is  an  excellent  guide  for  the 
use  of  coroners  and  other  physicians  who  have  oc- 
casion to  perform  necropsies  and  to  submit  tissues 
and  organs  to  pathologists  for  miscroscopical  ex- 
amination. 


THE  CARE  OF  THE  AGED  (Geriatrics),  by  Malford 
W.  Thewlis,  M.D.,  Attending  Specialist  General  Medicine, 
United  States  Public  Health  Hospitals,  New  York  City; 
Attending  Physician,  South  County  Hospital,  Wakefield, 
R.  I.j  Special  Consultant,  R.  I.  Department  of  Public 
Health.  Third  Edition,  entirely  rewritten;  with  50  illus- 
trations. The  C.  V.  Mosby  Company,  St.  Louis.  1941. 
$6.00. 

An  interesting  and  instructive  chapter  of  ex- 
pressions of  opinion  of  medical  men  and  philoso- 
phers on  the  physical  and  mental  peculiarities  of 
the  old  constitutes  the  introductory.  That  the 
aged  have  been  neglected  as  to  health  care,  and 
that,  for  various  reasons,  this  neglect  is  being  rem- 
edied, are  points  well  set  forth. 

There  are  chapters  on  hygiene,  prevention  of 
premature  senility,  prolonging  life,  sex  life,  allergy, 
infectious  diseases  in  the  old,  the  old  man's  urinary 
troubles,  his  metabolism,  neurology,  skin  diseases, 
cancer  and  many  others. 

A  very  important  subject,  and  one  which  is 
yearly  becoming  more  important,  is  presented  in 
an  authoritative  and  scholarly  way.  It  would  be 
hard  to  think  of  a  way  in  which  any  doctor  could 
better  spend  six  dollars. 


THE  MARCH  OF  MEDICINE:  New  York  Academy 
of  Medicine  Lectures  to  the  Laity,  1940.  Columbia  Uni- 
versity Press,  Morningside  Heights,  New  York  City.  1941. 
$2.00. 

Five  years  ago  the  New  York  Academy  of  Med- 
icine inaugurated  a  course  of  Lectures  to  the  Laity 
which  has  been  continued  to  the  present.  This 
booklet  contains  the  lectures  for  the  fifth  year. 
Among  the  subjects  discussed  are  the  inheritance 
of  mental  disease,  chemical  warfare  against  disease, 
the  story  of  our  knowledge  of  the  blood,  viruses, 
the  ascent  from  bedlam,  the  romance  of  bronchos- 
copy. 

These  subjects,  of  themselves,  proclaim  their 
great  interest  for  all  persons.  The  excellent  man- 
ner in  which  these  subjects  are  covered  makes  the 
volume  a  valuable  addition  to  any  school  or  public 
library.  This  volume,  all  previous  volumes,  and 
any  to  come  should  be  taught  in  the  public  schools 
and  placed  in  every  public  library  for  the  correct 
instruction  of  the  general  public  as  to  what  can 
and  what  can  not  be  done  in  medicine,  and  as  to 
how  and  by  whom  this  slowly-  and  painfullv- 
acquired  knowledge  was  gained. 

It  would  not  be  amiss  for  the  various  States' 
Board  of  Health  Bulletins  to  carry  a  large  part  of 
the  contents  of  these  volumes  in  their  monthly 
issues. 


CLINICAL  IMMUNOLOGY  BIOTHERAPY  .AND 
CHEMOTHERAPY  in  the  Diagnosis,  Prevention  and 
Treatment  of  Disease,  by  John  A.  Kolmer,  M.S.,  M.D., 
Dr.P.H.,  Sc.D.,  LL.D.,  L.H.D..  F.A.C.P,  Professor  of 
Medicine,  Temple  University  School  of  Medicine;  Director 
of  the  Research  Institute  of  Cutaneous  Medicine;  and 
Louis  Tuft,  M.D.,  Assistant  Professor  of  Medicine  and 
Chief  of  Clinic  of  Allergy  and  Applied  Immunology,  Tem- 
ple University  School  of  Medicine.  941  pages  with  27 
illustrations  (including  11  color  plates.)  H-'.  B.  Saunders 
Company,   Philadelphia   and   London.    1941.    Price   $10.00. 

Here  are  clearly  explained  how  living  agents 
produce  disease;  the  nature  of  natural  and  acquir- 
ed immunity;  antigens,  antibodies,  phagocytosis, 
anti-toxic  and  anti-bacterial  immunity;  anaphy- 
laxis and  allergy;  diagnostic  reactions;  active  im- 
munization and  vaccine  therapy;  passive  immuni- 
zation and  serum  therapy;  bacteriophage  therapy; 
methods  of  diagnosis  and  treatment  of  allergy; 
blood  transfusion  therapy;  nonspecific  protein  ther- 
apy; chemotherapy. 

The  second  half  of  the  book  gives  in  detail  the 
practical  applications  of  immunity,  biotherapy  and 
chemotherapy  in  the  prevention  and  cure  of  va- 
rious diseases. 

Dr.  Kolmer  speaks  with  authority  on  many  sub- 
jects. His  book  is  a  balanced  consideration  of  this 
important  group  of  subjects. 


QUINIDINE   AND   DIGITALIS 

(Graham    Asher,    Kansas    City,    Mo.,    in    Med.    Times.    July) 
Therapeutic  indication  for  digitalis  are: 

1.  Congestive   heart   failure   without    bradycardia. 

2.  Auricular  fibrillation  or  flutter  with  rapid  ventri- 
cular rate. 

3.  Therapeutic  test  in  impending  failure  in  cardiac 
overstrain  such  as  hypertension  of  chronic  val- 
vular disease. 

Contraindications   are: 

1.  High-grade  heart  block  with  Adams-Stokes  syn- 
drome. 

2.  Hypersensivity    with    previous    digitalis    poisoning. 

3.  Neurocirculatory  asthenia  and  collapse  after  se- 
vere infection   and  anesthesia. 

4.  Hyperthyroidism. 
Therapeutic    indications    for    quinidine: 

1.  Auricular  fibrillation  in  young  hearts  without  con- 
gestive  failure.     To   regularize   after   thyroidectomy. 

2.  Multiple  premature  contractions  where  hyperirri- 
tability  is  known  and  toxic  factor   removed. 

3.  Auricular  flutter  immediately  following  digitaliza- 
tion. 

4.  Occassional  paroxysmal  auricular  tachycardia  after 
digitalization  has  failed. 

5.  Yentricular   tachycardia. 

6.  In  coronary  thrombosis,  in  the  hope  of  lessening 
myocardial    irritability,    prophylactic    against    ven- 
tricular   tachycardia    and    fibrillation. 

Contraindications  are: 

1.  Congestive  heart  failure,  since  quinidine  has  a  de- 
pressant effect  on  the  myocardium. 

2.  Quinidine  sensitivity. 

3.  In   known   depression   of   respiratory   center. 
Indications   for   simultaneous   administration   of   digitalis 

and  quinidine  are:  thyroid  crisis  wth  auricular  flutter 
of  fibrillation,  and  rapid  ventricular  response  with  con- 
gestive failure. 


August,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


**^~ 


r^ 


^< 


/. 


ADSORPTION  OF  ACID 


THAT'S    HOW   SYNTROGEL    TABLETS    WORK 


Excess  stomach  acid  clings  to  the  surface  of 
Syntrogel  Tablet  particles  very  much  as  excess 
ink  adheres  to  the  surface  of  a  blotter,  or  iron 
filings  to  the  surface  of  a  magnet.  In  the  case  of 
aluminum  hydroxide  that  property  is  adsorption. 
The  chief  ingredient  of  Syntrogel  Tablets  is 
aluminum  hydroxide  of  highest  quality;  other 
important    ingredients    are    Syntropan    (nontoxic 


Syntrogel 


TABLETS    AND    CAPSULES 


antispasmodic),  calcium  carbonate,  and  bismuth 
subcarbonate.  Peppermint  flavored. 

The  tablets  are  small,  pleasantly  flavored,  and 
they  can  be  easily  chewed,  or  dissolved  on  the 
tongue,  or  swallowed  whole.  Their  effect  in  re- 
lieving hyperacidity  is  immediate.  The  usual  indi- 
cations include  relief  of  gastric  hyperacidity  or 
flatulence;  symptomatic  relief  of  peptic  ulcer; 
gastric  neuroses;  dyspepsia  due  to  mental  upsets; 
dietary  indiscretions;  intolerance  towards  certain 
foods;  gastric  disturbances  due  to  tobacco  or  alco- 
hol; gastric  inflammations.  Tablets:  (Sanitaped)  in 
boxes  of  48  and  96.  Capsules:  boxes  of  50  and  100. 

HOFFMANN -LA  ROCHE,  INC. 


ROCHE   PARK     •     NUTLEY 
Patronage  of  our  Advertisers  is  a  Mark  of  Friendship  to  the  Journal 


NEW  JERSEY 


SOUTHERN  MEDICINE  &  SURGERY 


August,   1941 


NEWS 


Dr.  James  Franklin  Blades  announces  the  opening  of 
his  offices  for  the  practice  of  General  Surgery  at  Richmond, 
with  offices  in  the  Medical  Arts  Building  and  the  Medical 
College  of  Virginia  Hospital. 


Dr.  Paul  M.  Deaion  has  become  a  member  of  the  med- 
ical staff  of  the  H.  F.  Long  Hospital  of  Statesville.  Dr. 
Deaton  is  a  native  of  Statesville,  a  graduate  in  medicine 
of  the  University  of  Pennsylvania,  and  he  has  just  finished 
an  interneship  in  the  Lankenau  Hospital  in  Philadelphia. 


Dr.  Walter  J.  Lackey,  of  Fallston,  has  returned  from 
Chicago,  where  he  took  an  intensive  course  in  Rectal  Dis- 
eases. For  a  number  of  years  Dr.  Lackey  has  been  taking 
care  of  these  needs  of  his  patients,  and  this  course's  objec- 
tive was  obtaining  familiarity  with  most  recent  develop- 
ments. 


Dr.  W.  B.  Hunt,  of  Lexington,  has  been  appointed  by 
Governor  Broughton  a  director  of  the  North  Carolina  Rail- 
road Company. 


Dr.  W.  deB.  MacNtder,  Professor  of  Pharmacology  in 
the  University  of  North  Carolina  Medical  School,  has  been 
elected  president  of  the  Society  for  Experimental  Biology 
and  Medicine  for  the  coming  year. 


Dr.  Oscar  Lee  Miller,  of  Charlotte,  has  been  elected 
to  honorary  membership  in  the  Argentine  Society  of  Sur- 
geons. 


Dr.  Claude  C.  Coleman  announces  that  Dr.  John 
M.  Meredith,  formerly  of  the  department  of  neurological 
surgery  University  of  Virginia,  has  returned  to  Richmond 
and  is  now  associated  with  him  in  the  practice  of  Neuro- 
logical Surgery. 


Dr.  Oscar  Belleter,  formerly  of  Chicago,,  is  the  new 
residentt  surgeon  at  Hugh  Chatham  Hospital,  Elkin,  N. 
C. 


Dr.  James  Walter  Brown,  Jr.,  son  of  Mr.  and  Mrs.  J. 
W.  Brown,  of  Gatesville,  has  started  on  a  year's  internship 
at  Orange  Memorial  Hospital.  Orange,  N.  J.  Having  re- 
ceived his  degree  in  medicine  at  Duke  University  this 
spring,  he  has  in  the  succeeding  months  done  intern  work 
at  Watts  Hospital,  Durham. 


Two  of  the  new  buildings  of  the  North  Carolina  Hos- 
pital for  Negroes  at  Goldsboro  have  been  named  for  two 
members  of  the  Board  of  Trustees — Graham  Woodard,  of 
Wilson,  and  C.  P.  Aycock,  of  Pantego. 


MARRIED 


Miss  Jane  Carrington.  of  Richmond,  and  Doctor  Edgar 
Sevier  Lotspeich,  Jr..  of  New  Orleans,  July  19th. 


Miss  Mary  Frances  Bauman.  of  Rele^gh.  N.  C,  and  Dr. 
Vincent  Wilcox   II.  of  Georgetown.   D.  C,  July   21st. 


Dr.  Neuval  Virso  Cutchins.  Jr.,  of  Atlanta,  and  Miss 
Ann  Kaufelt  Christian,  of  Richmond,  were  married  on  Julv 
12th. 


Dr.  Anthony  Mealy  Dc  Muth,  of  Pittsburgh,  and  MV 
Morton  Holladay,  of  Farmville,  Virginia,  were  married  o  i 
July   12th. 


Dr.    Arthur   N.    Springall    and   Miss    Bernice   Trout,    of 
Ancon,  Canal  Zone,  were  married  on  June  16th. 


Miss  Vera  Alice  Hanson,  of  Richmond,  and  Doctor  Alvah 
Duckett  Doughton,  of  Falls  Church,  Virginia.  July  18th. 


Dr.  Thomas  J.  Holt.  Jr.,  of  Warrenton,  North  Carolina, 
and  Miss  Lela  Manning,  of  Bainbridge,  Georgia,  were  mar- 
lied  on  July   19th. 


DIED 

Dr.  W.  Bernard  Kinlaw,  of  Rocky  Mount,  N  C...  was 
killed  in  an  automobile  accident  July  24th. 

Dr.  Kinlaw,  a  graduate  of  the  University  of  North  Caro- 
lina in  the  class  of  1914.  received  his  M.D.  degree  at  the 
University  of  Pennsylvania.  As  a  heart  and  chest  specialist, 
he  practiced  at  Rocky  Mount  1924  to  1937,  since  then 
he  had  practiced  in  New  York  State  and  in  Boston,  Mass. 
He  returned  to  Rocky  Mount  in  January.  1941.  He  had 
been  president  of  the  Edgecombe  Medical  Society,  presi- 
dent of  the  Nash  County  Tuberculosis  Association  and  aid- 
ed in  the  formation  of  the  Kiwanis  Tuberculosis  Clinic  and 
the  Rotary  Heart  Clinic.  Before  removing  from  North 
Carolina  he  was  active  in  the  affairs  of  the  Tri-State  Medi- 
cal Association. 


Dr.  Edgar  A.  Pole,  71,  died  July  19th  at  a  Charlottesville 
hospital.  He  had  practiced  for  35  years  at  Hot  Springs. 
Va. 


Dr.  W.  C.  Hearin,  54,  of  Greenville,  S.  C.  died  sud- 
denly July  9th.  while  making  rounds  at  St.  Fransis 
Hospital. 


August,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


Dr.  Claude  Ernest  Simons,  of  Wilson,  and  Miss  Margaret 
Smith  Move,  of  Goldsboro,  were  married  on  August   Sth. 


Medical  College  of  Virginia 

Faculty  promotions  for  the  fiscal  year  beginning  July  1st 
are  as  follows: 

Dr.  Webster  P.  Barnes  from  associate  in  to  assistant  pro- 
fessor of  surgery. 

Guy  W.  Horsley  from  associate  in  to  assistant  professor 
of  surgery. 

Lawther  J.  Whitehead  from  assistant  professor  to  asso- 
ciate professor  of  radiology. 

Thomas  D.  Rowe  from  assistant  professor  to  associate 
professor  of  pharmacy. 

Rudolph  Thomason  from  associate  in  to  assistant  pro- 
fessor of  ophthalmology. 

Delbert  A.  Russell  from  assistant  to  instructor  in  radi- 
ology. 

Edward  A.  Delarue,  Jr.,  from  assistant  to  instructor  in 
medicine. 

John  P.  Lynch,  Jr.,  from  assistant  to  instructor  in  med- 
icine. 

W.  Hughes  Evans  from  instructor  to  associate  in  ob- 
stetrics. 

W.  C.  Winn  from  instructor  to  associate  in  obstetrics. 

Walter  J.  Rein  from  assistant  to  instructor  in  ophthal- 
mology. 

William  A.  Johns  from  instructor  to  associate  in  surgery. 

Robert  Y.  Terrell  from  instructor  to  associate  in  proc- 
tology. 

E.  I.  Evans  from  assistant  to  instructor  in  surgery. 

John  Robert  Massie  from  assistant  to  instructor  in  sur- 
gery- 
Charles  M.  Nelson  from  instructor  to  associate  in  urol- 
ogy. 

Miss  Edna  J.  Townsend.  from  instructor  to  associate  in 
pediatric  nursing. 

Mabel  Blount  from  assistant  to  instructor  in  dietetics. 

Harriet  Stevens  from   assistant  to  instructor  in  dietetics. 

Dr.  Allen  Pepple  from  assistant  to  instructor  in  derm- 
atology and  syphilology. 

St.  George  Tucker  from  assistant  to  instructor  in  med- 
icine. 

Miss  Ann  Parsons  and  Miss  Edna  Townsend,  who  have 
been  on  leave  of  absence  for  study,  returned  to  the  school 
of  nursing  on  July  1st. 

Dr.  William  T.  Sanger,  president,  attended  the  Institute 
for  Officials  of  Higher  Institutions  at  the  University  of 
Chicago  the  second  week  in  July. 

The  psychiatric  section  occupying  a  whole  floor  of  the 
new  hospital  was  opened  July  21st.  Thirty-eight  beds  are 
available. 

The  Association  of  American  Medical  Colleges  has  ac- 
cepted the  invitation  of  the  college  to  hold  its  annual 
meeting  here.  October  27th-29th. 

Gifts  and  grants  to  the  college  for  the  fiscal  year  ending 
June  30th  totaled  $366,844.34. 


URINARY  FINDINGS 
(Win.  Elliott,  Virginia,  in  Minn.  Med.,  July) 
In  the  absence  of  definite  findings  in  cases  of  obscure 
abdominal  distress  cystoscopy  is  an  easier  way  to  approach 
the  problem  than  by  exploratory  operation.  Even  though 
cystoscopic  examination  is  not  resorted  to,  the  routine 
urinalysis  could  be  supplemented  by  high  speed  centrifuging 
and  the  growing  of  cultures,  procedures  which  are  not  tech- 
nically difficult,  but  which  would  frequently  disclose  the 
presence  of  active  disease  of  the  genito-urinary  tract  as 
evidenced  by  the  number  of  cases  of  pyelonephritis  in 
which  positive  urinary  findings  were  found  by  these  meth- 
ods. 


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SOUTHERN  MEDICINE  &  SURGERY 


August,   1941 


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can   be   applied   quickly,   easily   and   gently. 
There  are  three  sizes — regular,  medium  and  large, 
but  the  regular  size  will  usually  fit  the  average, 
normal  cervix. 

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Physician's  Samples   (limited)    60c  each. 

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NEWPORT,   R.   I. 


RUPTURE  OF  THE  INTESTINES  FROM  NONPENE- 
TRATING  INJURIES   OF  THE  ABDOMEN 

(T.    R.    Veal    &    E.    B.    Barnes     Washington,    in    Med.    Ann. 
D.    C.    July) 

The  frequency  of  rupture  of  the  intestines  from  non- 
penetrating injuries  of  the  abdomen  presents  an  urgent 
problem.  The  diagnosis  of  an  intestinal  rupture  must  be 
made  in  many  cases  by  the  simple  fact  that  it  cannot  be 
ruled  out,  rather  than  by  positive  evidence  of  its  presence. 
By  the  adoption  of  such  an  attitude  and  through  the  in- 
sistence upon  immediate  exploration  many  lives  will  be 
saved.  In  exploring  the  abdomen  the  entire  intestinal 
tract  must  be  examined.  The  surgery  in  the  majority  of 
cases  will  consist  of  the  simple  closure  of  the  rupture  and 
aspiration   of   the   escaped   fluid. 


DOCTORS  USE  OF  AUTOMOBILES 

(Editorial    in    Northwest    Med.,    July! 

The  Automobile  Manufacturers  Assocation  in  its  bulletin 
Automobile  Facts  for  June  reports  a  recent  survey  of  phy- 
sicians' use  of  automobiles.  Doctors,  according  to  this 
survey,  drive  more  miles  per  year  than  any  other  group 
except  traveling  salesmen,  the  average  being  nearly  13,000 
miles.  Doctors  make  more  round  trips  than  any  other 
group,  averaging  nearly  a  thousand  annually.  Ninety  per 
cent  of  the  number  of  trips  are  described  as  being  for 
professional  use.  while  sixty-six  per  cent  of  total  mileage 
is  reported  as  for  necessity  purposes.  In  rural  areas 
half  of  the  professional  trips  of  physicians  average  more 
than  15  miles,  while  in  the  cities  four  out  of  10  physi- 
cians  average   the   same   or   more. 

In    comparison    the    report    states    that    annual    mileage 


of  traveling  salesmen  runs  slightly  less  than  19.000  miles, 
while  farmers  drive  their  cars  less  than  6.000.  Farmers 
make  392  necessity  trips  per  year,  while  doctors  make 
947.  Both  maintain  the  same  percentage  of  total  mileage 
devoted  to  necessity  trips,  namely  sixty-six  per  cent. 
Physicians  average  40  miles  in  pleasure  trips,  while  the 
general   average  of  professional  trips  is  10  miles. 

Finally,  physicians  trade  in  their  cars  more  frequently 
than  do  most  groups.  Eighty-nine  per  cent  of  the  group 
surveyed  drove  cars  less  than  five  years  old  and  one- 
third  owned  cars  a  year  or  less  in  age. 


THE    COMBINED    ALKALOIDAL    TREATMENT    OF 
PARKINSONISM 

(A     Simon    &    J.    L.    Morrow,    WashinRton,    in    Med.    Ann. 
D.  D.,  July) 

The  product  used  is  known  as  Rabellon  and  was  fur- 
nished by  Sharpe  and  Dohme  of  Philadelphia.  Rabellon 
is  a  synthetic  preparation  containing  in  0.5  mg.  of  alkaloids: 
hyoscyamine  0.45  mg.,  atropine  0.037  mg.,  and  scopola- 
mine 0.012   mg. 

A  group  of  32  patients  (25  with  postencephalitic  park- 
insonism and  7  with  other  extrapyramidal  disorders)  were 
treated   with    Rabellon. 

After  treatment  for  2  days  to  5'/2  months — there  were 
14  unimproved,  4  slightly  improved,  and  7  moderately 
improved  in  the  postencephaletic  group.  In  the  group  with 
other  extrapyramidal  disorders,  6  were  unimproved  and 
1   slightly  improved. 

The  symptoms  ameliorated  were  rigidity,  gait  difficul- 
ties,  speech    disturbances,    sialorrhea    and    tremor. 

The  details  of  treatment  with  Rabellon  and  the  possible 
complications  have  been  discussed. 


August.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


PUZZLING  ABDOMINAL   PAIN 

W.    C.    Alvarez,    Rochester,    Minn     in    The    Recorder    of    the 
Columbia,  S.   C.   Med.  Soc.  July 

The  consultant  sees  many  persons  with  puzzling 
types  of  abdominal  pain  which  his  experience  tells 
him  are  not  due  to  any  demonstrable  disease  in 
the  abdominal  cavity.  In  such  cases  he  can  say 
that  an  exploratory  operation  is  likely  to  do  more 
harm  than  good.  It  may  well  be  that  there  are  ab- 
dominal neuralgias  just  as  there  are  head  neural- 
gias, pains  which  arise  in  nervous  tissue  with  no 
demonstrable  cause.  Some  pains  are  probably  due 
to  chemical  disturbances  in  the  tissues.  In  this 
connection  one  thinks  first  of  the  sore,  tender  liver 
or  colon  of  many  nervous  women. 

Burnings,  particularly  in  Jewish  patients,  are 
almost  always  paresthesias  in  the  abdominal  wall, 
and  the}-  are  seldom  relieved  by  any  operation. 

It  is  helpful  to  find  that  a  pain  is  not  related 
to  any  phase  of  digestion.  When  there  has  been 
no  sign  of  obstruction  in  the  digestive  tract,  no 
hemorrhages,  there  is  a  low  blood  sedimentation 
rate  and  roentgenograms  of  the  stomach  and  bowel, 
are  negative,  the  physician  had  better  stop  think- 
ing of  a  lesion  in  the  digestive  tract. 

Stabbing  and  aching  abdominal  and  thoracic 
pains  that  are  made  worse  by  sitting  or  lying 
down  are  usually  spondylitic.  Pains  due  to  spondy- 
litis are  extremely  common  and  are  seldom  diag- 
nosed properly. 

When  a  Sippy  cure  does  not  promptly  bring  re- 
lief, the  pain  is  probably  not  due  to  peptic  ulcer. 
Pain  not  relieved  by  a  good  dose  of  morphine  is 
likely  not  due  to  demonstrable  disease  in  ureter 
or  kidney  or  gallbladder. 

Watch  for  the  equivalents  of  migraine:  painful 
abdominal  storms  with  much  prostration,  mental 
suffering,  perhaps  vomiting,  perhaps  duodenal  stasis, 
and  only  a  mild  headache;  attacks  usually  come 
when  the  patient  is  under  nervous  strain.  In  the 
presence  of  these  curious  types  of  pain  and  distress, 
little  abnormalities  in  the  roentgenograms  of  stom- 
ach or  bowel  must  be  disregarded. 

Pain  in  the  left  upper  quadrant  which  is  not  re- 
lated to  any  part  of  the  digestive  cycle  is  usually 
without  macroscopic  cause  and  is  commonly  in- 
curable. Occasionally,  if  it  comes  with  exercise 
after  a  large  meal  in  a  man  past  40,  it  is  due  to 
coronary  thrombosis. 

Pain  above  the  pubes  may  be  due  to  disease 
of  the  posterior  urethra  or  the  prostate. 

If  the  patient  has  never  had  an  attack  of  acute 
appendicitis,  pain  in  the  right  lower  quadrant  can 
narely  be  cured  by  an  appendectomy. 

Certain  pain  syndromes  should  make  the  diag- 
nosis from  a  typical  history  and  not  from  the  fact 
that  the  laboratory  and  roentgenologic  and  special- 
ists' reports  are  negative. 


TYPHUS  FEVER 

J     L.   Thompson,   Jr.,    Washington,   in   Med.    Ann.   D.    C.    July 

Typhus  fever  is  transmitted  to  man  by  the  bite 
of  an  infected  body  louse  or  rat  flea.  The  endemic 
form  is  prevalent  in  the  Southern  United  States. 

Characteristic  are  sudden  onset,  continuous  high 
fever  of  two  weeks,  a  rash  on  the  4th  or  5  th  day, 
first  on  the  trunk,  prostration;  and  often  delirium 
and  other  severe  nervous  manifestations.  A  posi- 
tive Weil-Felix  reaction  in  high  dilutions  is  given. 
There  may  be  either  bronchitis  or  bronchopneu- 
monia. 

For  the  Eastern  type  of  Rocky  Mountain  spotted 
fever  the  vector  is  the  dog  tick,  and  the  disease  oc- 
curs in  the  late  spring  and  summer,  whereas  ende- 
mic typhus  fever,  transmitted  by  the  rat  flea  or 
body  louse,  is  seen  toward  the  end  of  winter.  The 
onset  of  the  two  diseases  is  practically  identical. 
The  history  of  the  finding  of  a  full  tick  on  the  per- 
son is  an  important  clue  in  the  beginning  of  the 
illness,  pointing  to  a  diagnosis  of  Rocky  Mountain 
spotted  fever.  In  both  diseases  a  rash  appears  on 
the  4th  or  5th  day;  in  typhus  fever  on  the  trunk, 
spreads  peripherally,  and  does  not  appear  on  the 
face,  In  Rocky  Mountain  spotted  first  on  ankles, 
wrist  and  forehead  and  spreads  towards  the  center. 
In  both  diseases  rose-colored  macules  which  dis- 
appear on  pressure  and  which  later  become  brown- 
ish-red or  purple.  Areas  of  hemorrhagic  necrosis 
may  appear  in  either  disease.  Each  lasts  two  or 
three  weeks  and  resolves  by  lysis.  The  patient 
with  typhus  usually  appears  more  ill. 

There  is  no  specific  treatment  for  either  disease. 
Symptomatic  and  supportive  measures  are  all  that 
can  be  offered.  Prophylaxis  for  Rocky  Mountain 
spotted  fever  consists  in  stripping  the  body  of 
clothes  once  or  twice  each  day  and  removing  any 
ticks,  care  being  taken  not  to  crush  them  between 
the  fingers.  The  yearly  use  of  vaccine  for  persons 
liable  to  exposure  is  advised.  As  for  typhus  fever, 
persons  working  in  rat-infested  areas  should  keep 
scrupulously  clean  and  should  have  their  working 
clothes  treated  frequently  with  dry  heat  or  steam. 
There  is  no  accepted  method  of  vaccination. 


A  THEORY  AS  TO  HYPERTENSION 
(A.  Ravich,  Brooklyn,  in  Med.  Timet,  July) 
A  kidney  pelvis  of  the  fetal  type,  i.e.,  an  intrarenal  pel- 
vis which  is  almost  completely  surrounded  by  renal  tis- 
sue, predisposes  to  hypertension.  Enlargement  of  the 
intrarenal  pelvis  due  to  obstruction  or  infection  compresses 
the  neighboring  renal  vessels  and  leads  to  renal  ischemia 
and  hypertension.  Excretion  urography  is  of  utmost  im- 
portance in  the  diagnosis,  prognosis  and  treatment  of  "es- 
sential" hypertension.  In  addition,  it  is  possible  by  this 
diagnostic  procedure  to  determine  at  an  early  period  those 
individuals  who  arc  most  likely  to  develop  hypertension. 


Top  minnows  destroy  the  larva]  forms  of  mosquitoes  in 
the  dark  as  in  the  light. 


SOUTHERN  MEDICINE  &  SURGERY 


August,  1941 


CHUCKLES 


AND  40  YEARS  AFTER  THE  CIVIL  WAR  YOU 
COULDN'T  GET  A  YET  INTO  A  HOSPITAL 
UNLESS  HE  WAS  UNCONSCIOUS 
CCiba  Symposia) 
On   June    10th,    1861,   the    Secretary   of   War   appointed 
Dorothea  L.  Dix  Superintendent  of  Female  Nurses  of  the 
Army,  vested  with  full  power  to  assemble  and  train  a  corps 
of  army  nurses.   Miss  Dix  had  circulars  published  citing  the 
qualifications  necessary  for  army  nursing  candidates.  They 
read  in  part:  "No  women  under  30  years  of  age  need  apply 
to  serve  in  government  hospitals.    All  nurses  are  required 
to   be  very   plain   looking   women.   Their   dresses   must   be 
brown  or  black,  with  no  bows,  no  curls,  no  jewelry,  and 
no  hoop  skirts.''    One  of  the  replies  to  this  circular  said: 
"I  am  in  possession  of  one  of  your  circulars,  and  will  com- 
ply  with   all   of   your   requirements.     I   am   plain   looking 
enough  to  suit  you,  and  old  enough.    I  have  no  near  rela- 
tives in  the  war;  no  lover  there.    I  never  had  a  husband, 
and  am  not  looking  for  one." 


Shakespeare  had  heard  his  star  actor,  Richard  Burbage, 
make  an  appointment  with  a  woman,  at  her  room,  after 
the  play.  "When  I  knock  you  will  ask  'Who  is  there?'; 
and  I  will  say:  'King  Richard!'"  (the  part  he  was  play- 
ing) .  Shakespeare,  having  finished  his  minor  part  before 
the  end  of  the  play,  slipped  out  and  anticipated  Burbage. 
When  Burbage  spoke  his  password.  "King  Richard,''  the 
voice  of  Shakespeare  was  heard  from  within:  "William  the 
Conqueror  came  before  King  Richard;  so  begone." 


Doctor:    "Was    your    wife's    reducing    diet    a    success?" 
Husband:     "Rather!    She    disappeared    completely    last 
Thursday." 


"I'll  never  take  you  to  another  party  as  long  as  I  live," 
she  fumed. 

"Why?"  the  doctor  asked  in  amazement. 

"You  asked  Mrs.  Jones  how  her  husband  was  standing 
the  heat." 

"Well?'' 

"Her  husband  has  been  dead  for  two  months." 


"Mandy,  what  you  need  is  birth  control." 
"Oh,   no,  ma'am,"  Mandy   replied,  "that's  all   right   for 
you  but  I'se  married." 


Physician  (attending  A.  M.  A.  Convention) :  "May  I 
have  some  stationery?" 

Hotel  clerk  (haughtily) :  "Are  you  a  guest  of  the 
house?" 

Physician:  "Oh,  no!  I'm  buying  it,  paying  twenty  dol- 
lars a  day!" 


Professor  (who  has  spoken  for  two  hours) :  "I  shall  not 
keep  you  much  longer.  There  is  no  clock  in  the  room,  and 
I  must  apologize  for  not  having  a  watch  with  me." 

Student:    "There  is  a  calendar  behind  vou,  doctor.'' 


"Doctor,  what   should  a  woman  take  when  she  is  run 
down?" 

"The  license  number,  madam,  the  license  number." 


Patient:  "Well,  have  any  of  your  childhood  ambitions 
been  realized,  doctor?" 

Doctor  (father  of  a  large  family) :  "At  least  one  of 
them — it  was  always  my  desire  to  wear  long  trousers;  now 
I  believe  I  wear  them  longer  than  anybody  else." 


A  doctor's  wife  decided  to  give  a  formal  reception,  so 
she  summoned  her  maid  to  give  her  instructions,  saying: 
"Molly,  I  want  you  to  stand  at  the  drawing  room  door 
and  call  the  guests'  names  as  they  arrive." 

"Very  good  ma'am,"  said  Molly  happily.  "I've  been 
wanting  to  do  that  for  years.  I  suppose  the  first  thing  that 
comes  into  me  head  will  do." 


SUICIDAL  ATTEMPTS 

(D.    M.    Palmer   Columbus,   O.,   in   Jl.   Ncrv.    &  Mental  Dis.,  93: 

421,   1941) 

The  motivations  for  the  act  are  to  be  found  in  the  per- 
sonality structure  of  the  individual  to  a  far  greater  extent 
than  in  the  present  environment  to  which  person  appears 
to  be  maladjusted. 

The  alleged  "cause"  of  the  average  suicidal  attempt  is 
often  only  a  precipitating  event. 

An  arrest  in  psychosexual  development  appears  to  be  the 
basic  mechanism  in  a  majority  of  suicidal  attempts.  This 
arrest  is  often  due  to  the  unavailability  of  one  or  both 
parents  as  love-objects,  as  "stepping-stones"  in  psycho- 
sexual  development,  and  as  active  forces  in  super-ego  for- 
mation. 

Spite  as  a  motive  is,  at  least  in  some  cases,  a  rationaliza- 
tion of  a  deep-lying  defect  in  psychosexual  development 
rather  than  a  direct  incitement. 


VALUE   OF   "ENRICHED"   FLOUR   IN 

AMERICAN   DIET 

Margaret    Pewters,    et    al    in    Proc.    Staff    Meetings 

Mayo   Clinic,   July  2nd 

This  study  was  begun  in  October  1940  to  learn  the 
relative  nutritive  values  of  (1)  white  flour,  (2)  white 
flour  fortified  with  thiamine  and  riboflavin,  and  (3)  a 
whole-grain  flour.  At  the  time  of  the  beginning  of  the 
study  "enrichment"  of  flour  and  bread  had  not  yet  been 
recommended,  which  explains  our  failure  to  study  flour 
fortified  with   nicotinic   acid. 

Weaning  white  rats  caged  in  groups  of  eight  animals 
were  allowed  free  access  to  the  diet  and  the  amounts  of 
diet  consumed  were  measured. 
Evidence  derived  from  studies  of  the  growth  of  rats 
indicates  that  substitution  of  whole-grain  wheat  flour 
for  white  flour  in  the  preparation  of  human  diets  material- 
ly improves  the  nutritive  quality  of  a  "poor"  diet. 

Enrichment  of  white  flour  with  thiamine  alone  im- 
proves the  quality  of  the  "poor"  diet ;  enrichment  of  the 
flour  with  both  thiamine  and  riboflavin  improves  the  diet 
yet   further. 

Flour  must  be  enriched  with  nutrients  other  than  thia- 
mine and  riboflavin  to  obtain  a  flour  of  nutritive  qualitv 
comparable  to  that  of  whole-wheat  flour.  The  effect  of 
enrichment  of  flour  with  nicotinic  acid  as  well  as  thiamine 
and  riboflavin  is  the  subject  of  a  study  now  in  progress. 


SEVEN-MILE  JUMPS 

(Jane   Stafford   in  Science  Ne)ws   Letter) 

Occasionally   a  plane   dropping   destruction   from   35,000 

to  40,000  fet  above  the  earth's  surface  does  not  get  away 

safe. 

Walter  M.  Boothby,  of  the  Mayo  Clinic,  states: 

"If  he  gets  into  a  dogfight  up  in  those  high  altitudes, 

and  his  plane  bursts  into  flames,  he  is  a  gone  duck  unless, 

after   bailing   out,   he   can   be   kept   alive   for   at   least    10 

minutes   with   oxygen   until   he   floats   down   to   the    18,000 

level.'' 


Plasma  and  Serum. — There  is  every  reason  to  believe 
that  enthusiasm  for  their  use  will  continue. — Alfred  Bla- 
lock. 


August,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


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August,  1941 


PRODUCTS  OF   BAXTER    LABORATORIES 

for  Maximum  Yield 
of  Plasma  or  Serum 


•     1941     • 

FLORIDA'S  NEWEST  —  FINEST  &  LARGEST 

All- Year  Hotel 


THE     RIVIERA 

Near  Daytona  Beach. 

Ideal  Convention  or  Conference  Headquarters.     Capacity  400. 

The  only  Hotel  Bar  open  all  year  between 
Jacksonville  &  Palm  Beach. 

Radio  and  Fan  in  Every  Room.  Golf  Links.  Artesian  Swimming 
Pool  with  Sand  Beach.  Tennis,  Badminton.  Ping  Pong,  Croquet, 
Horseshoe  and  Shuffleboard  Courts.  Ballroom  and  Convention 
Hall.    Banquet  Facilities.    Spacious  Grounds. 

COOLEST  SPOT  IN  ALL  FLORIDA,  AT  THE  BIRTHPLACE  OF 
THE  TRADE  WINDS.  Where  the  Labrador  (Arctic)  Current 
meets  the  Gulf  Stream,  and  Summer  Bathing  and  Fishing  are 
Superb. 

Write  for  Special  Summer  Rates.  April  to  December. 

Hotel  Riviera,  Box  429,  Daytona  Beach,  Fla. 

MOUNTAINEER,  TAR  HEEL  &  CRACKER 

VACATION  HEADQUARTERS. 


use  BAXTER  equipment 

The  height  of  the  Baxter  Centri-Vac, 
and  its  small  diameter  make  it  ideal  for 
the  preparation  of  plasma  or  serum  by 
centrifugation,  a  method  which  provides 
maximum  yield.  Completely  closed  tech- 
nique safeguards  against  contamination. 


BLOOD    TRANSFUSIONS! 

BAXTER  TRANSFUSO-VAC 

*  A  completely  closed  system. 
Vacuum  is  mechanically  induced,  positive 
assurance  that  transfusion  will  not  be  inter- 
rupted by  low  vacuum —  and  that  blood  will 

trols  flow  and  preserv 
uum,  preventing 


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August,  1941 


SOUTHERN  MEDICINE  &  SURGERY  473 


Southern  Railway's 

SOUTHERNER 


Built  of  high-tensile  steel,  with  sheathing  of  stainless  steel,  THE  SOUTHERN- 
ER which  will  operate  as  three  Diesel-powered  trains,  includes  all  the  latest  refine- 
ments for  the  ultimate  in  safety,  speed  and  comfort.  Each  train  will  consist  of 
Straight,  Partition  and  Baggage-Dormitory  Chair  Cars,  Dining  Car  and  Lounge- 
Tavern-Observation  Unit,  all  reflecting  the  latest  ideas  in  structural  development 
and  modern  styling  and  beauty. 

Passenger  units  have  thermostatically  controlled  heating  and  air  conditioning, 
are  insulated  throughout.  Judicious  use  is  made  of  a  number  of  advancements  favor- 
ing gracious  living.  A  good  part  of  the  luxury  picture  appears  in  the  comfortable 
seating  arrangement  in  all  cars,  the  commodious  and  up-to-date  dining  car  arrange- 
ments and  the  facilities  for  en  route  enjoyment  offered  in  lounge,  tavern  and  obser- 
vation rooms. 

Diesel  locomotives  for  the  trains  are  built  by  the  Electro-Motive  Corporation, 
a  subsidiary  of  General  Motors. 

Particularly  interesting  from  the  standpoint  of  detailed  comfort  planning  is  the 
fact  that  chair  cars  have  twin-rotating,  reclining-type  seats,  cushioned  and  attrac- 
tively finished.  The  dining  car  has  accommodations  for  48  persons  in  satin  metal 
framed  chairs  with  rubber  seats  and  back  cushions.  Settees,  lounge  chairs,  writing 
desk,  card  section  and  refreshment  facilities  have  been  planned  to  fit  the  comfort 
and  utility  requirements  of  passengers  in  the  Lounge-Tavern-Observation  unit. 

A  rich  decorative  treatment  has  been  designated  for  all  units  of  THE  SOUTH- 
ERNER the  basic  colors  being  blue,  green  and  beige  in  light,  medium  and  dark 
tones.  Blue  and  beige  are  distributed  in  straight  chair  car  planning,  each  car  carry- 
ing out  variations  of  the  same  color  treatment  throughout .  Partition  chair  cars  em- 
phasize beige  and  the  Baggage-Dormitory-Chair  Cars  are  done  in  tones  of  blue. 
Green  is  the  predominating  scheme  in  dining  car  and  Lounge-Tavern-Observation 
units. 

The  whole  scene  is  enriched  with  an  attractive  arrangement  of  photo-murals 
which  have  been  especially  planned  to  heighten  the  atmosphere  of  luxury  and  beauty 
in  THE  SOUTHERNER. 


PROFESSIONAL   CARDS 


August,  1941 


GENERAL 

Nail*  Cllnlt  Building                                                                                   412  North   Church  Street,  Charlotte 

THE  NALLE  CLINIC 

Telephone— 3-2141    (//  no  answer,  call  3-2621) 

General  Surgery                                             General  Medicine 

BRODIE   C.   NALLE,   M.D. 
Gynecology   &   Obstetrics.. 
EDWARD   R.   HIPP,   M.D. 

Traumatic  Surgery 

PRESTON  NOWLIN,   M.D. 

Urology 

LUCIUS   G.   GAGE,  M.D. 
Diagnosis 

LUTHER  W.  KELLY,  M.D. 
Cardio-Resptratory   Diseases 

Consulting   Staff 

DRS.   LAFFERTY,   BAXTER  &  PARSONS 

Radiology 

BARRET  LABORATORY 

Pathology 

J.  R.  ADAMS,  M.D. 
Diseases  of  Infants  &  Children 

VV.  B.  MAYER,  M.  D. 
Dermatology  &  Syphllology 

C— H— M   MEDICAL   OFFICES 

DIA  GNOSIS— SURGER  Y 

X-RAY— RADIUM 

Dr.  G   Carlyle  Cooke — Abdominal  Surgery 

&  Gynecology 
Dr.  Geo    W.  Holmes— Orthopedics 
Dr.  C.  H.  McCants — General  Surgery 
222-226  Nissen  Bid.                    Winston-Salem 

WADE   CLINIC 

Wade  Building 
Hot   Springs  National  Park,   Arkansas 

H.  King  Wade,  M.  D.                           Urology 
Charles  S.  Moss,  M.D              General  Surgery 
Jack  Ellis,  M.D.                     General  Medicine 

1-rank  M.  Adams,  M.D.         General  Medicine 
M.  B.  Burch,  M.D.    Eye,  Ear,  Nose  &  Throat 
Raymond  C.  Turk,  D.D.S.        Dental  Surgery 
A.  W.  Scheer                            X-ray  Technician 
Etta  Wade                             Clinical  Pathology 
Martorie  Wade                                 Bacteriology 

INTERNAL  MEDICINE 

ARCHIE  A.   BARRON,  M.  D.,   F.A.  C.P. 
INTERNAL    MEDICINE— NEUROLOGY 
Professional   Bldg.                                 Charlotte 

JOHN  DONNELLY,  M.  D. 

DISEASES  OF  THE  LUNGS 

324Y2  N.  Tryon  St.                                Charlotte 

CLYDE   M.    GILMOixE,   A.  B.,   M.D. 
CARDIOLOGY— INTERNAL    MEDICINE 
Dixie  Building                                    Greensboro 

JAMES  M.  NORTHINGTON,   M.D. 
INTERNAL    MEDICINE— GERIATRICS 
Medical   Building                                   Charlotte 

ORTHOPEDICS 

HERBERT   F.   MUNT,   M.D. 
ACCIDENT  SURGERY  &  ORTHOPEDICS 

FRACTURES 
Nissen  Building                        Winston-Salem, 

August,   1941 


PROFESSIONAL   CARDS 


475 


NEUROLOGY  and  PSYCHIATRY 


J.  FRED  MERRITT,  M.  D. 

NERVOUS  and  MILD  MENTAL 
DISEASES 

ALCOHOL  and  DRUG  ADDICTIONS 

Glenwood   Park   Sanitarium  Greensboro 


EYE,  EAR,  NOSE  AND  THROAT 


H.  C.  NEBLETT,  M.  D. 

OCULIST 

Phone   3-58S2 

Professional   Bldg.  Charlotte 


AMZI  J.  ELLINGTON,  M.  D. 

DISEASES  of  the 
EYE,  EAR,  NOSE  and  THROAT 

Phones:  Office  992 — Residence  761 

Burlington  North   Carolina 


UROLOGY,   DERMATOLOGY   and    PROCTOLOGY 


THE  CROWELL   CLINIC   of   UROLOGY   and   UROLOGICAL   SURGERY 
Hours— Nine  to  Five  Telephones— 3-7101 — 3-7102 

STAFF 

Andrew  J.  Crowell,  M.  D. 

(1911-1938) 

Angus  M.  McDonald,  M.  D.  Claude  B.  Squires,  M.  D. 

Suite  700-711  Professional  Building  Charlotte 


Dr.  Hamilton  W.  McKay 


DOCTORS  McKAY  and  McKAY 


Dr.  Robert  W.  McKay 


Practice  Limited  to   UROLOGY  and  GENITO-URINARY  SURGERY 
Hours  by  Appointment 

Occupyinc  2nd  Flood  Medical  Arts  Bldg.  Charlotte 


Raymond   Thompson.   M.  D.,   F.  A.  C.  S. 


Walter   E.   Daniel,   A.  B.,  M.  D. 


THE  THOMPSON  -  DANIEL  CLINIC 

of 

UROLOGY  &  UROLOGICAL  SURGERY 


Fifth  Floor  Professional  Bldg. 


Charlotte 


C.  C.  MASSEY,  M.  D. 

L.  D.  McPHAIL,  M.  D. 

PRACTICE  LIMITED 

RECTAL  DISEASES 

TO 

DISEASES   OF   THE   RECTUM 

Professional   Bldg.                                 Charlotte 

Professional   Bldg.                                 Charlc 

WYETT   F.   SIMPSON,   M.  D. 

GENITO-URINARY   DISEASES 

Phone   1234 

Hot  Springs  National  Park  Arkansas 


476 


PROFESSIONAL   CARDS 


August,  1941 


SURGERY 


R.  S.  ANDERSON,  M.  D. 

GENERAL  SURGERY 

144  Coast   Line  Street  Rocky   Mount 


R.  B.  DAVIS,  M.  D.,  M.  M.  S.,  F.A.C.P. 
GENERAL  SURGERY 

AND 
RADIUM   THERAPY 

Hours  by  Apteinlmer,! 

Piedmont-Memorial  Hosp.  Greensboro, 


WILLIAM    FRANCIS    MARTIN,    M.D. 
GENERAL  SURGERY 

Professional   Bldg.  Charlotte 


OBSTETRICS  &  GYNECOLOGY 


IVAN  M.  PROCTER,  M.D. 

OBSTETRICS   &   GYNECOLOGY 

133   Fayetteville   Street  Raleigh 


SPECIAL  NOTICES 


THE  EDITING  OF  MEDICAL  PAPERS 

This  journal  has  arranged  to  meet  the  demand  for  the  service  of  editing  and  revis- 
ing papers  on  medicine,  surgery  and  related  subjects,  for  publication  or  presentation 
to  societies.  This  service  is  rendered  on  terms  comparing  favorably  with  those  pre- 
vailing generally  in  other  Sections  of  the  Country. 


SOUTHERN  MEDICINE  &  SURGERY. 


THE  JOURNAL  OF 
SOUTHERN  MEDICINE  AND  SURGERY 

306  North  Tryon  Street,  Charlotte,  N.  C. 

The  Journal  assumes  no  responsibility  for  the  authenticity  of  opinion  or  statements  made  by  authors  or  in  communica- 
tions submitted  to   this  Journal  for  publication. 


JAMES   M.   NORTHINGTON,   M.  D.,   Editor 


Vol.   cm 


CHARLOTTE,  N.  C,  SEPTEMBER,  1941 


Some  Refinements  in  the  Extracapsular  Method  of  Extraction  of 
Uncomplicated   Senile  Cataract  with  Preliminary  Iridectomy 

Neilson  H.  Turner,  M.D.,  Richmond 


THE  THEME  of  this  article  is  the  improved 
application  of  long-known  principles,  which 
when  properly  employed,  in  the  overwhelm- 
ing majority  of  the  cases,  results  in  an  excellent 
cosmetic  effect,  in  a  shorter  postoperative  convales- 
ence,  and  in  an  improved  visual  acuity  in  many 
patients  that  otherwise  would  fail  to  get  it. 

Since  the  advent  of  the  Smith-Indian  operation 
at  Jullunder,  India,  in  1895,  the  intracapsular 
method  of  extraction  has  gradually  increased  in 
popularity;  but  when  considered  from  the  stand- 
point of  immediate  or  end-results,  the  reason  for 
this  is  difficult  to  find.  In  any  type  of  cataract 
extraction,  irrespective  of  whether  it  is  a  series  of 
cases  by  one  or  a  group  of  individuals,  if  a  consid- 
erable percentage  of  the  patients,  because  of  exces- 
sive and  unnecessary  traumatism  of  the  ciliary  re- 
gion and  of  the  cornea,  are  confined  to  the  bed  for 
two  weeks  or  longer;  if  there  is  in  some  cases,  care- 
less spilling  of  vitreous,  resulting  in  degenerative 
changes  in  some  of  these  eyes  with  vitreous  opaci- 
ties and  retinal  detachment;  and  if  not  a  very  few 
preoperatively  favorable  cases,  with  their  proper 
correcting  lenses,  get  only  20/40  or  less,  it  is  not 
an  indication  of  competent  ophthalmic  surgery. 
Unfortunately  the  unlucky  patient  is  the  victim. 

I  will  not  go  into  detail  about  the  preparation  of 
the  patient,  as  that  is  the  same  in  all  cases  in  which 
an  extraction  is  to  be  done.  It  is  essential  to  thor- 
oughly examine  to  discover  any  condition  which 
might  affect  the  outcome  unfavorably. 

In  the  preparation  of  the  operative  field,  except 
to  have  as  thorough  cleansing  and  sterilization  of 
the  area  as  is  compatible  with  safety,  little  will  be 


said,  as  its  manner  of  accomplishment  depends  on 
the  choice  of  the  operator. 

To  allay  uneasiness  and  control  nervousness,  one 
of  the  barbital  compounds  may  be  given  from 
twenty  to  forty  minutes  prior  to  the  time  of  oper- 
ation, or  other  satisfactory  hypnotics  may  be  used. 
All  members  of  the  morphine  group  should  be  re- 
jected because  of  their  tendency  to  cause  nausea  or 
vomiting. 

The  instillation  of  one  drop  of  4  per  cent  cocaine 
solution,  followed  at  three-minute  intervals  by  two 
of  a  10  per  cent  solution,  with  the  subconjunctival 
injection  four  or  five  mm.  above  the  limbus  of  two 
or  three  minims  of  the  4  per  cent  solution  or  of  a 
4  per  cent  preparation  of  novocain,  will  produce  in 
practically  all  cases  anesthesia  for  the  preliminary 
iridectomy. 

With  the  speculum  in  position  and  the  eye  sup- 
ported by  a  suitable  fixation  forceps,  a  four-mm. 
angular  keratoma  incision  is  made  in  the  cornea  in 
the  vertical  meridian  above,  just  anterior  to  the 
limbus  and  on  a  plane  parallel  with  the  anterior 
surface  of  the  iris.  The  fixation  forceps  is  now 
removed,  and  the  closed  blades  of  a  Mathieu's  or 
Liebreich's  type  of  iris  forceps  are  passed  through 
the  wound  until  within  one  mm.  of  the  pupillary 
border,  then  opened  for  ll/2  mm.  and  the  iris 
caught  and  carefully  pulled  through  the  corneal 
incision  until  enough  is  exposed  to  include  the 
sphincter  iridis.  This  portion  is  then  excised.  If 
the  sphincter  is  left  intact,  an  iris  hook  can  be  used 
to  expose  it  for  cutting.  With  the  iris  repositor  the 
cut  edges  of  the  iris  should  be  gently  stroked  away 
from  the  wound.  One  per  cent  sterile  atropine  solu- 
tion should  then  be  instilled,  White's  ointment  ap- 


REFINEMENTS    IN    CATARACT    EXTRACTION— Turner 


September,   1941 


plied  and  a  dressing  placed  over  the  eye.  It  is  not 
necessary  for  the  patient  to  stay  in  the  hospital 
following  this  operation,  but  he  or  she  should  re- 
main quiet  until  the  second  day.  The  atropine  is 
to  be  continued  until  all  irritability  has  disappear- 
ed, which  is  usually  within  two  weeks. 

Done  in  this  manner,  a  narrow  coloboma  results, 
which,  as  it  is  obscured  by  the  upper  eyelid,  gives 
an  excellent  cosmetic  effect  and  little  disturbance 
from  photophobia.  It  is  not  necessary  to  wait  for 
the  cataract  to  become  fully  mature  before  doing 
the  preliminary  iridectomy. 

While  immature  senile  opacification  of  the  lens 
can  be  operated  upon  by  the  extracapsular  method, 
prudence  based  on  experience  says  that  it  is  usually 
best  to  wait  until  the  cataract  is  about  ripe,  even 
in  persons  over  sixty-five  years  of  age.  Following 
the  iridectomy  the  eye  should  be  quiet  before  an 
extraction  is  attempted. 

Excellent  local  anesthesia  is  provided  by  injec- 
tions of  2-  to  4-per  cent  novocain  in  1:10,000 
adrenalin  chloride  solution  intraorbitally,  subcu- 
taneously  in  the  upper  and  lower  eyelids  at  the 
orbital  margin,  and  in  front  of  the  external  audi- 
tory meatus  (O'Brien's  akinesis)  on  the  side  of  the 
eye  to  be  operated  upon,  along  with  the  local  in- 
stillations as  for  the  iridectomy,  except  that  the 
subconjunctival  injection  of  the  4-per  cent  cocaine 
solution  is  made  a  few  mm.  above  the  limbus  di- 
rectly preceding  the  making  of  the  corneal  incision. 

With  the  speculum  in  position  and  the  eye  held 
in  proper  place  by  a  fixation  forceps,  the  corneal 
incision  is  made  for  the  upper  one-fifth  of  the  cir- 
cumference, ending  in  a  conjunctival  flap  at  or 
below  the  site  of  the  subconjunctival  injection  of 
cocaine  of  not  over  two  or  three  minims.  More 
would  interfere  with  the  making  of  the  flap,  where- 
as the  necessary  amount  facilitates  it.  The  fixation 
forceps  is  now  removed.  The  wound  can  be  en- 
larged by  the  use  of  narrow-bladed,  blunt-pointed 
scissors.  This  procedure  lessens  the  possibility  of 
damage  to  the  iris. 

To  split  the  anterior  layer  of  the  lens  capsule,  a 
Knapp  cystotome  is  drawn  temporally  and  nasally 
in  arc  formation  near  the  periphery  of  the  lens, 
meeting  above,  and  then  carried  in  the  form  of  an 
X  in  the  central  portion.  No  pressure  is  to  be  ap- 
plied in  making  these  incisions.  A  wide  exposure 
facilitates  delivery  of  the  lens  substance  and  has- 
tens absorption  of  any  remaining  cortex,  removing 
one  of  the  factors  in  the  production  of  so-called 
after-cataract — the  retention  and  regeneration  of 
lens  cells  between  layers  of  the  capsule. 

Gentle  pressure  directed  slightly  upward  applied 
below  at  the  limbus  by  the  back  of  a  lens  spoon,  or 
better  by  a  smooth,  curved  lens  expeller,  should 
result  in  the  upper  periphery  of  the  lenticular  body 
appearing  at  the  wound.   The  point  of  pressure  on 


the  anterior  corneal  surface  should  be  gradually 
raised  until  it  is  expelled.  No  pressure  by  the  blunt 
end  of  a  hook  is  needed  or  desired.  Trauma  must 
be  minimal,  that  there  may  be  no  distortion,  and 
later  failure  to  get  an  expected  visual  acuity  with 
proper  lenses.  By  gentle  upward  stroking  any  re- 
maining cortex  may  be  expressed;  or  it  may  be 
carefully  washed  out,  using  an  anterior  chamber 
irrigator  and  half-normal  saline  solution.  Any  lens 
substance  or  capsule  in  the  wound  should  be  re- 
moved, the  iris  is  restored  to  its  normal  position 
away  from  the  cut  edges  of  the  incision,  1-per  cent 
sterile  atropine  solution  is  instilled,  the  cut  edges 
of  the  cornea  carefully  approximated  and  the  con- 
junctival flap  gently  replaced.  These  manipula- 
tions are  done  with  the  iris  repositor.  No  conjunc- 
tival stitch  is  necessary.  The  speculum  is  now  re- 
moved very  gently,  first  from  the  lower  and  then 
from  the  upper  lid,  after  pulling  the  blade  slightly 
forward  and  then  downward  so  as  not  to  disturb 
the  corneal  section.  If  necessary,  the  upper  lid  is 
now  caught  by  the  lashes,  pulled  forward  to  pre- 
vent contact  with  the  wound  and  then  downward 
to  close  the  eye.  Tape  to  keep  the  eyelids  closed 
is  now  applied  without  pressure,  White's  ointment 
is  used  in  both  eyes,  a  light  dressing  applied  over 
the  eye  operated  on  and  a  fairly  tight  but  not 
uncomfortable  one  over  the  other  eye,  and  a  Rin- 
ger's mask  placed  in  position. 

On  making  the  pressure  below  at  the  limbus  to 
remove  the  lens,  if  it  fails  to  appear  promptly  in- 
spect to  determine  the  cause.  The  upper  periphery 
of  the  lens  may  impinge  on  the  iris,  which  in  turn 
is  blocked  by  the  cornea.  Moving  the  cut  edge  of 
the  cornea  forward  slightly  with  the  iris  repositor 
will  promptly  correct  the  trouble.  Posterior  syne- 
chiae  may  require  passing  the  blade  of  the  fine  iris 
repositor  into  the  posterior  chamber  at  the  colo- 
boma, and  then  toward  the  pupil  between  the  iris 
and  the  anterior  layer  of  the  capsule.  It  may  be 
that  the  corneal  section  is  not  large  enough  to  allow 
the  lens  to  come  out.  in  which  case  it  is  necessary 
to  enlarge  it. 

The  postoperative  care  in  these  cases  is  very 
simple — to  lie  flat  on  the  back,  not  moving  the 
head  at  all,  and  liquid  diet  for  the  first  twenty- 
four  hours.  Following  this  the  head  may  be  turned 
to  the  side  of  the  eye  not  operated  on  for  rest,  and 
the  food  may  be  of  the  soft  and  liquid  varieties. 
Unless  there  is  some  trouble  the  eye  is  not  opened 
until  the  fourth  day.  At  this  time  the  tape  is  re- 
moved, 1-per  cent  atropine  solution  instilled, 
White's  ointment  applied,  a  light  dressing  placed 
over  the  eye,  and  the  cut-out  portion  of  the  Rin- 
ger's mask  which  covered  the  eye  is  placed  over  it 
and  securely  held  in  position  by  ample  adhesive 
tape.  The  other  eye  is  now  left  open.   General  diet 


September,   1941 


REFINEMENTS    IN    CATARACT    EXTRACTION—  Turne 


479 


may  be  given  after  the  fourth  day,  and  the  atten- 
tion directed  given  until  the  patient  leaves  the 
hospital  on  the  sixth  or  seventh  day.  During  the 
hospital  stay,  special  nursing  care  is  necessary,  as 
the  patient  must  not  get  up  or  out  of  the  bed  for 
anything.  After  leaving  the  hospital,  it  is  necessary 
to  see  the  patient  every  second  day  for  a  week  or 
ten  days,  then  every  several  days  until  all  signs 
of  congestion  have  disappeared,  which  is  usually 
within  another  two  weeks.  Atropine  instillations 
should  be  continued  until  the  eye  is  quiet. 

The  very  small  number  of  operations  required 
for  after-cataract  can  be  accomplished  (after  anes- 
thesia similar  to  that  for  the  preliminary  iridec- 
tomy and  ample  dilatation  from  atropine)  by  mak- 
ing, through  a  5-  or  6-mm.  angular  keratome  in- 
cision just  anterior  to  the  limbus  above,  two  ver- 
tical arc-shaped  cuts  in  the  lens  capsule,  with  their 
concave  sides  toward  the  pupillary  center  and  as 
far  apart  as  prudence  will  permit.  They  can  be 
made  with  a  sharp  knife-needle  or  with  a  fine, 
narrow-bladed  cataract  knife.  The  closed  blades  of 
a  Bourgeois  type  of  capsulectomy  forceps  are  then 
passed  into  the  anterior  chamber,  opened  and  the 
part  of  the  capsule  between  the  two  incisions 
grasped,  rotated  and  the  rolled  section  brought  out 
through  the  wound  opening.  A  pair  of  capsule  for- 
ceps, the  blades  of  which  open  in  scissors  fashion, 
may  be  used,  catching  the  section  of  the  lens  mem- 
brane below  and  breaking  its  attachment,  then 
grasping  it  near  its  upper  pole  and  pulling  it  out 
through  the  corneal  opening.  The  eye  is  dressed 
as  for  the  iridectomy  above  and  the  after-care  is 
similar. 

It  is  better  to  wait  for  two  months  or  more  from 
the  date  of  the  operation  before  ordering  the  per- 
manent lenses.  This  allows  time  for  any  perma- 
nent effect  on  the  refraction  resulting  from  cicitri- 
cial  changes  in  the  corneal  wound  to  become  man- 
ifest. 

Done  in  this  manner  by  those  adept  at  ophthal- 
mic surgery,  the  consistently  good  results  obtained 
with  a  minimum  of  operative  complications,  the 
comparatively  short  postoperative  period,  the  good 
cosmetic  effect  and  the  excellent  visual  results  in 
the  overwhelming  majority  of  the  cases,  far  out- 
weigh the  disadvantages  and  will  be  highly  gratify- 
ing to  the  ophthalmologist  and  to  the  patient. 


Frequently  in  the  large-vessel  type  of  sclerosis  cerebral 
hemorrhage  occurs,  often  preceded  by  periods  of  vertigo 
and  transitory  loss  of  muscular  power  in  an  extremity.  If 
the  patient  survives  the  hemorrhage  he  will  often  be  found 
to  have  shown  considerable  increase  in  his  mental  symp- 
toms. At  this  point  encouragement  is  extremely  important 
to  prevent  a  tendency  to  self-pity  and  a  feeling  of  hope- 
lessness. Sometimes,  instead  of  a  typical  cerebral  hemor- 
rhage, rather  serious  epileptiform  or  apoplectiform  attacks 
occur  with  only  transitory  paralyses  following,  but  usually 
succeeded  by  marked  confusion.  Patients  of  this  type  often 
deteriorate  mentally  rather  rapidly,  and  it  may  be  entirely 
impossible  to  care  for  them  in  the  home. 

Mental  changes,  however,  frequently  occur  in  persons 
who  survive  this  era  of  life  without  marked  arteriosclerosis. 
Dotage  may  begin  as  early  as  65,  whereas  from  time  to 
time  very  aged  persons  are  found  who  are  apparently  un- 
scathed mentally.  The  borderline  between  dotage  and  defi- 
nite disorder  is  a  shadowy  one.  A  psychosis  in  an  elderly 
person  may  be  precipitated  or  aggravated  by  serious  illness 
or  by  a  surgical  operation.  He  may  develop  the  idea  that 
the  family  are  trying  to  be  rid  of  him,  are  trying  to  secure 
his  property,  and  otherwise  are  discriminating  against  him; 
unfortunately,  on  some  occasions  this  is  no  delusion.  Gen- 
erally the  basis  for  such  ideas  is  thoughtlessness  and  lack 
of  sympathy  on  the  part  of  the  rest  of  the  family. 

A  patient  of  this  type  often  makes  a  comfortable  ad- 
justment outside  of  the  home,  particularly  with  other 
elderly  persons  with  whom  he  may  feel  at  ease.  Delusions 
of  poisoning  may  interfere  with  the  eating  habits  of  the 
patient.  Some  of  the  acute  senile  deliria  respond  amazingly 
to  vitamin  therapy. 

A  tendency  to  doze  after  meals  and  at  odd  times  and  at 
night  be  wakeful  may  develop  into  night  prowling.  Feeling 
chilly,  a  patient  may  attempt  to  light  a  fire,  sometimes 
with  serious  results.  Patients  of  this  type,  unless  they  re- 
spond favorably  to  warm  baths  and  drinks  at  bedtime,  or 
to  hypnotic  medication,  require  institutional  care. 

One  interesting  type  of  senility  is  presbyophrenia,  a  con- 
dition in  which  the  disorder  of  memory  is  covered  up  by 
free  confabulation.  The  patient  may  not  remember  where 
he  was  10  minutes  before,  but  rather  than  admit  this  he 
evolves  a  fanciful  story  which  may  be  suggested  to  him 
by  the  examiner  or  may  be  evolved  from  his  own  fantasy. 
Sexual  advances  either  in  the  line  of  fondling  or  exposure 
of  person  may  be  made  upon  very  small  children. 

Mental  hospital  care  should  be  thought  of  for  cases  of 
mental  disorder  in  the  aged  only  as  a  last  resort  and  after 
every  attempt  at  home  care  or  nursing  in  a  nursing  home 
or  some  similar  institution  has  been  exhausted.  Many  of 
these  patients  are  suffering  from  a  condition  which  is 
irreversible  and  progressive,  and  by  the  very  inelasticity  of 
old  age  they  do  not  adjust  well  to  new  conditions  of  life. 

With  the  progress  of  these  changes  all  of  the  ingenuity 
of  the  practitioner  and  all  of  the  sympathy  and  under- 
standing of  family  and  friends  are  called  for. 


SOME  MENTAL  PROBLEMS  OF  AGING  AND  THEIR 
MANAGEMENT 
(Winded  Ovcrholser,  Washington,  in  Med.  Ann.  D.  C.  June) 
In  cases  of  this  type  we  must  not  over-invalidize  the 
patient.  Forgetfulness  may  be  made  less  conspicuous  by 
encouraging  the  patient  to  carry  a  scratch-pad  with  him 
and  some  form  of  mild  activity  should  be  required.  On  the 
other  hand,  it  is  often  necessary  to  relieve  the  patient  of 
business  activities  on  account  of  his  increasingly  poor  judg- 
ment. 


TRIGEMINAL  NEURALGIA 
The  injection  of  2%  procaine  solution  into  the  exact 
point  located  by  the  patient  as  the  area  whence  all  pain 
seems  to  arise  has  been  of  great  benefit  to  a  series  of 
trigeminal  neuralgia  patients.  The  temporary  relief  ob- 
tained often  becomes  permanent  after  the  injections  are 
repeated  two  or  three  times.  In  some  cases,  the  injection 
of  one  zone  will  unmask  a  second  zone,  which  should  also 
be  infiltrated  with  the  local  anesthetic. — W.  K.  Livingston, 
in  West.  Jl.  Surg.,  Ob.  &  Gynec,  Aug.,  '40. 


A    WET    SOLUTION    OF    ALCOHOL    AND    GLYCERIN    aa.    makes 

an  excellent  wet  dressing  to  keep  a  wound  soft,  maintain 
drainage,  and  prevent  infection. 


SOUTHERN  MEDICINE  &  SURGERY 


September,    1941 


Oophorrhagia* 

Analysis  of  Nine  Cases 

Robert  H.  Owen,  B.S.,  M.D.  Margaret  L.  Owen,  A.B.,  M.S.,  M.D. 

Surgeon  to  Haywood  County  Hospital  Attending  Physician  Haywood  County  Hospital 

Canton,  North  Carolina 

Received  for  publication  August  6th,  1941. 


THE  PURPOSE  of  this  paper  is  to  report 
cases  of  ovarian  hemorrhage  and  to  con- 
gratulate Castallo  and  Feo1  for  suggesting 
oophorrhagia  as  the  descriptive  term  for  this  clini- 
cal condition. 

The  word  oophorrhagia  is  derived  from  the 
Greek — oon,  egg  +  phoros,  bearer  -f-  rhegnymi,  I 
burst  forth — a  bursting  forth  from  the  ovary.  The 
ending,  rrhagia,  by  common  usage  denotes  hemor- 
rhage, the  origin  of  which  is  denoted  by  the  stem 
of  the  word.  Future  references  will  be  more  easily 
obtained  from  the  literature  if  this  term  is  adopted 
and  used.  There  is  no  doubt  that  this  condition  will 
be  reported  much  more  frequently  in  the  future 
than  formerly.  The  lengthy  descriptive  diagnoses 
formerly  used  are  conflicting  and  difficult  to  index. 
For  an  example,  as  one  of  us  looked  back  through 
the  records  of  nine  cases  these  seven  different  post- 
operative diagnoses  were  found:  (1)  Ruptured 
right  ovary:  (2)  Ruptured  bleeding  left  ovary; 
(3)  Bleeding  left  ovary  with  peritoneal  cavity  filled 
with  blood ;  ( 4 )  Left  cystic  bleeding  ovary ;  ( 5  ) 
Ruptured  bleeding  hemorrhagic  right  ovarian  cyst: 
(6)  Bleeding  left  ovary  (three  times):  (7)  Right 
tube  ovarian  disease  with  bleeding  ovary.  The  lit- 
erature is  filled  with  lengthy  titles,  such  as:  intra- 
peritoneal or  abdominal  hemorrhage  of  ovarian 
origin,2  4  acute  hemorrhage  from  corpus  luteum 
and  graafian  follicle3,  hemoperitoneum  from  rup- 
tured corpus  luteum"'  etc. 

Oophorrhagia  is  that  condition  in  which  there  is 
bleeding  from  an  ovalutory  site.  The  amount  of 
hemorrhage  varies  from  slight  to  profuse  and  from 
intraovarian  to  the  free  peritoneal  type  }.  The  au- 
thors' cases  were  all  of  the  type  with  bleeding  into 
the  peritoneal  cavity  producing  clinical  symptoms. 

Bleeding  in  a  normal-looking  ovary  without  the 
formation  of  cysts"  is  found  to  be  more  common 
than  h?,s  been  supposed.  In  most  cases  it  does  not 
produce  well-defined  diagnostic  symptoms  and  it 
is  only  when  blood  passes  freely  into  the  abdomi- 
nal cavity  that  the  clinical  picture  becomes  dis- 
tinct'1. Acute  hemorrhages  simulate  those  from  ex- 
trauterine pregnancy.  In  the  severe  cases  explora- 
tory laporotomy  is  demanded  at  once.  In  four  of 
the  authors'  cases  life  was  saved  by  immediate 
operation. 


The  number  of  ovarian  hemorrhages  reported  has 
grown  rapidly.  In  1917  Novak2  found  40  cases  of 
acute  hemorrhage  from  corpus  luteum  and  graafian 
follicle.  In  1930  Johnson3  brought  the  total  num- 
ber to  77,  while  Israel,"  in  1937,  states  that  more 
than  300  cases  had  been  recorded  and  to  this  list 
he  added  10.  In  July,  1941,  Castallo  and  Feo1  re- 
corded 28  more  cases,  thus  bringing  the  total  to 
about  338.  We  are  reporting  nine  additional  cases. 
The  etiology  of  oophorrhagia  is  not  definitely 
known.  Hemorrhage  resulting  from  injury  such  as 
sudden  trauma  may  be  responsible. s  Corpus  luteum 
perforation  has  occurred  following  an  abdominal 
blow,  or  during  quiet  sleep,  or  during  coitus;9  fre- 
quently while  engaged  in  ordinary  household  duties, 
or  while  walking,  swimming  or  dancing.5  Inflam- 
matory ovarian  congestion,  excessive  menstrual 
hyperemia,1"  chronic  oophoritis"  and  bimanual  pel- 
vic examination1"  n  12  are  other  causative  factors. 
Corpus-luteum  cysts  are  attributed  to  the  same 
causes  as  are  follicle  cysts.  According  to  old  ideas 
they  are  the  result  of  the  chronic  pelvic  inflamma- 
tion caused  by  gonorrhea,  puerperal  sepsis  or  ap- 
pendicitis, or  of  metastatic  infection  from  acute 
constitutional  diseases,  as  influenza,  scarlet  fever 
and  so  on.  More  recently  there  has  been  a  ten- 
dency to  correlate  them  with  exaggerated  follicle 
ripening.  One  author  (Vogt)  regards  follicle  cyst 
formation  as  a  kind  of  constitutional  disease  in 
which  the  follicles  are  peculiarly  sensitive  to  incre- 
tory  dysfunction."  Castallo  and  Feo  state  that  the 
possibility  of  an  endocrine  imbalance  seems  more 
acceptable.  Ovulation,  with  the  nicely  adjusted 
phases  of  folliculization,  egg  expulsion  and  forma- 
tion of  the  corpus  luteum,  is  possible  only  when  a 
balance  of  the  involved  hormones  exists.  An  im- 
balance of  this  intricate  and  delicate  mechanism 
may  cause  abnormal  functioning,  such  as  oophor- 
rhagia. Yet  we  have  been  unable  to  find  a  report 
of  this  having  occured  more  than  once  in  the  same 
individual. 

A  characteristic  relationship  exists  between  the 
time  of  ovarian  rupture  and  the  menstrual  cycle. 
Follicular  rupture  occurs  at  the  middle,  corpus 
luteum  rupture  during  the  last  half,  of  the  cycle. 
In  our  series  of  nine  cases,  three  were  at  the  mid- 
interval,  five  during  the  premenstruum,  one  seven 


•Read  before  the   Haywood  County  Medical  Society  and  the  Haywood  County  Hospital  Staff  on  August  21st.   1941. 


September.    1941 


OOPHORRHAGIA— Owen  &  Owen 


481 


days  after  the  menses.  Two  of  our  patients  awak- 
ened in  the  night  with  severe  abdominal  pain;  one 
was  working  in  a  paper  plant  when  she  became  ill 
and  fainted;  another  in  a  rayon  plant  and  was 
forced  to  leave  immediately,  and  the  remaining  five 
were  up  and  going  about  the  house. 

TABLE  I 

Color  Age  S  or  M  Relation  to  menses 

1 — Feb..  1938  w  20  ....  m       7  days  post  menses 

2 — April.  1939  w  25  s  ....  15  days  post  menses 

3 — March.  1940  w  25  s  ....  7  days  premenses 

4 — May,  1940  w  14  s  ....  7  days  premenses 

5 — Jan.,  1941  w  17  s  ....  14  days  post  menses 

6 — April,  1941  w  28  ....  m  Period  due 

7 — May,  1941  w  24  ....  m  7  days  premenses 

8— June,  1941  w  18  s  ....  Period  due 

9 — July.  1941  w  22  s  ....  15  days  post  menses 

It  is  interesting  to  find  that  one  case  developed 
in  1938,  one  in  1939,  two  in  1940  and  five  in  1941, 
hence  our  enthusiastic  interest  in  this  condition. 
Each  month  from  January  through  July  oophorrha- 
gia occurred,  but  we  had  no  case  during  either  of 
the  last  five  months  of  the  year.  Six  cases  were  in 
single  girls  but  one  of  these  had  given  birth  to  a 
child.  The  remaining  three  were  married,  one 
nulliparous,  others  had  borne  one  child  each.  All 
were  white,  the  youngest  14,  the  oldest  28,  average 
age  21. 

A  short  review  is  given  of  each  case  in  the  order 
of  their  occurrence. 

Case  Reports 

Case  1. — A  white  married  woman,  aged  20,  was  admitted 
on  Feb.  2nd.  1938,  with  chief  complaint  of  sharp  pain  in 
the  left  lower  quadrant,  which  began  48  hours  previously. 
No  nausea  or  vomiting.  Periods  irregular  for  one  year. 
Last  period  was  seven  days  ago.   No  pregnancies. 

Physical  examination  was  negative  except  the  abdomen 
showed  tenderness  with  some  rigidity  over  left  lower 
quadrant.  Vaginal  examination  revealed  a  large  tender 
mass  in  the  posterior  cul-de-sac.  There  were  4,250,000  red 
cells.  hi_'bn.  was  Sl%.  white  cells  10,450,  b.  p.  120/90,  urine 
negative 

A  preoperative  diagnosis  was  made  of  retroverted  uterus 
and  left  cystic  ovary.  At  laporotomy  under  ether  anesthetic 
three  ounces  of  blood  with  several  small  clots  were  found 
in  the  posterior  cul  de  sac.  The  bleeding  was  traced  to  a 
perforation  in  the  left  ovary.  A  left  oophorectomy,  sus- 
pension of  uterus  and  appendectomy  we'e  done,  closure 
without  drainage.  The  patient  made  an  uneventful  recov- 
ery and  was  discharged  from  the  hospital  on  her  15th  post- 
operative day. 

Dr.  Alfred  Blumberg  of  Asheville  gave  the  following 
pathological  report:  The  ovary  measures  4x3xJ/2  cm. 
Externally  it  is  pale,  and  somewhat  bluish  on  one  end. 
On  cross  section  the  bluish  area  is  excava'ed  and  contains 
trumblini:  blood-tinted  material  which  has  replaced  the 
Ovarian  parenchyma.  The  surrounding  parenchyma  is  pig- 
mented. The  rest  of  the  ovary  contains  many  small  cysts. 
The  appendix  measures  5  cm.  x  6  mm.  Its  distal  portion  is 
somewhat  swollen  and  veins  are  distended. 

Mi.  roscopic  examination  of  ovary  shows  distended,  thin- 
walled  blood  vessels,  deposit  of  blood  pigment  in  the  pa- 
renchyma and  follicle  cysts.  The  serosa  of  appendix  is  in- 
filtrated by  round  cells.    Many  pmn.  leucocytes  are  found 


in  the  region.   Diagnosis:  Hemorrhagic  cyst  in  ovary  show- 
ing degeneration.    Appendicitis  secondary. 

Case  2. — A  white  single  woman,  aged  25,  entered  on 
April  7th,  1939,  vomiting,  prostrated  and  complaining  of 
severe  sharp  pain  in  the  right  lower  quadrant  and  diarrhea. 
She  had  been  entirely  well  and  was  working  in  a  paper 
plant  until  three  hours  before  admission.  She  had  fainted 
twice.  The  menstrual  periods  had  been  regular  and  the 
last  one  was  two  weeks  previous. 

The  abdomen  was  slightly  distended,  tender  and  rigid 
over  the  right  lower  quadrant.  The  blood  pressure  was 
70  50.  Because  of  generalized  tenderness  no  masses  could 
be  felt.  To  our  regret  a  vaginal  examination  was  not  done. 
Temperature  was  96,  pulse  74,  respiration  20.  The  reds 
were  2,540,000,  hgbn.  56%,  whites  14,450—75%  segs.,  9 
stabs  and  16  small  lymphs.   The  urine  was  negative. 

A  preoperative  diagnosis  of  acute  appendicitis  was  made. 
At  laporotomy  under  general  anesthetic  as  the  peritoneal 
cavity  was  opened  a  stream  of  blood  spouted  as  high  as  36 
inches  above  the  patient,  and  1500  c.c.  of  fresh  blood  was 
found  in  the  peritoneal  cavity.  The  bleeding  was  traced. to 
a  ruptured  right  ovary.  The  blood  was  bright  red,  only  a 
few  clots  were  present.  The  ovary  was  bleeding  freely. 
The  abdominal  cavity  contained  more  blood  and  the  ovary 
was  bleeding  more  freely  than  in  any  case  of  ectopic 
pregnancy  than  either  of  us  has  seen.  It  was  necessary  to 
remove  the  right  tube  with  the  right  ovary  and  the  appen- 
dix was  removed  incidentally. 

Dr.  C.  C.  Carpenter,  of  the  Bowman  Gray  Medical 
School,  gave  this  description  of  the  specimen: 

The  ovary  measures  5x3Hx4H  cm.,  is  dark  brown  and 
wrinkled.  On  section  the  normal  ovarian  tissue  is  found 
to  have  been  replaced  by  a  dark  brown  tissue  which  ap- 
pears to  be  hemorrhagic.  Near  the  periphery  several 
smooth-walled  follicle  cysts  are  seen.  The  ovary  shows  the 
follicle  cyst  that  contains  the  blood  clot.  Fallopian  tube- 
appendix. 

Case  3. — A  white  single  woman,  aged  25,  was  admitted 
to  the  Haywood  County  Hospital  on  March  17th,  1940, 
because  of  acute  pain  in  the  right  lower  abdomen.  She  was 
nauseated  and  vomiting.  Her  illness  began  24  hours  pre- 
viously. She  gave  history  of  dysmenorrhea.  Last  period  3 
weeks  ago. 

The  abdomen  was  tender  and  rigid  over  its  entire  lower 
extent,  greatest  over  the  right  lower  quadrant.  On  vaginal 
examination  a  mass  could  be  felt  in  the  right  cul  de  sac. 
Temperature  99,  pulse  95,  respiration  20,  red  cells  3,550,000, 
hgbn.  75%,  whites  8,400,  b.  p.  115/89. 

A  preoperative  diagnosis  of  acute  appendicitis  and  right- 
side  tuboovarian  disease  was  made.  At  laporotomy  under  a 
general  anesthetic  the  pelvis  was  found  to  contain  six 
ounces  of  dark  blood  with  several  clots  and  the  bleeding 
was  traced  to  a  perforation  in  the  right  ovary.  The  right 
ovary  and  tube  and  the  appendix  were  removed  and  the 
abdomen  closed  without  drainage.  Recovery  was  unevent- 
ful and  the  patient  discharged  on  her  13th  postoperative 
day. 

Dr.  Robert  P.  Morehead,  of  the  Bowman  Gray  Medical 
School,  gave  the  following  pathological  report: 

Sections  through  the  ovary  show  a  portion  of  the  wall 
of  a  hemorrhagic  corpus-luteum  cyst.  Several  cysts  of  the 
follicular  type  are  present.  There  is  no  evidence  of  an 
inflammatory  reaction  in  the  mucosa  of  the  tube,  but 
the  vessels  arc  dilated  and  contain  numerous  neutrophils. 
The  wall  of  the  appendix  is  fibrosed  and  contains  mono- 
nuclear cells  and  eosinophils.  The  vessels  are  prominent. 
The  serosa  appears  to  be  thickened. 

Diagnosis:  Hemorrhagic  corpus-luteum  cyst  of  ovary. 
Follicle  cyst  of  ovary.  Mild  acute  salpingitis.  Healing  ap- 
pendicitis. 


482 


OOPHORRHAGIA— Owen  &  Owen 


September,    1941 


Case  4. — A  white  girl,  aged  14,  was  admitted  on  May 
30th,  1940,  complaining  of  persistent  pain  in  the  left  lower 
quadrant  for  two  days.  One  of  us  examined  her  abdomen 
the  day  the  pain  began.  No  vaginal  examination  was  made. 
The  patient  was  sent  home  as  not  very  ill.  We  had  re- 
moved her  appendix  three  years  ago.  Her  temperature  was 
98,  pulse  80,  respiration  20,  white  cells  8,900,  reds  4,200,000, 
hgbn.  S5%.  b.  p.  110/85,  urine  negative. 

The  abdomen  was  distended,  tender  over  the  left  lower 
quadrant.  Vaginal  examination  revealed  a  tender  mass  in 
the  left  cul  de  sac. 

A  preoperative  diagnosis  of  left  tubobvarian  disease  or 
ruptured  ectopic  pregnancy  was  made.  The  abdomen  was 
found  to  contain  400  c.c.  of  dark  blood,  a  few  clots  in 
pelvis.  The  origin  of  the  bleeding  was  traced  to  a  rupture 
in  the  left  ovary.  The  rupture  was  repaired  with  mattress 
and  interrupted  sutures,  the  abdomen  closed  without  drain- 
age. Uneventful  recovery,  discharge  on  the  15th  postopera- 
tive day.    We  did  not  obtai  na  specimen. 

Case  5. — A  single  white  girl,  aged  17,  was  admitted  on 
Jan.  27th,  1941,  with  acute  pain  in  right  lower  quadrant 
and  vomiting.  The  onset  of  illness  began  16  hours  before. 
She  was  100  miles  away  from  home  when  the  attack  began 
and  a  physician  there  advised  an  immediate  appendectomy, 
but  she  chose  to  come  on  home.  She  had  no  symptoms  re- 
ferable to  the  urinary  tract. 

The  abdomen  was  slightly  distended,  some  rigidity  over 
lower  part,  greatest  tenderness  over  right  lower  quadrant. 
Blood  pressure  100/70,  temp.  99.6,  pulse  120,  respiration 
25,  red  cells  4,050.000,  hgbn.  80%,  whites  16,250— segs.  65, 
stabs  12,  juvs.  3,  small  lymphs  20 — coagulation  time  5  min- 
utes, urine  negative. 

A  preoperative  diagnosis  of  acute  appendicitis  was  made. 
At  laparotomy  under  general  anesthetic  800  c.c.  of  dark 
fluid  blood  and  several  large  clots  were  found  in  the  peri- 
toneal cavity  and  the  origin  of  the  bleeding  was  tiaced  to  a 
rupture  in  the  left  ovary,  which  was  behind  the  uterus 
and  slightly  to  the  right — entirely  out  of  its  usual  location 
— the  size  of  an  orange  and  ruptured  2  y2  inches  across. 
First  it  was  thought  that  we  were  dealing  with  the  right 
ovary.  It  was  impossible  to  save  a  portion  of  the  ovary. 
The  left  tube  and  ovary  and  the  appendix  were  removed, 
the  abdomen  closed  without  drainage.  Uneventful  recov- 
ery followed.  Unfortunately  the  nurses  in  the  operating 
room  misplaced  the  specimen  therefore  we  did  not  have  a 
pathological  report. 

Case  6. — A  white  married  woman,  aged  28,  admitted  on 
the  night  of  April  20th,  1941,  with  abdominal  pain,  which 
awakened  her  and  was  so  severe  that  she  was  immediately 
brought  to  the  hospital.  Pain  was  the  only  complaint. 
Her  period  was  due  in  two  days. 

There  was  some  distention  and  marked  tenderness  and 
rigidity  over  the  entire  lower  abdomen,  tenderness  in  both 
cul-de-sacs,  white  cells  10,700  segs.,  10  stabs,  22  small 
monos.;  reds  3,350,000,  hgbn.  60%,  b.  p.  118/90;  urine  was 
negative. 

A  preoperative  diagnosis  of  either  acute  appendicitis, 
ruptured  ovary,  or  ectopic  pregnancy  was  made.  At  laparo- 
tomy under  spinal  anesthetic  700  c.c.  of  fresh  blood  was 
found  in  the  peritoneal  cavity  and  the  bleeding  was  again 
traced  to  the  left  ovary,  which  was  immediately  removed. 
On  account  of  the  large  dilated  tubes  and  their  numerous 
adhesions  in  both  cul  de  sacs,  a  bilateral  salpingectomy 
was  done  followed  by  an  appendectomy,  and  closure  made 
without  drainage.  Uneventful  recovery  ensued  and  dis- 
charged on  10th  postoperative  day. 

The  microscopical  description  by  Dr.  Robert  P.  More- 
head  is  as  follows:  There  is  a  hemorrhagic  corpus-luteum 
cyst  seen  in  one  portion  of  the  ovary.  The  tubes  show 
thickening  of  the  walls  with  low-grade  chronic  inflamma- 
tory process.    The  wall  of  the  appendix  is  thickened  by 


fibrous  tissue.    Diagnosis:  Hemorrhagic  corpus-luteum  cyst. 

Case  7. — A  white  married  woman,  aged  24,  was  admitted 
on  May  13th.  1941,  with  a  chief  complaint  of  severe  pain 
Chronic  bilateral  salpingitis  and  fibrosis  of  the  appendix, 
in  the  left  lower  quadrant.  She  was  perfectly  well  until 
eight  hours  before,  when  while  working  in  a  rayon  plant 
she  developed  a  sharp  pain  in  the  left  lower  qu«drant. 
She  felt  like  fainting  and  was  forced  to  leave  her  work 
immediately.  She  is  the  mother  of  one  child.  She  gives  a 
history  of  having  had  one  miscarriage.  Her  periods  have 
been  regular  but  with  much  dysmenorrhea.  The  last  period 
was  three  weeks  ago. 

The  heart  and  lungs  were  normal,  blood  pressure  110' 
90.  A  large  midline  scar  was  present.  The  abdomen  was 
tender  and  rigid  over  the  left  lower  quadrant.  Vaginal 
examination  showed  a  tender  palpable  mass  on  the  left 
side.  Temperature  97,  pulse  60,  respiration  20,  white  cells 
10,650,  reds  4,560,000,  hgbn.  .83%,  coagulation  time  4'j 
min.   Urine  was  negative. 

A  preoperative  diagnosis  of  diseased  left  tube  and  ovary 
was  made.  At  laporotomy  700  c.c.  of  fresh  blood  was 
found  in  the  peritoneal  cavity  and  the  bleeding  was  traced 
to  a  rupture  of  the  left  ovary  which  was  bleeding  freely. 
The  ovary  was  beyond  repair,  therefore  this  organ  and  its 
tube  were  removed  and  the  abdomen  closed  without  drain- 
age. The  patient  had  an  uneventful  recovery  and  was  dis- 
charged on  her  12th  postoperative  day. 

The  pathological  report  by  Dr.  Robert  P.  Morehead  of 
the  Bowman  Gray  Medical  School: 

There  is  a  hemorrhagic  corpus-luteum  cyst  of  ovary  and 
numerous  follicle  cysts.    The  tube  is  without  evident  lesion. 

Diagnosis:  Hemorrhagic  corpus-luteum  cyst  and  follicle 
cyst  of  ovary.    Uterine  tube. 

Case  8. — A  white  single  girl  aged  18,  mentality  10  years, 
who  had  given  birth  to  a  monster  4  months  previous  was 
admitted  to  the  Haywood  County  Hospital  on  June  17th. 
1941,  because  of  pain  in  the  lower  abdomen  from  one 
month  following  the  delivery.  No  rigidity  or  distention 
was  present.  For  the  last  three  days  she  complained  of 
sharp  pain  in  the  left  lower  quadrant  and  we  did  a  vaginal 
examination  each  time  and  kept  putting  her  off  until  the 
admission  day.  She  had  menstruated  only  once  since  de- 
livery and  was  now  due. 

There  was  tenderness  over  both  lower  quadrants,  blood 
pressure  120/50,  tenderness  in  both  cul-de-sacs.  The  white 
cells  were  11.250,  reds  4,300,000,  hgbn.  887c.  temperature 
99,  pulse  95,  respiration  20. 

A  preoperative  diagnosis  of  bilateral  chronic  salpingitis 
was  made.  At  laparotomy  two  ounces  of  dark  blood  with 
a  few  small  clots  was  found  in  the  posterior  cul-de-sac  and 
the  origin  of  the  blood  was  traced  from  the  left  ovary. 
Bilateral  salpingectomy  and  left  oophorectomy  were  done, 
followed  by  an  incidental  appendectomy.  Abdomen  was 
closed  without  drainage.  Uneventful  recovery  ensued  and 
discharge  on  11th  postoperative  day. 

Dr.  Robert  P.  Morehead  gave  the  following  pathological 
diagnosis:  Corpus-luteum  cysts  of  ovary.  Follicle  cysts  of 
ovary.    Chronic  bilateral  salpingitis.    Fibrosis  of  appendix. 

Case  9. — A  white  single  girl,  aged  22,  was  admitted  to 
the  Haywood  County  Hospital  on  July  5th,  1941,  with 
chief  complaint  of  severe  pain  in  right  lower  quadrant. 
One  of  us  (RHO)  had  performed  an  appendectomy  on  her 
five  years  previous,  therefore  we  suspected  that  we  were 
dealing  with  some  pelvic  involvement.  The  pain  began 
three  days  before  admission  and  had  gradually  become 
worse.  There  was  nausea  but  no  vomiting.  Her  temper- 
ature was  98,  respiration  18,  pulse  80,  b.  p.  120  90,  red 
cells  3.650.C00  with  hgbn.  70% ;  whites  10,250—66  segs., 
10  stabs,  2  eosin.,  22  small  monos.  The  urine  was  negative. 
Last  period  two  weeks  ago. 


September,   1941 


OOPHORRHAGIA— Owen  &  Owen 


Physical  examination  was  negative  except  for  tenderness 
with  rigidity  over  the  right  lower  quadrant.  Vaginal  exam- 
ination revealed  a  palpable  tender  mass  in  the  right  cul-de- 
sac. 

A  preoperative  diagnosis  of  right  tuboovarian  disease 
was  made.  At  laporotomy  eight  ounces  of  clotted  blood 
was  found  in  the  right  side  of  pelvis  with  the  right  tube 
and  ovary  engulfed.  The  bleeding  was  traced  to  a  perfora- 
tion in  the  right  ovary.  The  blood  was  evacuated  from 
the  cavity  of  the  ruptured  ovary  and  the  organ  repaired 
with  several  mattress  and  interrupted  sutures  of  00  plain 
catgut.  The  right  tube  was  swollen  and  covered  with  what 
appeared  to  be  exudative  material,  hence  a  right  salpin- 
gectomy was  done.  The  abdomen  was  closed  without 
drainage.  Uneventful  recovery  ensued  with  discharge  from 
the  hospital  on  the  10th  postoperative  day. 

Pathological  report  by  Dr.  Robert  P.  Morehead: 

There  is  an  early  acute  inflammatory  reaction  limited 
to  the  serosa  of  the  tube. 

Diagnosis:  Early  acute  perisalpingitis  probably  second- 
ary to  hemorrhage  from  the  ovary  on  that  side. 

Summary 
Nine  cases  of  oophorrhagia  have  been  reported. 
Four  of  these  women  we  believe  would  have  died  if 
immediate  surgery  had  not  been  undertaken.  The 
left  ovary  was  ruptured  in  six  cases,  the  right  in 
three. 

TABLE  11 

Ovary  Involved  and  Type  No.  Cases 

Left   6 

Right 3 

Corpus-luteum  4 

Graafian   follicle  2 

No  specimen   3 

A  preoperative  diagnosis  of  acute  appendicitis 
was  made  in  three  cases.  In  one  case  we  made  a 
diagnosis  of  either  acute  appendicitis,  ruptured 
ovary  or  ectopic  pregnancy.  One  case  was  diag- 
nosed as  either  acute  appendicitis  or  right  tubo- 
ovarian disease,  another  as  bilateral  salpingitis. 
While  on  another  case  a  diagnosis  of  left  cystic 
ovary  and  retroverted  uterus  was  made.  Unilateral 
tuboovarian  disease  was  diagnosed  in  two  cases, 
left  tuboovarian  disease  with  possibly  ectopic  preg- 
nancy on  the  remaining  case. 

table  in 
Preoperative  Diagnosis  No.  Cases 

Acute   appendicitis   3 

Acute  appendicitis,  ruptured  ovary  or  ec- 
topic pregnancy  1 

Bilateral    salpingitis   1 

Left  cystic  ovary  and  retroverted  uterus....  1 

Unilateral  tube  and  ovarian  disease 2 

Left     tuboovarian     disease    with     possible 

ectopic  pregnancy  1 

All  patients  were  young,  strong  and  healthy.  No 
death  occurred.  The  second  case  was  the  only  one 
in  which  drainage  was  used.  The  average  stay  in 
the  hospital  was  13  days.  No  wound  or  pulmonary 
complication  developed. 

Associated  pathologic  conditions  were  found  in 
four  cases — two  of  chronic  salpingitis,  one  of  acute 
salpingitis  and  one  of  secondary  appendicitis. 


TABLE  TV 

Signs  and  Symptoms  No.  Cases 

Nausea    _ 2 

Vomiting  4 

Distention  4 

Tenderness   7 

Rigidity  7 

Palpable  mass  in  cul-de-sac S 

Four  cases  showed  some  abdominal  distention; 
tenderness  and  rigidity  over  the  abdomen  was  pres- 
ent in  seven  cases.  Four  patients  vomited  two  or 
more  times,  while  only  two  were  nauseated.  On 
vaginal  examination  five  showed  a  palpable  mass  in 
the  cul-de-sac. 

Conclusions 

1.  The  clinical  term,  oophorrhagia,  suggested  by 
Castallo  and  Feo  is  endorsed. 

2.  Nine  cases  are  presented  with  signs,  symp- 
toms and  physical  examination  in  each  case. 

3.  Oophorrhagia  is  mentioned  as  a  possible  pre- 
operative diagnosis  in  only  one  case. 

4.  Emergency  operation  was  necessary  for  four 
cases. 

5.  Laporotomy  was  performed  without  hesitancy 
in  all  cases. 

6.  It  was  necessary  to  do  radical  ovarian  surgery 
in  seven  cases — 70.7  per  cent. 

7.  An  associated  disease  process  was  present  in 
four  cases — 44  per  cent. 

8.  No  postoperative  complication  developed  in 
any  case  in  the  series. 

9.  The  average  hospitalization  period  was  13 
days. 

References 

1.  Castallo,  M.  A.,  Leo,  L.  G.:  Am.  J.  Surg.,  7:82,  1941. 

2.  Novak,  E.:  /.  A.  M.  A.,  68:1160,  1917. 

3.  Johnson,  V.  E.:  Am.  J.  Surg.,  9:538,  1930. 

4.  Sackett,  N.  B.:  Am.  J.  Obst.  &  Gynec,  23:849,  1932. 

5.  McSweeney,  D.   J.,  and  Wood,  F.  O.:   N.  E.  J.  M., 
222:167,204,  1940. 

6.  Graves'  Textbook:  W.  B.  Saunders,  1927,  p.  487. 

7.  Israel,  S.  L.:  Am.  J.  Obst.  &  Gynec,  33:30,  1937. 

8.  Shaw,  W.  J.:   //.  Obst.  &  Gynec.  oj  Brit.  Emp.,  34: 
300,  1927. 

9.  Stukert,  H.  J.:  J.  A.  M.  A.,  94:1227,  1930. 

10.  Greenhill,  J.  P.:  Am.  J.  Obst.  &■  Gynec,  22:902,  1930. 

11.  Pratt,  J.  P.:  Idem,  27:816,  1934. 

12.  Morton,  P.  C:  N.  Y.  S.  J.  M.,  32:116,  1932. 


SPIDER  BITE 

(Z.  B.  Noon  &  W.  L.   Mincar,  in  Southwestern  Med.,  June) 

It  is  possible  that  by  giving  double  the  usual  dose  of  the 
antivenin  in  the  severe  cases  and  when  time  is  a  factor  (a 
long  period  having  elapsed  after  the  bite)  even  prompter 
relief  would  result. 

Untreat'-d  or  symptomatically  treated  cases  of  the  black 
widow  spicier  bite  usually  have  a  long  period  of  morbidity 
and  a  possible  mortality. 

Treatment  with  specific  antivenin  (Latrodectus  mactans) 
results  in  minimal  morbidity  and  no  mortality.  The  earlier 
the  antivenin  is  given  the  more  prompt  is  the  relief. 

Coronary  Thrombosis. — A  case,  verified  by  autopsy,  is 
reported  (Jour.  A.  M.  A.)  in  a  man  of  21  years. 


SOUTHERN  MEDICINE  &  SURGERY 


September,    1941 


Stress  and  Disease 

Mai. ford  \Y.  Thewlis,  M.D.,  Wakefield,  Rhode  Island 


STRESS  is  described  as  hardship,  adversity, 
affliction,  overpowering  pressure  of  some  ad- 
verse force  or  influence,  strained  exertion, 
strain  of  a  load  or  weight. 

Deprivations,  strains,  and  dissatisfactions  have 
physiologic  effects — depletion  of  body  substance, 
fatigue,  and  emotional  tension  (Robinson).  The 
purposes  of  this  article  are  to  show  (1)  the  effect 
of  voluntary  stress  on  organic  disease;  (2)  possible 
errors  in  diagnosis  made  while  the  patient  is  under 
stress,  and  (3)  the  relation  of  stress  to  preclinical 
medicine  and  gerontology.  Severe  stress  reactions 
brought  on  by  marital  unhappiness,  accidents,  and 
death,  resulting  in  psychoneurosis,  are  not  taken 
up. 

Effect  of  Voluntary  Stress  on  Organic  Diseaie 

The  causes  of  stress  may  be  external  or  internal. 
Persons  who  are  "caught  in  the  trap  of  life"  are 
not  necessarily  constitutionally  inadequate  nor  are 
they  necessarily  emotionally  unbalanced.  A  well- 
balanced  prize-fighter  may  stand  punishment  for 
15  rounds  and  then  be  defeated  by  staggering 
blows.  Anyone  may  reach  the  limit  of  endurance. 
Then  too,  pin-pricks  frequently  repeated  do  more 
damage  than  hard  blows.  To  be  sure,  lack  of  in- 
dependence, security  and  affection  often  are  in  the 
background  but  many  persons  are  caught  in  the 
trap  who  do  not  fall  into  this  class.  With  some 
people  family  life  on  a  farm  or  in  a  city  apartment 
becomes  so  complex  that  they  become  entangled 
in  a  web  from  which  there  is  no  apparent  escape. 

Few  persons  are  willing  to  recognize  the  ageing 
process.  A  man  aged  fifty  attempts  to  do  the 
things  he  did  when  twenty.  As  a  result  of  volun- 
tary stress  and  strain  the  patient  may  make  an 
organic  lesion  out  of  one  which  could  be  functional. 
Many  of  these  persons  do  not  suffer  from  adverse 
social  conditions;  apparently  they  have  everything 
to  make  them  happy.  In  spite  of  this  they  become 
involved  with  minor  compulsions  and  obsessions. 
Fixed  ideas  are  evident  in  a  thousand  and  one  de- 
tails of  their  daily  routine.  It  should  not  be  for- 
gotten that  fiyed  ideas  occur  in  the  normal  mind. 

The  working  man  has  his  mortgages,  notes  at 
high  rates  of  interest,  high-premium  insurance,  dif- 
ficulties with  automobiles,  illness,  surgical  opera- 
tions and  accidents.  The  laborer  is  never  certain 
of  his  job  and  he  lives  in  fear  of  an  illness  which 
will  incapacitate  him.  High-pressure  sales  methods 
make  a  person  accumulate  a  multitude  of  gadgets 


and  contraptions  which  require  a  great  deal  of 
care  and  money  to  keep  going. 

Those  better  situated  financially  have  their  so- 
cial problems.  Fear  of  economic  disaster,  increased 
taxation,  servant  problems,  social  engagements 
made  ahead  much  as  a  dentist's  appointments,  are 
causes  of  stress.  With  all  these  problems  the  well- 
to-do  often  find  just  as  much  drudgery  and  inse- 
curity as  the  truck  driver  who  has  a  large  family 
to  support.  Moreover,  wealthier  persons  usually 
have  less  fortunate  relatives  to  support. 

It  seems  strange  that  one  should  allow  himself 
to  be  upset  over  trivial  things  when  millions  of 
persons  in  Europe  are  homeless  and  without  ade- 
quate nourishment.  It  is  unfortunate  that  people 
go  through  life  with  a  multitude  of  petty  annoy- 
ances and  make  no  attempt  to  correct  them.  Such 
weakness  can  be  overcome  at  times  when  the  phy- 
sician encourages  the  patient  to  utilize  some  of  the 
strength  he  has  hidden  within  himself. 

Everyone  is  apt  to  find  himself  fixed  within  his 
own  home.  He  makes  himself  a  prisoner  in  the 
house  he  built  to  make  him  happy.  Whatever  the 
disease,  it  may  be  aggravated  by  stress.  Thus  per- 
sons with  cardiovascular  disease,  diabetes,  asthma, 
syphilis,  digestive  system  disease,  or  psychoneuro- 
sis may  suffer  more  from  stress  than  from  disease 
itself.  Stress  before  surgical  intervention  may  lead 
to  serious  consequences. 

The  following  case  reports  showing  the  relation 
of  stress  to  organic  disease  are  taken  from  the  rec- 
ords of  a  private  establishment  under  the  direct 
supervision  of  a  resident  physician  where  there  are 
rooms  to  take  care  of  patients  under  observation. 
The  locality  is  quiet  and  the  patient  is  literally 
"blacked  out"  from  the  outside  world  for  a  few 
days,  under  the  immediate  care  of  an  attendant 
who  is  cheerful,  calm,  quiet,  and  sympathetic. 
The  patient  is  seen  several  times  a  day  and  is  re- 
assured. 

A  matron,  aged  52.  complained  of  swollen  and  painful 
ankles  and  cough.  She  spoke  of  a  "tired  heart."  She  had 
rheumatic  fever  20  years  ago  and  one  brother  died  from 
this  disease.  For  several  weeks  she  had  been  doing  too 
much  work,  which  was  not  required  of  her.  She  also  did 
some  outside  work  for  an  aged  lady  who  lived  on  the  estate 
of  which  her  husband  had  charge. 

She  went  to  a  quiet  place  to  "get  away  from  every- 
thing." She  worried  about  being  crippled.  For  some  time 
she  had  been  tired  and  had  no  appetite  for  the  food  which 
she  had  prepared.  The  relief  was  almost  immediate,  once 
her  bodv  and  mind  were  at  ease. 


September,    1941 


STRESS  &  DISEASE— Thewlis 


485 


The  blood  picture  during  her  stay  was  as  follows: 

1st  day       2nd  day      3rd  day      4th  day 
Hemoglobin:*      10.63  Gm.  11.37  Gm.  13.18  Gm.  13.24  Gm. 
Red  blood  cells:      3.4  3.6  4.2  4.0 

Color  index:  1.0  1.01  1.0  1.06 

*based  on  15.6  Gm.  as  100  per  cent. 

There  was  no  cardiac  murmur  suggesting  rheumatic  heart 
disease.  Electrocardiogram  showed  some  myocardial  dam- 
age. 

Edema  of  the  ankles  and  cough  disappeared  on  the  sec- 
ond day  of  her  stay.  When  she  arrived  she  appeared  ten 
years  older  than  her  age,  but  on  the  fourth  day  of  treat- 
ment she  seemed  even  younger  than  her  age.  On  discharge 
she  was  told  to  avoid  any  extra  work,  any  strain  on  the 
heart,  to  rest  in  bed  each  afternoon,  and  to  take  a  rounded 
diet. 

A  matron,  aged  68,  had  had  rheumatic  heart  disease 
during  childhood  but  no  symptoms  of  cardiac  decompensa- 
tion until  February,  1940.  Since  then  she  had  had  severe 
dyspnea  and  edema  of  the  extremities.  For  several  months 
she  had  been  busy  in  her  new  house.  She  was  a  perfection- 
ist who  overlooked  no  details  and  when  she  came  for  con- 
sultation she  was  worn  out.  Everything  disturbed  her. 
She  remained  in  this  establishment  for  a  week  and  with 
complete  rest  the  edema  disappeared  after  three  days  and 
she  was  able  to  he  flat  in  bed  without  distress.  When  she 
arrived  the  basal  metabolism  rate  was  plus  26  per  cent,  but 
it  had  dropped  to  plus  12  per  cent  when  she  left.  She  was 
sent  to  a  general  hospital  since  she  carried  hospital  insur- 
ance. The  noise  and  confusion  present  in  any  general  hos- 
pital disturbed  her  sleep,  and  in  a  few  days  she  was  under 
the  same  stress  which  she  had  been  under  in  the  beginning. 
When  she  finally  returned  to  her  home  for  prolonged  bed 
rest  her  mind  was  not  at  ease  and  she  did  not  do  well. 
Undoubtedly  a  complete  rest  of  mind  and  body  for  six 
months  might  improve  her  condition,  but  these  basic  con- 
ditions are  difficult  to  find  in  a  complex  world. 

Since  many  nervous  conditions  come  from  the 
continual  application  to  the  same  thing  each  day 
without  respite,  there  should  be  a  break  in  routine. 
The  break  may  come  with  a  vacation;  on  the  other 
hand,  the  average  person  gets  into  more  complexi- 
ties while  motoring  long  distances  or  traveling  by 
sea  than  he  does  in  his  own  house.  He  merely  sub- 
stitutes one  form  of  activity  for  another. 

One  of  the  chief  dangers  of  stress  is  the  loss  of 
appetite  with  resulting  nutritional  deficiency.  Per- 
sons with  a  troubled  mind  do  not  eat  as  they 
would  normally.  It  is  surprising  how  quickly  some 
of  these  persons  return  to  normal  after  a  few  days' 
rest  and  a  normal  diet.  Others  take  months  to  re- 
pair the  damage  from  a  defective  diet. 
Errors  in  Diagnosis  While  the  Patient  is  Under  Stress 

When  a  patient  has  a  basal  metabolism  estima- 
tion he  is  assumed  to  be  in  a  basal  state.  He  goes 
to  a  hospital  and  "rests"  for  a  half  hour  amid  the 
noise  and  confusion  of  an  institution.  Frequently 
only  a  single  estimation  is  made  and  the  diagnosis 
is  dependent  on  this  single  test.  When  the  patient 
has  a  thorough  examination  in  a  physician's  office 
a  diagnosis  is  often  made  in  a  single  visit.  Many 
times  this  suffices  but  when  the  patient  is  confused 
or  has  been  under  stress  for  some  time,  the  various 


tests  are  not  as  accurate  as  they  might  be  and  the 
patient  sometimes  goes  on  a  regimen  which  is  un- 
necessary, perhaps  expensive,  with  loss  of  time.  In 
some  instances  these  tests  will  show  normal  results 
after  three  or  four  days'  rest  under  proper  condi- 
tions where  stress  has  been  relieved.  Thus  the  pa- 
tient who  had  an  increased  metabolic  rate,  hyper- 
glycemia, anemia,  or  arterial  hypertension  may  not 
an  apparent  blood  picture  of  pernicious  anemia, 
need  medication  but  a  relief  from  stress.  Even  with 
the  patient  may  be  normal  after  stress  has  been  re- 
moved. 

It  is  even  more  necessary  to  see  how  the  patient 
acts  under  stress.  If  the  first  examination  of  the 
patient  is  made  at  rest  it  is  possible  to  overlook 
some  abnormality  during  stress.  In  one  instance 
the  blood  pressure  was  not  taken  upon  the  patient's 
arrival,  but  it  was  found  to  be  normal  after  the 
patient  had  had  a  night's  rest.  When  she  returned 
to  the  physician  who  had  referred  her,  he  found  the 
systolic  blood  pressure  was  180  mm.  mercury,  while 
my  report  showed  a  normal  pressure. 

A  matron,  aged  52,  had  severe  neuritis  in  both  arms.  Pain 
was  severe  and  she  had  not  slept  for  several  nights — she 
had  been  walking  outdoors  in  the  middle  of  the  night  be- 
cause of  pain.  She  worked  long  hours  in  her  home  for  her 
family  of  four  and  had  been  knitting  at  night.  She  was 
not  obliged  to  strain  herself  with  such  work,  since  she 
could  afford  to  have  someone  else  do  her  housework. 

On  the  first  day  this  patient's  basal  metabolic  rate  was 
plus  68  per  cent;  on  the  second  day,  plus  30  per  cent;  plus 
28  per  cent  on  the  third  day;  on  the  fifth  day  it  was  nor- 
mal. On  the  first  day  the  color  index  was  0.87 ;  on  the 
second,  0.98;  on  the  third  day  1.13,  and  1.06  on  the  fourth 
day.  After  the  second  day  with  rest  alone  and  with  relief 
of  stress  she  had  no  more  pain  in  the  arms  and  no  sedatives 
were  given.  In  this  instance,  rest  was  sufficient  to  relieve 
the  suffering;  the  patient  went  to  her  home  and  the  pain 
recurred  at  times  as  soon  as  she  worked.  This  is  given  to 
show  variations  in  the  basal  metabolic  rate  and  blood  pic- 
ture on  different  days,  which  might  lead  to  serious  errors 
in  diagnosis. 

A  physician's  opinion  which  is  made  before  he 
has  had  the  opportunity  to  evaluate  and  study  va- 
rious diagnostic  procedures  is  not  of  much  value. 
The  patient  as  a  whole  must  be  considered.  Facts 
must  be  weighed  and  probabilities  balanced  and 
the  physician  must  take  time  to  eradicate  his  preju- 
dices. 

Relation  of  Stress  to  Preclinical  Medicine  and 

Gerontology 
Preclinical  medicine  makes  possible  the  preven- 
tion of  disease  by  study  of  disease  soils  and  condi- 
tioning periods.  It  goes  beyond  preventive  medi- 
cine as  commonly  practiced,  since  it  is  an  attempt 
to  detect  disease  tendencies  and  to  see  the  patient 
before  he  reaches  the  symptom  stage.  Preclinical 
medicine  is  the  natural  approach  to  the  prevention 
of  premature  ageing.  This  study  is  connected  with 
gerontology    (problems   of   ageing)    and   geriatrics 


486 


STRESS  &  DISEASE— Thewlis 


September,   1941 


(diseases  of  senescence).  It  is  a  study  of  the  pa- 
tient's hereditary  background,  constitutional  type, 
racial  factors,  intellectual  equipment,  reaction  to 
climate,  occupation,  and  past  diseases. 

Stress  is  one  of  the  more  important  factors  af- 
fecting metabolism.  Loss  of  appetite  and  loss  of 
sleep  disturb  the  entire  system.  The  resulting  nu- 
tritional deficiency  may  condition  the  patient  for 
disease. 

Because  of  continued  stress  the  weakest  part  of 
the  body  shows  the  result  of  strain.  Influenced  by 
hereditary  tendencies  the  following  conditions  may 
result  from,  or  be  aggravated  by,  stress:  hyper- 
metabolism, hyperglycemia,  arterial  hypertension, 
peptic  ulcer,  autonomic  nervous  system  imbalance, 
endocrine  disturbance,  cardiovascular  disease,  and 
anemia.  Frequently  persons  with  a  hereditary  ten- 
dency to  diabetes  have  hyperglycemia  which  is 
corrected  when  the  metabolic  load  is  lightened, 
when  stress  is  relieved  after  a  few  days'  rest.  It  is 
not  uncommon  to  find  a  person  with  systolic  blood 
pressure  of  180  mm.  mercury  whose  pressure  drops 
to  130  mm.  after  two  days'  rest  under  proper  con- 
ditions. A  woman  of  60  had  worried  a  great  deal 
about  controversies  caused  by  the  settlement  of  her 
mother's  estate.  When  she  came  for  observation 
she  was  in  a  tense  state  and  the  systolic  blood  pres- 
sure was  178  mm.  mercury.  Her  blood  pressure 
was  normal  after  two  days.  A  man  of  55  had  been 
overworking  for  several  months  and  had  only  a  few 
hours'  rest  at  night.  Diastolic  blood  pressure  was 
108  mm.  mercury,  systolic  pressure  130  mm.  The 
urine  showed  low  specific  gravity  and  casts  in  the 
sediment.  With  less  work  and  two  days  of  partial 
rest  and  an  additional  hour's  sleep  each  night  the 
abnormalities  disappeared  in  the  course  of  a  month. 

When  there  is  weakness  of  one  part  of  the  body 
because  of  defective  genes,  stress  is  one  of  the  fac- 
tors which  aggravate  the  condition.  Moreover,  if 
stress  is  continued  over  a  long  period,  permanent 
damage  may  result.  The  important  thing  is  to  dis- 
cover these  weak  points  before  the  damage  becomes 
permanent.  In  some  instances  the  damage  might 
be  repaired  in  a  short  time;  in  others  one  or  two 
years  or  even  longer  are  necessary.  The  advantage 
of  observation  of  the  patient  under  close  supervis- 
ion is  that  the  proper  regimen  can  be  outlined  dur- 
ing the  interviews.  These  may  be  repeated  until 
the  patient  comes  at  intervals  for  a  check-up  to 
ascertain  if  the  condition  is  under  control. 

By  such  a  plan  some  diseases  may  be  prevented. 
There  is  no  reason  why  this  treatment  should  cause 
any  apprehension  if  the  clinician  considers  the  per- 
sonal equation.  He  must  be  careful  to  make  pa- 
tients health-conscious  rather  than  disease-con- 
scious.   Some  of  these  people  are  disease-conscious 


when  they  come  to  the  physician  and  the  cure  rests 
in  dispelling  their  fears. 

Patients  are  eager  for  any  information  which  will 
prevent  illness.  Observation  in  quiet  surroundings 
allows  time  for  effective  instruction  in  social  ad- 
justment and  hygiene.  The  patient  can  unload  his 
mind  of  all  his  troubles  during  frequent  interviews 
with  the  physician.  This  "mental  catharsis"  in  it- 
self plays  an  important  part  in  the  adjustment  of 
the  patient.  Robinson  pointed  out  that  the  patient 
should  be  taught  to  take  a  rational  rather  than  an 
emotional  attitude  toward  his  adverse  social  con- 
ditions. Reassurance  is  one  of  the  chief  weapons 
for  the  attack  on  disease  but  this  can  only  be  given 
after  a  complete  physical  examination.  Even  three 
or  four  days'  observation  under  treatment  and  a 
frank  discussion  of  the  patient's  problem  may  re- 
lieve permanently  the  worries,  anxieties,  and  other 
emotional  disturbances.  The  patient  may  then  take 
an  entirely  different  attitude  toward  life. 

Most  of  these  disturbances  are  not  deeply  rooted 
and  a  superficial  study  of  the  adverse  conditions 
with  guidance  and  encouragement  will  suffice  to 
effect  a  cure. 

References 

Gambet,  A.:    Personal  communication  to  author. 

Robinson,  G.  C:  The  Patient  as  a  Person,  New  York, 
1939.    The  Commonwealth  Fund. 

Stark,  L.:    Personal  communication  to  author. 

Thewlis,  M.  W.:  Preclinical  Medicine,  Baltimore,  1939. 
Williams  and  Wilkins. 

Thewlis,  M.  W.:  The  Care  of  the  Aged  (Geriatrics), 
Ed.  3,  St.  Louis,  1941.    The  C.  V.  Mosby  Co. 

Wilson,  W.  G:    Personal  communication  to  author. 


BURBOT  LIVER  OIL  IN  THE  TREATMENT  OF 
VARIOUS  DERMATOSES 

(J.    F    Wilson,   Philadelphia,  in  Minn.  Med.,  June) 

Ointment  containing  80  per  cent  of  burbot  liver  oil  was 
used  in  the  treatment  of  varicose  ulcers,  ecthyma  vulgaris, 
indolent  ulcers  following  surgical  procedures  and  psoriasis. 

All  varicose  ulcer  patients  improved  while  using  the 
ointment.  Some  suffered  dermatitis  at  the  border  of  the 
ulcer  where  the  ointment  came  in  contact  with  the  skin. 
This  quickly  healed  when  the  application  was  limited  to 
the  ulcerated  area. 

Seven  patients  with  severe  echthyma  of  the  lower  ex- 
tremities were  treated.  All  of  these  ulcers  healed  rapidly. 
Three  ulcers  following  surgical  procedures  had  been  slow 
in  healing.  Following  the  application  of  the  ointment  im- 
provement was  rapid  and  they  healed  quickly. 


Our  greatest  hope  of  stemming  the  flooding  tide  of 
chronic  mental  disease  lies  in  prompt,  intensive  treatment 
of  patients  with  acute,  recoverable  disorders,  in  an  envir- 
onment which  does  not  bear  the  stigma  of  a  mental  hos- 
pital.— V.  S.  P.  H.  Reports. 


Hemorrhage  from  the  stomach  and  duodenum  is  due  to 
peptic  ulcer  in  70%  of  all  cases.— Battle  Malone. 


Rheumatic  heart  disease  is  not  a  complication,,  or  a 
sequel  of  rheumatic  fever;  it  is  a  part  of  it. 


September,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


Vaginal  Hysterectomy  in  the  Management  of  Uterine  Prolapse* 

Robert  A.  Ross,  M.D.,  F.A.C.S.,  Durham,  North  Carolina 


From  the  Department  of  Obstetrics    and    Gynecology 
Duke   University   School    of    Medicine 


THE  DEVELOPMENT  of  the  special  ther- 
apeutic aids  endocrine  therapy,  chemother- 
apy, physiotherapy  and  x-rays  has  altered 
the  operative  approach  to  certain  gynecologic  ail- 
ments. By  no  means  has  surgery  been  minimized. 
It  has  only  been  subordinated  to  maintenance  of 
the  female  in  anatomic  and  physiologic  normality. 
The  additions  to  this  armamentarium  have  been 
so  stupendous  as  to  give  the  doctor  who  has  a  first- 
class  acquaintance  with  these  measures  and  agents 
a  far  better  control  over  the  ailments  peculiar  to 
women.  With  this  orderly  progress  has  come  a 
broader  concept  of  the  problem  of  operative  pro- 
cedures and  of  the  individuals  subjected  to  sur- 
gery. This  has  manifested  itself  especially  in  the 
selection  and  preparation  of  the  patient,  the  choice 
of  the  anesthetic,  the  type  of  operation,  the  post- 
operative care  and  the  scrupulous  follow-up.  All 
these  details  are  important;  but  naturally  the  focal 
point  is  the  operation,  and  this  newer  approach  to 
details  and  perfection  of  technique  has  in  turn 
brought  about  wider  application  of  operative  pro- 
cedures. Nowhere  has  healthy,  intelligent  contro- 
versy been  more  beneficial  than  in  considering  the 
problem  of  the  woman  with  prolapse  of  the  uterus. 

At  Duke  Hospital  during  the  last  10  years  the 
operation  of  vaginal  hysterectomy  has  been  per- 
formed on  136  patients  with  varying  degrees  of 
prolapsus  uteri  as  a  complication  warranting  oper- 
ation. W.  L.  Thomas  is  at  present  evaluating  this 
material  and  a  complete  report  will  soon  be  forth- 
coming. It  is  probably  worthy  of  note  that  more 
than  half  of  the  operations  were  performed  by  the 
house  staff.  Of  the  one  death,  which  gave  a  mor- 
tality figure  of  .73  per  cent,  the  cause  was  peri- 
tonitis. This  was  in  a  negrees  who  had  pelvic  in- 
fection, which  was  overlooked  before  operation, 
but  which  should  have  been  suspected.  The  peri- 
toneum and  vagina  were  sutured  tight  at  the  time 
of  operation.  One  patient  had  profuse  secondary 
bleeding  24  days  postoperative  and  required  re- 
peated hospitalization  over  a  period  of  months. 
This  also  was  a  negrees  who  had  pelvic  infection 
and  the  initial  episode  was  precipitated  by  coitus. 
In  this  series  there  were  only  5  colored  patients, 
yet  our  gynecologic  service  is  about  equally  divided. 
This  discrepancy  is  probably  due  to  two  factors; 
the  high  incidence  of  pelvic  infection,  which  com- 


plicates this  type  of  procedure,  and  the  oft-quoted 
observation  that  in  this  locality  we  do  not  find 
marked  relaxation  of  the  vagina  so  often  in  the 
colored  clinic  patients.  In  one  white  private  patient 
the  left  ureter  was  damaged  with  resulting  tempo- 
rary uretero-vaginal  fistula,  which  closed  after  re- 
peated ureteral  catheterizations.  To  date  our  fol- 
low-up is  only  70  per  cent  reliable  and  our  per- 
centage of  cures  is  between  65  and  70.  Most  of 
our  patients  come  from  a  radius  of  25  to  200  miles 
which  makes  the  follow-up  difficult.  Our  morbidity 
figure  is  approximately  20  per  cent. 

A  Meyer1  lays  down  5  points  in  treating  pro- 
lapse of  the  uterus.  1.  Correction  of  the  weakness 
of  the  bladder  sphincter.  2.  Treatment  of  cystocele. 
3.  Suture  of  the  levator  ani  muscles.  4.  Handling 
of  retroversion  of  the  uterus.  5.  Treatment  of  the 
symptoms  of  bleeding  of  the  uterus  and  danger  of 
development  of  subsequent  uterine  disease. 

E.  H.  Richardson2  clearly  shows  the  anatomic 
requirements  that  must  be  met  before  any  repair 
operation  can  be  of  permanent  benefit. 

A.  H.  Curtis3  and  his  group  and  Lilian  K.  P. 
Farrar4  review  the  pertinent  literature  on  the  an- 
atomy of  the  pelvis  and  add  many  valuable  obser- 
vations. These  works,  together  with  their  references 
and  the  contributions  of  many  others,  constitute  a 
comprehensive  basis  for  the  approach  of  the  prob- 
lem of  prolapse. 

The  illuminating  work  of  Mengert5  proves  the 
importance  of  the  broad  ligments  and  paravaginal 
tissue  in  maintaining  the  position  and  station  of 
the  uterus. 

Heaney0  outlines  his  technique  and  gives  his  inci- 
dence of  morbidity  and  mortality.  It  is  his  opera- 
tion of  choice  for  removal  of  the  uterus  unless  the 
pelvis  contains  inflammatory  masses,  adhesions  or 
an  unusually  large  fibroid.  In  a  later  article  he 
advocates  the  use  of  the  procedure  in  prolapse  and 
emphasizes  the  necessity  of  employing  special  care 
in  the  prevention  and  cure  of  rectocele  and  cysto- 
cele. 

Heaney  and  Kennedy7  are  probably  the  two 
strongest  advocates  of  the  operation  of  vaginal  hys- 
terectomy in  this  country.  Kennedy  advocates  and 
describes  in  his  textbook,  the  operation  as  it  is  done 
with  the  clamp  method  in  the  treatment  of  pro- 
lapse.   He  maintains  that   this  method   is  recom- 


•Group  Clinical  Confer 


Clinical   Congress  of  the  Amer 


College  of   Surgeons,   Chicago,   Octoher  25th,    1940. 


VAGINAL  HYSTERECTOMY— Ross 


September,   1941 


mended  because  of  the  greater  retraction  and  con- 
traction of  the  supporting  structures  of  the  vagina 
and  uterus  incident  to  the  procedure.  By  pushing 
up  the  clamps  and  the  supporting  use  of  gauze  the 
bladder  is  elevated — an  elevation  necessary  for  the 
successful  alleviation  of  the  symptoms  associated 
with  prolapse.  His  objection  to  the  suture  method 
is  that  it  will  shorten  the  vagina  and  that  sutures 
in  the  sustaining  ligaments  will  prevent  the  retrac- 
tion and  contraction  of  these  structures.  He  also 
emphasizes  the  time  element,  that  by  this  method 
correction  can  be  completed  in  one-fourth  the  time 
required  for  other  methods.  He  claims  that  a  mod- 
erate cystocele  can  be  cured  by  this  method  without 
additional  surgery. 

A.  Sampolinski8  says  that  one  of  the  chief  ob- 
jections to  the  clamp  method  is  that  perineorrhaphy 
is  not  advisable  at  the  time  and  one  must  wait  at 
least  10  to  12  days  before  completing  the  operative 
program,  which  entails  repair  of  the  posterior  va- 
gina. 

J.  Chavannaz9  favors  the  use  of  clamps  and  if 
necessary  performs  a  repair  operation  3  to  4 
months  later. 

M.  G.  Potter10  also  prefers  the  clamp  method 
and  employs  this  method  in  about  30  per  cent  of 
patients  with  uterine  dislocation. 

L.  Averett11  reports  348  operations  with  no 
deaths.  He  adapts  it  to  meet  many  indications, 
some  of  which  might  be  considered  of  a  minor 
nature,  yet  his  figures  are  conclusive.  A  later  pa- 
per increases  his  report  to  934  with  3  deaths — 0.33 
per  cent. 

W.  C.  Danforth12  reports  a  series  of  260  vaginal 
hysterectomies  with  no  deaths  and  gives  in  detail 
the  technique  employed  by  his  group. 

F.  V.  Emmert13  describes  and  illustrates  the  Gel- 
horn-Dickinson  technic  of  vaginal  hysterectomy  for 
prolapse  of  the  uterus.  His  motion  picture  of  this 
operation  is  convincing. 

C.  H.  Tyrone14  reports  the  results  obtained  for 
240  patients  who  had  vaginal  hysterectomy.  He 
was  able  to  follow  only  175,  170  of  whom  experi- 
enced complete  relief.  However,  the  large  percent- 
age had  not  shown  remarkable  relaxation. 

Cogswell13  maintains  that  the  morbidity  figures 
are  in  favor  of  vaginal  hysterectomy  only  in  the 
procidentia  cases. 

Dorsett10  thinks  that  hysterectomy  should  be 
reserved  for  patients  with  a  definitely  diseased 
uterus. 

Faure17  has  advocated  the  operation  of  vaginal 
hysterectomy  for  a  quarter  of  a  century,  but  finds 
that  his  students  do  not  follow  his  teaching.  To 
his  mind,  the  chief  indication  is  infection  of  the 


uterus.  He  is  only  a  mild  advocate  of  the  proce- 
dure in  pronounced  prolapse.  This  seems  a  bit 
paradoxical  in  the  light  of  the  opinions  of  other 
writers. 

Phaneuf18  calls  attention  to  the  necessity  of  tak- 
ing care  of  hernias  in  the  cul-de-sac  of  Douglas  in 
treating  any  vaginal  relaxation. 

J.  L.  Baer  et  al.,19  in  an  analysis  of  220  patients 
whose  operations  for  prolapse  included  1 1 6  vaginal 
hysterectomies,  report  one  death — 70.7  per  cent 
successful  results,  18.4  per  cent  partially  success- 
ful, 10.8  per  cent  failures — conclude  that  ''vaginal 
hysterectomy  will  be  restricted  to  those  instances 
of  prolapse  in  which  the  pathology  of  the  uterus 
itself  carries  the  indication  for  hysterectomy." 

Campbell,20  in  a  comprehensive  paper,  outlineb 
the  anatomy  of  the  pelvis,  the  factors  leading  to 
prolapsus  uteri,  the  selection  and  preoperative  care 
of  the  patients,  presenting  illustrations  of  his  oper- 
ative approach  and  giving  the  postoperative  care. 
Apparently  at  the  Montreal  General  this  is  the 
operation  of  choice  in  treating  prolapse. 

In  order  to  successfully  treat  prolapsus  uteri  one 
must  be  familiar  with  several  methods  of  approach. 
In  reading  Greenhill's  yearly  summary  one  repeat- 
edly encounters  the  wise  admonition  that  the  doc- 
tor individualize.  Influencing  factors  are  the  amount 
of  prolapse;  associated  local  conditions;  the  general 
condition  of  the  patient;  adaptability  of  the  proce- 
dure and  ability  to  change  in  the  event  of  a  minor 
or  major  crisis;  the  operator's  familiarity  and  suc- 
cess with  the  different  operative  procedures  em- 
ployed to  correct  prolapsus  uteri  and  his  desire  to 
learn  new  methods.  It  is  only  natural  to  suppose 
that  only  the  operator  who  is  familiar  with  the 
anatomy  and  physiology  of  the  pelvis  and  has  a 
basic  knowledge  of  pelvic  surgery  will  undertake  to 
apply  vaginal  hysterectomy  for  the  relief  of  pro- 
lapsus. 

This  report  is  not  a  general  discussion  of  the 
application  of  vaginal  hysterectomy  as  a  gynecolo- 
gic operaiton,  but  is  an  attempt  to  give  it  its  proper 
place  in  the  operative  treatment  of  prolapse,  an 
operative  method  which  is  invaluable. 

The  fact  that  one  can  remove  the  uterus  through 
the  vagina  is  no  reason  that  it  should  always  be 
done. 

The  choice  of  the  type  of  vaginal  hysterectomy, 
we  would  say  from  our  experience,  matters  very 
little.  The  multiplicity  of  types  of  operations  prob- 
ably implies  that  all  of  them  are  good,  and  empha- 
sizes the  necessity  of  adaptability.  When  one  learns 
that  Battey21  successfully  removed  the  uterus  by 
the  vaginal  approach  in  1876,  and  when  one  reads 
the  clear  description  by  Mayo  22  one  realizes  that 


September,   1941 


VAGINAL  HYSTERECTOMY— Ross 


the  sum  total  of  useful  knowledge  of  the  operation 
has  had  little  added  to  it.  It  is  our  practice  to  have 
the  resident  review  Mayo's  paper,  together  with  the 
work  of  other  authors  quoted  in  this  bibliography, 
and  proceed  to  apply  the  principles  they  have 
learned  to  the  patient  undtr  consideration.  Under 
adequate  supervision,  a  fair  salvage  of  patients 
with  prolapsus  uteri  has  been  effected  without  in- 
curring an  unusually  high  mortality  incidence. 
Bibliography 

1.  Meyer,  A.:  A  few  points  concerning  operation  for  pro- 
lapse of  uterus."  Monatschr.  f.  Geburtsh.  u.  Gynak., 
Oct..  1936,  105:194-197. 

2.  Richardson,  E.  H.:  An  efficient  composite  operation 
for  uterine  prolapse  and  associated  pathology.  Amer. 
J.  Obst.  &  Gynec,  Nov.,  1937,  34:827-S39. 

3.  Curtis,  A.  H.,  el  al.\  Anatomy  of  pelvis  and  uro- 
genital diaphragms  in  relation  to  urethrocele  and  cysto- 
cele.   5.,  G.  &  0.,  Feb.,  1939,  68:161. 

4.  Farrar,  Lilian  K.  P.:  The  upper  pelvic  floor  and  its 
importance  in  total  abdominal  hysterectomy.  Trans. 
Amer.  Gynec.  Soc.,  1937,  62:11-23. 

5.  Mengert,  W.  F.:  Factors  influencing  uterine  support, 
experimental  study.  Amer.  J.  Obst.  &  Gynec.,  May, 
1936,  31:775. 

6.  Heaney,  N.  S.:  Vaginal  hysterectomy  performed  for 
benign  pelvic  disease.  Amer.  J.  Obst.  &  Gynec,  Nov., 
1934,  28:751. 

7.  Heaney,  N.  S.,  and  Kennedy,  J.  W.:  Vaginal  hyster- 
ectomy, clamp  method,  for  uterine  prolapse.  Amer.  J. 
Surg.,  Sept.,  1936,  33:428. 

8.  Sampollnski,  A.:  Simplified  local  vaginal  hysterec- 
tomy, indications  and  contraindications.  Amer.  J. 
Surg.,  May,  1936,  32:230. 

9.  Chavannaz,  J.:  Reflections  on  vaginal  hysterectomy. 
Rev.  franc  de  gynec.  el  d'obst.,  1938,  33:877. 

10.  Potter,  M.  G.:  Experiences  with  vaginal  hysterectomy 
with  clamp  method.  New  York  State  J.  Med.,  Oct.  15, 
1939,  39:1962-1968. 

11.  Averett,  L.:  Vaginal  hysterectomy,  study  of  348  cases. 
Amer.  J.  Obst.  &  Gynec,  June,  1938,  35:978. 

12.  Danforth,  W.  C:  Place  of  vaginal  hysterectomy  in 
present-day  gynecology.  Amer.  J.  Obst.  &  Gynec, 
Nov.,  1938,  36:787-797. 

13.  Emmert,  F.  V.:  Gellhorn-Dickinson  technic  for  va- 
ginal hysterectomy  for  prolapse  of  uterus.  Surgical 
Clinics  of  N.  A.,  Oct.,  1938,  18:1215. 

Idem:    Results   of    modern    technique   in   vaginal   hys- 
terectomy.   South.  Med.  Jour.,  July,  1938,  32:715-720. 

14.  Tyrone,  C.  H.:  Vaginal  hysterectomy,  its  indications, 
technique  and  end  results.  New  Orleans  M.  Jour.,  Feb., 
1936,  88:490. 

15.  Cogswell,  H.  D.:  Indications  for  vaginal  hysterec- 
tomy.  S.,  G.  &  O.,  Dec,  1937,  65-837-840. 

16.  Dorsett,  E.  L.:  Uterine  prolapse.  J.  Missouri  M.  A., 
June,  1936,  33:209. 

17.  Fairi.,  J.  L.:  A  propos  de  l'hysterectomie  vaginale. 
Bull.  Soc.  Gynec.  et  d'obst.,  Jan.,  1938,  27-45-50. 

18.  Phanelf,  L.  E.:  Surgical  management  of  prolapse  of 
the  uterus  and  vagina.   5.,  G.  &  O.,  Sept.,  1936,  63:386. 

19.  Baer,  J.  L.,  Reis,  Ralph,  and  Laemle,  Robert  L.: 
Prolapse  of  the  uterus,  shifting  trends  in  treatment. 
Trans.  Amer.  Gyn.  Soc,  1937,  62:126-144. 

20.  Campbell,  A.  D.:  Vaginal  hysterectomy  in  prolapsus 
uteri.   Amer.  Jour.  Obst.  &  Gynec,  Feb.,  1937,  33:209. 

21.  Gi.i.lhorn,  G.:  Discussion.  Amer.  J.  Obst.  &  Gynec, 
Feb.,  1933,  25:273. 

22.  Mayo,  C  H.:  Uterine  prolapse  with  associated  pelvic 
relaxation.  S.,  G.  &  O.,  March,  1915,  20:253. 


"Complete"  Studies  Not  Always  Indicated. 
— I  am  afraid  that  in  our  day  of  refined  diagnosis 
it  not  rarely  happens  that  the  chance  of  effective 
interference  in  acute  disease  is  lost  while  we  ex- 
amine the  secretions  and  record  the  temperature 
and  search  the  blood. — Wm.  Pepper,  1899. 


TRICHINOSIS  IN  MAN 
(P.  B  Beeson,  in  Proc.  Royal  Soc.  of  Med..  England,  July) 
Trichinosis  is  acquired  in  only  one  way:  by  eating  meat 
which  contains  living  larvae  of  the  nematode,  Trichina 
spiralis.  During  the  digestion  of  infected  meat  trichina 
larvae  are  set  free  in  the  intestine,  where  they  mature 
within  a  few  days,  and  mate.  The  females  burrow  into  the 
wall  of  the  intestine  and  deposit  their  larvae  there.  The 
larvae  enter  blood  vessels  and  are  carried  in  the  blood  to 
all  parts  of  the  body.  The  adult  females  and  males  are 
gradually  excreted  in  the  feces.  As  the  larvae  grow  they 
become  too  large  to  pass  through  capillaries,  and  are  ar- 
rested in  various  organs.  Those  which  lodge  in  voluntary 
muscle  may  become  encysted  and  remain  alive  for  many 
years.  Those  which  are  arrested  in  other  organs  stimulate 
an  acute  inflammatory  reaction  and  are  usually  destroyed 
within  a  few  weeks. 

Illness  of  the  host  occurs  only  during  the  period  of  in- 
vasion by  the  parasite.  Subsequently  the  host  apparently 
suffers  no  adverse  effect  from  the  presence  of  encysted 
larvae  in  his  muscles.  As  usually  described  ,the  illness 
caused  by  trichinosis  has  four  cardinal  features:  fever, 
orbital  edema,  myalgia  and  eosinphilia.  Many  other  signs 
and  symptoms  may  occur,  depending  on  chance  deposition 
of  parasites  in  various  parts  of  the  body.  Inflammatory 
reactions  of  the  brain,  lungs  or  heart  may  give  rise  to 
clinical  signs  suggestive  of  encephalitis,  pneumonia  or  myo- 
carditis. Recovery  usually  begins  within  three  weeks  of  the 
time  of  onset  of  symptoms.  Some  stiffness  and  weakness 
may  persist  for  months. 

Among  persons  or  animals  not  previously  exposed  to 
trichinosis  there  appears  to  be  marked  variation  in  natural 
susceptibility. 

Some  degree  of  active  immunity  is  developed  after  one 
infestation. 

Clinical  diagnosis  of  trichinosis  is  often  difficult,  two 
practical  methods  are  differential  leucocyte  count  is  fairly 
reliable  within  three  months  of  the  time  of  infestation;  the 
skin  test  with  Trichina  antigen  is  a  more  specific  method, 
and  simpler. 


MEDICAL  STUDENTS  COMING  WITH  MULTIPLE 

DEGREES 
(F.  C  Zapper,  Chicago,  in  //.  Assn.  Amer.  Med.  Col.,  July) 
The  number  of  students  coming  to  medical  college  with 
multiple  degrees  is  increasing  steadily.  In  1939,  there  were 
163  students  in  this  group;  the  accomplishment  of  these 
students  does  not  compare  favorably  with  the  work  of  the 
class  as  a  whola  in  any  bracket.  The  reason  is  not  appar- 
ent. 

Work  of  the  women  students  does  not  quite  measure  up 
to  that  of  the  men  students. 


Shaine  reports  (Rev.  Gastroent.)  the  cases  of  6  patients, 
all  of  whom  had  had  flatulence,  not  associated  with  organic 
abdominal  disease,  in  which  Prostigmin  Bromide  (15-mg. 
tablets)  taken  orally  4  i.  d.  relieevd  the  distressing  symp- 
toms promptly.  No  untoward  effect  was  noted  except  in  a 
single  instance  in  which  abdominal  discomfort  required 
temporary  suspension  of  the  treatment.  After  the  symp- 
toms subsided  Prostigmin  therapy  was  resumed  and  alle- 
viation of  the  flatulence  was  unattended  by  the  original 
by-effect.  Shaine  found  Prostigmin  helpful  in  one  of  his 
cases  of  paroxysmal  tachycardia. 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


DEPARTMENTS 


HUMAN  BEHAVIOUR 

James   K.   Hall,  M.  D.,   Editor,   Richmond,   Va. 

FATAL  PLUMBIC  PSYCHOTHERAPY 

Life  is  filled  with  evidences  of  reversion.  The 
wise  man,  as  a  result  of  his  wisdom,  recorded  his 
opinion  ages  ago  that  the  thing  that  hath  been  it  is 
that  which  shall  be.  Organized  medicine  and  gov- 
ernment itself  live  in  constant  dread  of  an  outbreak 
of  a  pestilential  malady  that  has  lain  somewhere  in 
latent  abeyance  for  generations.  The  pendulum  is 
fatalistically  pulled  upon  by  an  unseen  force  to 
fetch  it  back  to  where  it  had  been.  Such  a  pull  is 
not  limited  to  the  domain  of  matter.  The  most 
upright  man  must  live  in  constant  apprehension  of 
the  danger  of  slipping  backward  or  downward  in 
behaviour  to  that  plane  in  which  he  once  lived, 
ancestrally.  Warfare  may  have  some  such  origin.  I 
fear  me  that  we  are  innate  killers. 

I  see  on  the  countenance  of  the  so-called  sports- 
man the  facial  representation  of  the  most  satisfying 
elation  as  he  goes  forth  at  sunrise  on  the  first  day 
of  the  hunting  season.  He  sets  out  heavily  armed, 
and  for  no  other  purpose  than  to  kill — and  to  kill 
the  witless,  unarmed,  harmless  members  of  the 
native  wild-life  that  haye  no  defense  to  offer  except 
that  afforded  by  obvious,  and,  therefore,  dangerous 
flight.  The  sportsman's  risk  of  injury  to  himself 
lies  in  his  own  carelessness  and  in  that  of  his  fellow- 
killer.  I  know  of  no  more  inept  use  of  language 
than  that  involved  in  the  application  of  the  word 
sportsman  to  the  armed  hunter  of  wild-life. 

The  psychiatric  shooting  season  in  Virginia 
opened  on  August  23rd.  In  consequence  of  the 
suddenness,  the  unexpectedness,  and  the  violence 
attending  the  inception  of  the  season,  the  popula- 
tion of  the  Commonwealth  has  been  lessened  and 
the  health  of  the  citizenship  has  been  impaired.  A 
deputy  sheriff  of  Augusta  County  is  dead,  the  sher- 
iff of  the  County  is  wounded,  and  so  is  Staunton's 
chief  of  police.   A  Negro  lies  dead. 

The  Negro,  said  to  have  been  insane,  shot  to 
death  the  deputy  sheriff,  wounded  the  sheriff  and 
the  police  officer.  Such  a  large  posse  of  citizens 
participated  in  shooting  the  insane  Negro  to  death 
that  it  may  prove  to  be  difficult,  if  not  impossible, 
to  determine  which  citizens  deserve  the  credit  for 
applying  such  effective  psychotherapy  to  the  flee- 
ing, insane  Negro.  Many  patriotic  deeds  have  been 
lost  in  the  confusion  of  history. 

Edgar  Allan  Poe  expressed  the  opinion  that  one 
of  the  qualities  of  the  immortal  poem  is  brevity. 
The  great  tragedies    have    been    quickly    enacted. 


Homer's  Devil  occupied  only  a  summer's  day  in 
falling  steadily,  without  a  parachute,  from  Heaven 
to  Hell.  Pliny  the  Younger  looked  upon  the  oblit- 
eration of  Pompeii  by  the  wave  of  lava  flowing 
from  erupting  Vesuvius.  A  splendid  city  was  no 
more.    Its  inhabitants  had  been  incinerated. 

Charles  Johnson,  a  thirty-six-year-old  Negrto, 
lived  alone  in  his  cabin,  two  or  three  miles  from 
Staunton.  He  went  to  the  pump  of  a  neighbour 
(whose  house  is  rented  from  Johnson's  father)  for 
a  bucket  of  water.  There  Johnson  ordered  the 
neighbour's  wife  to  use  no  more  of  the  water  from 
the  pump,  and  he  threatened  the  woman,  and 
knocked  her  down.  She  had  the  occurrence  reported 
to  Johnson's  father,  who  works  in  Staunton.  The 
fatner  of  Charles  Johnson  swore  out  a  lunacy  war- 
rant, and  placed  it  in  the  hands  of  the  sheriff  of 
Augusta  County — G.  M.  Gilkeson.  He  went  with 
his  deputy,  F.  L.  Armstrong,  to  the  Negro's  cabin. 
But  when  the  sheriff  and  his  deputy  started  from 
their  car  across  the  open  space  to  the  cabin,  the 
Negro  cursed  them  and  opened  fire  on  them.  Dep- 
uty Armstrong  fell,  shot  through  the  head,  dead. 
The  sheriff,  wounded,  had  to  crawl  away.  Other 
officers  came,  and  a  crowd  of  several  hundred  citi- 
zens searched  for  the  Negro,  who  had  left  his  cabin. 
As  the  posse  closed  in  on  the  Negro  in  a  forest,  he 
wounded  the  chief  of  police  of  Staunton,  John  M. 
Webb.  The  sheriff  and  the  chief  of  police  are  re- 
covering from  their  wounds  in  a  hospital.  The 
deputy  sheriff,  F.  L.  Armstrong,  and  the  Negro, 
thought  to  be  insane,  Charles  Johnson,  are  dead. 

The  fact  that  the  Negro  was  found  at  his  death 
to  be  armed  with  rifle,  shotgun  and  revolver  tends 
to  indicate  that  he  was  living  in  delusional  appre- 
hension of  being  attacked.  The  approach  of  the 
officers  probably  fitted  in  perfectly  with  his  delu- 
sion. The  fact  that  he  had  in  his  pockets,  when 
dead,  more  than  $200.00  he  had  made  as  a  worker 
in  a  quarry  tends  to  indicate  that  his  insanity  did 
not  make  it  impossible  for  him  to  labour  and  to 
earn.  In  a  protected  environment  he  might  have 
lived  productively  into  peaceful  old  age. 

Thus,  in  the  Valley  of  Virginia,  within  three 
miles  of  Woodrow  Wilson's  birthplace,  and  within 
a  lesser  distance,  perhaps,  of  a  great  State  Hospital, 
more  than  a  hundred  years  old,  prompt  and  effec- 
tive leaden  therapy  is  applied  by  official  appre- 
hending officers,  and  probably  by  some  of  the  mem- 
bers of  what  must  have  constituted  a  mob,  to  a 
Negro  thought  to  be  deranged.  Over  the  mountain, 
scarcely  forty  miles  away,  stands  Mr.  Jefferson's 
University  in  which  medicine,  psychiatric  and  oth- 
erwise, is  taught.  But  Woodrow  Wilson's  advent  in 
1856;  the  opening  of  the  Insane  Asylum  in  1828; 
Monticello  and  Thomas  Jefferson  and  the  Declara- 


September,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


tion  of  Independence  and  the  University  of  Virginia 
were  of  no  avail  to  Charles  Johnson  when  his  mind 
went  wrong  and  he  knocked  down  his  neighbour's 
wife  and  she  went  into  town  and  told  Charles' 
father  how  his  son  had  treated  her,  and  the  father 
went  to  the  sheriff  to  get  him  to  go  and  get  his  son 
and  put  him  where  he  would  be  safe,  and  where  he 
could  not  scare  and  threaten  the  neighbours. 

Can  any  one  find  in  the  story  anything  but  naked 
tragedy  resulting  from  insanity  in  the  Negro  and 
from  stupidity  in  the  white  man's  law?  Why,  in 
God's  holy  name,  should  the  law  designate  and 
compel  an  apprehending  officer  to  go  out  heavily 
armed  to  fetch  in  a  crazy  man?  Craziness  is  merely 
an  unfortunate — with  Charles  Johnson,  a  fatal — 
form  of  sickness.  Why  should  armed  officials  be 
sent  out  to  minister  to  the  mentally  sick?  Has 
Augusta  County,  Virginia,  no  Health  Department? 
Has  the  Commonwealth  of  Virginia  no  Department 
of  Public  Health?  Are  there  no  State  Hospitals 
within  the  Commonwealth  in  which  women  and 
men  are  trained  to  deal  with  the  mentally  sick, 
some  of  whom  may  be  dangerously  violent?  I  have 
no  doubt  that  Dr.  Brent,  the  modest  and  highly 
efficient  Superintendent  of  the  splendid  State  Hos- 
pital for  Negroes  at  Petersburg,  could  have  dis- 
patched a  colored  attendant  to  Augusta  County, 
unarmed,  who  could  have  brought  back  Charles 
Johnson  quietly  and  without  violence.  Many  an 
attendant  is  daily  engaged  in  working  with  such  a 
patient  as  Charles  Johnson.  But  he  knows  his  pa- 
tient is  irrational,  he  expects  irrational  and  not  ra- 
tional behaviour  from  his  patient,  and  he  does  not 
threaten  or  assault  his  patient  because  he  does  not 
behave  sensibly.  Of  course,  an  attendant  or  nurse 
of  doctor  sometimes  forgets  to  keep  open  all  the 
psychiatric  eyes  all  'round  the  head,  and  occasion- 
ally some  one  is  cracked  on  the  head,  and  some- 
times a  nurse  or  a  doctor  is  killed.  But  that  is  bet- 
ter than  to  do  the  killing.  So  long  as  ships  and  sail- 
ors go  down  to  the  sea,  so  long  will  they  fail  some- 
times to  come  back  again. 

No  words  have  been  written  in  criticism  of  any 
individual.  No  one  who  knew  the  officer  now  dead, 
and  no  one  who  knows  the  sheriff  and  the  chief  of 
police  doubts  their  courage,  and  their  devotion  to 
duty.  The  complaint  is  not  man-ward.  The  criti- 
cism is  directed  against  that  stupidity  and  asininity 
and  tradition-cursed  ignorance  that  still  associates 
mental  abnormality  with  criminality.  The  public 
health  organizations  that  do  not  deal  fully  with 
mental  sickness  in  all  its  manifestations  as  a  public 
health  problem  are  not  performing  their  duties. 
Armed  apprehending  officers  have  no  more  business 
in  dealing  with  psychotic  patients  than  they  have 
in  obstetrical  delivery  rooms. 


INSURANCE  MEDICINE 


H.  F.  Starr,  M.D.,  Editor,  Greensboro,  N.  C. 

THE  EFFECT  OF  PREMATURE  CONTRAC- 
TIONS ON  INSURABILITY 

Insurance  opinion  concerning  the  prognostic 
significance  of  premature  contractions  or  extra  sys- 
toles coincides  closely  with  that  of  clinical  medi- 
cine. Considering  the  frequency  of  the  sign  in 
apparently  normal  individuals  there  is  a  surpris- 
ingly small  number  of  statistics  on  the  mortality 
among  insured  person  showing  premature  contrac- 
tions at  time  of  examination.  However,  the  proce- 
dure for  underwriting  these  cases  is  fairly  uniform. 

Premature  contractions  seldom  shorten  the  span 
of  life.  Yet  they  indicate  a  disturbance  of  cardiac 
nutrition  which  may  be  insignificant  or  serious, 
temporary  or  permanent.  It  is  the  underlying 
cause  of  the  disturbance  and  the  associated  condi- 
tions that  are  of  prognostic  significance.  When 
they  are  transient,  the  disturbance  in  the  cardiac 
muscle  is  temporary,  and  when  infrequent  and  aris- 
ing from  a  single  focus  the  underlying  defect  is 
probably  limited  and  of  no  great  consequence. 
When  they  occur  frequently  or  constantly  there  is 
reason  to  suspect  greater  damage.  When  they  arise 
from  multiple  foci,  which  can  only  be  determined 
by  the  electrocardiogram,  the  evidence  is  strongly 
suggestive  of  important  defects.  These  may  be 
permanent  and  progressive  or  only  temporary.  It 
must  be  borne  in  mind  that  seriously  damaged 
hearts  may  show  very  infrequent  premature  con- 
tractions or  none  at  all,  and  that  many  persons 
have  enjoyed  good  health  with  premature  contrac- 
tions from  childhood  to  old  age.  The  prognosis 
therefore  depends  more  upon  the  underlying  and 
associated  conditions  than  upon  the  presence  of 
premature  contractions. 

When  present  they  call  for  a  thorough  examina- 
tion, bearing  in  mind  that  they  are  often  associated 
with  signs  of  myocardial  disease,  aortic  regurgita- 
tion, mitral  stenosis  and  infections.  A  history  of 
rheumatic  infection  is  present  in  a  large  percentage 
of  cases.  Excessive  use  of  tobacco,  full  doses  of 
digitalis,  or  nervous  excitement  may  precipitate 
them.  Digestive  disturbances  are  common.  Re- 
examination and  a  period  of  observation  may  be 
necessary  to  determine  their  significance.  The  elec- 
trocardiogram is  of  value  in  verifying  the  diagnosis, 
in  determining  whether  there  is  more  than  one  fo- 
cus of  origin,  and  in  demonstrating  the  possible 
presence  of  other  abnormalities  which  may  be  of 
greater  significance  than  the  premature  contrac- 
tions. An  electrocardiogram  normal  in  all  other 
respects  is  reassuring. 


492 


SOUTHERN  MEDICINE  &■  SURGERY 


September,   1941 


To  sum  up  the  generally  accepted  insurance 
view  we  may  say  that  infrequent  premature  con- 
tractions in  young  persons  do  not  affect  longevity, 
but  they  should  warn  us  to  look  for  causal  or  as- 
sociated conditions  which  may  affect  the  outlook. 
They  are  less  apt  to  be  associated  with  a  serious 
condition  in  younger  tha  nin  older  persons.  When 
they  occur  frequently,  particularly  after  age  40,  an 
increased  mortality  requiring  an  extra  rating  for 
life  insurance  is  to  be  expected. 

The  following  schedule  indicates  in  a  general 
way  the  extra  mortality  many  companies  provide 
for  in  rating  cases  showing  premature  contractions 
on  examination.  Individual  circumstances  and 
judgment  may  alter  cases: 

ADDITIONAL  MORTALITY  RATINCS  DUE  TO  PREMATURE 
CONTRACTIONS** 

Without   Electrocardiogram : 

Ages  Ages  Ages  Ages 

Wo.   per  minute  15-35  36-45         46-55  56-60 

1  to    4    _ 10%  15%  35%  507c 

5  to  10    15  25  50  75 

Over  10  30  60  90  125 

With  favorable  Electrocardiogram: 
Under  age  40 — Reduce  rating  shown  above  by  50% 
Age  40  and  over — Reduce  rating  shown  above  by  25%. 

**In  this  table  the  additional  mortality  rating  is  added 
to  that  of  the  average  normal  risk,  which  is  100%.  Insur- 
ance at  standard  rates  is  generally  issued  when  the  expect- 
ed mortality  of  the  risk  does  not  exceed  125%.  The  above 
table  takes  into  consideration  the  presence  of  premature 
contractions  only.  When  all  factors  in  the  case  are  weighed 
and  credits  are  given  for  the  favorable  and  debits  for  un- 
favorable factors  the  expected  mortality  for  the  entire  risk 
may  vary  considerably  from  that  indicated  by  these  figures. 


DERMATOLOGY 

J.  Lamar  Calloway,  M.D.,  Editor,  Durham,  N.  C. 


THE  MANAGEMENT  OF  PYOGENIC  SKIN 
DISEASES 

Under  this  heading  are  included  impetigo  con- 
tagiosa, infectious  eczematoid  dermatitis,  sycosis 
barbae,  folliculitis,  and  other  diseases  of  the  skin 
in  which  secondary  pyogenic  invasion  plays  an  im- 
portant role.  Frequently  scabies,  dermatophytosis, 
"eczema"  and  other  cutaneous  affections  and  infec- 
tions which  are  not  primarily  pyogenic  are  so  com- 
plicated by  secondary  pyogenic  infections  that  un- 
less this  factor  is  recognized  and  treated  the  under- 
lying dermatosis  will  prove  extremely  recalcitrant 
to  therapy. 

Pyogenic  infections  are  markedly  influenced  by 
high-carbohydrate  intake  as  has  been  demonstrated 
by  Pillsbury  and  Sternberg  and  others.  This  is  well 
illustrated  in  the  frequency  of  furunculosis  in  pa- 
tients having  diabetes.  Accordingly,  we  feel  very 
certain  that  the  carbohydrate    intake    should    be 


lowered  drastically  in  all  patients  showing  pyogenic 
manifestations. 

In  a  like  manner  the  ingestion  of  iodides  and 
bromides  should  be  restricted,  since  these  frequent- 
ly make  pyogenic  conditions  worse.  Iodide:  even 
in  the  form  of  iodized  table  salt  should  be  testrict- 
ed  as  well  as  all  medications  containing  iodides  and 
bromides  if  at  all  feasible. 

Locally  warm  wet  compresses  such  as  normal  sa- 
line, 1:4000  KMNO4  solution,  or  boric  acid  solu- 
tion should  be  used,  changing  the  compresses  every 
two  hours  during  the  day  and  every  four  hours  at 
night.  Mechanical  debridement  should  be  done  in 
which  crusts  are  lifted  off,  and  vesicles,  bullae  and 
pustules  evacuated  by  clipping  off  the  top  of  the 
lesions. 

Chemotherapy  should  be  used  depending  to  some 
extent  on  the  type  of  organism  found.  It  has  been 
shown  that  in  staphylococcic  infectons  2  per  cent 
gentian  violet  solution  is  one  of  the  most  effective 
remedies,  while  in  streptococcic  infections  3  to  S 
per  cent  ammoniated  mercury  gives  best  results. 
Recently  the  use  of  the  various  sulfonamids,  par- 
ticularly 5  per  cent  sulfathiazol  ointment,  has  been 
invaluable  in  the  management  of  pyogenic  condi- 
tions. It  has  been  shown  by  Pillsburv  and  others 
that  sulfathiazol  ointment  works  best  in  an  emul- 
sion-type base  rather  than  in  the  usual  greasy  oint- 
ment bases.  Occasionally,  patients  are  found  sensi- 
tive to  this  preparation  but  no  more  frequently 
than  when  administered  by  mouth. 

Chemotherapy  using  the  sulfonamids,  particular- 
ly sulfathiazol  and  more  recently  sulfadiazine,  is 
sometimes  necessary  when  local  measures  fail.  The 
same  precautions,  such  as  daily  blood  counts,  daily 
urinalyses,  and  observations  for  other  toxic  mani- 
festations, govern  the  use  of  the  sulfonamids  when 
used  for  cutaneous  eruptions  as  when  used  for  sys- 
temic infections. 

Ultraviolet  light  irradiation  generalized  in  the 
form  of  sunbaths  or  artificial  ultraviolet  light  as  a 
tonic  oftentimes  gives  the  pull  necessary  for  com- 
plete eradication  of  the  infection.  X-ray  therapy  in 
selected  cases  administered  by  a  physician  especial- 
ly trained  in  its  use  for  dermatological  conditions  is 
beneficial.  In  a  like  manner,  the  use  of  staphylo- 
coccus toxoid,  autogenous  vaccine,  colloidal  man- 
ganese, tin  and  other  adjuncts  may  be  necessary 
when  the  regimen  outlined  has  failed:  and  it  is 
usually  advisable  to  seek  aid  by  a  consultation  with 
a  physician  trained  in  dermatological  therapy. 


Doubtful  or  positive  syphilis  reactions  were  found  by 
Lynch,  of  St.  Paul,  in  16%  of  263  persons  studied  after  pri- 
mary vaccinia.  Such  reactions  may  be  strongly  positive 
and  therefore  a  source  of  confusion  to  the  clinician  foi 
several  months  after  vaccination. 


September.   1941 


SOUTHERN  MEDICINE  &  SURGERY 


GENERAL  PRACTICE 

James    L.    Hamner,    M.  D.,    Editor,    Mannboro,    Va. 


EMERGENCY  ABDOMINAL  CONDITIONS 
AMONG  INFANTS  AND  CHILDREN 

Abdominal  emergencies  in  practice  among  chil- 
dren are  frequent  and  serious.  This  consideration 
of  the  subject1  should  serve  to  freshen  our  interest 
and  information. 

In  the  newborn  infant  the  prompt  return  of  food 
may  occur  after  every  feeding,  at  times  with  bile. 
In  the  presence  of  abdominal  distention,  particu- 
larly in  the  epigastrium,  in  the  absence  of  stools 
and  sometimes  with  visible  peristalsis  from  left  to 
right,  congenital  atresia  or  other  pyloric  or  duode- 
nal obstruction  is  probable.  If  the  obstruction  is 
complete,  surgical  measures  must  be  carried  out 
promptly. 

Evidence  of  pain  is  the  most  common  indication 
of  acute  abdominal  disease  in  infants  and  children. 
Crving  or  screaming  by  the  small  infant  usually  is 
interpreted  as  colic.  A  careful  history  usually  will 
reveal  the  infant's  birth  and  progress  normal  up  to 
two  or  three  weeks  of  age;  since  that  time  the  baby 
cried  much,  drew  up  the  legs  while  crying,  and  kept 
the  family  awake.  All  sorts  of  feedings'  were  tried. 
The  child  continued  to  gain  in  weight.  The  abdo- 
men is  soft,  not  distended,  not  tender,  no  palpable 
masses.  The  rectal  temperature  is  normal,  inguinal 
rings  are  closed,  navel  not  bulging,  and  not  red- 
dened. The  problem  in  such  a  case  is  one  of  con- 
vincing the  family  that  there  is  nothing  seriously 
wrong  and  of  allowing  the  baby  to  be  quiet  and  to 
develop  regular  habits  of  eating,  resting  and  per- 
haps also  of  crying.  If  the  supply  of  breast  milk 
has  not  disappeared,  the  baby  should  be  returned 
to  the  breast.  Complementary  feeding  may  have 
to  be  resorted  to  until  the- supply  of  breast  milk  has 
become  adequate. 

Ordinarily,  pyloric  stenosis  or  obstructing  bands 
do  not  create  the  picture  of  an  acute  condition,  yet 
the  first  indication  of  their  presence  may  be  sudden 
and  there  be  evidence  of  severe  pain  and  vomiting. 
Visible  peristaltic  waves  passing  from  left  to  right 
are  evidence  of  obstruction  at  or  near  the  pylorus. 

Colicky  abdominal  pain  among  infants  of  from 
six  months  to  two  years  should  give  rise  to  the  sus- 
picion of  incarcerated  hernia  or  of  intussusception. 
For  some  time  after  the  onset  of  intussusception 
the  only  symptoms  may  be  a  sharp  cry  at  intervals 
to  an  hour.  Between  the  paroxysms  the  child  ap- 
pears to  be  rather  comfortable.  He  may  and  fre- 
quently does  fall  asleep.  His  general  condition  does 
not  appear  to  be  bad.   Later  vomiting  arid  bloody 

1.  R.  L.  J.  Kennedy  Rochester,  Minn.,  in  //.  Kansas  Med. 
Soc,  Aug. 


discharges  from  the  bowel  appear.  Usually,  in  12 
to  18  hours  there  is  toxemia  and  shock.  The  child 
may  become  more  quiet  with  pale,  sunken  eyes  and 
fever  of  variable  degree. 

For  sometime  the  abdomen  may  be  held  rigid 
during  the  paroxysms  of  pain.  In  the  intervals  the 
typical,  sausage-shaped  mass  may  be  palpated 
along  the  ascending  and  transverse  colon.  Failure 
to  palpate  such  a  mass  may  be  disregarded  if  the 
other  striking  features  are  present.  A  palpable 
mass  is  less  likely  in  the  cases  of  ileo-ileal  than  in 
the  more  usual  ileocolic  or  colocolic  forms. 

Within  the  first  few  hours  digital  examination  by 
the  rectum  probably  will  not  reveal  the  mass.  How- 
ever, the  examining  finger  on  withdrawal  will  be 
coated  with  blood  or  bloody  mucus,  corroborative 
of  intussusception  and  an  indication  for  immediate 
surgical  treatment.  In  most  cases  the  mass  presents 
in  the  rectum,  but  by  the  time  this  happens  gan- 
grene has  occurred. 

If  in  every  instance  the  condition  could  be  rec- 
ognized and  treated  within  12  hours,  the  mortality 
rate  would  be  low.  Parents  should  be  taught  to  re- 
port to  the  physician  untoward  behavior  on  the 
part  of  infants,  and  the  physician  should  learn  to 
regard  seriously  the  early  symptoms  of  these  two 
conditions  which  may  be  so  lightly  dismissed. 

If  intussusception  is  ileocecal,  the  smaller  ileum 
can  be  withdrawn  from  the  larger  colon,  frequently 
with  ease.  Attention  can  be  directed  to  the  bowel 
so  as  to  prevent  recurrence.  Occasionally,  intussus- 
ception undergoes  spontaneous  regression,  or  this 
may  be  brought  about  during  the  administration  of 
an  anesthetic  preliminary  to  operation.  Supportive 
measures  to  combat  toxemia  and  shock  also  are  of 
importance.  Transfusions  of  blood  and  the  intra- 
venous and  subcutaneous  administration  of  solu- 
tion of  sodium  chloride  and  glucose  are  the  chief 
supportive  measures. 

An  infant  who  has  not  only  cried  lustily,  but 
has  screamed  at  intervals  of  a  few  minutes  to  an 
hour  for  a  few  hours  or  a  day,  who  has  seemed  to 
be  well  up  to  the  time  of  the  crying,  should  have  a 
careful  history  and  examination,  including  abdom- 
inal. The  inguinal  rings  may  give  evidence  of  a 
firm  mass,  palpation  of  which  may  result  in  in- 
creased outcry.  A  previous  hernia  makes  such  a 
diagnosis  almost  certainly  correct.  The  fact  that 
the  hernia  is  small  may  give  rise  to  the  belief  that 
the  symptoms  of  pain,  emesis  and  later,  toxemia, 
are  of  other  origin.  Occasionally,  the  rather  cystic 
feel  of  the  herniated  mass  to  the  examinee's  hand 
simulates  hydrocele.  Acute  inguinal  adenitis  must 
be  distinguished  from  hernia. 

In  the  case  of  strangulated  hernia,  spontaneous 
reduction  may  take  place  or  the  hernia  may  reduce 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


itself  on  the  administration  of  an  anesthetic.  If  the 
evidence  is  strong  that  strangulation  was  of  short 
duration  nothing  further  need  be  done.  If  strangu- 
lation still  persists  or  has  persisted  for  a  consider- 
able time  before  spontaneous  reduction  occurs,  sur- 
gical exploration  is  demanded. 

Rarely,  the  same  type  of  crying  is  present  as 
that  of  inguinal  hernia,  and  can  be  accounted  for. 
by  a  ventral  or  umbilical  hernia  in  which  a  portion 
of  underlying  tissue  has  been  caught,  the  tension, 
pull  or  pressure  of  the  surrounding  tissue  causing 
the  pain. 

Other  less  frequent  causes  of  obstruction  are  vol- 
vulus, thrombosis  of  mesenteric  vessels  and  cysts  of 
the  intetinal  wall.  Distention  is  much  more  likely 
when  the  site  of  the  obstruction  is  high.  In  any 
case  in  which  obstruction  is  suspected,  it  may  be 
useful  to  make  a  roentgenogram  of  the  abdomen. 

Of  all  the  acute  abdominal  conditions  which  may 
afflict  infants  and  children,  appendicitis  continues 
to  be  the  most  frequent  and  the  most  dangerous. 
Infants  of  two  years  and  less  are  likely  to  cry  as 
the  only  evidence  of  pain  of  acute  appendicitis. 
Emesis  that  does  not  relieve  the  pain  is  corrobora- 
tive. Emesis  and  fever  may  or  may  not  be  present. 
The  important  factor  is  the  examination.  With  the 
patient  relaxed  even  for  an  instant  between  cryings, 
tenderness  and  muscle  spasm  can  be  elicited  over 
McBurney's  point  by  even  the  lightest  touch  or 
may  be  evident  only  on  deep  palpation.  The  ap- 
pendix of  children  usually  is  higher  than  in  adults, 
and  frequently  is  retrocecal,  in  which  case  the  point 
of  maximal  tenderness  would  be  higher  or  less  defi- 
nite. 

Rectal  examination,  which  offers  even  greater 
difficulty  in  the  young,  frequently  more  than  repays 
the  time  spent  in  gaining  the  confidence  of  the  pa- 
tient. In  the  presence  of  an  acutely  inflamed  ap- 
pendix, increased  tenderness  on  the  right  side  is 
likely  to  be  elicited,  occasionally  an  inflammatory 
mass. 

The  leukocyte  count  usually  is  12,000  or  more, 
largely  of  pmn.  cells  to  80  per  cent  or  more.  The 
absence  of  such  an  increase  does  not  rule  out,  and 
the  presence  of  leukocytosis  does  not  establish,  the 
diagnosis  of  acute  appendicitis. 

It  is  among  infants  and  younger  children  in  par- 
ticular that  delay  usually  takes  place  and  it  is 
among  these  patients  that  perforation  occurs  with 
such  great  frequency — in  inverse  ration  to  the  age 
of  the  patient  and  to  the  curve  of  incidence. 

There  is  necessity  for  distinguishing  between  ap- 
pendicitis and  pneumonia.  Pain  in  the  thorax, 
characteristic  facies  with  dilatation  of  the  alae 
nasae,  abdominal  breathing  and  grunting  respira- 
tion all  serve  to  indicate  pneumonia.    Vomiting  in 


appendicitis  is  rather  frequent,  rare  in  pneumonia. 
Diarrhea  is  much  more  common  in  diseases  of  the 
respiratory  tract.  The  severe,  constant  and  gener- 
alized nature  of  abdominal  pain  in  pneumonia  dif- 
fers from  the  paroxysmal,  localized  pain  of  appen- 
dicitis. The  abdominal  tenderness  in  pneumonia  is 
usually  marked,  but  it  is  possible  to  press  deeply 
without  increase  of  discomfort.  In  appendicitis  the 
opposite  is  true.  The  rectal  examination  usually 
will  elicit  more  tenderness  on  the  right  in  cases  of 
appendicitis.  The  leukocyte  count  in  pneumonia 
and  the  temperature  are  higher.  If  the  history, 
physical  examination  and  leukocyte  count  do  not 
remove  doubt,  make  a  roentgenogram  of  the  thorax. 

Two  conditions  usually"  impossible  to  distinguish 
from  acute  appendicitis  are  inflamed  Meckel's 
diverticulum  and  acute  mesenteric  adenitis.  It 
would  be  an  error  to  close  the  abdomen  after  re- 
moval of  a  normal-appearing  appendix  without  the 
making  of  a  search  for  more  definite  signs  of  dis- 
ease. If  there  is  a  historv  of  intermittent  melena, 
the  presence  of  Meckel's  diverticulum  may  be 
strongly  suspected.  Children  who  are  well  nour- 
ished are  bountifully  supplied  with  lymphoid  tissue. 
To  be  certain  that  acute  mesenteric  adenitis  is  the 
cause  of  the  symptoms,  it  is  necessary  to  remove  a 
lymph  node  and  demonstrate  by  pathologic  exam- 
ination the  presence  of  acute  inflammation. 

Of  abdominal  pain,  generalized  tenderness  and 
rigidity  among  infants  and  children  the  most  com- 
mon cause  is  perforated  appendix  with  spread  of 
infection  throughout  the  peritoneal  cavity.  Primary 
peritonitis  may  be  present  without  any  of  the  three 
cardinal  signs  of  peritoneal  infection.  It  has  hap- 
pened at  the  clinic  that  an  infant  suddenly  became 
very  ill,  presented  the  picture  of  severe  intoxication 
with  ashen-gray  pallor,  sunken  eves,  high  fever  and 
marked  leukocytosis,  and  died  within  36  hours 
without  evident  abdominal  tenderness,  rigidity  or 
distention,  only  to  have  demonstrated  at  necropsy 
the  fact  that  the  cause  of  illness  and  death  was 
acute  primary  peritonitis. 

A  distended  bladder  caused  by  acute  retention 
of  urine  will  explain  some  masses,  the  catheter  will 
diagnose  from  other  conditions. 

Hydronephrosis  may  manifest  itself  in  an  acute 
manner. 

Cysts  of  the  mesentery,  omentum  and  spleen 
rarely  give  rise  to  acute  symptoms  and  although 
they  are  easily  palpable  after  they  have  attained 
considerable  size,  are  usually  present  for  long  pe- 
riods before  they  are  discovered. 

Pelvic  tumors  most  frequently  arise  from  the 
ovaries.  If  pedunculated  and  become  twisted,  se- 
vere pain,  abdominal  tenderness,  vomiting  and  leu- 


September.   1941                                       SOUTHERN  MEDICINE  &  SURGERY  495 

kocytosis  may  follow.   Although  the  suspicion  may  Prevention  of  Postoperative  Wound  Infections: 

be  entertained  that  such  a  tumor  is  present,  the  Two  chief  sources  of  operative  wound  infections, 

diagnosis  is  seldom  made  for  children  until  the  time  aside  from  infection  introduced  into  the  wound  by 

of  operation.  operating  in  an  infected  field,  are  the  skin  and  the 

...            .,            ,   •„„„,  operating  room  air.   The  number  of  bacteria  in  the 

As  to  trauma  to  the  abdomen  the  most  impor-  ..,..,,         ,     t             f^Q  T,lirv,uor  „f  ™>r 

. ,        .       .                     ,                      /-„!„,.  air  is  directly  dependent  upon  the  number  ot  per- 

tant  consideration  is  rupture  of  a  viscus.     Color,  ... 

i           i          r  u          i  u-     „   a  ov„  sons  in  the  room, 

respiration,  pulse,  values  of  hemoglobin  and  ery-  _ 

throcvtes  may  be  helpful.  Ninety-eight  per  cent  of  the  organisms  on  the 

In 'cases  in  which  injurv  has  been  extensive,  the  skin  can  be  removed  by  10  minutes  scrubbing  with 

child  probably  will  be  in  such  shock  as  to  mask  soap,  under  running  water,  the  hands  then  rinsed 

some  of  the  abdominal  signs.   As  the  obvious  indi-  in  70%  alcohol.  We  have  not  found  that  the  num- 

cations  for  antishock  treatment  are  carried  out,  re-  ber  of  bacteria  increases  during  the  wearing  of  rub- 

peated  careful  examination  of  the  abdomen  will  be  ber  gloves,  indicating  that  rescrubbing  is  not  nec- 

of  most  help  in  elicitation  of  points  of  tenderness,  essary  between  operations  or  if  glove  is  punctured 

Injurv  to  each  of  the  viscera  may  result  in  obser-  during  an  operation. 

ations  that  are  indicative  of  the  special  viscus  in-  The  skin  should  be  washed  with  soap  and  water; 

jure(j.  then  acetone  as  a  fat  solvent;   and,  finally,  three 

The  organ  most  frequently  injured  is  the  spleen,  applications  should  be  made  of  the  antiseptic  de- 

and  perhaps  secondly  the  liver.  scribed  hitherto.    Time  should  be  given  for  each 

; . —  application  to  dry  before  putting  on  the  next  coat. 

THERAPEUTICS  Treatment  of  Wounds:    Never  use  any  alcoholic 

T    r-   xt         »   r.     *j;      c  -  *  t>    i     wr  antiseptic  in  a  wound!    Let  live  tissues  live!    The 

J.  F.  Nash,  M.  D.,  Editor,  Saint  Pauls,  N.  C.  ,     ,  .                  ,     ,                  j               u        i          ~a 

;  area  of  skin  around  the  wound  may  be  cleansed 

SURGERY  IN  GENERAL  PRACTICE*  **  we^  ^h  soaP  and  water,  defatted  with  acetone, 

The  practical  information  contained  in  this  and  Painted  with  the  mercuric-alcohol-acetone  an- 

Symposium  will  greatly  assist  any  general  practi-  tiseptic.   The  wound  itself  is  best  washed  out  with 

tioner  to  handle  many  of  his  surgical  cases  in  such  physiologic    saline    solution.     Irrigations    of    y2Jo 

a  way  as  to  be  satisfactory  to  him  and  to  his  pa-  (1:200)  iodine,  aqueous,  do  not  injure  subcutane- 

tients.    It   is  refreshing  to  see  a  medical  writing  <™s  tissues.    A  wound  can  cleanse  itself  of  many 

which  frankly  considers  cost.  infections.    I  have  shown  that  wound  healing  time 

is  doubled  by  applying  an  antiseptic  tincture  in  a 
I.  M.  V.  Novak  wound 
The  Cheapest  Antiseptic:    After  extensive  clin- 
ical and  experimental  work,  the  following  formula  Inexpensive   Instrument   Sterilization:     The   use 
was  found  to  be  as  effective  as  any  antiseptic  on  of  a  2%  compound  cresol  solution  and  5%  glycerin, 
the  market.   In  quantities,  it  can  be  made  for  35c  a  >"  a  mixture  of  equal  parts  of  alcohol  and  water, 
]]on  for  sterilization  of  instruments,  has  proved  effec- 
'      .    .   ,„.w,                               ,,,„   „„  tive.   All  pathogenic  bacteria  are  killed  in  one  min- 

Alcohol    (93%)    525.0    c.c.  ,          .                  _,,  .          .               .              ,     , 

Acetone  loo.o  ute  or  slightly  longer.    This  mixture  is  much  less 

Cresol,  U.  S.  P 5.0  expensive  than  commercial  preparations  used   for 

Mercuric  chloride  0.7   Gm.  sterilization  of  knives,  scissors,  and  other  instru- 

^"iTiuchsin 008  ments.   The  cresol  solution  also  prevents  rusting. 

Water  q.s    ad     .                              ,..   1000.0    c.c  n    Ra]ph  T    Rnight 

It  is  quick-drying,  quick-acting,  is  not  injurious  ,                 ,    . 

7.      ,      /    &V       ,.     .  .      ,,        ,  .     ,.     .  Morphine    Intravenously:     If   a    >sth    or    l/6th 

to  the  skin  (unless  the  patient  is  allowed  to  lie  in  .      f                               -'           .      '      .              . 

.  .  ,           ,               ..                                ,  grain  dose  does  not  stop  the  pain  within   10  min- 

a  puddle  of  it),  to  the  operating  room  personnel,  °                                       V/i-wi.  *     1  /^n.    u     u  u= 

F                      '      .           \,       ,        .  .     j  utes.  a  further  dose  of  l/12th  to  1  /6th  should  be 

or  to  linens,  and   is  capable  of  sustained  action.  .                         ,.,.,         '.     .            .                    ,  , 

•1   ,.              .  ,  .        .     .    ,           ,            ,    ,  given  slowly,  until  the  patient  experiences  complete 

Ordinary  rubbing  alcohol  may  be  used  (recomput-  °           ™.         ..     ,  .        .           t.             *              *  •- 

,   3  .         ,                       J  ^     ,       .1            ,  relief.   This  method  is  safe,  as  the  exact  amount  is 

ing    the    formula    to    compensate    for    the    weaker  .                                                                  .         , 

.    ,       ,     ,    ,.      .,  .          .  .        ..       c     .  given  that   the  patient  needs.    When  given  nvpo- 

strength  of  the  alcohol  .    It  is  an  interesting  fact  °       .                  ^                           .         ,° 

„„^      ,    ,    ,      -,,  ,  .,,            •  dermically,  one  must  wait  for  half  an  hour  or  more 

that  50  to   70rr    alcohol  will  kill  organisms  more  ■"                                                 ,           .... 

.  ,  ,      .          .„    ,     „„_,     .         .,  before  one  can  determine  if  a  further  dose  will  be 

quickly  than  will  the  90%  strength.  ,       .        ,    .                , 

M         J  needed,  and  then  guess  as  to  the  size  of  the  second 

•Highlights  of  an  intensive  postgraduate  course  siven  by  the  dose.    After  complete  relief  is    obtained,    a    small 

^ilhi?iSfcSo?^Jri«~1AQledicine■  March  10''7'  154°'  dose  maY  be  given  hypodermically,  if  needed,  to 

,k"<A"nf  tfC.kC0TT?vUt°y,s  '"(MiZr1™  arc  mcmhcr'  of  maintain  the  effect. 

the  faculty  of  the  University  of  Minnesota. 


SOUTHERN  MEDICINE  cr  SURGERY 


September,   1941 


Painful  examinations  or  operations  under  local 
anesthesia  are  made  much  more  comfortable  by 
the  intravenous  injection  of  morphine  just  prior  to 
commencing  the  operation.  Here  the  dose  cannot 
be  gaged  by  the  relief  of  pain,  so  the  patient  must 
be  asked  if  he  experiences  dizziness,  weakness, 
drowsiness,  warmth,  numbness,  tingling,  neuralgic 
pain,  or  backache.  When  one  such  symptom  ap- 
pears, the  injection  is  stopped.  The  morphine  is 
dissolved  in  2  c.c.  of  distilled  water  and  injected 
slowly  (2  min.) 

The  patient  who  has  received  Pentothal  Sodium 
or  Evipal  intravenously  must  be  carefully  guarded 
for  some  hours  afterward.  Although  he  may  appear 
to  be  normal  and  may  be  able  to  answer  questions, 
his  coordination  is  poor  for  several  hours  and  he 
should  not  be  allowed  to  walk  through  traffic  or 
drive  a  car,  but  should  be  sent  home  in  the  care  of 
a  responsible  person.  Pentothal  sodium  is  pre- 
ferred, because  1)  relaxation  is  better;  2)  its  ac- 
tion is  longer;  3)  there  is  less  coughing  and  hic- 
cuping:  and  4)  excitement  is  less. 

Local  Anesthesia:  The  first  injection  of  pro- 
caine should  be  made  between  the  lesion  and  the 
source  of  nerve  supply,  so  that,  in  as  short  a  time 
as  possible,  the  further  injections  will  be  made  in 
anesthetized  tissues. 

Local  anesthesia,  obtained  by  infiltration  of  the 
landmarks  with  a  needle  while  injecting  any 
solution,  is  being  much  used  for  gynecologic  proce- 
dures. Probably,  the  ideal  anesthetic  for  upper  ab- 
dominal surgery  is  the  combination  of  a  small  dose 
of  spinal  anesthetic  with  a  light  general  anesthetic, 
or  the  use  of  pentothal  sodium. 

Be  Very  slow  and  gentle  in  approaching  bony 
landmarks  with  a  needle  while  injecting  procain 
solution.  If  the  needle  is  forcibly  jabbed  against 
the  bone,  the  point  will  be  bent  back  into  a  hook 
and  the  tissues  will  be  torn  on  its  withdrawal. 
When  infiltrating  along  a  line  the  needle  should  be 
pulled  out  until  the  point  is  in  the  subcutaneous 
fat  before  it  is  inserted  in  another  direction. 

Vinyl  Ether  administered  on  a  small  gauze  mask 
directly  over  the  nose  is  a  very  effective  obstetric 
anesthetic. 

We  routinely  aspirate  bronchial  secretions 
through  a  bronchoscope  after  every  thoracic  and 
upper  abdominal  operation.  Apparently,  it  mark- 
edly decreases  the  number  of  postoperative  pneu- 
monias and  pulmonary  atelectases. 

Ill  A.  A.  Zierold 

Colic:    Do  not  make  a  diagnosis  of  gallbladder 

dysfunction  if  the  patient  does  not  have  definite 

attacks  of  pain.    Do  not  carry  out  a  gallbladder 

operation  unless  the  patient  has  recurring  colics. 


The  patient  who  has  had  biliary  colic  will  be  re- 
lieved by  proper  surgery. 

The  phrase,  "fat  intolerance/'  should  be  dis- 
carded, as  these  patients  are  often  able  to  eat  a 
high-fat  diet.  Distress  after  eating  fatty  meals  is 
often  due  to  the  associated  achlorhydria. 

Bowell  distress,  due  to  cathartics  or  roughage,  is 
often  misdiagnosed  as  mild,  chronic  cholecystitis. 
"Dyspepsia"  may  be  entirely  due  to  a  decreased 
amount  of  gastric  acidity. 

Acute  Cholecystitis:  Conservative  management 
(local  heat,  complete  rest  in  bed,  analgesics  and 
nasal  suction,  if  needed)  should  be  used  in  the 
treatment  of  acute  cholecystitis.  The  analogy  to 
acute  appendicitis  is  a  poor  one,  as  only  3%  of 
gallbladders  perforate  and  only  a  few  of  these  re- 
sult fatally,  thus  giving  a  mortality  rate  of  1  to 
lyife.  A  mortality  rate  of  3  to  6rr  is  encountered 
when  the  acutely  obstructed  gallbladder  is  attacked 
surgically.  Empyema  of  the  gallbladder  is  a  mis- 
nomer, as  culture  of  the  purulent-appearing  fluid 
in  these  gallbladders  reveals  bacteria  in  less  than 

50rr. 

IV  O.  K.  Campbell 

Colonic  Obstruction:  This  is  not  a  surgical 
emergency.  The  bowel  will  has  been  thinned  by 
pressure  of  contained  gas  and  fecal  material,  and 
does  not  respond  well  to  suturing.  Contamination 
is  almost  inevitable.  The  mortality  rate  of  any 
surgical  relief  of  colonic  obstruction  is  in  the  neigh- 
borhood of  30% . 

Medical  Decompression:  This  routine  should  be 
used,  even  if  there  is  no  clinical  evidence  of  ob- 
struction (crampy  pains,  obstipation): 

1.  A  low-residue  diet. 

2.  Large  amounts  of  mineral  oil  (3  to  5  ounces 
of  mineral  oil  daily,  in  divided  doses)  until  leaking 
occurs. 

3.  Daily  saline  enemas. 

4.  Daily  injections  of  200  mg.  of  cevitamic  acid 
(vitamin  C). 

5.  Intravenous  injections  of  dextrose  solution 
(50  c.c.  of  a  50%  solution). 


THE  COBRA  STRIKES  AT  PAIN 
(P.   E    Craig,  Coffeyville.   Kansas,  in  Clin.  Med..   Aug.) 

Sixtv-six  patients,  exhibiting  a  wide  variety  of  painful 
conditions,  were  treated  with  cobra  venom,  and  all  but  one 
experienced  relief. 

Cobra  venom  is  a  powerful  analgesic  of  relatively  low 
toxicity,  which  effectually  controls  pain  by  its  cumulative 
action  on  the  central  nervous  system. 

It  is  safe,  dependable,  and  non-habit  forming  and,  in 
my  opinion,  is  a  valuable  therapeutic  agent  which  has  an 
ever-widening  field  of  usefulness. 


Giardia,  an  organism  generally  considered  harmless,  may 
turn  out  to  be  disease-producing  in  man. 


September,    1941 


SOUTHERN  MEDICINE  &  SURGERY 


OPHTHALMOLOGY 

Herbert  C.  Neblett,  M.  D.,  Editor,  Charlotte,  N.  C. 


THE  LAYMAN'S  VIEWPOINT  OF  A   CLEANS- 
ING    EYE  WASH  AND  OTHER  INGRE- 
DIENTS FOR  LIDS  AND  EYESACS 

Oculists  and  others  of  the  medical  profession 
have  the  opportunity  to  use  their  efforts  to  educate 
the  public  against  the  ever-increasing  viewpoint 
that  some  form  of  eye  treatment,  self-prescribed 
and  administered,  is  necessary  for  the  maintenance 
of  the  health  of  the  eyes.  This  belief  has  been  en- 
gendered bv  makers  and  dispensers  of  proprietary 
preparations  for  the  eyes  through  well  laid  schemes 
of  advertising,  through  cosmeticians  and  those  who 
make  their  supplies,  as  the  result  of  the  desire  of 
womankind  in  particular  to  resort  to  all  and  sun- 
dry measures  which  they  think  may  improve  the 
appearance  of  their  eyes;  and,  finally,  too  often  by' 
physicians  who,  when  advice  is  sought  for  some 
medication  for  the  eyes,  advise  the  patient  to  use 
this  or  that  medication  in  the  absence  of  any  spe- 
cific reason  or  basis  for  so  doing  and  no  admoni- 
tion as  to  a  specific  period  of  time  to  discontinue 
the  application  of  the  drug. 

The  indiscriminate  and  long  continued  use  of 
the  various  advertised  eye  washes,  lotions,  salves 
and  cosmetics,  as  well  as  those  drugs  specifically 
necessary  in  the  treatment  of  eye  conditions,  has  a 
deleterious  effect  upon  the  mucous  membrane  of 
the  eyes,  the  excretory  apparatus  of  the  lids,  the 
skin  of  the  lids  and  the  eyes  themselves  when  not 
prescribed  for  a  specific  purpose  for  a  specific  pe- 
riod and  under  the  guidance  of  a  physician  who 
should  know  what  drug  or  drugs  are  indicated  and 
when  the  desired  result  is  obtained. 

The  writer  finds  that  too  many  physicians  pre- 
scribe argyrol  ad  lib  for  any  and  all  types  of  eye 
inflammations,  for  symptoms  of  irritation,  for 
"tired  eyes,"  for  infants  and  adults  with  stenosis 
of  the  tear  duct  and  just  as  a  "cure  all." 

Argyrol  has  no  direct  and  specific  action  against 
any  organism  commonly  found  in  the  eye  sacs,  not 
even  the  gonococcus  for  which  it  has  been  advo- 
cated for  years.  It  can  produce  a  permanent  cos- 
metic defacement  of  the  ocular  and  palpebral  mu- 
cous membrane  known  as  argyrosis.  The  writer 
has  seen  a  half  doben  such  cases  in  the  past  year 
who  gave  the  history  of  using  argyrol  for  an  indefi- 
nite period  either  by  prescription  from  a  physician 
or  of  their  own  volition.  Some  gave  the  history  of 
using  a  IS  to  25  per  cent  solution  which  was  a  year 
old  or  older  and  hence  the  solution  had  become 
greatly  concentrated. 

The  writer  not  infrequently  sees  a  patient  who 
uses  a  saturated  solution  of  boric  acid  or  other  eye 


wash  several  times  daily  and  has  been  doing  so  for 
a  protracted  period.  The  same  may  be  said  of 
various  eye  ointments.  In  neither  instance  was 
there  any  reason  for  their  use  save  the  patient's 
viewpoint  that  because  of  the  dust  and  smoke  and 
frhat-not  commonly  present  in  urban  districts  the 
eye  sacs  should  be  washed  out  and  more  frequently 
than  the  face  and  hands  to  say  nothing  of  the  body. 
A  well  known  over-the-counter  eye-drop  solution 
to  be  had  in  practically  all  drug  stores  is  used  by  a 
fairly  large  number  of  people  because  of  its  claim 
to  strengthen  the  eyes  and  make  them  more  bril- 
liant. The  so-called  brilliancy  it  produces  is  the 
constricting  effect  of  the  superficial  blood  vessels  of 
the  mucous  membrane  the  result  of  its  adrenalin 
content.  The  use  of  adrenalin  is  not  without  dan- 
ger in  some  eyes,  especially  in  those  of  the  aged, 
and  in  those  with  actual  or  potential  glaucoma,  be- 
cause of  its  mydriatic  effect  on  the  pupil.  Many, 
especially  women,  use  all  manner  of  dyestuffs  upon 
their  eyelashes,  applied  at  "beauty  parlors"  or  by 
the  individual  personally  via  arduous  and  meticu- 
lous effort  for  the  desired  cosmetic  result.  Some 
people  have  a  sensitive  reaction  to  them  as  well  as 
to  many  ointments  and  drops  commonly  used.  A 
fair  number  of  persons  seem  to  have  presented  a 
mild  to  severe  inflammation  of  the  skin  of  the  lids, 
the  mucous  membrane  of  the  lids  and  globe,  to 
partial  desquamation  of  the  cornea,  from  the  use 
of  these  preparations.  Within  the  year  he  has  had 
four  cases  presenting  a  severe  reaction  of  the  eyes 
from  the  use  of  eye  cosmetics.  Two  of  these  had 
the  cosmetic  applied  in  a  "beauty"  parlor  and  two 
purchased  it  over  the  counter  and  applied  it  per- 
sonally. All  four  cases  led  to  litigation  and  a  gen- 
erous settlement  with  each  individual  by  the  maker 
of  the  product  used.  The  moral  here  would  seem 
to  be  to  protect  the  product  for  the  use  of  the 
many  who  are  gullible  and  resistant  to  its  effects 
as  against  the  few  who  are  non-resistant  to  its  irri- 
tative action. 

Oculists  in  particular  and  physicians  in  general 
should  apprize  their  patients  of  the  uselessness,  and 
often  danger,  of  the  prolonged  use  of  any  eve  wash, 
drops  or  salves  and  the  use  of  cosmetics  about  the 
eyes  and  their  adnexa.  They  should  prescribe  a 
certain  drug,  if  at  all,  for  a  specific  reason  for  a 
specified  time  and  this  under  their  special  super- 
vision; and  at  no  time  to  prescribe  any  drug  for 
use  in  the  eye  indiscriminately  or  as  a  placebo. 
Unless  a  diagnosis  has  been  made  of  a  disease  in 
which  a  known  drug  is  indicated,  to  strongly  advise 
the  patient  against  the  use  of  any  drug  in  the  eye, 
fortifying  this  statement  with  the  explanation  that 
the  tears  with  their  lysozyme  content,  against  the 
common  diseases  of  the  eye  sacs,  are  a  better  eye 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


wash  and  a  better  protector  than  drugs,  that  the 
prolonged  use  of  foreign  ingredients  so  alters  the 
composition  of  the  tears  as  to  destroy  their  bac- 
tericidal effect  thereby  making  the  mucous  mem- 
brane of  the  eyes  less  resistant  to  the  growth  of  the 
commoner  forms,  of  bacteria. 


PUBLIC  HEALTH 

N.  Thomas  Ennett,  M.D.,  Editor,  Greenville,  N.  C. 


MILESTONES  IN  N.  C.  PUBLIC  HEALTH 
Public  health  and  preventive  medicine 
make  so  large  a  part  of  the  daily  work  of  the  pri- 
vate physician  we  feel  safe  in  assuming  that  he  will 
be  interested  in  the  high  lights,  chronologically  ar- 
ranged, of  the  development  of  organized  Public 
Health  in  this  State  as  set  forth  by  Dr.  G.  M. 
Cooper,  Assistant  State  Health  Officer: 

1877  Board  created  by  the  General  Assembly. 
Annual  appropriation,  $100. 

1878  First  educational  Pamphlet  issued.  Subject, 
"Timely  Aid  for  the  Drowned  and  Suffo- 
cated." 

1879  — Dr.  Thomas  F.  Wood  elected  first  Secre- 
tary of  the  Board,  May  21st;  Dr.  S.  S. 
Satchwell  first  President.  Other  legislative 
provisions:  (1)  Chemical  examination  of 
water,  and  (2)  organization  of  county 
boards  of  health  composed  of  all  regular 
practicing  physicians  and,  in  addition,  the 
mayor  of  the  county  town,  the  chairman  of 
the  board  of  county  commissioners  and  the 
county  surveyor.  Four  educational  pamph- 
lets issued.  Subjects:  "Disinfection,  Drain- 
age, Drinking  Water  and  Disinfectants"; 
"Sanitary  Engineering";  "Methods  of  Per- 
forming Post-mortem  Examinations";  "Lim- 
itation and  Prevention  of  Diphtheria." 

1880  A  survey  of  schoolhouses  was  carried  out 
through  the  County  Superintendents  of 
Health.  Most  of  the  schoolhouses  were  of 
one-teacher  size,  of  frame  and  log  construc- 
tion, and  none  of  them  in  rural  districts 
had  any  type  of  privy. 

1881  General  Assembly  passed  a  law  requiring 
regulation  of  vital  statistics  at  annual  tax 
listing;  law  ineffective. 

1882  Dr.  Thomas  F.  Wood,  State  Health  Officer, 
was  President  of  the  North  Carolina  Medi- 
cal Society  and  the  annual  Meeting  was 
held  at  Concord.  At  this  meeting  the  State 
Board  of  Health  appointed  a  committee  for 
each  county  of  one  physician  to  "canvass 
(the  people)  in  the  interest  of  prospective 
legislation"  on  public  health  matters.    The 


chief  items  of  public  health  interest  this 
year  were  the  emphasis  placed  on  the  effec- 
tiveness of  smallpox  vaccination  and  in- 
creasing realization  of  polluted  water  as  a 
source  of  typhoid  fever. 

1883  A  meeting  of  all  county  superintendents  of 
health  was  called  in  Raleigh  early  in  the 
next  session  of  the  Legislature.  One  of  the 
chief  purposes  of  the  proposed  meeting  was 
to  urge  the  enactment  of  vital  statistics  leg- 
islation, and  to  procure  a  small  appropria- 
tion for  printing. 

Several  epidemics  of  smallpox  with  numer- 
ous deaths  were  reported — one  of  the  most 
severe  was  in  Clay  and  Graham  counties. 

1884  Dr.  Wood,  Secretary  and  Treasurer  of  the 
State  Board  of  Health,  made  a  pessimistic 
report.  He  pointed  out  that  it  was  impossi- 
ble to  inaugurate  public  health  work  to  say 
nothing  of  carrying  it  on,  without  money. 

1885  General  Assembly  made  county  boards  of 
health  more  efficient;  allowed  printing  priv- 
ileges not  to  exceed  $250  annually.  Annual 
appropriation,  $2,000. 

These  data  taken  from  the  Twenty-eighth  Biennial  Report  N. 
C  State  Board  of  Health.  July,  193S — June  1940,  and  entitled: 
"The  Chronological  Development  of  Public  Health  Work  in  North 
Carolina." 

{To  be  continued) 


DENTISTRY 

J.   H.   Gotok,   D.  D.  S.,   Editor,   Charlotte,   N.   C. 


DENTAL  FOCI  OF  INFECTION 

Dental  decay  is  the  major  problem  of  dentistry. 
When  evidences  of  infection  are  in  direct  communi- 
cation with  the  outside  world,  drainage  is  more 
easily  established  and  the  dangers  of  systemic  or 
distant  involvement  are  less. 

The  cause  of  a  radiolucent  area  is  usually  de- 
struction, as:  1)  In  caries  due  to  actual  loss  of 
tooth  substance;  2)  when  a  root  of  a  tooth  has 
been  removed,  destroyed  or  resorbed;  and  3)  in 
bone  with  an  abscess;  granuloma  or  cyst;  with 
sequestration  in  osteomyelitis;  with  a  destructive 
tumor.  Radiopaque  areas  deserve  less  considera- 
tion. 

When  successive  x-ray  pictures  originally  reveal  a 
radiolucent  area,  and  subsequently  more  and  more 
radiopacitv,  with  a  history  and  symptoms  and  signs 
suggesting  a  dental  focus,  such  evidence  is  con- 
vincing that  the  probability  of  such  a  lesion  caus- 
ing systemic  manifestations  is  less  and  less. 

The  sedimentation  test  only  exceptionally  may 
indicate  the  activity  of  a  dental  focal  infection. 

Periodontoclasia  (pyorrhea)  represents  another 
major  problem  as  a  probable  dental  focus.    This 

ew  York  City,  in  Bull.   N.   Y.  Acid,  of 
Med.,  Aug  ) 


1,  C.  G.   Darlingto 


September,    1941 


SOUTHERN  MEDICINE  &  SURGERY 


499 


cannot  be  dismissed  lightly.  Possibilities  as  to  the 
modus  operandi  should  be  mentioned:  Absorption 
of  bacteria  or  their  products  directly  into  the  sys- 
temic circulation  from  pockets;  an  exudation  of 
purulent  or  infected  material  into  the  mouth  and 
subsequent  swallowing  of  such  infected  material; 
lastly,  interference  with  mastication  as  the  result 
of  loose  teeth.  While  the  positive  proof  in  support 
of  any  of  these  contentions  is  difficult,  appreciation 
of  the  fact  that  most  of  the  lesions  are  open  lesions 
at  least  diminishes  the  probability  of  absorption  of 
bacteria  or  their  products  directly  into  the  systemic 
circulation. 

In  pyorrhea,  the  chief  pathological  features  are: 
alveolar  resorption,  pocket  formation,  loosening  of 
the  teeth  with  or  without  suppuration.  Usually, 
calculus  and  evidences  of  infection  in  pockets  are 
present. 

Information  as  to  the  probable  cause  and  length 
of  time  retention  has  been  present  will  be  very 
helpful  in  evaluating  such  a  focus.  Where  roots 
have  been  retained  for  years  and  the  x-ray  is  nega- 
tive or  possibly  shows  condensation  in  contrast  to 
a  radiolucent  area,  there  is  less  probability  of  an 
active  focus. 

When  a  tooth  is  traumatized  so  severely  as  to 
completely  sever  its  periodontal  attachment  with 
death  of  the  pulp,  this  may  or  may  not  act  as  a 
focus.  Usually,  such  injury  will  result  in  loss  of 
the  tooth  within  a  short  time.  In  such  cases,  on 
account  of  open  socket  and  free  drainage,  if  infec- 
tion does  occur  the  local  defense  will  usually  be 
adequate. 

Inadequate  root  canal  therapy,  sometimes  the 
fault  of  the  dentist,  often  the  neglect  of  the  pa- 
tient, may  be  responsible  for  dental  foci.  All  pulp- 
less  teeth  should  not  be  sacrificed  on  the  altar  of 
focal  infection. 

Radicular  granulomas  practically  are  all  associ- 
ated with  devitalized  teeth,  sometimes  a  tooth 
which  has  had  root  canal  therapy,  but  more  often 
has  not.  They  represent  infection,  possibly  of  a 
latent  type,  and  are  thereby  a  menace. 

They  are  present  in  many  individuals  whose 
health  is  excellent  and  remains  so  indefinitely. 

An  extensive  list  of  conditions  have  been  attrib- 
uted to  dental  foci.  The  organs  involved  include: 
joints,  muscles,  nerves,  kidney,  heart,  eye,  gastro- 
intestinal tract,  nasopharynx  and  gallbladder.  As 
to  relation  of  dental  infection  to  heart  disease, 
comment  will  be  made  only  on  the  relation  of  ex- 
tractions to  endocarditis.  Several  reports,  have 
been  made  on  subacute  bacterial  endocarditis  de- 
veloping within  a  short  time  after  extraction  of  in- 
fected teeth.  At  Montefiore  Hospital,  of  215  hos- 
pital cardiac   cases   of   rheumatic,   arteriosclerotic 


and  syphilitiic  patients,  from  whom  a  total  of  1126 
teeth  had  been  extracted  under  local  anesthesia, 
there  was  no  case  of  subacute  bacterial  endocardi- 
tis. 

More  direct  mechanisms  and  pathways  of  ex- 
tension have  been  emphasized  by  several  authors 
in  affections  of  the  antrum  and  eye.  In  striking 
contrast  to  the  other  parts  of  the  body,  the  patho- 
genesis strongly  indicates  a  direct  extension  or 
direct  pressure  on  dental  nerves  rather  than  the 
usually  accepted  explanation  of  hematogenous 
spread. 

Although  the  ravages  of  infection  may  be  in- 
capable of  repair,  the  progress  of  infection  may  be 
arrested  and  the  source  eradicated. 


HISTORIC  MEDICINE 


MERCURIUS'  PLAGUE-TRACT 

Whoever  might  be  disposed  to  believe  that  the 
sects  of  our  own  day  who  claim  to  cure  by  being 
in  direct  partnership  with  God,  and  loudly  disclaim 
their  love  for  filthy  lucre,  while  showing  the  great- 
est avarice  in  obtaining  all  of  it  they  possibly  can, 
will  do  well  to  read  attentively  the  following  ab- 
stract of  an  instructive  article.1 

This  is  the  vade-mecum  of  an  itinerant  and  pic- 
turesque Italian  charlatan  of  the  late  15th  and 
early  16th  century,  Giovanni  Mercurio  of  Correg- 
gio.  It  gives  a  vivid,  if  rather  terrifying,  picture  of 
a  society  held  in  subjection  by  superstition  and  be- 
lief in  magic.  It  is  well  to  recall  that  newspapers, 
magazines  and  other  publications  of  our  own  day 
freely  advertise  "remedies"  that,  no  less  than  those 
of  Mercurius,  ask  for  ,and  receive  a  total  "suspen- 
sion of  disbelief."  The  tides  of  ignorance  and  su- 
perstition recede  slowly. 

The  title,  in  abstract,  is: 

AGAINST  THE  PLAGUE:  WHOEVER  IS  A 
THIEF  AND  INIQUITOUS  WILL  VERY 
RASHLY  ATTEMPT  TO  PRINT  THIS  SAME 
WITHOUT  THE  AUTHOR'S  PERMISSION. 
THE  PESTILENCE  WILL  CONSUME  HIM 
WITH  SWIFT  &  VENGEFUL  FURY. 

This  and  the  text's  essence  are  reproduced  as 
illustrating  the  fact  that  the  ways  of  the  charlatan 
have  changed  little  in  the  centuries  since  Mercurius 
(or  -o)  flourished. 

I,  John  Mercury  of  Correggio,  following  the  in- 
ner, celestial,  and  spiritual  man,  one  endowed, 
finally,  (through  the  grace  of  God)  with  the  triple 
(namely,  earthly,  celestial,  and  divine);  I,  myself, 
(depending  on  neither  the  boastfulness  of  the  em- 

1.  W    B.   McDanicI,   II,  Philadelphia,   in    Trans,   Col.   of   Phys. 
of  Phila.,  June) 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


pirics,  nor  the  artifices  of  the  sophists,  nor  for  the 
sake  of  unspeakable  or  filthy  lucre;  but,  rather,  on 
the  fervor  of  universal  charity  and  the  divine  love 
of  ones  neighbor)  thus  openly  speak  with  a  her- 
ald's voice,  and  I  say: 

Whoever  in  this  exalted,  glorious,  and  most  cele- 
brated city  has  ears  and  eyes  for  taking  heed,  let 
him  do  so;  and  who  takes  heed,  let  him  learn  ;and 
whoso  desires  and  wishes  to  have  a  remedy  and 
medicine  straight  from  God,  let  him  hasten  to  me 
quickly  (from  every  direction)  and  with  confi- 
dence. Quickly,  and  I  indeed  with  balanced  scale 
and  liberal  hand  will  share  with  him  the  medicine 
itself,  in  the  sign  and  name,  the  word  and  spirit  of 
God  the  Lord  Jesus  Christ.  If  a  man  were  to  give 
thirty  silver  pieces  (thinking  thus  to  have  paid  a 
fair  price  for  it),  he  would  be  valuing  it  at  nothing 
at  all.  Be  not  afraid,  and  be  not  anxious;  nor  let 
your  heart  be  struck  with  terror,  but  rather  let  it 
be  comforted,  since  (as  we  read  in  Holv  Writ) 
God  does  not  make  death,  nor  rejoice  in  the  de- 
struction of  the  living.  For  (as  all  the  wise  assert) 
God  and  nature  neither  abound  with  superfluous, 
nor  yet  fail  with  what  is  needed. 

Let  the  sick  man  hold  fast  to  this  thought,  who- 
ever he  may  be:  that,  when  this  lash  from  God  is 
removed,  he  will  escape  wholly,  and  be  completely 
free  from,  everv  other  fatal  and  savage  pestilence. 

The  cautious  and  pious  will  seek  hand  and  foot 
to  obtain  this  miraculous  and  incomparable  medi- 
cine of  ours,  which  preserves  and  guards  a  healthv 
man  from  all  contagions  of  the  plague-bearing  virus 
(not  only  those  of  which  I  have  so  far  made  men- 
tion in  this  present  proclamation),  but  which  also, 
(by  the  widest  projection  of  the  divine  charity 
hitherto,  by  the  mystery  of  eternity,  and  by  the 
work  and  sacrament  of  the  united  and  individual 
sacrosanct  Trinity),  most  agreeable  cures,  and 
heals,  and  liberates  (as  if  by  a  miracle).  And  so, 
indeed,  with  all  their  hearts  and  with  joy  and  glad- 
ness, they  will  render  thanks  and  honor  and  praise 
and  all  benediction  to  Him,  the  Creator  of  all  heal- 
ing, who  alone  smites  and  heals,  wounds  and  makes 
sound,  who  leads  us  to  the  very  portals  of  death 
and  bringeth  us  back,  who  is  death  to  Death  and 
destruction  to  the  infernal  regions. 

This  privilege  (of  distributing  and  dispensing  the 
gift  of  the  same  Lord  God)  has,  without  question, 
been  granted  to  us  alone.  Whoever  is  incredulous 
will  show  himself  crafty  and  deceitful.  The  curse 
and  anathema  of  the  dread  and  fearful  Judge  him- 
self (even  as  we  said  in  the  beginning)  will  con- 
sume him  most  horribly  and  pitilessly. 


SURGERY 

Geo.   H.   Bunch,  M.   D.,  Editor,   Columbia,   S.   C. 


Spontaneous  pneumothorax  may  simulate  acute  coro- 
nary occlusion. 


.  THE  ACUTELY  DISEASED  APPENDIX 
WHICH  RUPTURES  IN  DELIVERY 

The  acutely  diseased  appendix  may  present  me- 
chanical and  physical  difficulties  to  delivery  which 
may  make  operative  removal  without  rupture  im- 
possible. Every  surgeon  doing  much  abdominal 
work  has  had  the  appendix  rupture  in  delivery. 
Certain  precautions,  carefully  observed,  materially 
lessen  the  incidence. 

The  first  essential  is  complete  relaxation  of  the 
abdominal  wall.  This,  in  our  e  cperience,  is  best 
assured,  except  in  small  children,  by  the  adminis- 
tration of  a  spinal  anesthetic. 

Next,  it  is  important  that  the  abdominal  incision 
be  placed  so  that  it  will  best  afford  adequate  access 
to  cecum  and  appendix.  When  the  preoperative 
diagnosis  of  acute  appendicitis  is  not  in  doubt  we 
use  the  muscle-splitting  incision.  If  exposure  proves 
inadequate  the  incision  in  the  skin  and  in  the  ex- 
ternal oblique  muscle  may  be  extended  upward  or 
downward  as  indicated  and  an  additional  muscle- 
splitting  opening  be  made  through  the  internal 
oblique  at  the  desired  level.  By  gently  packing  off 
the  small  intestine  with  warm  moist  laparotomy 
pads  the  cecum  may  be  exposed  and  the  base  of 
the  appendix  be  recognized.  Traction  made  on  a 
tape  passed  through  its  mesentery  and  around  the 
base  facilitates  identification  and  freeing  of  the  dis- 
tal portion  of  the  appendix. 

The  third  essential  is  deliberation  and  gentleness 
in  the  handling  of  a  structure  which  is  often  gan- 
grenous and  adherent,  and  deeply  situated  and  dif- 
ficult of  access. 

The  subject  of  rupture  of  the  appendix  at  opera- 
tion aptly  illustrates  a  fundamental  principle  in  the 
care  and  in  the  prognosis  of  cases  of  early  perfora- 
tion. In  our  experience  cases  operated  upon  shortly 
after  perforation,  before  peritonitis  has  begun, 
rarely  develop  peritonitis  if,  along  with  the  appen- 
dix, the  escaping  infectious  appendiceal  contents 
are  removed.  With  this  done  and  continuous  soil- 
ing prevented  the  peritoneum  in  most  cases  is  suf- 
ficiently resistant  to  infection  to  successfully  over- 
come the  contamination.  We  do  not  remember  to 
have  lost  a  patient  whose  appendix  ruptured  in  de- 
livery. It  is  surprising  that,  in  sharp  contrast  to 
this  experience  and  the  principle  which  we  believe 
it  illustrates,  in  a  series  of  nearly  20,000  clinical 
records  in  a  statewide  survey  of  the  cases  of  acute 
appendicitis  in  Pennsylvania,  Bower  (5.  G.  &  0., 
July,  1941)  found  that  of  the  70  patients  who  suf- 
fered rupture  of  the  appendix  at  operation,  58  died 
^-a  mortality  rate  of  83  per  cent.    The  mortality 


September,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


of  the  localizing,  spreading  or  abscess  groups  was 
24.35,  24.05,  and  1.2  per  cent,  respectively.  This 
investigator  says:  "Most  of  these  patients  devel- 
oped high  fever  and  tachycardia  almost  immediate- 
ly after  operation.  Some  of  them  died  so  quickly 
that  their  abdominal  walls  were  rigid  at  death. 
Distention,  the  usual  accompaniment  of  spreading 
peritonitis  deaths,  did  not  have  time  to  develop. 
Some  of  them  never  regained  consciousness  and 
died  in  a  toxic  delirium." 

In  every  series  of  cases  of  acute  appendicitis 
seen  by  us  in  the  literature  the  greatest  mortality 
has  been  in  the  cases  of  acute  perforation  with  dif- 
fuse spreading  peritonitis.  We  cannot  understand 
why  in  the  Pennsylvania  series  the  mortality 
should  be  greatest  in  the  early  cases  in  which  the 
appendix  was  removed  before  peritonitis  has  devel- 
oped— a  group  with  which  our  own  experience  has 
been  quite  gratifying- 


TUBERCULOSIS 

J.  Donnelly,  M.  D.,  Editor,  Charlotte,  N.  C. 


CLOSED  INTRAPLEURAL  PNEUMOLYSIS 
Collapse  therapy,  more  particularly  artificial 
pneumothorax,  is  the  most  valuable  and  effec- 
tive method  of  treatment  which  has  been  intro- 
duced since  the  discovery  of  the  cause  of  the  dis- 
ease. The  effectiveness  of  this  method  of  treatment 
is  oftentimes  interfered  with  by  the  presence  of 
adhesions,  varying  from  a  single  cord-like  adhesion 
to  an  extensive  adherence  of  the  two  layers  of  the 
pleura,  completely  obliterating  the  pleural  space. 
Some  degree  of  pleural  involvement  may  be  ex- 
pected in  almost  every  tuberculous  infection  of  the 
lungs  which  has  progressed  beyond  the  minimal 
stage,  and  this  fact  is  important  because  closure  of 
pulmonary  cavities,  essential  in  collapse  therapy, 
may  be  prevented  by  adherent  pleurae. 

In  an  article  in  the  August,  1941,  issue  of  Dis- 
eases of  the  Chest,  Hoffman  and  Brentigan  quote 
Alexander's  experience  of,  in  42-50"/<  of  his  cases, 
effective  collapse  being  prevented  in  varying  de- 
grees by  pleural  adhesions.  These  authors  state 
that,  in  their  series  of  100  consecutive  cases  in 
which  pneumothorax  treatment  was  tried,  in  26% 
there  was  complete,  or  so  nearly  complete,  oblit- 
eration of  the  pleural  space,  that  only  slight  col- 
lapse could  be  obtained,  and  in  62%  adhesions 
prevented  a  satisfactory  collapse. 

In  such  cases  pneumothorax  is  inadequate,  and 
for  the  great  majority  they  advocate  closed  pneu- 
molysis, or  the  severing  of  the  adhesions  by  means 
of  the  cautery,  as  the  method  of  choice.  Some  pre- 
fer to  do  a  phrenic  neve  interruption  first,  follow- 
ing, if  this  is  unsuccessful,  with  a  closed  pneumoly- 


sis. The  closed  pneumolysis  they  regard  is  the 
proper  primary  supplementary  measure,  because 
phrenic  nerve  surgery  rarely  causes  a  sufficient  rise 
of  the  diaphragm  for  cavity  closure,  particularly 
when  the  adhesions  are  horizontal,  and  time  is 
wasted  in  waiting  to  see  if  the  phrenic  interruption 
will  get  the  desired  results.  The  routine  use  of  the 
phrenic  operation  is  deprecated.  Once  a  collapse  is 
started  the  closing  of  the  cavity,  or  the  control  of 
the  disease,  should  be  accomplished  as  quickly  as 
can  be  done  with  safety. 

High  intrapleural  pressures  are  opposed  because 
of  the  danger  of  rupture  of  the  lung,  and  from  the 
fact  that  the  majority  of  pleural  adhesions  in  these 
cases  are  too  thick  to  stretch  to  a  degree  sufficient 
to  allow  closure  of  cavities.  In  fact,  the  writers 
believe  that  the  reverse  of  stretching  is  likely  to 
occur  because  pleural  adhesions  are  the  result  of 
tuberculous  lesions  in  the  two  layers  of  the  pleura 
and  it  is  characteristic  of  fibrous  tissue  to  contract. 
Is  is  not  an  infrequent  occurrence  for  the  shorten- 
ing of  pleural  adhesions  to  completely  close  the 
pneumothorax  space,  and  this  quite  rapidly. 

There  is  general  agreement  that  the  greater  pro- 
portion of  satisfactory  pneumothoraces  become  suc- 
cessful within  three  months  and  that  to  continue 
partially  successful  pneumothorax  beyond  this  time 
is  unwise.  Although  the  authors  admit  that  there 
is  no  best  time  interval,  they  favor  shortening  this 
three  months'  waiting  period,  as  young  adhesions 
are  easier  to  cut  and  bleeding  is  less  likely  to  occur. 
A  thoracoscopic  examination  is  advised  as  soon  as 
a  pneumothorax  is  found  to  be  ineffectual,  and  the 
adhesions  severed  immediately,  if  the  operation  is 
considered  safe.  The  authors  have  found  all  types 
of  x-ray  unsatisfactory  in  judging  whether  or  not 
an  adhesion  can  be  cut.  The  ideal  pneumothorax 
is  the  selective  type  in  which  the  diseased  portion 
of  the  lung  remains  collapsed,  the  sound  part  only 
partially  collapsed.  Adhesions  prevent  selective 
collapse,  hence  it  is  necessary  to  sever  the  adhe- 
sions in  order  to  obtain  this  result.  The  writers 
prefer  the  galvano-cautery  to  the  electro-cautery 
for  this  work,  although  they  state  that  the  indi- 
vidual operator  will  use  that  instrument  which  has 
given  him  best  results. 

Frequently,  because  of  numerous  adhesions,  it 
becomes  necessary  to  perform  the  operation  in  sev- 
eral stages,  because  too  long  an  operation  might 
cause  injury  to  the  chest  wall  from  the  heat  and 
pressure  of  the  instrument.  The  authors  rarely  pro- 
long any  one  operation  over  60  minutes. 

Frequent  fluoroscopic  examinations  for  the  first 
week  after  a  closed  pneumolysis  are  necessary,  as  a 
pneumothorax  can  be  lost  by  passage  of  air  through 
the  operative  puncture  wounds.  This  loss  is  often 
evidenced  by  subcutaneous  emphysema.   Fluid  is  a 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


routine  complication  following  pneumolysis,  but 
does  not  often  cause  trouble,  unless  infected,  the 
rule  being  spontaneous  absorption.  Tuberculous 
empyema  was  a  complication  in  5  per  cent  of  the 
cases  reported,  but  most  of  these  cases  were  con- 
trolled by  means  of  irrigation  and  antiseptics.  One 
pneumo-  had  to  be  converted  into  an  oleo-thorax. 
Summary  of  conclusions: 

1.  When  adhesions  prevent  a  satisfactory  col- 
lapse, the  operation  of  closed  pneumolysis  is  the 
operation  of  choice. 

2.  The  sooner  it  is  done  the  less  the  possibility 
of  complications. 

3.  The  only  accurate  method  for  determining 
the  operability  of  adhesions  is  an  examination  by  a 
thoracoscope. 

4.  A  closed  pneumolysis  is  less  hazardous  than 
maintaining  an  ineffectual  pneumothorax,  or  an  in- 
effectual phrenic  nerve  crushing. 

5.  The  indications  for  bilateral,  are  the  same  as 
for  unilateral,  pneumolysis. 


UROLOGY 


For  this  issue  Walter  E.  Daniel,  M.D.,  Charlotte,  N.  C. 


CHRONIC  URETHRITIS  IN  WOMEN 

Non-specific  chronic  urethritis  with  narrowing 
of  the  urethral  lumen  in  females  is  much  more 
prevalent  than  is  commonly  supposed.  I  do  not  use 
the  term  to  include  dense  fibrous  urethral  stric- 
tures resulting  from  repair  following  wholesale  tis- 
sue destruction  or  the  congenital  stricture  of  the 
urethral  meatus.  The  term  is  used  to  include  only 
the  low-grade  chronic  infections  of  non-specific 
character  in  the  urethra  resulting  in  slight  narrow- 
ing of  the  urethral  lumen  and  symptoms  which  are 
out  of  all  proportion  to  the  amount  of  pathology 
present. 

The  female  urethra  is  so  situated  that  it  is  con- 
stantly being  bathed  in  infected  material  from  the 
genital  tract.  Add  to  this  the  trauma  of  intercourse 
and  parturition  and  later  senile  changes,  and  the 
stage  is  set  for  the  common  bacteria  to  infect  the 
urethra  and  start  a  train  of  symptoms  which  has 
caused  many  otherwise  normal  women  to  be  classi- 
fied as  neurotic. 

The  local  symptoms  consist  of  frequency  of  uri- 
nation, burning,  urgency,  dysuria  and  nocturia. 
Pain  in  the  stem  of  the  bladder  is  a  common  com- 
plaint. Referred  pains  from  the  female  urethra 
may  simulate  both  ureteral  and  pelvic  disease. 
Folsom  and  Stanton  intimate  that  many  cases  of 
supposed  ureteral  stricture  are  relieved  by  the  ure- 
thral dilatation  incident  to  cystoscopy. 

A  specimen  of  urine  taken  by  catheter  contains 
very  few  pus  cells  unless  there  is  a  coexisting  cys- 


titis. The  lumen  of  the  urethra  is  narrowed  and 
as  seen  through  a  panendoscope  is  congested  and 
granular.  At  times  small  polypoid  projections  are 
seen  hanging  from  the  superior  margin  of  the  vesi- 
cal neck.  The  urethral  meatus  is  sometimes  red- 
dened with  mucosal  folds  projecting  from  its  in- 
ferior margin  which  on  section  show  only  chronic 
inflammatory  reaction.  Because  of  the  appearance 
of  the  meatus  the  condition  is  frequently  mistaken 
for  a  urethral  caruncle. 

Simple  urethral  dilatation  is  oftentimes  sufficient 
to  relieve  the  symptoms.  However,  topical  applica- 
tions of  20  per  cent  silver  nitrate  solution  applied 
best  through  a  urethroscope  are  usually  necessary 
to  eradicate  the  infection. 

If  the  lowly  urethra  is  examined  and  appropriate 
treatment  instituted  when  the  condition  just  de- 
scribed is  found,  many  women  having  vague  pelvic 
and  flank  pains  together  with  mild  bladder  symp- 
toms can  be  cured  and  will  remain  forever  grate- 
ful. 

Thompson-Daniel  Clinic 
Professional  Building 


LYMPHOGRANULOMA  VENEREUM 
(A.  W.  Grace,  New  York,  in  Bull.  N.   Y.  Acad,  of  Med.,  Aug  ) 

A  widespread,  contagious  venereal  disease  of  human  be- 
ings caused  by  a  minute  organism. 

The  infective  agent  enters  the  body  through  the  skin  of 
the  external  genitalia  without,  however,  always  producing 
a  demonstrable  lesion  at  the  portal  of  entry.  It  may  also 
enter  by  way  of  the  mucosa  of  the  anal  or  rectal  canals, 
and,  much  less  frequently,  by  extragenital  routes.  The 
virus  multiplies  readily  in  the  lymph  nodes  draining  the 
affected  areas,  and  probably,  also,  in  the  anal  and  rectal 
mucosae.  The  lesions  are  inflammatory,  subacute  or 
chronic,  often  marked  by  the  development  of  multiple 
small  foci  of  suppuration. 

Diagnosis  of  lymphogranuloma  venereum  is  made  by 
means  of  a  skin  test  (Frei)  of  a  high  degree  of  specificity 
and  sensitivity.  Treatment  with  certain  members  of  the 
sulfonamides,  sulfanilamide  and  sulfathiazole,  has  been  very 
successful. 


HOSPITALS 

R.  B.  Davis,  M.D.,  Editor,  Greensboro,  N.  C. 


HOW  CAN  THE  PRIVATE  NURSE  BE 
HELPED 

The  private  nurse  is  neither  lazy  nor  selfish  but 
is  weak  in  ability  to  solve  financial  problems.  This 
is  not  her  fault;  rather  it  is  the  fault  of  the  educa- 
tional system  before  and  after  she  enters  training. 
The  average  nurse  doing  private  duty  does  not 
make  sufficient  income  to  adequately  support  her 
and  lay  up  something  for  a  rainy  day. 

Since  the  nursing  profession  constitutes  such  a 
large  part  of  the  successful  practice  of  medicine  and 
good  hospitalization  it  is  the  duty  of  those  repre- 
senting these  professions  to  look  upon  this  situation 
of  the  nurses  with  a  sympathetic  heart  and  under- 


September,    1941 


SOUTHERN  MEDICINE  &  SURGERY 


503 


standing  mind.  A  large  number  of  graduate  nurses 
have  been  led  to  believe  that  the  physicians  and 
hospital  administrators  are  not  in  sympathy  with 
their  cause.  The  writer  does  not  feel  that  it  is  in 
the  scope  of  this  paper  to  discuss  this  phase  of  the 
nursing  profession.  Suffice  it  to  say  that  the  sins 
of  misleading  the  nursing  profession  will  be  rightly 
put  upon  the  guilty  authorities  ere  this  generation 
passes  away. 

The  private  nurse  has  reached  such  a  condition 
in  her  economic  life  that  recently  she  has  deter- 
mined to  do  something  about  it.  However,  that 
something  is  going  to  reduce  her  income  rather  than 
increase  it.  It  will  diminish  her  contacts  with  the 
sick  public  and  it  will  dangerously  reduce  the  value 
of  her  contribution  to  sick  mankind.  None  of  these 
is  her  desire.  It  is  sincerely  hoped  that  every  nurse 
in  North  Carolina  will  have  an  opportunity  to  read 
and  take  to  heart  the  purpose  of  this  paper.  If  she 
will  she  will  be  able  to  see  herself  as  others  see  her 
and  then  see  herself  as  she  would  like  to  be  seen. 

The  following  is  a  plan  which  has  occurred  to 
me  as  worthy  of  their  consideration  and  which  is 
applicable  to  the  problem  of  finance. 

The  average  patient  in  the  ward  and  in  the  semi- 
private  room  usually  is  as  sick  as  the  person  in  the 
private  room;  however,  it  is  seldom  that  these  pa- 
tients feel  able  to  have  special  nurses,  and  if  they 
do  it  is  often  a  considerable  time  before  the  nurses 
are  paid.  The  nurse  has  prepared  herself  to  render 
service  to  sick  mankind.  There  is  no  reason  to 
suspect  that  she  is  happy  doing  anything  else,  and 
least  of  all  when  she  is  loafing  and  draining  the 
savings  she  has  buying  three  meals  a  day.  There 
can  be  no  argument  about  what  she  had  rather  do. 
The  only  reason  that  she  is  not  nursing  the  poorer 
class  of  patients  is  because  she  has  not  been  taught 
economic  laws. 

The  average  hospital  sells  its  service  to  the  indi- 
vidual according  to  his  ability  to  pay  and  the  pa- 
tient's need  of  the  service.  The  average  physician 
does  the  same  thing.  Therefore,  during  the  last  ten 
years  the  services  of  both  hospitals  and  physician 
have  been  greatly  increased.  Medical  schools  have 
become  so  crowded  that  hundreds  have  been  turned 
away.  Almost  every  hospital,  large  or  small,  new 
or  old,  has  enlarged  its  bed  capacity.  This  is  not 
true  of  the  graduate  nurse's  service.  The  supply  of 
graduating  nurses  to  take  care  of  the  sick,  particu- 
larly in  the  South,  has  been  diminished  to  a  very 
dangerous  degree.  The  population  is  increasing  and 
the  need  for  nursing  service  is  increasing  but  the 
number  of  nurses  is  not  keeping  pace. 

There  should  be  immediately  an  increase  in  the 
facilities  for  educating  young  women  to  become 
nurses.   The  private  nurse,  if  she  will,  can  see  that 


it  is  far  better  for  her  pocketbook  to  render  service 
to  the  poor  patient  at  a  livable  wage  than  it  is  to 
be  idle  waiting  for  a  call,  during  which  time  she 
uses  up  the  balance  of  a  nice  fee  which  she  received 
last  week  for  a  few  days'  nursing.  On  the  other 
hand,  it  is  clearly  the  duty  of  the  hospital  and  the 
doctor  to  see  that  she  does  not  get  stuck  too  long 
on  a  case  where  the  patient  is  unable  to  pay  a  fee 
which  she  might  otherwise  be  entitled  to. 

The  nursing  profession  would  be  wise  to  notify 
the  hospitals  and  the  medical  profession  that  it  is 
prepared  and  willing  to  nurse  every  patient  in  the 
hospital  who  needs  special  nursing  for  a  fee  equal 
to  that  charged  by  the  hospital  for  the  room  or 
bed  occupied  by  the  patient  plus  her  board  with 
this  one  proviso,  that  it  shall  be  considered  entirely 
ethical  for  the  special  nurse  to  leave  any  case  after 
five  days'  service  for  one  on  which  the  patient  is 
willing  and  able  to  pay  her  more.  The  five-day 
period  is  not  an  arbitrary  period  but  should  be 
settled  upon  by  the  nursing  association,  the  medical 
association  and  the  hospital  association. 

If  this  system  were  adopted  it  would  establish 
valuable  assets  to  the  nursing  profession.  It  would 
render  service  to  a  vastly  larger  number  of  sick 
men  and  women.  It  would  vastly  increase  the  total 
income  to  the  nursing  profession  of  any  commu- 
nity. It  would  be  the  most  favorable  propaganda 
which  the  nursing  profession  could  possibly  inaugu- 
rate. It  would  increase  their  contacts  to  such  an 
extent  that  no  one  very  ill  would  consider  going  to 
the  hospital  without  having  a  special  nurse.  This 
would  mean  a  tremendous  gain  in  volume  of  work. 
And  last,  but  not  least,  it  would  occupy  the  grad- 
uate nurse's  idle  days  during  which  time  she  is 
unhappy  and  is  spending  for  the  necessities  of  life 
what  she  has  saved. 


OBSTETRICS 

Henry  J.  Langston,  M.D.,  Editor,  Danville,  Va. 


PUERPERAL  INFECTION 
The  vagina  is  the  only  situation  in  nature1  that 
the  anaerobic  streptococcus  is  found  with  any  fre- 
quency. 

The  principal  organism  associated  with  puerpe- 
ral infection  is  the  anaerobic  streptococcus.  In 
most  instances  there  is  no  evidence  of  patho- 
genicity in  the  postpartum  period.  Infections  with 
this  organism  follow  most  often  a  prolonged  ex- 
hausting labor,  often  with  ruptured  membranes, 
and  usually  terminated  by  difficult  operative  proce- 
dures.  Careful  antepartum  study  should  anticipate 


1.     Wm.  E.  Studdiford,  New  York  City,  in  Bull.  N.   Y.  Acad, 
uf  Med.,  Aug. 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


and  should  lead  to  the  decision  to  deliver  a  certain 
proportion  by  cesarean  section. 

Lowering  the  morbidity  has  followed  the  use  of 
mercurochrome  instillations  during  labor.  The  or- 
ganisms rapidly  reappear  and  the  new  flora  con- 
tains many  organisms  not  present  before;  so  these 
instillations  are  regarded  as  of  no  value,  and  since 
they  may  injure  the  defense  mechanisms  of  the  va- 
ginal mucous  membrane,  they  may  be  harmful. 

Gonococcal  infections  respond  readily  in  the  ma- 
jority of  instances  to  sulfanilamides.  In  refractory 
cases  additional  treatment  with  sulfapyridine  will 
often  clear  up  this  infection.  The  value  of  sulfapy- 
ridine in  pneumococcus  infections,  both  with  and 
without  serum,  has  been  abundantly  demonstrated 
and  should  be  of  value  in  both  primary  and  sec- 
ondary genital  infections.  Sulfathiazole  and  sulfa- 
methylthiazole  appear  to  be  better  agents  in  com- 
batting staphylococcus  infections. 

The  advances  in  chemotherapy  have  been  of 
great  assistance  in  the  treatment  of  a  small  group 
of  cases  caused  by  certain  specific  organisms.  For- 
tunately, in  this  group  we  find  infections  of  the 
most  severe  and  fatal  type,  notably  the  Group  A 
beta-streptococcus.  In  the  vast  majority  of  puer- 
peral infections  a  mixed  group  of  organisms  is  pres- 
ent. In  a  few  of  these  cases  we  know,  and  in  a  large 
number  we  have  cause  to  suspect,  that  the  anae- 
robic streptococcus  plays  a  leading  part.  There  is 
no  known  agent  which  affects  favorable  infections 
caused  by  this  organism.  This  may  well  be  due  to 
the  type  of  lesion  produced  which  is,  in  a  high  pro- 
portion of  cases,  suppurative  thrombophlebitis. 


GENERAL  PRACTICE 

Walter  J.  Lackey,  M.D.  Editor,  Fallston,  N.  C. 


INSECTS  IN  HOSPITALS  AND  HOMES 

Every  family  doctor  should  know  about  the  de- 
struction of  insect  and  rodent  pests.  Here  are  some 
British1  methods. 

Houseflies  will  travel  13  miles  in  a  couple  of 
days,  and  contamination  can  take  place  two  days 
after  infection  of  the  fly,  which  means  that  a  source 
of  fly  trouble  can  be  manure  or  refuse  heaps,  stable 
yards,  or  privies  up  to  that  distance  away! 

These  flies  breed  in  fresh  manure  (not  more  than 
a  fortnight  old),  a  blob  of  saliva  is  ejected  to  dis- 
solve the  food  before  they  suck  it  back  in  solution, 
contaminating  much  more  food  than  they  consume. 
Their  minimum  life  is  34  days. 

Manure  can  be  sterilized  with  iron  sulfate  with- 
out injuring  its  agricultural  use,  or  by  stacking  the 
fresh  manure  daily  upon  a  wooden  platform,  sup- 
ported by  foot-high  posts  over  a  4-inch  concrete 


1.  Eric   Hardy,    Liverpool,   Eng.,   in   Clin.   Med.,   Aug. 


basin  kept  full  of  water.  The  flies  will  choose  this 
fresh  manure  for  breeding  sites  and  their  maggots 
leaving  the  manure  to  seek  a  pupating  site,  fall  into 
the  water  and  are  drowned.  Up  to  99%  of  the 
larvae  can  be  destroyed  by  this  method. 

Indoors,  flies,  mosquitos  and  gnats  are  best  pre- 
vented by  the  use  of  repelling  colors.  Pale-yellow 
is  the  most  repelling  color  where  gnats  or  mosqui- 
tos are  concerned.  Curtains,  lampshades,  fanlights. 
walls  and  ceilings  of  this  color  will  distract  the  in- 
sects. Discourage  houseflies  which  are  attracted  to 
rooms  by  whitewash,  white  ceilings  and  walls. 

Pale  blue  is  a  better  color  than  white;  govern- 
ment stables  in  Denmark  removed  their  fly  trouble 
by  using  a  blue  wash  instead  of  a  whitewash. 

A  saucer  of  10%  formalin,  as  the  only  available 
drinking  material  in  a  room,  will  attract  and  kill 
the  flies,  and  a  2%  formalin  spray  is  effective  on 
their  dancing  parties,  which  generally  consist  of 
male  lesser  houseflies  in  their  jerky  courtship  flight. 
Poisoning  fly  papers,  hung  from  lamp  brackets, 
etc.,  are  most  effective  when  the  fly  is  attracted  by 
an  enticing  odor  like  that  of  geranium  or  rose  oil. 
Insects  on  ground,  wasps,  blue  bottles,  biting  gray 
stable  flies,  ants,  and  bees  are  generally  only  acci- 
dental visitors,  but  if  they  appear  regularly,  there 
is  a  nearby  breeding  place.  Wasps'  nests  may  be 
in  the  ground,  amongst  tree  roots,  rat  or  rabbit 
holes,  banks,  in  hollow  trees,  or  even  suspended  in 
out-houses,  etc.  The  nest  has  to  be  located,  but 
nothing  is  done  until  dusk,  when  all  have  returned 
home.  Creosote  or  gasoline  is  poured  down  and  the 
entrance  well  plugged  up. 

Cockroaches  and  crickets.  The  most  effective 
control  is  a  simple  trap,  made  from  a  glass  jam  jar 
or  any  handy  size,  baited  with  cooked  vegetable, 
banana  or  orange  peel,  or  meat'flavored  with  anise 
seed  or  beer,  and  fitted  with  an  inverted  cone  cap 
of  stiff,  smooth  paper  with  sufficient  space  at  the 
apex  for  the  insect  to  slip  through.  The  odor  of 
the  bait  attracts  the  night-hunting  cockroach  or 
cricket,  which  gains  access  to  the  top  by  a  board 
or  cardboard  gangway  or  steps  and,  attracted  by 
the  odor,  slips  down  into  the  jar,  whose  smooth 
glass  sides  prevent  its  escape.  A  number  of  such 
traps  can  be  placed  in  likely  haunts  in  the  evening 
and  collected  in  the  morning,  the  captives  being 
tipped  out  into  boiling  water  to  kill  them. 

Poison  baits  for  cockroaches  and  crickets  consist 
of  three  parts  sodium  fluoride  to  one  of  pyrethrum 
powder,  or  borax  and  pyrethrum.  flavoring  these 
with  castor  sugar  or  chocolate. 

For  rats  and  mice,  traps  or  poison  baits  should 
be  varied,  numerous.  Attractive  bait  is  fish,  oat- 
meal, or  rolled  oats. 

A  bait,  harmless  to  domestic  animals,  to  be 
wrapped  in  smell  twists  of  tissue  paper,  can  be 


September,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


505 


made  from  one  part  by  weight  of  liquid  red  squill 
extract;  2), 2  parts  of  fine  oatmeal  or  rolled  oats; 
and  \]/2.  parts  of  fat  dripping — mix  into  a  paste. 

SECTION  OF  THE  ANAL  SPHINCTER 

An  incision  that  I  have  found  of  great  help  in 
my  proctologic  work  is  the  subject  of  an  article1 
which  sets  forth  the  advantages  in  a  clear  way. 

The  treatment  of  chronic  anal  fissure  often  en- 
tails a  partial  posterior  anotomy,  since  often  the 
condition  has  existed  for  so  long  a  time  that  there 
is  a  thickening  of  the  entire  posterior  commissure, 
which,  with  hypertrophy  of  the  sphincter  from 
long-continued  spasm,  results  in  a  narrowed  anal 
outlet.  Even  though  this  is  not  the  case,  a  posterior 
incision  relieves  spasm  and  the  resultant  pain,  giv- 
ing the  fissure  an  opportunity  to  heal,  and  is  pref- 
erable to  divulsion. 

In  the  removal  of  numerous  large  internal  hem- 
orrhoids one  frequently  finds  it  necessary  to  remove 
so  much  tissue  that  the  outlet  has  been  materially 
decreased  in  size.  The  time  to  determine  whether 
or  not  this  has  been  done,  and  to  remedy  it,  is 
while  the  patient  is  still  on  the  operating  table,  and 
not  three  weeks  later.  If  at  the  completion  of  the 
operation  the  tip  of  the  index  finger  enters  the 
canal  only  snugly,  it  is  probably  too  narrow  for 
future  comfort,  and  an  incision  should  be  made  in 
the  posterior  commissure  to  enlarge  it  to  the  needed 
size.  Even  should  this  be  not  necessary  it  will  do 
no  harm.  Sutures  and  ligatures  with  their  resultant 
tension  contribute  largely  to  the  discomfort  follow- 
ing hemorrhoidectomy,  hence  it  is  my  practice  to 
make  posterior  anotomy  in  all  patients  where  there 
is  any  doubt  as  to  the  size  of  the  lumen,  this  proce- 
dure diminishes  postoperative  pain. 

An  incision  in  the  posterior  commissure  is  usual- 
ly productive  of  but  little  bleeding.  If  there  is  any 
of  conseqence  it  is  easily  controlled  by  a  ligature 
or  two  since  exposure  is  easily  attainable  under 
local  anesthesia.  The  incision  should  be  made  with 
one  finger  in  the  canal  to  determine  the  progress 
made  in  enlarging  the  lumen.  The  wound  is  packed 
with  a  strip  of  either  dry  or  vaselined  gauze  which 
is  left  in  for  24  or  48  hours.  Doses  of  mineral  oil 
or  some  form  of  demulcent  should  be  started  the 
same  day  as  the  operation,  general  diet,  and  hot 
sitz  baths  taken  once  or  twice  a  day.  From  the 
second  day  on  the  finger  is  inserted  every  two  or 
three  days  until  firm  healing  has  taken  place.  The 
author  has  never  seen  an  anal  sphincter  rendered 
either  wholly  or  partially  incompetent  by  this  pro- 
cedure. 


Acute  coronary  occlusion  with  localization  of  pain  in 
the  upper  part  of  the  abdomen:  no  other  cxtraabdominal 
condition  so  closely  counterfeits  acute  abdominal  emergen- 
cies.— A.  R.  Elliott. 

1.  H.  E.  Hullsiek,  St.  Paul,  in  Minn.  Med.,  Sept. 


CARDIAC  EMERGENCIES  AND  THEIR 
TREATMENT 

For  most  of  the  conditions  about  which  we  are 
consulted  there  is  time  for  reading  up.  Emergencies 
demand  prompt  action.  Here  is  abstracted  an  arti- 
cle1 for  brushing  up  your  information  which  is 
often  needed  right  now. 

The  emergencies  associated  with  acute  myocar- 
dial infarction  are  pain,  left  ventricular  failure  and 
the  arrhythmias. 

Pain  is  frequently  an  emergency  because  of  its 
severity  and  duration.  Usually  it  is  substernal  or 
paresternal,  heavy,  pressing;  it  may  be  epigastric. 
It  lasts  usually  an  hour  or  longer  and  frequently 
radiates  to  the  left  shoulder  and  down  the  inner 
aspect  of  the  left  arm  and  the  ulnar  side  of  the 
hand;  it  may  radiate  to  both  shoulders,  to  the 
back,  or  to  the  jaw;  it  is  often  associated  with 
nausea  and  vomiting  and  peripheral  circulatory 
collapse. 

Morphine  in  doses  of  an  eighth  to  a  fourth 
grain,  and  repeated  at  half-hour  intervals  if  pain 
is  not  relieved.  Once  the  severity  of  the  pain  has 
been  lessened  or  abolished,  codeine  gr.  %Va  to  J^ 
with  phenobarbital  gr.  ^  to  /2  t.  i.  d.,  p.c,  may 
be  used  for  a  few  days  longer.  Nitroglycerin  is 
m:ntioned  only  to  discourage  its  use.  It  may  pro- 
duce headache,  ectopic  beats,  tachycardia  and  low- 
ered blood  pressure. 

In  left  ventricular  failure  with  dyspnea,  cyanosis, 
weakness  and  sweating  in  its  early  stages  and  basal 
rales  and  pulmonary  edema  as  the  failure  increases, 
there  is  usually  a  fall  in  blood  pressure,  although 
at  the  height  of  pain  the  blood  pressure  may  be 
increased.  The  pulse  may  or  may  not  be  acceler- 
ated. In  mild  cases  absolute  bed  rest,  morphine 
for  pain,  and  oxygen  inhalation  of  40  to  60  per 
cent  will  be  sufficient;  severe  cases  with  pulmonary 
edema  require  100  per  cent  oxygen,  and  atropine 
sulfate  gr.  1/1 50,  repeated  in  IS  to  20  minutes.  In 
severe  dyspnea,  cyanosis  and  congestive  failure, 
bleeding  of  350-450  c.c.  is  often  promptly  effectual. 
Digitalis  is  not  used  in  the  first  few  days  of  acute 
myocardial  infarction  unless  continuous  auricular 
fibrillation  occurs  or  pulmonary  engorgement,  with 
swelling  of  the  cervical  veins,  enlarged  liver  and 
edema.  For  rapid  digitalization  tincture  of  digitalis 
may  be  given  by  mouth  in  one  dose,  1  minim  per 
pound  of  body  weight;  or  ^th  of  the  entire  dose 
intravenously  or  intramuscularly  and  '/&  of  the 
total  dose  every  four  hours  for  four  doses.  Then 
gr.  \y2,  t.  i.  d.,  p.c,  until  patient  is  completely 
digitalized;  watch  carefully  for  nausea,  vomiting, 
premature  beats  and  tachycardia. 

In  cases  of  myocardial  infarction  which  are  com- 
plicated by  Cheyne-Stokes  breathing  or  coma, 
aminophyllin   intravenously  in  doses  of   5   to  7^ 

1.  M    A.  Murphy.  Brooklyn,  in  Med.  Times,  Au£. 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


grains,  injected  very  slowly  may  benefit.  The  ef- 
fects of  this  drug  are  very  transitory. 

Mercupurin  relieves  congestive  failure  through 
diuresis. 

Irregularities  of  the  heart  are  quite  common  in 
the  course  of  myocardial  infarction.  Serial  electro- 
cardiograms are  important  in  the  diagnosis  and  for 
proper  therapy.  The  important  arrhythmias  of 
myocardial  infarction  in  the  order  of  their  frequency 
and  importance  are:  auricular  fibrillation,  auricular 
flutter,  ventricular  tachycardia,  paroxysmal,  sinus 
and  auricular  tachycardia,  partial  heart  block  and 
complete  heart  block. 

Auricular  fibrillation  and  flutter  are  treated  by 
digitalis,  the  slow  or  the  rapid  course,  according  to 
the  severity  of  the  case. 

Paroxysmal  auricular  tachycardia  by  carotid 
sinus  pressure  or  ocular  pressure;  if  not  successful 
digitalis  in  adequate  doses. 

Ventricular  tachycardia  calls  for  immediate  ad- 
ministration of  quinidine  sulfate:  grains  10,  q.  2  h. 
for  six  or  seven  doses  and  then  q.  3  or  4  h.  until 
heart  beat  is  regular.  In  some  cases  it  may  be  nec- 
essary to  give  quinidine  sulfate  gr.  3  every  hour  or 
two.  This  arrhythmia  may  lead  to  ventricular 
fibrillation  and  death.  Therefore  prompt  and  ener- 
getic treatment  is  necessary. 

In  complete  heart  block,  1  c.c.  of  adrenalin  chlo- 
ride (1-1000)  is  given  and  repeated  every  half  hour 
until  cardiac  rate  is  either  increased  or  it  changes 
from  a  labile  rate  to  a  more  fixed  one  in  which 
standstill  of  the  ventricle  does  not  occur. 

When  premature  beats  of  the  ventricle  occur, 
quinidine  sulfate  gr.  3  four  i.  d.  may  be  given  to 
abolish  the  focus  of  irritable  muscle  in  the  ven- 
tricle. 

In  terminal  asystole  and  ventricular  fibrillation 
death  is  usually  so  sudden  that  treatment  (such  as 
intracardiac  injection  of  adrenalin)  is  of  no  avail. 

If  the  systolic  blood  pressure  remains  above  80, 
it  is  not  necessary  to  do  anything  about  it,  but  if  it 
falls  much  below  80  for  any  length  of  time,  the  pa- 
tient will  die  no  matter  what  is  done.  Caffeine  so- 
dium benzoate  is  an  excellent  means  of  keeping  the 
blood  pressure  above  this  critical  level. 

I  do  not  believe  that  atropine  is  of  much  value 
in  left  ventricular  failure  with  pulmonary  edema. 

In  the  discussion  Dr.  Bauer  said  oxygen  is  al- 
most, if  not  quite,  as  potent  as  morphine  in  reliev- 
ing cardiac  pain. 


ing  is  not  sick  because  of  primary  organic  disease. 

Patients  requiring  psychiatric  care  are  as  a  rule  seen  in 
consultation  by  rive  times  more  physicians  than  are  pa- 
tients of  other  sorts.  They  are  practically  always  seen  at 
some  time  by  a  surgical  consultant.  The  adults,  in  the  vast 
majority  of  cases,  have  complaints  referable  to  the  abdo- 
men. Of  our  female  psychoneurotic  patients  having  symp- 
toms involving  the  alimentary  tract,  those  26  years  of  age 
have,  on  an  average,  undergone  without  benefit  at  least 
one  abdominal  operation;  this  is  true  of  one-half  of  the 
male  psychoneurotic  patients. 

Many  personality  difficulties  begin  as  rather  simple  re- 
actions to  ordinary  life  situations  that  should  be  recognized 
by  any  physician.  The  prevention  of  mental  ill  health  lies 
in  the  hands  of  the  family  physician  to  whom  the  patient 
first  goes  for  help. 

In  the  diagnosis  of  disorders  producing  abdominal  symp- 
toms, it  is  important  to  obtain  a  complete  statement  in 
the  patient's  own  words  of  the  circumstances  under  which 
the  complaint  began.  Physical  and  neurologic  examination 
with  indicated  laboratory  tests,  his  mood,  sentiments  and 
attitudes,  his  beliefs,  his  thinking  and  his  memory  should 
be  as  surely  tested  as  his  ability  to  down  and  pass  through 
his  alimentary  tract  a  barium  sulfate-laden  meal. 

The  next  most  important  procedure  is  to  explain  the  dis- 
order to  the  patient  in  words  that  he  can  understand  and 
not  to  instill  in  him  further  anxiety  and  insecurity  by  mak- 
ing some  organ  or  bacterium  the  scapegoat.  If  this  is  done 
in  an  orderly  and  understanding  way  and  if  the  patient  is 
essentially  one  for  psychiatric  care,  treatment  is  50  per  cent 
accomplished,  for  the  patient  begins  to  understand  and  to 
see  opportunities  for  correcting  the  problems  rendering  him 
ill. 


EXTRA-ABDOMINAL  DISEASES  THAT  MAY  CAUSE 
ABDOMINAL  SYMPTOMS 
(E    G.   Billings,   Denver,  in   Wise.   Med.   Jl.,   Aug.) 
A  study  of  over  2,000  patients  in  the  Colorado  General 
Hospital  indicates  that: 

One  of  every  14  patients  consulting  a  physician  for  his 
various  aches  and  pains  and  his  disordered  bodily  function- 


A  FAMOUS  QUACK  OF  A  CENTURY  AND  A  HALF 
AGO 

(Hon.  Wm.  R.  Riddell  Toronto.  Canada,  in  Med.  Rec.,  Sept. 
3rd) 

The  most  noted  of  all  the  noted  quacks  in  London  in 
the  LSth  century  was  "Dr."  James  Graham  (1745-1794). 
Born  in  Edinburgh,  he  took  lectures  in  the  School  of  Med- 
icine of  the  University  of  that  city.  There  is  no  record  of 
his  receiving  a  degree.  He  came,  about  1768  or  1769,  to 
Philadelphia  where  he  practiced  as  an  oculist  and  aurist, 
and  there  he  conceived  the  "electrical  bed,''  upon  which 
most  of  his  fame  rests. 

Returning  to  Britain  in  1774,  he  practiced  as  an  oculist 
and  aurist  at  Bath.  The  next  year  he  went  up  to  London. 
In  1779,  he  established  on  the  Royal  Terrace.  Adelphi,  his 
"Temple  of  Health,"  an  elaborately  decorated  house  facing 
the  Thames,  which  is  said  to  have  cost  10,000  pounds. 
There  he  gave  lectures  at  high  prices,  sold  bis  medicines, 
and  exhibited  his  shining  electrical  machines  to  non-pa- 
tients. For  a  time  he  had  as  his  "Goddess  of  Health"  in 
his  temple  of  Apollo,  Emma  Lyon,  later  to  become  the 
mistress  of  Hon.  Charles  Grenville,  and  still  later,  Lady 
Hamilton,  the  favorite  of  Lord  Nelson. 

The  most  noted  of  his  medicinal  means  was  his  mar- 
vellous bed  described  by  himself  as  "my  celestial  or  mag- 
netoelectrical  bed,  which  is  the  first  and  only  one  that 
ever  was  in  the  world,  supported  by  six  massive  glass  pil- 
lars, with  Saxon  blue  and  purple  satin  hangings,  perfumed 
with  Arabian  spices  in  the  style  of  those  in  the  seraglio  of 
the  Grand  Turk."  This  "any  gentleman  and  his  lady  de- 
sirous of  progeny  ....  may,  by  a  compliment  of  a  50 
pound  bank  note,  be  permitted  to  occupy  for  the  night." 


Irvin  Barness,  arrested  for  drunkenness  because  of  his 
staggering  gait  and  vomiting  on  the  street,  was  found  suf- 
fering from  benzene  poisoning.  Irvin  works  in  a  straw-hat 
factory. 


September,    1941 


SOUTHERN  MEDICINE  &  SURGERY 


507 


PULP  TRACTION:  THE  STILETTE  METHOD 

IB.   T.    Keon-Cohen,   Melbourne,   in  Aust.   &  New  Zealand  II,   of 

Surg.,  July) 

Traction  is  necessary  in  the  treatment  of  certain  fractures 
of  metacarpals,  metatarsals  and  phalanges.  The  most  effi- 
cient method  of  getting  such  traction  is  by  means  of  a  fine 
stainless  steel  wire  through  the  pulp  of  the  terminal  pha- 
lanx. 

The  technique  is  simple.  Trauma  is  negligible.  A  fine 
wire  (gauge  30)  is  used,  with  complete  freedom,  so  far, 
from  infection  and  or  wasting  of  the  pulp. 

As  usual,  a  plaster  cast  is  applied  to  the  forearm  or  leg. 
Incorporated  in  the  cast,  and  extending  distally  so  as  to 
clear  the  extended  fingers  or  toes,  is  a  loop  of  stout  wire, 
shaped  at  the  end  like  a  Thomas  splint. 

Local  anesthesia  is  quite  satisfactory.  The  needle  se- 
lected is  the  smallest  that  will  "take''  the  wire  after  the 
manner  of  a  stilette. 

1.  Transfix  the  pulp  of  the  terminal  phalanx  with  the 
needle. 

2.  Thread  the  wire  through  the  needle  like  a  stilette. 

3.  Secure  the  distal  end  of  the  wire  and  withdraw  the 
needle.   The  wire  is  left  in  situ. 

The  "spreader"  must  be  wide  enough  to  ensure  that  the 
wire,  distal  to  the  level  of  transfixion,  clears  the  side  of  the 
pulp.  It  is  made  to  measure  from  an  ordinary  wooden 
tongue  spatula. 

Traction  is  obtained  by  means  of  fine  rubber  tubing 
passed  proximally  through  a  hole  bored  in  the  center  of 
the  spreader  (knotted  to  prevent  it  pulling  through),  and 
attached  distally  to  the  wire  frame.  The  tension  of  the 
tubing  is  adjusted  as  required,  so  that  the  traction  is  both 
elastic  and  continuous. 


TREATMENT  OF  RICKETS  WITH  A  SINGLE 
MASSIVE  DOSE  OF  VITAMIN  D 

(I.  J.  Wolf,  Paterson,  in  /(.  Med.   Soc.  N.  J.,   Sept.) 

Five  cases  of  active  rickets  in  infants  between  the  ages 

of  five  and   18  months  were   treated,   each  with   a  single 

massive  dose  of  vitamin  D,  called  ertron.  The  official  name 

for  this  form  of  vitamin  D  is  "calciferol"  or  "viosterol." 

Ertron  is  marketed  in  capsules  of  50,000  units  each.  Six 
capsules,  or  300,000  units,  are  opened  and  the  powder  is 
mixed  with  the  formula  or  Pablum.  Two  feedings  are 
given,  or  a  total  dosage  of  600,000  units.  No  toxic  symp- 
toms were  observed;  on  the  contrary,  those  infants  who 
suffered  from  irritability  and  lack  of  well-being  as  a  result 
of  the  rickets  showed  a  remarkable  change  in  their  condi- 
tion within  a  few  days. 

The  clinical  diagnosis  of  rickets  was  supported  by  roent- 
genograms and  the  blood  chemistry. 


INFECTIOUS  RELAPSE  IN  SYPHILIS 

(J.  C.  Kern,  Lewiston,  Ida.,  in  Northwest  Med.,  Sept.) 
Infectious  relapse  in  syphilis  is  more  frequent  than  any 
statistical  studies  would  indicate.  Relapse  is  defined  in  this 
study  as  any  mucocutaneous  recurrence  of  acute  syphilis 
which  appears  after  the  institution  of  antisyphilitic  therapy. 
For  this  study  80  cases  were  selected  as  examples.  Those 
cases  with  questionable  histories  antedating  their  first  ap- 
pearance at  the  clinic  were  omitted. 

The  site  of  relapse  were  the  skin,  genitalia  and  oral  mu- 
cous membranes.  Of  the  80  cases,  55  were  Wassermann- 
fast  throughout  treatment;  in  21  the  Wassermann  and 
Kahn  tests  became  negative  under  treatment  and  relapsed 
to  a  positive  reaction  coincidental  with  the  clinical  relapse. 
In  four  cases  the  serologic  tests  for  syphilis  were  only  par- 
tially positive  at  the  time  of  relapse.  Thus  no  case  pre- 
sented entirely   negative  Wassermann   and   Kahn  reactions 


at  the  time  of  the  clinical  relapse.  Sixty  of  these  were 
considered  to  have  inadequate  treatment.  The  12  cases 
receiving  adequate  treatment  (20  or  more  arsenicals  with  a 
corresponding  amount  of  heavy  metal)  relapsed  at  much 
longer  intedvals  after  the  onset  of  infection — none  in  the 
first  year,  one  in  the  second,  four  in  the  third,  seven  be- 
tween the  third  and  eighth  year. 

These  cases  illustrate  the  necessity  for  continued  obser- 
vation of  patients  after  completion  of  routine  syphilo- 
therapy. 

Relapse  occurs  most  frequently  in  patients  whose  treat- 
ment is  begun  in  the  primary  stage  of  infection,  slightly 
less  frequently  when  treatment  is  begun  in  the  secondary 
stage,  and  extremely  infrequently  when  it  is  begun  in  the 
latent  stage. 

Two-thirds  of  the  patients  developing  mucocutaneous 
relapse  have  lesions  at  sites  which  are  particularly  favor- 
able for  transmission  of  infection. 

Serologic  tests  for  syphilis  are  positive  in  practically  all 
relapse  cases. 

As  a  rule,  the  frequency  of  relapse  decreases  as  the  num- 
ber of  arsenical  injections  increases. 


NONSPECIFIC-PROTEIN  THERAPY  IN  OCULAR 
DISEASE 

(T.  E.  Sanders,  St    Louis,  //.  Iowa  State  Med.  Soe.,  31:51, 
1941) 

Nonspecific-protein  therapy  is  one  of  the  most  valuable 
procedures  in  ocular  therapy. 

Fever  is  the  best  criterion  as  to  the  severity  of  the  re- 
action, and  of  the  results  to  be  expected. 

Typhoid  vaccine  has  proved  the  most  effective  agent. 
As  an  initial  dose  for  a  healthy  man  50  million,  for  a 
woman,  35  million.  For  children  between  5  and  10  years 
of  age,  a  dose  of  10  million,  doubling  each  successive  dose 
keeps  the  injection  at  a  reacting  level.  If  a  reaction  is  se- 
vere, the  same  dose  may  be  used,  or  increased  only  one- 
half.  If  practically  no  reaction,  three  times  the  dose  may 
be  used,  usually  a  maximum  of  six  is  given  in  a  single 
course,  every  other  day,  of  any  typhoid-paratyphoid  vac- 
cine, such  as  that  used  for  active  immunization  against 
typhoid  fever,  properly  diluted. 

After  the  injection  of  typhoid  vaccine  or  antigen  H,  the 
patient  is  advised  to  remain  in  bed,  and  fluids  are  forced. 
Salicylates  are  discontinued  during  the  next  24  hours,  be- 
cause they  tend  to  suppress  the  rise  in  fever.  Usually  the 
discomfort  and  inconvenience  to  the  patient  are  surpris- 
ingly small. 

The  author  believes  that  foreign-protein  therapy  may  be 
indicated  at  times  in  any  type  of  ocular  inflammation  and 
holds  that  it.  use  in  certain  conditions  should  be  almost 
routine.  In  inflammation  of  the  uveal  tract  its  use  tends 
to  shorten  the  course  and  reduce  the  permanent  damage. 
Its  use  is  almost  routine  in  severe  iritis  and  iridocyclitis. 
It  is  valuable  in  the  management  of  ocular  trauma.  Prac- 
tically every  case  of  ocular  inflammation  or  infection 
ihould  have  the  benefit  of  foreign-protein  therapy. 


BRUCELLOSIS 

(W.  M.   Simpson,  Dayton,  O.,  in  Bull.  N.   Y.  Acad,  of  Med., 

Aug) 

Because  brucellosis  presents  many  symptoms  and  signs 
common  to  typhoid  fever,  malaria,  tuberculosis  and  influ- 
enza, many  physicians  have  arrived  at  a  tardy  diagnosis 
only  after  repeated  negative  Widal  reactions,  failure  to 
demonstrate  the  malaria  Plasmodium,  and  inability  to  elicit 
physical  signs  or  x-ray  evidence  of  tuberculosis.  The  dis- 
ease has  been  confused  with  acute  rheumatic  fever,  sub- 
acute bacterial  endocarditis,  bronchitis,  pyelitis,  appendicitis, 
cholecystitis  and  tularemia. 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


SURGICAL  OBSERVATIONS 


OF   THE    STATF 

DAVIS  HOSPITAL 

Statesville 


THE  TREATMENT  OF  THE  MENOPAUSAL 
SYNDROME 

Menopausal  symptoms  come  on  when  the 
ovarian  secretions,  especially  hormones,  become 
deficient  in  quantity  or  quality.  Nervousness  is 
often  very  severe.  There  are  often  hot  flashes,  chilly 
sensation  either  or  both.  The  symptoms  become 
more  severe,  more  pronounced  and  the  individual 
may  be  completely  incapacitated. 

The  many  women  who  go  through  the  meno- 
pausal period  without  any  great  disturbance  are 
extremely  fortunate. 

It  is  not  uncommon  during  this  period  for  a  wo- 
man to  undergo  a  great  change  in  personality,  de- 
stroying the  peace  and  happiness  of  the  home.  The 
unfortunate  woman,  not  understanding  why,  be- 
comes estranged  from  her  own  family  and  friends, 
who  do  not  know  about  these  things  and  judge  the 
patient  too  harshly,  possibly  accuse  her  of  being 
mentally  unbalanced,  when  all  that  is  wrong  is  that 
she  is  going  through  a  period  of  change  which  she 
cannot  help,  and  for  which  very  often  little  is 
done. 

Theoretically,  the  treatment  of  the  menopausal 
syndrorne  is  simply  to  supply  a  substance  or  some 
biological  product  which  supplies  to  that  individual 
the  hormones  produced  by  the  ovaries  and  corre- 
lated glands.  The  anterior  pituitary  may  be  con- 
sidered a  part  of  this  system.  Many  patients  are 
greatly,  but  not  completely,  relieved  by  this  treat- 
ment. Each  patient  must  have  a  very  careful  study 
in  order  to  determine  what  other  conditions  need 
treatment  and  what  to  do  for  the  patient. 

Where  the  menopausal  syndrome  has  become  se- 
vere and  the  nervous  and  mental  reaction  extreme, 
it  is  essential  that  the  patient  be  taken  firmly  in 
hand  and  treated  promptly  and  thoroughly.  The 
first  thing  is  to  get  the  patient  away  from  her  fam- 
ily and  friends  and  in  the  care  of  a  competent  and 
sympathetic  nurse  who  is  agreeable  to  the  patient. 

Treatment  should  be  directed  toward  obtaining 
the  quickest  possible  relief  for  the  patient.  See 
that  she  gets  a  few  nights  of  comfortable  and  rest- 
ful sleep.  For  this  purpose,  thorough  sedation  is 
necessary.  We  then  start  giving  either  an  estro- 
genic hormone  or  Stilbestrol.  Our  own  preference 
is  for  Stilbestrol.  In  case  it  causes  nausea  the  dose 
is  to  be  reduced.  The  action  of  this  drug  is  prompt 
and  definite.  Just  how  much  Stilbestrol  to  give  is 
a  question  which  must  be  decided  in  each  individ- 
ual case:  it  should  be  given  until  the  symptoms 
are  controlled,  so  far  as  possible  to  do  so  with  this 


drug.  It  is  necessary  that  we  give  this  in  consider- 
able dosage  at  frequent  intervals  until  relief  is 
given  from  the  hot  flashes  and  extreme  nervousness. 
We  usually  give  one  milligram  of  Stilbestrol  in  oil 
intramuscularly  once  daily  for  two  or  three  days 
until  the  symptoms  subside.  We  should  then  con- 
tinue moderate  sedation  and  the  administration  of 
Stilbestrol  in  gradually  reduced  dosage  until  we 
lave  the  patient  in  the  best  possible  condition. 

We  have  found  that  when  we  once  get  the  nerv- 
ous symptoms  relieved  and  keep  them  relieved  for 
a  period  of  two  or  three  weeks  that  we  then  only 
need  to  give  very  small  doses  at  much  longer  in- 
tervals. 

There  are  a  great  many  other  conditions  that 
must  be  treated  at  the  same  time,  if  present.  Ane- 
mia should  be  appropriately  treated.  Diseased 
teeth,  sinuses  or  tonsils,  hemorrhoids,  pelvic  condi- 
tions, leucorrhea,  gastrointestinal  disturbances — all 
these  things  must  be  looked  for,  accurately  diag- 
nosed and  properly  treated.  Unless  we  take  care  of 
the  other  things,  the  treatment  for  the  menopausal 
syndrome  itself  may  not  give  the  patient  anything 
like  the  relief  that  is  given  where  all  possible 
sources  of  trouble  are  carefully  searched  for  and 
treated. 

Three  major  indications  in  the  menopausal  syn- 
drome are: 

1.  Give  proper  treatment. 

2.  Keep  up  the  treatment  until  the  patient  has 
passed  that  trying  period  when  treatment  is  no 
longer  necessary. 

3.  Find  and  treated  associated  disease  condi- 
tions. 

DIAPHRAGMATIC  HERNIA  DEVELOPING 

SIX  YEARS  AFTER  A  KNIFE  WOUND 

IN  THE  LEFT  CHEST 

A  man  32  years  of  age  was  brought  to  the  hos- 
pital complaining  of  pain  in  the  left  side  and  across 
the  middle  of  the  abdomen.  He  stated  that  while 
he  was  swimming,  three  days  before,  he  felt  a  sud- 
den, severe  pain  in  the  left  abdomen.  He  returned 
to  his  home  but  did  not  call  a  doctor  until  some 
time  later,  when  he  was  immediately  referred  to 
the  hospital. 

This  man  had  developed  what  was  apparently 
an  obstruction  of  the  colon  near  the  splenic  flexure. 
At  the  same  time,  he  developed  an  acute  pleural 
effusion  with  a  dense  shadow  in  the  lower  half  of 
the  left  chest. 

A  barium  enema  revealed  stoppage  at  the  sig- 
moid margin.  A  diagnosis  of  obstruction  of  the 
colon  at  the  splenic  flexure  was  made  and  opera- 
tion was  done  immediately. 

On  opening  the  abdomen  it  was  found  that  there 
was  a  large  loop  of  the  colon,  principally-  the  trans- 


September,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


509 


verse,  which  had  entered  through  a  diaphragmatic 
opening,  posteriorly,  and  was  up  in  the  left  pleural 
cavity.  The  opening  was  so  tightly  filled  that  it 
was  necessary  to  clip  the  margin  to  permit  the  in- 
troduction of  a  tube  into  the  left  pleural  cavity,  to 
allow  air  to  enter  and  make  it  easier  to  bring  the 
colon  back  down  into  the  abdomen.  The  opening 
in  the  diaphragm  was  sutured  and  the  abdominal 
incision  closed. 

This  patient  states  that  six  years  prior  to  this 
time,  he  had  a  knife  wound  in  the  back.  Examina- 
tion of  the  scar  showed  this  to  be  in  the  lower  cos- 
tophrenic  area  and  it  is  evident  that  the  knife  had 
penetrated  through  the  costophrenic  space  and  the 
diaphragm,  producing  an  opening  between  the  left 
pleural  cavity  and  the  abdomen.  Ever  since  this 
accident  he  had  considerable  pain  in  this  side.  The 
considerable  amount  of  omentum  in  this  opening 
and  tightly  adherent  makes  it  probable  that  the 
opening  was  plugged  at  the  time  of  the  accident, 
which  accounts  for  the  fact  that  he  had  consider- 
able pain  across  the  abdomen  and  in  the  left  side 
for  the  past  six  years. 

The  strain  while  in  swimming  and  the  pressure 
from  the  abdominal  muscles  evidently  helped  to 
force  the  transverse  colon  through  this  opening  into 
the  left  pleural  cavity,  causing  a  diaphragmatic 
herniation  of  the  large  segment  of  the  transverse 
colon  and  producing  a  certain  amount  of  osbtruc- 
tion  of  the  colon. 

Diaphragmatic  hernia  is  not  so  uncommon  as 
might  be  supposed  and  sometimes,  when  there  is  no 
obstruction,  may  give  curious  symptoms,  but  any 
trouble  in  the  abdomen  followed  by  trouble  in  the 
chest,  such  as  pleural  effusion,  should  remind  us  of 
this  possibility. 

In  this  case  the  x-ray  picture  of  the  chest  show- 
ed what  was  apparently  a  pleural  effusion  and  since 
barium  did  not  pass  up  into  the  portion  of  the 
colon  which  was  in  the  chest,  naturally  there  was 
no  way  of  making  a  definite  diagnosis  by  x-ray 
examination,  as  would  have  been  the  case  had  some 
of  the  barium  passed  on  up  into  the  left  part  of 
the  colon  which  was  above  the  diaphragm. 

THE  INCIDENCE  OF  UNDULANT  FEVER 

A  disease  which  is  very  prevalent  and  which 
often  goes  unrecognized  is  undulant  fever,  and  its 
being  one  of  the  most  protean  of  all  diseases  and 
in  many  instances  of  such  mild  form  makes  it  dif- 
ficult to  recognize,  often  not  recognized  at  all.  The 
specific  tests  are  not  always  positive.  The  symp- 
tomatology varies  so  widely  that  it  may  simulate 
any  one  of  a  number  of  diseases. 

The  temperature  curve,  charted  over  a  period 
of  a  few  davs,  is  more  or  less  typical  of  the  dis- 
ease, often  giving  a  definite  clue  to  the  diagnosis. 


The  skin  test  is  very  helpful,  also  the  agglutination 
test;  both  may  fail  us  when  the  diseases  exists  in 
a  very  mild  form — the  form  which  gives  most 
trouble  in  diagnosis.  A  careful  study,  however,  of 
the  patient  who  has  a  continued  fever  and  the  use 
of  the  specific  tests  will  usually  enable  the  doctor, 
after  a  few  days,  to  make  a  diagnosis. 

The  treatment  of  undulant  fever  is  not  easy. 
There  are  many  different  treatments,  each  of  which 
has  some  merit.  In  our  experience  fever  therapy 
has  given  quickest  and  most  lasting  results.  This 
treatment,  however,  cannot  be  taken  except  by 
fairly  robust  persons. 

The  vaccine  treatment  gives  gratfying  results  in 
some  cases. 

Blood  transfusions  of  whole  blood  from  non- 
immune donors  is  of  great  help;  of  more  help  is 
blood  from  those  who  have  had  the  disease  and 
whose  blood  has  a  high  titer.  Recently  we  have 
been  unable  to  get  blood  from  patients  who  have 
been  immunized  against  undulant  fever. 

By  immunizing  donors  that  are  non-immune,  we 
can  get  a  very  high  titer  of  blood  and  this,  second 
only  to  fever  therapy,  used  as  a  blood  transfusion, 
is  the  most  satisfactory  treatment. 

We  should  use  every  means  at  our  command  for 
treating  the  fever.  Fever  therapy,  transfusions  from 
immune  donors  and  from  those  who  have  had  the 
disease — one  or  all  of  these — will  give  the  best 
possible  results.  Vaccine  therapy  in  the  slow, 
shronic  cases  is  of  great  help  and  we  have  used 
this  with  the  idea  of  finally  eliminating  the  disease. 

The  treatment  may  not  give  a  great  deal  of  re- 
sults at  first  but  must  be  persisted  in  until  the  pa- 
tient is  well.  By  nature,  this  is  a  very  chronic  dis- 
ease and  the  treatment  should  be  continued  until 
the  patient  is  entirely  well. 


PEPTIC  ULCER 
(O.   H.   Wangensteen,  Minneapolis,   in  ///.  Med.  Jl.,   Aug. 

Ulcer  is  the  commonest  cause  of  death  in  abdominal 
lesions,  with  the  exceptions  of  cancer  of  the  stomach  and 
appendicitis.  Throughout  the  life  span,  from  birth  to 
advanced  years,  patients  may  suffer,  be  incapacitated,  or 
die  from  ulcer  or  one  of  its  complications.  Death  from 
hemorrhage,  and  even  perforation  may  recur  several  times 
and  the  infant,  as  well  as  the  octogenarian.  Obstruction, 
hemorrhage,  and  even  perforation  may  recure  several  times 
during  the  life  time  of  a  patient  with  an  ulcer. 

The  frequent  ingestion  of  food  is  probably  the  most  im- 
portant single  item  in  the  control  of  gastric  acidity.  The 
selection  of  food  is  of  lesser  importance  than  frequent 
feeding.  All  the  food,  including  water,  may  stimulate  the 
secretion  of  acid. 

Uncontrolled  night  secretion  is  the  item  over  which 
effective  management  of  ulcer  breaks  down.  An  alarm 
clock  can  be  used  to  good  purpose  to  lengthen  the  hours 
of  control  of  acidity  by  frequent  feedings.  A  physiologic 
dose  of  atropine  at  bedtime  should  prove  helpful  also. 


Excerpt  from  a  letter  from  patient  John   Bock:   "Dear 
Doctor.  I  feel  good.  Thanks  for  not  coming.'' 


510 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


RADIOLOGY 

Edith  Miller,  M.D.,  Editor,  Petersburg,  Va. 


DIAPHRAGMATIC  HERNIA 

Relatively  little  has  been  written  about  dia- 
phragmatic hernia  and  its  cardinal  symptoms,  and 
too  little  attention  is  usually  given  in  clinical  diag- 
nosis and  in  diagnostic  x-ray  procedure  to  the  pos- 
sible presence  of  this  condition. 

One  author  states  that  its  frequency  varies  as 
the  diligence  with  which  it  is  sought. 

Dr.  D.  S.  Beilin  of  Chicago,  in  a  paper  which 
was  published  in  the  Journal  of  Radiology  in  July, 
has  very  well  classified  the  types  of  diaphragmatic 
hernia  into  congenital  and  acquired.  Many  of  the 
congenital  types  no  doubt  are  present  throughout 
life,  without  symptoms  and  undiagnosed  unless 
noted  by  chance  in  examinations  for  disease  condi- 
tions elsewhere  in  the  respiratory  or  gastrointestinal 
tract. 

As  Beilin  states,  the  usual  symptoms  of  diaphrag- 
matic hernia  are  primarily  due  to  the  mechanical 
and  irritative  influence  exerted  by  food  or  gaseous 
distention  of  the  herniated  portion  of  the  stomach, 
with  resultant  pain  and  epigastric  distress.  The 
pain  is  not  infrequently  substernal  and  accompa- 
nied by  shortness  of  breath  and  weakness;  there- 
fore, at  times  closely  simulating  a  coronary  disturb- 
ance. One  of  the  distinguishing  features  in  the 
history,  however,  is  the  appearance  of  pain  on  ly- 
ing down  and  more  or  less  relief  on  assuming  an 
upright  position. 

Indigestion  and  eructation  of  gas  after  eating, 
frequently  followed  by  either  spontaneous  or  force- 
ful vomiting,  occur  in  many  cases,  the  latter  usually 
giving  immediate  relief.  These  symptoms  might 
easily  be  confused  with  those  of  gallbladder  dis- 
turbance. 

Hematemesis  is  a  usual  symptom  and  frequently 
gives  a  misleading  impression  of  gastric  or  duodenal 
ulcer. 

Embryological  maldevelopment  and  slight  anom- 
alies are  ample  explanation  for  the  more  frequent 
occurrence  of  the  congenital  type  of  herniation. 
These  are  separated  into  two  groups;  those  with  a 
congenitally  shortened  esophagus  which,  by  retrac- 
tion, draws  the  cardiac  portion  of  the  stomach 
through  the  esophageal  hiatus.  The  other  group  is 
made  up  of  true  herniations  of  the  cardia  through 
a  congenitally  relaxed  hiatus,  with  redundancy  of 
the  distal  portion  of  the  esophagus.  These  groups 
comprise  about  80  per  cent  of  all  diaphragmatic 
hernias. 

Traumatic  hernia  occurs  secondarily  to  direct 
trauma  or  increased  intraabdominal  pressure  and  is 
usually  suggested  by  the  history;  however,  the  en- 


tity is  often  not  kept  in  mind  and  may  be  misinter- 
preted. 

Positive  diagnosis  can  be  made  by  x-ray  exam- 
ination; much  too  often  it  is  made  by  direct  sur- 
gical procedure.  Preliminary  x-ray  study  is  desir- 
able for  evaluation  of  the  extent  and  location  of 
the  lesion  even  though  surgery  may  be  anticipated. 

In  the  discussion  of  Dr.  Beilin's  paper  fluoro- 
scopic examination,  using  a  thick  barium  mixture 
with  the  patient  in  Trendelenburg  position,  was 
suggested.  If,  however,  under  direct  observation 
the  stomach  is  well  filled  or  distended  with  a  thin 
barium  mixture,  the  patient  placed  in  modified 
Trendelenburg  position  and  asked  to  cough  forci- 
bly, the  barium  gravitates  readily  into  the  herni- 
ated portion  of  the  viscus,  or,  if  this  is  filled,  slides 
through  the  hiatus.  In  this  way  an  accurate  visual- 
ization of  the  herniation  is  obtained. 

A  thick  barium  mixture  is  no  doubt  of  advantage 
in  differentiating  a  congenitally  shortened  esopha- 
gus, because  of  the  better  delineation  of  the  muco- 
sal folds  of  the  stomach. 

The  treatment  of  diaphragmatic  hernia  is  largely 
symptomatic.  Frequently  the  patient  is  completely 
relieved  by  therapeutic  procedure  with  instructions 
as  to  diet,  avoidance  of  gastric  distention  and  pos- 
ture after  eating.  In  severe  cases,  after  the  acute 
phase  is  relieved  by  esophageal  intubation,  lavage 
and  dilatation  of  the  cardiac  opening  of  the  stom- 
ach or  such  palliative  therapy  as  is  indicated,  sur- 
gery with  repair  of  the  diaphragmatic  opening  is 
advisable. 


Stone  tn  the  Common  Duct. — Pain  was  referred  only 
to  the  left  side  in  one  case,  to  both  sides  with  equal  in- 
tensity in  the  other.  In  the  latter  case,  distention  of  the 
common  duct  postoperatively  produced  pain  on  the  left 
side  only.  Common-duct  obstruction,  therefore,  may  cause 
pain  referred  only  to  the  left  side  and  in  the  absence  of 
other  signs  or  symptoms  suggesting  disease  in  the  biliary 
tract.  It  is  not  always  necessary  to  assume  the  presence 
of  pancreatitis  or  some  other  inflammatory  process  spread- 
ing to  the  left  of  the  midline  to  explain  left-side  pain  in 
disease  of  the  biliary  system. — J.  Fine  &  A.  Starr,  Boston, 
in  New  Eng.  Jl.  of  Med.,  Aug.  28th. 


The  injection  of  10  mc.  of  thiamin  chloride  (vitamin 
Bj)  daiy,  plus  the  injection  of  7  units  of  liver  extract 
thrice  weekly,  has  relieved  80%  of  cases  of  trigeminal  neu- 
ralgia. The  treatment  may  need  to  be  continued  for  several 
months  and  the  thiamin  dosage  increased  to  100  mg.  daily 
(rarely  needed).  The  oral  administration  of  vitamin  B 
complex  is  of  definite  value. — H.  Borsook,  in  Jl.  A.  M.  A., 
April  13th,  1940. 


Many  patients  with  mild,  chronic  disorders  can  make  a 
successful  adjustment  to  life  outside  the  hospital,  after  a 
period  of  treatment.  The  "boarding-out"  system  adopted 
by  a  number  of  public  mental  hospitals  has  released  much 
needed  beds  and  improved  the  status  of  the  patients.  Fur- 
ther developments  in  this  direction  may  well  be  considered 
for  civilian  mental  health. — U.  S.  P.  H.  Reports. 


September,   1941                                      SOUTHERN  MEDICINE  &  SURGERY  511 

SOUTHERN  MEDICINE  &  SURGERY 

Off.cial  Organ  EXAMINATION  OF  THE  HEART 

TRI-STATE    MEDICAL    ASSOCIATION    OF   THE  Last  year  was  published  a  booklet1  on  the  clin- 

CAROLINAS  AND  VIRGINIA  ical  examination  of  the  heart  without  the  help  of 

James  M.  Northington,  M.D.,  Editor  any   instrument  other  than  the  stethoscope.    The 

; techniques  of  inspection,  palpation,  percussion  and 

Department  Editors  auscultation  are  used  to  determine  the  size  of  the 

Human  Behavior  heart,  any  abnormalities  in  the  sounds  or  adven- 

James  K.   Hall,  M.D Richmond,  Va.  ^.^    ^^     (murmurs)i    any    abnormality    of 

Orthopedic  Surgery  rhythm.    It  is  often  much  easier  in  a  given  case  to 

Oscar  Lee  Miller,  M.D.  i                Charlotte,  N.  C.  be  sure  the  heart  is  diseased,  than  it  is  in  another 

John  Stuart  Gaul,  M.D.  | ...           , 

Uroi0gy  case  to  be  sure  the  heart  is  not  diseased. 

Raymond  Thompson,   M.D Charlotte,  N.   C.  The  size  of  the  heart  may  be  difficult  to  deter- 

Surgery  mine  by  any  method,  particularly  in  obese  or  very 

Geo.  H.  Bunch,  M.D Columbia,  S.  C.  muscl,iar  subjects,  and  when  the  chest  is  emphy- 

Obstetncs  sematous;   but  palpation  and  percussion  still  yield 

H,y,  v   t    T  ivrsTON    M  D                          ....   Danville,   Va.  x-     r-                        i-          .         .     , 

tV'FTOME:::::..: Raleigh,  N.  C.  useful  information.    The  left  margin  of  the  max- 

Gynecology  'mal  aPex  impulse  is  the  most  accurate  point  for 

Chas.  R.  Robins,  M.D Richmond,  Va.  determination  of  the  left  border  of  the  heart.   The 

G.  Carlyle  Cooke,  M.D Winston-Salem,  N.  C.  midclavicular  line  is  a  better  landmark  than  either 

Pediatrics  the  nipple  line  or  an  arbitrary  measurement  from 

G.  W.  Kuwcher,  Jr.,  M.D Asheville.  N.  C.  ^  midsternum     The  apex  is  often  in  the  fourth 

j    L    Hamner    U^eneral^'l Mannboro,  Va.  space  in  those  under  seven.   The  finding  of  an  apex 

W.  J.  Lackey'  M.D Fallston,  N.  C.  in   the  sixth   interspace  should  make  one  suspect 

Clinical  Chemistry  and  Microscopy  cardiac  enlargement,  though  it  may  be  found  in  a 

C.  C.  Carpenter,  M.D I  normal  subject  with  a  vertical  heart. 

R.  pi  Morehead'  B.S.,  M.A.,  M.D..f' Wake  Forest'  N'  C'  Percussion  for  the  left  border  of  the  heart  should 

Hospitals  be  carried  mesially  from  the  axilla  to  a  point  of 

R.  B.  Davis,  M.D Greensboro,  N.  C.  definite  dullness.     Percussing  toward  the  sternum 

Cardiology  m  tne  fourth  interspace,  the  first  change  in  note  as 

Clyde  M.  Gilkore,  A.B.,  M.D Greensboro,  N.  C.  ^  ^  ^  ^^  ^^  ^  considered  as  the 

S  Tho.   Ewett  mJ*  HeaHh. Greenville,  N.  C.  right  border  of    dullness.    Two    other    percussion 

Radiology  areas  should  be  noted,  the  left  border  of  dullness 

Wright  Clarkson,  M.D.,  and  Associates....Petersburg,  Va.  in  the  third  space  and  the  right  border  in  the  sec- 

R.  H.  Laeeerty,  M.  D.,  and  Associates,     Charlotte,  N.  C.  ond   gpace      Jn   the  normal  heart,   there   should  be 

Therapeutics  n0  cnange  in  the  percussion  note  in  these  areas 

J.  F.  Nash,  M.D., Saint  Pauls,  N.  C.  ^  ^  ^^  ^  stemum;   j{  definite  dullness 

M    Tubercvlos'5          rharlntt„    N    r  is  found  in  the  third  left  space,  it  is  suggestive  of 

John    Donnelly,    M.D Charlotte,   IN.    L.  .  ,                   , 

Dentistry  enlargement  of  the  right  ventricle,  or  pulmonary 

j    H.  Guion,  D.  D.  S Charlotte,  N.  C.  conus,  rarely  of  the  left  auricle  or  its  appendage. 

Internal  Medicine  Dullness  in  the  second  and  third  right  interspaces 

Georce  R.  Wilkinson,  M.D Greenville,  S.  C.  ;s  suspicious  of  enlargement  of  the  first  portion  of 

Ophthalmology  the  aorta.    Percussion  of  the  great  vessel  dullness 

Herbert  C.  Neblett,  M.  D., Charlotte,  N.  C.  fe  Qf  j.^  ^  un]ess  the  vessds  arg  much  enlarged. 

n       m  *          Rhino-Oto-Laryngology  Enlargement  of  the  chambers  other  than  the  left 

Clay  W.  Evatt,  M.  D.,  Charleston,  S.  L.  & 

Proctology  ventricle,  unless  advanced,  cannot  be  detected  on 

Russell  von  L.  Buxton,  M.D Newport  News,  Va.  .    physical  examination.    Study  by  rbntgen  methods 

Insurance  Medicine  is  frequently  necessary,  as    when    one    desires    to 

H.  F.  Starr,  M.D., Greensboro,  N.   C.  know  the  size  of  the  left  auricle  in  suspected  mitral 

Dermatology  valvular  disease,  or  the  width  of  the  aorta  when 

J.  Lamar  Calloway,  M.D Durham,  N.  C.  .                 '    . 

syphilitic  aortitis  is  suspected. 

Offerings  )or  the  pages  of  this  Journal  are  requested  and  Palpation   is  of   importance  in   finding  the  maxi- 

liven  careful  consideration  in  each  case.    Manuscripts  not  ^    g           jmpulse   and    thrills   Over    the    aortic   and 

found   suitable    for    our    use    will    not    be    returned    unless  •               r                 .                                    .         ™, ,,.„,, „-o 

author  encloses  postage.  pulmonary   valve   regions.    Thrills,   with   murmurs 

As  is  true  of  most  Medical  Journals,  all  costs  of  cuts,       ~~[~u    ,.    Spragtl,   ,,  „;,  Bo  i in  Booklet  A r.  Heart  Assn., 

etc.,  for  illustrating  an  article  must  bt  born4  by  the  author.  (1940) 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


which  are  themselves  diagnostic,  are  of  little  im- 
portance. Such  a  thrill  is  the  apical  diastolic  (pre- 
systolic) thrill  occurring  with  the  diastolic  murmur 
of  mitral  stenosis.  The  continuous  .  often  widespread 
thrill  felt  with  patent  ductus  arteriosaus,  only  con- 
firms the  evidence  of  the  continuous  murmur.  Pal- 
pation will  sometimes  discover  a  slight  extra  apex 
thrust  in  diastole  in  gallop  rhythm  more  readily 
than  the  ear  may  detect  the  sound.  A  forceful 
impulse  to  the  left  of  the  lower  sternum,  plus  ab- 
normal dullness  over  the  lower  end  of  the  sternum, 
is  evidence  of  right  ventricular  enlargement. 

Alteration  in  the  sounds  natural  to  the  sound 
heart  are  often  as  important  as  the  appearance  of 
abnormal  sounds.  Determination  of  the  normal  in- 
tensity of  the  first  and  second  sound  must  be 
reached  only  after  considering  the  thickness  of  the 
chest  wall  as  affected  by  obesity,  heavy  muscula- 
ture and  breast  tissue,  and  the  modifying  influence 
of  emphysema.  In  the  timing  of  all  heart  sounds 
and  murmurs,  the  examiner  listens  first  at  the  base 
of  the  heart  to  fix  in  his  mind  the  place  in  the  car- 
diac cycle  of  the  sharp  second  sound.  He  then 
moves  the  stethoscope  gradually  toward  the  apex 
and  retains  the  relation  of  this  sound  to  other 
sounds  and  murmurs.  There  is  slight  delay  between 
the  first  sound  and  the  carotid  pulse  which  makes 
timing  difficult  bv  this  method  if  the  heart  rate  is 
rapid. 

Diminution  of  the  intensity  of  the  first  heart 
sound  at  the  apex  in  a  chest  of  ordinary  thickness 
suggests  myocardial  weakness.  Accentuation  or  a 
sharp  quality  of  the  first  sound  should  make  one 
listen  at  the  apex  for  the  late  distolic  murmur  of 
mitral  stenosis.  Splitting  of  the  first  sound  may  be 
a  physiologic  occurrence,  or  be  caused  by  the  con- 
traction of  the  ventricles  not  starting  at  exactly 
the  same  time,  this  due  to  bundle-branch  block. 

Accentuation  of  the  aortic  second  sound  occurs 
in  hypertension,  atheroma  of  the  aorta  and  syph- 
ilitic aortitis.  Accentuation  of  the  pulmonic  second 
sound  is  found  when  the  pressure  in  the  pulmonary 
circulation  is  increased  (especially  when  the  left 
ventricle  fails  or  in  the  presence  of  mitral  stenosis). 
Splitting  of  the  second  sound  at  the  base  of  the 
heart  is  due  to  a  slight  difference  in  time  of  closure 
of  the  aortic  and  pulmonary  valves.  Reduplication 
of  these  sounds  at  the  base  suggests  an  increase  in 
pressure  in  either  the  greater  or  trie  lesser  circula- 
tion. The  second  aortic  sound  is  often  diminished 
or  absent  in  aortic  regurgitation.  This,  with  a  sys- 
tolic murmur  at  the  aortic  area  is  important  evi- 
dence of  aortic  stenosis. 

In  most  children  and  in  many  older,  particularly 
those  with  thin  chests  and  active  circulations,  a 
third  sound  may  be  heart  at  the  apex  shortly  after 
the  second,  of  low  pitch  and  intensity  and   best 


heard  by  lightly  applying  the  bell  to  the  chest  wall, 
with  the  subject  in  the  supine  or  left-lateral  posi- 
tion. It  occurs  at  the  time  of  rapid  ventricular  fill- 
ing, and  should  be  regarded  with  suspicion  in  per- 
sons of  middle  age  or  older.  An  accentuation  of 
this  sound,  with  a  first  sound  of  poor  quality,  is 
the  most  common  mechanism  in  the  production  of 
pathological  gallop  rhythm.  The  gallop  sound  can 
frequently  be  intensified  by  accelerating  the  heart 
by  exercise.  This  accentuated  sound  in  diastole, 
with  a  third  degree  impulse  which  can  be  seen  and 
felt  in  the  region  of  the  apex  is  evidence  of  ven- 
tricular dilatation.  Attention  to  the  time  and  char- 
acter of  the  third  sound  in  normal  individuals,  and 
its  accentuation  in  gallop  rhythm,  is  evidence  of  a 
skillful  examination  of  the  heart. 

Starting  at  the  base  of  the  heart,  the  second 
sound  can  be  placed  with  accuracy,  and  the  timing 
of  murmurs  elsewhere  can  be  decided  by  gradually 
moving  the  stethoscope  toward  the  apex.  Only  after 
listening  at  all  the  waive  regions,  with  the  naked- 
ear  and  with  both  the  bell  and  the  diaphragm, 
should  one  decide  that  no  murmur  is  there. 

The  murmur  to  be  heard  over  most  hearts  is 
systolic  in  the  second  interspace  to  the  left  of  the 
sternum.  Listen  in  this  area  first.  This  murmur 
may  be  transmitted  to  other  parts  of  the  precor- 
dium.  It  is  usually  normal,  caused  by  the  blood 
rushing  into  the  distensible  pulmonary  artery  which 
is  close  to  the  chest  wall,  particularly  at  expiration. 
This  murmur  will  change  considerably  with  change 
of  position  of  the  patient  from  upright  to  recum- 
bent and  will  be  decreased  or  removed  by  full 
inspiration.  Such  a  murmur,  as  a  solitary  heart 
finding,  is  almost  always  of  no  importance. 

Another  extremely  common  systolic  murmur 
heard  over  the  precordium  is  the  cardio-respiratory, 
due  to  air  rushing  into  the  lungs  at  the  time  when 
the  heart  contracts,  or  to  displacement  of  air  within 
the  lung.  It  also  varies  with  change  of  position 
and  with  respiratory  phases.  Have  the  patient 
breathe  slowly  and  deeply.  At  some  point  in  the 
cycle,  the  murmur  will  often  disappear  completely. 

Systolic  murmurs  at  the  apex  of  the  heart  are 
not  uncommon  in  young  healthy  persons.  However, 
those  unimportant  are  blowing,  inconstant  from 
day  to  day  and  in  different  positions,  and  not  ac- 
companied by  heart  enlargement.  Acute  infections 
or  other  ill  health  may  produce  such  murmurs, 
probably  by  inducing  slight  cardiac  dilatation  and 
increasing  the  speed  of  the  blood  flow.  Faint  sys- 
tolic murmurs  can,  at  times,  be  heard  in  over- 
active normal  hearts,  variable  in  localization  from 
one  examination  to  another,  sometimes  localized  to 
the  left  of  the  sternum,  or  to  its  lower  portion. 
They  are  short,  never  harsh  and  may  be  mid-sys- 


September.    1941 


SOUTHERN  MEDICINE  &  SURGERY 


513 


tolic.  Apical,  systolic  murmurs  of  importance  gen- 
erally merge  with  the  first  heart  sound  and  are 
rougher  and  more  intense.  They  usually  signify 
mitral  valve  deformity.  Systolic  murmurs  over  the 
pulmonary  valve  region,  if  attended  bv  a  thrill  and 
cyanosis,  are  due  in  many  cases  to  a  congenital 
heart  lesion.  Such  murmurs  indicate  x-ray  and  elec- 
trocardiographic study.  Systolic  murmurs  over  the 
aortic  area  usually  mean  dilatation  of  the  aorta  or 
stenosis  of  the  aortic  valve.  In  the  latter  case  there 
is  diminution  or  absence  of  the  aortic  second  sound 
and  usually  a  systolic  thrill,  felt  best  by  palpating 
over  the  second  and  third  right  interspaces,  above 
the  clavicle,  or  in  the  suprasternal  notch  with  the 
patient  leaning  forward  at  full  expiration.  A  rare 
systolic,  coarse  murmur  associated  with  a  systolic 
thrill  heard  all  over  the  heart,  loudest  in  the  third 
interspace,  is  caused  bv  an  interventricular  septal 
defect. 

Of  the  two  diastolic  murmurs  of  great  impor- 
tance, one  is  the  low-pitched,  rumbling,  mid-  and 
late-diastolic  murmur  of  mitral  stenosis,  heard  best 
at  the  apex  with  the  bell,  the  patient  in  the  supine 
or  left-lateral  position,  often  sharply  localized. 
Careful  auscultation  of  the  entire  apical  region 
should  be  carried  out  before  deciding  this  murmur 
is  not  being  produced.  Accentuation  of  the  first 
sound  should  always  make  us  suspicious  of  the  pro- 
duction of  this  murmur.  In  the  early  stages  of 
mitral  valves  narrowing,  the  murmur  starts  a  short 
time  after  the  second,  and  ceases  shortly  before  the 
first,  sound.  In  older  patients,  the  murmur  usually 
continues,  with  a  presystolic  accentuation,  into  a 
sharp  first  sound.  The  other  is  a  blowing  early 
diastolic  murmur,  usually  heard  best  along  the  left 
sternal  border  directly  after  the  second  sound,  by 
the  unaided  ear  or  with  the  aid  of  the  diaphragm, 
usually  best  heard  with  the  patient  standing,  lean- 
ing slightly  forward,  holding  the  breath  in  full  ex- 
piration. When  the  aortic  regurgitation  is  greater, 
as  is  common  in  syphilitic  aortic  valve  disea.se,  this 
murmur  may  be  very  loud  and  heard  with  the  pa- 
tient in  any  position  and  all  over  the  chest. 

The  only  important  continuous  murmur  is  that 
of  patency  of  the  ductus  arteriosus.  It  is  loudest 
over  the  second  or  third  left  interspace  near  the 
sternum,  usually  accompanied  by  a  thrill.  The 
systolic  phase  is  louder  but  the  murmur  continues 
through  the  whole  cardiac  cycle  with  a  blowing  or 
harsh  quality. 

In  some  children  a  continuous  humming  murmur 
can  be  heard  across  the  upper  sternum  due  to  the 
normal  vibrations  from  the  flow  of  blood  in  the 
great  veins  of  the  neck.  The  bell  lightly  applied 
over  the  clavicle,  with  the  child's  head  turned  away 
from  that  side,  will  reveal  a  louder  continuous  hum 
in  these  cases  and  will  thus  decide  the  origin  of 


the  murmur  heard  distantly  in  the  upper  chest. 

Heart  rate  and  rhythm  in  normal  persons  often 
depart  from  regular  beating  and  a  rate  of  70-80. 

Tachycardia,  simple  acceleration  of  the  heart 
rate,  often  occurs  during  examination  of  the  nerv- 
ous individual.  It  may  be  as  fast  as  160,  slowing 
gradually  as  nervousness  decreases,  or  when  the 
person  lies  down.  It  often  slows  temporarily  on 
forced  expiration  after  a  deep  breath. 

Bradycardia,  low  heart  rate,  even  to  SO  is  not 
uncommon  in  healthy  athletic  persons.  Increase  of 
rate  on  exercise  will  prove  that  there  is  no  heart 
block,  as  will  speeding  of  the  rate  on  inspiration 
and  slowing  on  expiration. 

Sinus  arrhythmia,  the  usual  finding  in  young 
persons  and  a  common  finding  in  those  older,  con- 
sists of  a  rhythmic  increase  in  heart  rate  on  in- 
spiration and  decrease  on  expiration.  This  relation- 
ship to  breathing  is  diagnostic  and  can  be  demon- 
strated more  obviously  by  slow  forced  respiration. 

Premature  beats  (extrasystoles)  is  the  momen- 
tary interruption  of  a  regular  heart  rhythm,  or  one 
with  the  irregularity  just  described,  by  an  early 
beat  followed  by  a  pause.  In  most  instances  this 
is  of  no  importance.  The  diagnosis  of  the  condi- 
tion should  always  be  made  by  auscultation  of  the 
heart  and  not  by  taking  the  pulse.  Frequent  re- 
currence of  the  premature  beat  indicates  the  need 
for  electrocardiographic  study,  as  this  should 
arouse  a  suspicion  of  myocardial  disease. 

In  auricular  fibrillation  the  heart  beat  is  con- 
tinuously and  completely  irregular,  it  does  not 
change  its  rate  in  relation  to  breathing.  The  heart 
should  be  listened  to  for  at  least  a  minute  because 
periods  of  apparent  regularity  may  occur.  Auricu- 
lar fibrillation  always  calls  for  further  study  of  the 
patient. 

Heart  block  is  a  rare  arrhythmia,  in  its  mildest 
form  diagnosable  on  physical  examination,  charac- 
terized by  sudden  cessation  of  all  cardiac  sounds 
for  the  duration  of  at  least  one  heart  cycle.  It  must 
always  be  diagnosed  at  the  heart  and  not  at  the 
wrist.  It  should  not  be  confused  with  a  faint  pre- 
mature beat  followed  by  a  pause.  Electrocardio- 
graphic study  may  be  needed  to  confirm.  In  com- 
plete block  the  heart  rate  is  between  30  and  40  in 
most  cases,  rhythm  regular,  and  normal  accelera- 
tion on  effort  does  not  occur.  Rates  under  50 
should  be  investigated  electrocardiographically. 

Other  abnormal  rhythms  of  the  heart,  usually 
characterized  by  continuous  rate  over  120,  or  by 
paroxysms  of  tachycardia,  often  require  electrocar- 
diographic interpretation. 

Examination  of  the  heart  should  always  include 
physical  examination.  Much  valuable  information 
concerning  the  functional  state  of  the  heart  can  be 
obtained    by   attention    to   other   organs.    Thus   it 


SOUTHERN  MEDICINE  &  SURGERY  September,   1941 


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September,    1941 


SOUTHERN  MEDICINE  &  SURGERY 


515 


should  be  an  invariable  procedure  to  listen  for  rales 
at  the  lung  bases  and  to  look  for  engorgement  of 
the  neck  veins,  enlargement  of  the  liver,  and  evi- 
dences of  edema.  Careful  determination  of  the 
blood  pressure  should  also  be  routinely  carried  out, 
preferably  in  both  arms.  In  addition,  observation 
should  be  made  of  the  peripheral  vessels,  and  of 
the  retinal  vessels  with  the  ophthalmoscope. 

Finally,  it  must  be  recognized  that  severe  or- 
ganic heart  disease  may  exist  in  the  complete  ab- 
sence of  any  findings  on  physical  examination 
This  is  particularly  true  in  coronary  artery  disease. 
Therefore,  when  a  cardiac  lesion  is  suspected  and 
physical  examination  is  inconclusive,  further  study 
with  special  techniques,  such  as  fluoroscopy,  x-ray 
examination  and  electrocardiography  is  advisable 
before  a  final  decision  is  made  as  to  the  presence 
or  absence  of  organic  heart  disease,  and  the  type 
and  severity  of  lesion  present. 

Here  is  a  fair  evaluation  of  the  methods  of  diag- 
nosis of  heart  conditions  which  every  doctor  has  at 
hand  at  all  times.  It  is  clearly  stated  that  the  older, 
less  complicated,  diagnostic  measures  will  yield  suf- 
ficient information  in  most  cases.  It  is  just  as 
clearly  stated  that  certain  findings  demand  the  use 
of  the  more  elaborate  and  expensive  methods.  This 
authoritative  statement  of  the  case  will  clear  up 
much  confusion. 


TRI- STATE  MEDICAL  ASSO- 
CIATION OF  THE  CARO- 
LINAS  AND  VIRGINIA 


THYMIC  DEATH 
(C.  A.  Hellwig,  Wichita,   in  Jl.   Kansas  Med.   Soc,  June) 

What  has  been  called  an  enlarged  thymus  is  in  reality 
the  normal  thymus  of  the  well  nourished  individual. 

There  is  no  relation  between  the  size  of  the  thymus 
gland  and  sudden  death.  Thymic  death  from  mechanical 
causes,  except  in  malignant  thymoma,  seems  to  be  extreme- 
ly rare. 

An  internal  secretion  of  the  thymus  has  never  been  dem- 
onstrated. The  experimental  data  concerning  its  function 
are  not  yet  applicable  to  clinical  medicine. 

The  term  status  thymico-lymphaticus  may  just  as  well 
be  discarded. 

There  is  no  treatment  of  the  thymus  by  injection  of  any 
extract,  by  radiation,  or  by  extirpation,  which  would  have 
any  effect  in  preventing  sudden  death. 

In  most  cases  of  sudden  death,  a  complete  autopsy  in- 
cluding bacteriological  and  chemical  studies  will  detect  a 
more  rational  cause  of  death  than  an  enlarged  thymus. 


Bleeding. — In  cases  of  dilatation,  from  whatever  cause, 
in  mitral  or  aortic  lesions  or  distention  of  the  right  ven- 
tricle in  emphysema,  when  signs  of  venous  engorgement 
arc  marked  and  when  there  is  orthopnoea  with  cyanosis, 
the  abstraction  of  from  20  to  30  ounces  of  blood  is  indi- 
cated. This  is  the  occasion  in  which  timely  venesection  may 
save  the  patient's  life.  It  is  particularly  helpful  in  the 
dilated  heart  of  arteriosclerosis. — Osier. 


Neo-Calclvcon. — There  are  numerous  reports  of  grati- 
fying results  from  the  injection  in  the  vein  of  10  c.c.  of 
this  chemical  in  poisoning  by  rhus,  and  by  stings  of  insects, 
including  the  black  widow. 


IN  MEMORIAM 

1941 
(To  be  continued  in  our  Issue  for  October) 

DOCTOR  HARVEY  PARK  BARRET 

Dr.  William  Allan,  Charlotte 

Harvey  Park  Barret  was  born  May  18th, 
1885,  at  Anchorage,  Kentucky.  At  sixteen  he  en- 
tered Centre  College  and  was  graduated  from  this 
institution  with  the  B.A.  degree  in  1904.  He  re- 
ceived his  M.D.  degree  from  the  University  of 
Louisville  in  1908  and  for  a  few  years  taught  there 
and  also  worked  with  the  Kentucky  State  Health 
Department. 

When  the  Charlotte  Sanatorium  asked  the 
Rockefeller  Institute  for  a  pathologist,  the  request 
was  forwarded  to  Dr.  Barret.  He  came  to  Char- 
lotte in  1911  to  take  charge  of  the  clinical  labora- 
tories. His  first  task  was  to  educate  the  local  pro- 
fession to  the  value  of  and  necessity  for  clinical 
pathology,  and  very  soon  he  began  to  train  tech- 
nicians who  went  to  supervise  laboratories  in  the 
hospitals  which  were  rapidly  being  developed  in 
the  surrounding  territory  at  that  time.  No  more 
valuable  and  practical  work  in  medical  education 
has  ever  been  done  in  North  Carolina. 

Dr.  Barret's  flair  for  original  investigation  early 
became  manifest.  He  collected  and  identified  the 
species  of  mosquitoes  indigenous  to  Mecklenburg 
County,  so  when  Camp  Greene  was  established 
and  Dr.  Henry  Carter  of  the  Public  Health  Service 
was  sent  here  for  a  malaria  survey,  Dr.  Barret 
already  had  the  necessary  information. 

He  repeated  Churchill's  work,  studying  the 
growth-inhibiting  effect  of  some  75  dyes  on  bac- 
teria, but  since  Dr.  Barret  found  the  writing  of 
articles  for  medical  journals  a  matter  of  extreme 
difficulty,  these  observations  were  never  published. 

The  study  of  intestinal  protozoa  early  enlisted 
Dr.  Barret's  interest.  At  the  time  when  Ashford 
was  attributing  to  Monilia  psilosis  the  causation 
of  sprue,  Dr.  Barret  examined  300  of  Dr.  Heath 
Nisbet's  patients,  finding  this  monilia  in  half  of 
them.  He  then  cultivated  Blastocysts ,  showing 
that  it  was  a  vegetable  and  not  a  protozoan  organ- 
ism. This  work  gradually  led  to  atempts  to  culti- 
vate the  parasitic  intestinal  protozoa — a  goal 
sought  after  by  medical  men  for  fifty  years.  Using 
cold-blooded  animals,  a  parasitic  ameba  from  the 
turtle  was  for  the  first  time  successfully  grown  on 
artificial    media   and    the   ameba   was   named    for 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


him — Endamoeba  barreti.    He  next  cultivated  the 
majority  of  the  intestinal  protozoa  in  man. 

Being  dissatisfied  with  his  cultures  of  Enda- 
moeba histolytica,  he  delayed  reporting  the  cul- 
tivation of  this  organism  until  after  its  cultivation 
was  reported  elsewhere.  His  work  was  promptly 
confirmed  in  this  country  and  abroad,  the  English 
and  French  giving  him  credit  for  priority  in  this 
field,  while  some  of  his  fellow-countrymen  neglect- 
ed to  do  so. 

On  one  occasion  he  discovered  that  bacterial 
contamination  of  blood  samples  changed  all  the 
blood  groups  to  Group  1  Moss  (AB),  and  during 
the  following  year  or  so  he  isolated  IS  bacteria 
possessing  this  property,  one  of  them  a  pathogenic 
streptococcus.  As  so  frequently  happened,  these 
observations  were  never  published.  However  few 
men  have  spent  as  many  nights  in  the  laboratory 
searching  for  new  knowledge,  after  the  day's  work 
was  done,  as  Harvey  Barret. 

Dr.  Barret  was  a  member  of  the  American  As- 
sociation of  Pathologists  and  Bacteriologists,  and 
of  the  American  Society  of  Clinical  Pathologists. 
Soon  after  the  World  War,  he  was  offered  the 
Chair  of  Bacteriology  at  Chapel  Hill.  At  the 
time  he  was  working  on  the  diarrheas  of  infants 
and  trying  to  develop  typhoid  immunization  by 
the  oral  route,  so  he  declined  the  offer,  believing 
he  could  be  more  useful  in  the  clinical  field. 

His  interest  outside  of  his  profession  lay  in 
medical  history,  the  collection  of  old  and  rare 
books,  the  collection  of  old  pewter  and  glass,  and 
the  training  of  track  teams  at  the  local  High 
School.  He  turned  out  championship  track  teams 
for  a  number  of  years  and  was  invited  to  train 
the  Davidson  College  team.  In  later  years  he  took 
up  the  study  of  the  minerals  in  North  Carolina 
and  learned  more  about,  and  accumulated  a  better 
collection  of,  the  State's  minerals  than  any  other 
man  in  the  State. 

But  no  recitation  of  Dr.  Barret's  work  and  ac- 
complishments would  serve  to  portray  the  lovable 
character  of  the  man;  his  custom  of  doing  labora- 
tory work  gratis  for  every  new  doctor  coming  to 
town  until  he  could  establish  himself;  his  shyness 
at  being  given  any  credit  for  his  work  (he  left 
town  to  escape  a  testimonial  dinner  that  was  being 
planned  in  his  honor) ;  his  insistence  that  he  be 
called  whenever  a  case  of  diabetic  coma  was 
brought  into  the  hospital,  so  he  could  share  the 
night-long  vigil  with  the  clinician;  his  readiness 
to  go  anywhere,  any  time,  for  blood  counts;  his 
unfailing  giving  of  his  time  and  means  to  civic 
causes,  leading  to  his  being  designated  by  the 
Kiwanis  Club  as  Charlotte's  most  useful  citizen. 
Because  of  his  unselfishness,  honesty  and  simplici- 
ty, in  a  quiet  way,  he  was  the  most  popular  man 
in  the  profession  of  our  city. 


In  the  death  of  Dr.  Barret  the  Charlotte  pro- 
fession has  lost  its  most  gifted  member. 

In  the  Spring  of  1911  he  married  Miss  Nanny 
Mason,  who  survives  with  three  daughters. 


This    Association's    official    journal's    issue    for 
May  of  last  year  carried  this  tribute  to  Dr.  Tucker: 
DOCTOR  JOHN  HILL  TUCKER 
Dr.  James  M.  Northington,  Charlotte 
Within    the   past   month   Charlotte   and   North 
Carolina   lost   one    of    their    foremost    personages. 
The  twenty-second  of  April  all  Charlotte  was  sad- 
dened  at   learning   that   in   the   night   before   Dr. 
John  Hill  Tucker  had  died. 

John  Hill  Tucker  was  born  at  Henderson.  Son 
of  a  learned  and  distinguished  doctor,  he  early 
chose  to  devote  his  life  to  medicine.  But  devoted 
as  he  was  to  medicine,  he  found  time  and  energy 
for  all  other  good  things.  After  graduation  in  medi- 
cine at  the  University  of  Virginia  and  a  few  years 
of  general  practice  in  his  native  town,  Dr.  Tucker 
took  special  studies  in  diseases  of  the  eye,  ear  and 
throat  and  removed  to  Charlotte.  Here  he  en- 
tered joyously  into  the  practice  of  his  specialty, 
the  work  of  the  Episcopal  Church  and  every  other 
enterprise  for  the  promotion  of  the  private  and 
public  good. 

A  few  years  ago  he  was  voted  and  proclaimed 
Charlotte's  foremost  citizen.  Never  was  honor 
more  deservedly  bestowed. 

And  to  the  time  he  was  stricken,  five  months 
before  his  death,  he  was  healer  and  restorer,  min- 
istering to  our  needs,  private  and  public. 

With  the  passing  of  the  weeks  and  months  since 
those  lines  were  penned  has  come  fuller  realization 
of  their  inadequacy. 

A  gentle,  kindly,  cultured  man,  ever  eager  to 
know  more  and  more  of  his  special  field  of  medi- 
cine, of  medicine  as  a  whole,  of  knowledge  as  a 
whole:  a  man  of  unbounded  energy,  enthusiasm 
and  courage,  it  was  inevitable  that  he  would  take 
a  high  place  in  his  profession  and  a  leading  part  as 
a  citizen. 


DOCTOR  JOHN  PETER  MUNROE 
Dr.  J.  M.  Northington,  Charlotte 
At  Charlotte,  in  the  night  of  October  14th,  died, 
at  the  age  of  83,  the  man  who  had  done  most  in 
Medicine  in  North  Carolina.  Dr.  Munroe  did  not 
initiate  medical  teaching  in  North  Carolina:  he 
did  advance  and  improve  it  over  a  half-centurv. 
It  may  well  be  that  none  of  those  be  turned  out 
to  minister  medically  made  any  great  improvement 
on  his  teacher's  teaching.  Certain  it  is  that  this 
teaching  was  of  the  best  for  the  dav  it  was  im- 
parted, that  those  he  taught  carried  healing  wher- 
ever thev  were  called. 


September,   1941 


SOUTHERN  MEDICINE  &■  SURGERY 


517 


Dr.  Munroe,  from  his  childhood,  loved  learning 
for  learning's  sake:  much  more  he  loved  learning 
for  the  place  it  gave  him  among  the  elect:  most 
he  loved  learning  for  what  power  of  control  it  gave 
him  over  pain  and  sickness  and  death. 

In  the  1840's  John  Peter  Mettauer,  at  Prince 
Edward  Court  House,  in  Virginia,  was  a  whole 
medical  faculty — and  a  good  one:  sixty-odd  years 
later  John  Peter  Munroe,  at  Davidson,  in  North 
Carolina,  was  a  whole  medical  faculty — and  a  good 
one.  And  the  total  of  medical  knowledge  to  be 
taught  had  been  increased  a  dozen  fold  in  the  in- 
terval. 

Xo  disparagement  of  the  grandson  of  La 
Fayette's  surgeon  is  implied,  only  the  even  greater 
accomplishment  of  our  own  John  Peter. 

Dr.  Munroe  made  his  own  way.  He  worked  with 
his  hands  for  the  wherewithal  to  train  his  mind, 
that  he  might  work  with  his  mind  for  the  where- 
withal to  further  train  his  mind  and  his  hands  for 
his  great  vocation  of  practitioner  and  teacher  of 
medicine.  Many  a  North  Carolina-born  doctor 
could  say  with  truth,  as  did  one  of  the  most  suc- 
cessful in  the  State  a  few  years  ago:  "But  for  Dr. 
Munroe  I  could  never  have  been  a  doctor."  It 
would  hardly  be  overstating  the  case  to  say  that 
what  Aycock  and  Mclver  did  for  general  education 
in  North  Carolina,  Munroe  did  for  medical  educa- 
tion. Some  years  ago  another  doctor,  himself  a 
great  teacher  of  medicine,  said  of  Dr.  Munroe: 
"He  has  taught  more  subjects,  and  taught  them 
all  well,  than  any  doctor  who  ever  lived." 

Omnivorous  as  was  his  craving  for  knowledge, 
catholic  as  was  his  learning,  he  had  none  of  the 
priggishness  of  scholasticism.  Learning  of  no  prac- 
tical usefulness  to  others  he  might  chew  as  a  pleas- 
ant cud;  but  learning  he  could  translate  into  the 
promotion  of  the  best  earthly  interest  of  mankind 
was  his  life-long  quest.  When  any  other  man  would 
have  been  content  to  pass  the  care  of  ailing  hu- 
mans on  to  younger  and  stronger  frames,  Dr. 
Munroe  gets  him  off  to  Europe  to  learn,  at  first 
hand,  from  one  who  says  he  can  do  something  for 
victims  of  general  paralysis  of  the  insane.  He  finds 
that,  for  many  of  these  most  pitiable  and  hitherto 
most  hopeless  of  those  made  in  His  image,  there 
is  hope  and  cure;  and  he  comes  back  to  diffuse 
this  hope,  to  make  these  cures.  When  his  sparse 
remaining  hairs  were  white,  his  legs  tottering  and 
his  speech  stumbling,  his  magnificent  mind — still 
untouched,  still  bent  on  his  life's  purpose — forced 
him  on  and  up;  and  he  might  have  been  seen, 
evening  after  evening,  intently  listening  and  in- 
dustriously taking  notes,  as  a  peripatetic  teacher 
of  matters  medical  disserted  on  some  new  thing. 

A  few  years  agone  the  idea  was  born  in  Char- 
lotte that  the  achievements  of  Dr.  Munroe  and  Dr. 
Andrew  Johnson  Crowell  should  be  accorded  spe- 


cial recognition  while  these  two  great  doctors  were 
yet  with  us.  So  a  dinner  was  arranged  and  many 
came  to  pay  the  two  heart  tribute.  Dr.  Munroe 
was  called  upon,  and  his  face  glowed  as  he  said 
that  this  celebration  had  made  his  cup  of  happiness 
full  to  overflowing. 

Dr.  Crowell  has  been  some  time  gone  from 
among  us.  Dr.  Munroe's  eager  mind  has  now 
ceased  its  craving  for,  "More  light."  In  honoring 
them  we  honored  ourselves. 

It  would  be  ill-befitting  that  the  ensample  of 
our  greatest  man  of  medicine  be  suffered  to  lapse 
and  go  to  naught.  He  would  not  have  wished  a 
likeness  monument  in  bronze  or  marble  to  stare 
about  and  be  stared  at. 

Fitting  it  would  be  to  perpetuate  the  memory  of 
this  good  doctor  by  raising  funds  to  meet  the  ex- 
penses of  the  care  of  at  least  one  illness,  in  each 
year,  in  each  of  the  100  counties  of  his  state. 

O,  eloquent,  just  and  mighty  Death !  Whom  none  could 
advise,  thou  hast  persuaded;  and  all  is  covered  over  with 
these  two  narrow  words,  Hie  jacetl 

And  they  die 
An  equal  death, — the  idler  and  the  man 
Of  mighty  deeds. 


DOCTOR  JAMES  WILSON  HUNTER, 
JUNIOR 

Dr.  C.  J.  Andrews,  Norfolk 

Dr.  James  Wilson  Hunter,  Jr.,  died  at  Hot 
Springs,  Arkansas,  May  11th,  1940,  having  been 
in  ill  health  for  some  time.  Dr.  Hunter  was  a  na- 
tive of  Norfolk  and  received  his  early  education 
here  under  private  tutorship.  He  was  graduated 
from  the  Episcopal  High  School  at  Alexandria,  re- 
ceived his  Master  of  Arts  degree  and  Doctor  of 
Medicine  degree  at  the  University  of  Virginia,  the 
latter  in  1901. 

He  early  interested  himself  in  x-ray  work  and 
became  a  pioneer  radiologist,  which  specialty  he 
followed  until  his  retirement  at  the  close  of  last 
year.  He  was  author  of  numerous  articles  in  ra- 
diology. 

He  was  a  member  of  the  Norfolk  County  Medi- 
cal Society,  of  which  he  was  past-president,  and 
had  been  a  member  of  the  Medical  Society  of  Vir- 
ginia for  thirty-eight  years.  He  was  also  a  mem- 
ber of  the  Tri-State  Medical  Association,  the 
American  College  of  Physicians,  the  American  Col- 
lege of  Radiology,  the  American  Association  for 
the  Advancement  of  Science,  The  American  Med- 
ical Association,  The  Seaboard  Medical  Associa- 
tion, the  Society  of  the  Sons  of  Cincinnati,  the 
Alpha  Omega  Alpha  Fraternity,  the  Huguenot  So- 
ciety of  America  and  a  veteran  of  the  World  War, 
a  Captain  in  the  Medical  Corps. 

Dr.  Hunter's  personality  was  that  characteristic 
of  a  cultured  gentleman.  His  work  contributed 
much  to  the  value  of  medical  practice  in  this  sec- 


518 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


tion  of  the  country.  His  accomplishments  were 
such  as  anyone  at  the  close  of  his  life  might  be 
justly  proud  and  the  occasion  of  much  satisfaction. 


DOCTOR  WILLIAM  TURNER  RAY 
Dr.  O.  Hunter  Jones,  Charlotte 

It  was  my  privilege  to  know  Dr.  William  Turner 
Ray  from  youth.  In  his  passing  I  lost  a  classmate, 
of  both  high  school  and  college  days,  and  a  friend. 

Turner  Ray  was  born  at  Wake  Forest,  N.  C, 
January  17th,  1903.  He  grew  up  in  this  college 
town,  attending  the  local  public  schools  and  later 
Wake  Forest  College,  where  he  was  graduated 
with  the  B.S.  degree.  He  received  his  M.D.  degree 
from  the  University  of  Maryland  in  1934,  interned 
at  the  Baltimore  City  Hospital  and  the  Franklin 
Square  Hospital  in  Baltimore,  following  which  he 
located  in  Charlotte  for  the  general  practice  of 
medicine.  Here  he  was  city  police  physician  for 
three  years.  He  was  a  member  of  the  Mecklenburg 
County  Medical  Society,  the  North  Carolina  Med- 
ical Society,  the  Tri-State  Medical  Association, 
and  the  American  Medical  Association. 

In  addition  to  his  professional  duties,  Dr.  Ray 
was  keenly  interested  in  the  alumni  activities  of 
Wake  Forest  College  and  was  secretary  of  the 
Mecklenburg  Chapter  at  the  time  of  his  death. 

He  is  survived  by  his  wife,  who  was  formerly 
Miss  Harriette  Mangum,  of  Wake  Forest,  and  an 
infant  son,  William  Turner  Ray,  Jr. 

To  know  Dr.  Ray  was  to  like  him.  He  possessed 
that  very  fine  quality  of  cheerfulness  and  of 
spreading  cheer.  He  enjoyed  living  to  the  fullest. 
It  is  tragic  indeed  that  one  who  loved  life  so  should 
have  been  stricken  at  the  early  age  of  37.  Medi- 
cally, his  distinguishing  quality  was  a  primary  con- 
cern for  the  welfare  of  his  patients.  He  never 
failed  to  seek  consultation  whenever  there  was 
even  the  slightest  possibility  that  the  patient  might 
benefit  therefrom — such  is  the  mark  of  the  true 
physician!  Dr.  Ray  was  honest  with  himself  and 
honest  with  his  patients,  and  in  turn  experienced 
that  inner  satisfaction  known  only  to  the  physi- 
cian who  enjoys  the  complete  confidence  and  trust 
and  gratitude  of  his  patients. 

Dr.  Ray  passed  away  suddenly,  June  16th, 
1940,  presumably  a  victim  of  coronary  heart  dis- 
ease. In  the  five  years  he  spent  among  us  this 
promising  young  physician  had  made  a  host  of 
friends.  He  will  be  greatly  missed,  and  his  place 
difficult  to  fill. 


(A  sonnet  written   by   Dr.   Hans  Zinsser  when  he   knew  h 
were  numbered;  Jl.  Assn.  Amer.  Med.  Col.,  July) 


Now  is  death  merciful.    He  calls  me  hence 
Gently,  with  friendly  soothing  of  my  fears 
Of  ugly  age  and  feeble  impotence 
And  cruel  disintegration  of  slow  years. 

He  does  not  leap  upon  me  unaware 
Like  some  wild  beast  that  hungers  for  its  prey, 
But  gives  me  kindly  warning  to  prepare, 
Before  I  go,  to  kiss  your  tears  away. 

How  sweet  the  summer!  And  the  autumn  shone 
Late  warmth  within  our  hearts  as  in  the  sky, 
Ripening  rich  harvest  that  our  love  had  sown. 
How  good  that   ere  the  winter  comes,  I  die ! 

Then  ageless,  in  your  heart  I'll  come  to  rest 
Serene  and  proud,  as  when  you  loved  me  best. 


September,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


S19 


NEWS 


THE  SCHERING  AWARD 

The  Schering  Award  is  offered  to  encourage  the  current 
interest  in  endocrinological  developments  by  offering  an 
opportunity  to  interested  medical  students  to  pursue  an 
inquiry  into  that  branch  of  the  history  of  endocrine  re- 
search which  may  appeal  to  them.  No  restriction  is  placed 
upon  the  historical,  philosophical  or  scientific  depth  which 
an  author  may  permit  himself. 

A  medical  student  matriculated  in  any  medical  school  in 
the  United  States  or  Canada  is  eligible  to  compete.  Grad- 
uate students  in  medical  schools  are  not  eligible.  Senior 
medical  students  are  eligible  with  the  understanding  that 
they  will  be  awarded,  if  successful,  an  equivalent  scholar- 
ship for  postgraduate  study  or  the  cash  equivalent  of  the 
scholarship,  at  the  option  of  the  medical  student. 

All  manuscripts  become  the  property  of  the  Journal  of 
the  Association  of  Medical  Students  when  submitted.  Ac- 
knowledgment will  be  made  of  every  manuscript  received, 
but  no  other  responsibility  can  be  assumed;  entrants  are 
advised  to  prepare  and  retain  duplicate  copies  as  a  safe- 
guard against  the  possibility  of  loss. 

Manuscripts  will  be  received  up  to  November  15th,  next. 

Offerings  will  be  judged  by  a  committee  of  distinguished 
endocrinologists  and  authorities  in  related  fields  of  medi- 
cine and  and  chemistry.  The  committee  includes:  Dr.  E.  C. 
Hamblen,  Duke  University  School  of  Medicine;  Dr.  R.  G. 
Hoskins,  Harvard  Medical  School;  Dr.  F.  C.  Koch,  Uni- 
versity of  Chicago;  Dr.  H.  Lisser,  University  of  California 
Medical  School;  Dr.  E.  P.  McCullach,  Cleveland  Clinic; 
Dr.  C.  R.  Moore,  University  of  Chicago;  Dr.  E.  Novak, 
University  of  Maryland;  Dr.  E.  L.  Sevringhaus,  University 
of  Wisconsin  Medical  School;  Dr.  E.  Shorr,  Cornell  Uni- 
versity Medical  College. 

The  names  of  successful  candidates  for  the  award  will  be 
announced  in  December.  1941,  when  the  prizes  will  be 
awarded. 

Notice  should  be  furnished  at  such  time  as  the  student 
decides  to  prepare  a  manuscript,  and  should  state  the  field 
selected  for  his  dissertation,  his  medical  school  year,  age 
and  home  address. 

Manuscripts,  notices  of  intention  to  participate,  and 
other  communications,  should  be  addressed  to 

Committee  on  the  Schering  Award,  Association  of  Med- 
ical Students, 

25  Madison  Square  North, 

New  York  City. 


ANNOUNCEMENT  OF  VAN  METER  PRIZE  AWARD 
The  American  Association  for  the  Study  of  Goiter  again 
offers  the  Van  Meter  Prize  Award  of  Three  Hundred  Dol- 
lars and  two  honorable  mentions  for  the  best  essays  sub- 
mitted concernine  original  work  on  problems  related  to  the 
thyroid  gland.  The  award  will  be  made  at  the  annual 
meeting  of  the  Association  which  will  be  held  at  Atlanta, 
June  1st,  2nd  and  3rd,  providing  essays  of  sufficient  merit 
are  presented  in  competition. 

The  competing  essays  may  cover  either  clinical  or  re 
search  investigations;  should  not  exceed  three  thousand 
words  in  length;  must  be  presented  in  English;  and  a  type- 
written, double  spaced  copy  sent  to  the  Corresponding 
Secretary,  Dr.  T  C.  Davison,  478  Peachtree  Street,  At- 
lanta, not  later  than  April  1st. 

A  place  will  be  reserved  on  the  program  of  the  annual 
meeting  for  presentation  of  the  Prize  Award  Essay  by  the 
author  if  it  is  possible  for  him  to  attend.  The  essay  will 
be  published  in  the  annual  Proceedings  of  the  Association. 
This  will  not  prevent  its  further  publication,  however,  in 
any  journal  selected  by  the  author. 


DR.  BERRYHILL  MADE  DEAN 
Walter  Reece  Berryhill  was  born  in  Charlotte  in  1900, 
and  graduated  from  the  University  in  1921.  He  was  presi- 
dent of  his  class  in  his  senior  year  and  president  of  the 
student  council.  In  1923  he  entered  the  Medical  School  of 
the  University,  and  went  on  to  Harvard  for  his  M.D.  de- 
gree. 

He  served,  successively,  as  intern  and  resident  physician 
in  the  Boston  City  Hospital,  as  resident  physician  at  the 
Lakeside  Hospital  in  Cleveland,  and  as  instructor  in  med- 
icine and  attending  physician  at  the  Lakeside  Hospital. 
After  he  had  been  University  physician  at  Chapel  Hill  for 
a  year  he  was  elected  associate  professor  of  medicine,  and 
in  1937  he  became  assistant  dean  of  the  Medical  School. 
He  is  now  elevated  to  the  deanship. 


Dr.  Hal  McCluney  Davison,  Dr.  James  C.  Thorough- 
man  and  Dr.  John  B.  Peschau  announce  their  association 
for  the  practice  of  Medicine  (Internal  Medicine,  Allergy), 
207  Doctors  Building,  Atlanta. 


Dr.  James  P.  Baker,  Richmond,  announces  the  removal 
of  his  offices  to  820  West  Franklin  Street. 


Whitman  Carlisle  McConnell,  M.D.,  announces  that 
his  son,  Whitman  Hurst  McConnell,  M.D.,  has  joined 
him  for  the  practice  of  Neuro-psychiatry  at  St.  Petersburg, 
Florida. 


Dr.  Robert  L.  Garrard,  Assistant  Physician  to  the  State 
Hospital  at  Morganton  for  the  past  fourteen  months,  has 
removed  to  Greensboro  for  private  practice  in  mental  and 
nervous  disorders.  He  is  a  native  of  Alabama,  graduated 
from  Harvard  Medical  School  in  1932  and  spent  several 
years  in  hospitals  of  Boston,  Providence  and  New  York. 
Dr.  Garrard  is  to  be  affiiliated  with  the  Duke  Hospital 
and  Medical  School  in  Durham. 


Dr.  J.  P.  King  and  Dr.  F.  A.  Strickler  announce  the 
association  of  Dr.  Wiley  D.  Lewis  with  offices  at  Saint 
Albans  Sanatorium,  Radford,  Virginia.  Practice  limited  to 
Neurology  and  Psychiatry. 


Dr.  W.  Gayle  Crutchfield  announces  the  removal  of 
his  offices  from  Richmond  to  The  University  of  Virginia 
Hospital,  Charlottesville,  where  he  is  in  charge  of  the 
Department   of  Neurological  Surgery. 


MARRIED 

Dr.  Marshall  Burt  Breath,  of  Galveston,  Texas,  and  Miss 
Kathleen  Douglas  MacDonald,  of  Farmville,  Virginia,  were 
married  on  August  30th. 

Dr.  Rufus  Henry  Temple  and  Miss  Eleanor  Frances 
Worthington,  both  of  Kinston,  were  married  on  September 
2nd. 


Dr.  Alfred  Hamilton,  of  Chapel  Hill,  and  Miss  Eileen 
O'Brien,  of  Providence,  Rhode  Island,  were  married  at 
Chapel  Hill,  September  4th.  Dr.  Hamilton,  a  lieutenant  in 
the  Medical  Corps,  United  States  Army,  is  stationed  at 
Camp  Blanding,  Florida. 


Dr.  Adlai  Stevenson  Oliver,  Jr.,  of  Raleigh,  and  Miss 
Mary  Anderson,  of  New  Bern,  were  married  on  September 
fith.  Dr.  Oliver  is  resident  physician  in  the  Bryn  Mawr 
Hospital. 


Miss  Kathryn  Elizabeth  Funk,  of  Middletown,  and  Doc- 
tor Theodore  Baldwin  McCord,  of  Fairfax,  Virginia,  July 
19th. 


S26 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


DIED 

Dr.  William  H.  Riley,  81,  of  Battle  Creek,  Mich.,  died 
August  24th,  after  a  two  weeks'  illness  at  The  Lodge, 
Amelia  County  home  of  his  son.  Dr.  Riley  was  graduated 
from  the  University  of  Michigan  in  1S86,  and  except  for 
the  years  1896  to  1902,  his  medical  career  had  been  with 
the  Battle  Creek  institution. 

After  his  graduation  Dr.  Riley  studied  in  New  York 
City,  at  Chicago,  Vienna,  Munich  and  London.  He  be- 
came a  member  of  the  Royal  Society  of  Medicine  of  Lon- 
don. He  was  the  author  of  various  articles  in  leading  med- 
ical journals  dealing  especially  with  diagnosis  of  brain  and 
spinal  cord  tumors  and  pernicious  anemia. 


BOOKS 


TO  MINIMIZE  AFTER-EFFECTS  OF  TONSIL 
REMOVAL 

(R.  H.  Fowler,  M.D.,  New  York,  in  /.  A.  M.  A..  Aug.  2nd) 
It  takes  but  a  minute  to  cut  a  flap  at  the  time  of  the 
first  incision  of  the  mucous  membrane;  it  takes  less  than  a 
minute  when  the  tonsil  has  been  removed  to  anchor  this 
flap  with  a  catgut  slipknot  to  the  fascia  at  the  center  of 
the  wound.  The  technic  must  be  accurate.  The  patient 
eats  breakfast  the  next  morning.  The  time  for  the  wound 
to  cover  over  is  lessened  by  half,  and  the  amount  of  scarr- 
ing is  almost  nil.  Covering  the  most  vulnerable  and  sensi- 
tive part  of  the  wound  quickens  the  healing  forces  of  na- 
ture to  repair  the  throat  with  a  minimum  of  discomfort, 
distortion  and  disturbance  of  function.  .  .  . 

The  number  of  operations  in  which  plastic  flaps  have 
been  used  has  run  into  the  thousands.  No  bad  results 
have  been  reported. 


ABDOMINAL  SURGERY  OF  INFANCY  AND 
CHILDHOOD,  by  William  E.  Ladd,  M.D.,  F.A.C.S  , 
William  E.  Ladd  Professor  of  Child  Surgery  at  Harvard 
Medical  School ;  Chief  of  Surgical  Service,  The  Children's 
Hospital,  Boston;  and  Robert  E.  Gross,  M.D.,  Associate 
in  Surgery,  the  Harvard  Medical  School;  Associate  Visiting 
Surgeon,  The  Children's  Hospital;  Associate  in  Surgery, 
The  Peter  Bent  Brigham  Hospital,  Boston.  455  pages  with 
268  illustrations.  Philadelphia  and  London.  W.  B.  Saun- 
ders Company.  1941.    Price  ?10.00. 

The  need  for  a  book  dealing  with  surgery  of  in- 
fancy and  childhood  as  an  art  in  many  ways  dif- 
ferent from  surgery  of  the  adult  has  been  felt  for 
a  long  time.  Here  is  the  answer  to  that  need,  com 
plete  and  authoritative,  all  the  way  from  congenital 
pyloric  stenosis  to  neuroblastoma  sympatheticum. 


ESSENTIALS  OF  GENERAL  SURGERY,  by  Wallace  P. 
Ritchie,  M.D.,  Clinical  Assistant  Professor,  Department 
of  Surgery,  University  of  Minnesota  Medical  School;  with 
237  illustrations.  The  C.  V.  Mosby  Company,  3525  Pine 
Boulevard,  St.  Louis.     1941.   $8.50. 

This  volume  is  presented  as  a  basic  outline  of 
the  important  surgical  points  which  the  student  of 


BIPEPSONATE 


Calcium   Phenolsulphonate    2  grains 

Sodium  Phenolsulphonate  2  grains 

Zinc  Phenolsulphonate,  N.  F 1  grain 

Salol,  U.  S.  P 2  grains 

Bismuth  Subsalicylate,  U.  S.  P 8  grains 

Pepsin,  U.  S.  P 4  grains 

Average    Dosage 

For  Children — Half  drachm  every  fifteen  minutes  for 
six  doses,  then  every  hour  until  relieved. 
For  Adults — Double  the  above  dose. 

How   Supplied 

In  Pints,  Five-Pints  and  Gallons  to  Physicians  and 
Druggists  only. 


Burwell  &  Dunn  Company 


Manufacturing 
Established 


Pharmacists 
in    1887 


CHARLOTTE,  N.  C. 


Sample    sent   to    any    physician    in    the    U.   S.    on 
request 


Patronage  of  our  Advertu 


Mark  of  Friendship  to  the  Journal 


September,   1941 


SOUTHERN  MEDICINE  &  SURGERY 

—  .„ 


SAFETY 

One  of  the  most  striking  characteristics  of  Allonal  is  that  it  can  safely  be  prescribed  night  after  night,  as 
required,  without  danger  of  cumulative  action  or  morning-after  hangover.  The  hypnotic  component  is 
destroyed  promptly  in  the  body  and  eliminated.  Because  of  the  synergism  of  its  two  ingredients,  allyl- 
isopropyl-barbituric  acid  and  acetophenetidin,  it  is  neither  a  short-acting  nor  a  long-acting  hypnotic.  One 
or  two  tablets  can  be  counted  on  to  bring  (>  lo  8  hours  of  refreshing  sleep  —  even  in  the  presence  of  pain. 
Allonal  does  not  contain  amidopyrine.   •  •  •  HOFFMANN  -  LA  ROCHE,  INC.  •  NUTLEY,  N.  J. 


ALLONAL,      SENSIBLE       H  Y  PN  O  -  AN  AL  G  ESI  C 

Patronage  of  our  Advertisers  is  a  Mark   of  Friendship  to  the  Journal 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


medicine  must  master.  Some  chapters  have  been 
written  by  other  members  of  the  faculty  of  the  Uni- 
versity of  Minnesota  Medical  School. 

A  brief  history  is  given  of  the  development  of 
surgery.  Chapters  are  devoted  to  anesthesia,  tech- 
nique, asepsis  and  antisepsis,  wounds  and  their  re- 
pair, mechanical  and  thermal  injuries,  hemorrhage 
and  shock,  gangrene  and  peripheral  vascular  dis- 
ease, inflammation  and  infection,  tumors,  the  skin, 
the  lymphatic  system,  the  blood  vessels,  the  peri- 
pheral nerves,  orthopedic  surgery,  fractures  and 
dislocations,  amputations,  tissue  transfer  and  trans- 
plantation, the  head,  brain  and  meninges,  the  oral 
cavity,  the  neck,  the  endocrine  glands,  the  breast, 
the  chest  wall,  pleura  and  lungs,  the  heart  and  peri- 
cardium, the  esophagus,  larynx,  and  trachea,  the 
spinal  cord,  autonomic  nervous  system,  the  abdom- 
inal wall  and  hernia,  the  peritoneum,  the  stomach 
and  duodenum,  the  small  and  large  bowel,  the 
biliary  system,  the  pancreas,  surgery  of  the  spleen, 
an  outline  of  urology. 

Throughout  the  description  is  clear,  the  teaching 
sound,  devoid  of  fads  and  fancies.  The  quarter- 
thousand  illustrations  so  amplify  the  text  as  to 
make  a  book  of  unusual  excellence. 


THE  COMPLETE  WEIGHT  REDUCER,  by  C.  J. 
Gerling.  Harvest  House,  70  Fifth  Ave.,  New  York  City. 
1941.    $3.00. 

This  seems  to  be  a  book  in  which  the  different 
elements  that  account  for  fatness  are  given  their 
proper  values;  i.e.,  in  which  eating  too  much  is 
given  chief  place.  Lack  of  exercise  is  given  a  well- 
deserved  second  place. 

The  various  fads  advertised  so  generally  are  an- 
alyzed and  shown  up.  "Acidosis"  is  intelligently 
discussed.  So  is  alcohol,  and  appetite.  Those  who 
belong  to  oversize  fat  families  are  warned  that  it 
may  be  dangerous  to  try  to  get  thin. 

Function  and  malfunction  of  the  endocrine 
glands,  in  their  bearings  on  the  laying  down  of  fat, 
are  amply  considered. 

The  sanity  and  balance  of  the  author  are  shown 
by  this  passage:  Many  a  housewife  will  spend 
money  on  an  expensive  rowing  machine  and  then 
hire  someone  to  do  all  the  housework.  Housework 
involves  all  the  movements  necessary  for  reduction, 
besides  saving  money. 

No  one  capable  of  thinking  in  those  terms  could 
write  a  foolish  book. 


FATAL  PARTNERS  WAR  AND  DISEASE,  by  Ralph 
H.  Major,  M.D.  Doubleday,  Doran  &  Co.,  Inc.,  Garden 
City,  N.  Y.,  1Q41.   $3.50. 

Warfare  in  early  times  was  simple.  Individual 
courage,  many  times  multiplied,  was  the  deciding 
factor.    A  club,  a  spear  or  a  crude  sword,  was  the 


whole  offensive  equipment,  a  pouch  of  parched 
grain  the  commissarv. 

The  Greek  word  surgeon  means  extractor  of  ar- 
rows. Plagues  of  disease  were  regarded  as  visita- 
tions of  Divine  wrath.  The  crusaders  are  shown  to 
have  been  marauding,  ignorant  fanatics.  The  rec- 
ord of  the  Hospitallers  is  a  bright  light  in  a  very 
dark  world.  Women,  as  a  part  of  the  military 
establishments,  make  remarkable  reading.  The 
American  origin  of  syphilis  is  espoused. 

There  are  sketches  of  most  of  the  great  wars — 
the  30-years  War,  the  Xapoleanic  Wars,  the  Civil 
War,  the  Crimean  War,  the  South  African  War,  all 
the  way  to  and  including  the  First  World  War — 
all  emphasizing  the  well-known  fact  that  up  to  the 
Russo-Japanese  War  ten  to  fifty  died  of  disease 
for  every  one  to  meet  death  in  battle. 

It  is  an  entertaining  and  instructive  narrative 
which  should  meet  with  a  favorable  reception  from 
doctors,  nurses  and  all  other  intelligent  persons. 


HANDBOOK  OF  COMMUNICABLE  DISEASES,  by 
Franklin  H.  Top,  A.B.,  M.D.,  M.P.H.,  Director,  Division 
of  Communicable  Diseases  and  Epidemology.  Herman  Kie- 
fer  Hospital  and  Detroit  Department  of  Health ;  Associate 
Professor  of  Preventive  Medicine  and  Public  Health, 
Wayne  University  College  of  Medicine;  and  Collaborators. 


September.    1941 


SOUTHERN  MEDICINE  &  SURGERY 


Ciba  MALE  SEX  HORMONES 

Now  in  3  Convenient  Forms 

PERAIVDREIM*  "Ciba"  represents  a  chemically  pure  and  synthetic 
testosterone  propionate,  the  most  potent  androgenic  substance  known. 
Supported  by  an  important  clinical  literature.  In  ampules  of  5,  10  and 
25  mg.  for  injection. 

PERANDREN  OINTIETS*  are  individual-dosage  tubes  each  con- 
taining  4  mg.  of  testosterone  propionate  in  a  bland  unguent  base. 
Administration  is  uniform,  clean,  easy. 

METAIMDREIV*  is  Ciba's  orally  administered  synthetic,  crystalline, 
chemically-pure  methyltestosterone.  Male  sex  hormone  efficiency  dem- 
onstrated in  animals  and  humans.  Scored  tablets,  10  mg.  each. 

Indications:  —  PERANDREN  is  used  in  disturbances  of  male  sexual 
development  such  as  cryptorchidism,  hypogonadism,  dystrophia  adi- 
posogenitalis;  also  when  impotence,  sterility,  male  climacteric  and 
prostatism  are  due  to  androgenic  deficiency.  For  females,  in  some 
menorrhagias,  metrorrhagias,  dysmenorrheas,  and  to  inhibit  post- 
partum lactation.  PERANDREN  OINTLETS  and  METANDREN  may  be  used 
in  conjunction  with  or  as  substitute  therapy  for  PERANDREN  where  the 
physician  deems  this  logical. 

•Trade  Mark  Reg.  U.  S.  Pat.  Off.  Word  "Perandren"  identifies  the  product 
as  testosterone  propionate  of  Ciba's  manufacture.  Word  "Metandren" 
identifies  the  product  as  17-methyltestosterone  of  Ciba's  manufacture. 
OINTLETS  designate  Ciba's  ointment  tubes  containing  accurate  doses. 


o 


o 


o 


CIBA  PHARMACEUTICAL   PRODUCTS,  INC.    •    SUMMIT,   NEW  JERSEY 


Patronage  of  our  Advertiser 


Mark  of  Friendship  to   the  Journal 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


With  73  text  illustrations  and  10  color  plates.    The  C.  V. 
Mosby  Company,  St.  Louis.    1941.   $7.50. 

There  is  still  confusion  as  to  what  are  injections 
and  contagious.  There  can  be  none  as  to  the  mean- 
ing of  communicable.  The  classification  by  portals 
of  entry  is  original  and  useful.  The  book  is  a  prod- 
uct largely  of  the  author's  own  experience  and  that 
of  an  associate.  It  brings  the  doctor  right  up  to 
now  in  knowledge  of  how  to  recognize,  and  what  to 
do  about,  diseases  which  may  be  communicated 
from  the  sick  to  the  well. 


CARDIAC  CLINICS:  A  Mayo  Clinic  Monograph,  by 
Frederick  A.  Willius,  B.S.,  M.D.,  M.S.,  in  Med.,  Head  of 
Section  of  Cardiology,  Mayo  Clinic  and  Professor  of  Med- 
icine, Mayo  Foundation  for  Medical  Education  and  Re- 
search, Graduate  School,  University  of  Minnesota,  Roches- 
ter. Illustrated.  The  C.  V.  Mosby  Company,  St.  Louis. 
1941.    $4.00. 

These  are  brief,  practical  discussions  of  heart 
conditions,  compiled  and  arranged  from  cases  pre- 
sented from  time  to  time  in  Staff  meetings  of  the 
Mayo  Clinic,  largely  for  the  general  practitioners, 
who,  as  the  author  says,  are  usually  accorded  little 
consideration  by  medical  authors. 

Here  is  teaching  fit  to  be  ranked  with  Sir  Thom- 
as Lewis's  Diseases  oj  the  Heart. 


SYNOPSIS  OF  APPLIED  PATHOLOGICAL  CHEMIS- 
TRY, by  Jerome  E.  Andes,  M.S.,  Ph.D.,  M.D.,  F.A.C.P., 
Director  of  Department  of  Health  and  Medical  Advisor, 
University  of  Arizona,  Tucson ;  Formerly  Assistant  Profes- 
sor of  Pathology  and  Clinical  Pathology,  West  Virginia 
University  Medical  School;  and  A.  G.  Eaton,  B.S.,  M.A., 
Ph.D.,  Assistant  Professor  of  Physiology,  Louisiana  State 
University  School  of  Medicine,  New  Orleans.  With  23  illus- 
trations. The  C.  V.  Mosby  Company,  St.  Louis.  1941. 
$4.00. 

The  authors  start  out  to  write  a  simple,  useful 
text  on  the  application  of  the  chemistry  of  disease 
conditions  to  the  diagnosis  and  cure  of  disease,  and 
right  well  do  they  do  the  job. 

The  text  is  concise;  there  is  no  superfluity.  For 
those  who  wish  encycopedic  information  abundant 
references  are  furnished. 


MICROBES  WHICH  HELP  OR  DESTROY  US,  by 
Paul  W.  Allen,  Ph.D.,  Professor  of  Bacteriology  and  Head 
of  the  Department,  University  of  Tennessee;  D.  Frank 
Holtman,  Ph.D.,  Associate  Professor  of  Bacteriology,  Uni- 
versity of  Tennessee,  and  Louise  Allen  McBee,  M.S., 
Formerly  Assistant  in  Bacteriology,  University  of  Tennes- 
see. With  102  text  illustrations  and  13  color  plates.  The 
C.  V.  Mosby  Company,  3525  Pine  Boulevard,  St.  Louis. 
1941.    $3.50. 

Chapter  heads  are  Microbes  and  the  Age  of 
Science,  The  Age  of  Superstition,  What  Are  Mi- 
crobes? Smallpox,  Nicolas  Appert,  Making  the 
World  Microbe  Conscious,  Surgeons  and  Microbes, 
The  Use  of  Disinfectants  and  Antiseptics,  Infection 
and  Resistance,  Community  Health  Activities. 

A  chapter  is  given  each  important  infectious  dis- 


ease, one  to  food  poisoning,  one  to  food  preserva- 
tion, one  to  safe  drinking  water,  leaven  in  bread, 
milk  and  its  products,  vinegar-making,  disposal  of 
waste  and  some  friendly  microbes  attract  the  in- 
terest. 

A  need  has  been  felt  for  a  long  time  for  a  book 
inculcating  a  sane,  differentiating  attitude  toward 
microorganisms  and  snakes,  according  as  individual 
specimens  are  harmful,  harmless  or  helpful.  Here 
is  the  answer  to  the  need  as  to  microorganisms. 
Now,  who  will  supply  a  like  book  on  snakes? 


Prognosis  in  Valvular  Disease. — The  question  is  en- 
tirely one  of  efficient  compensation.  So  long  as  this  is 
maintained  the  patient  may  suffer  no  inconvenience,  and 
even  with  the  most  serious  forms  of  valve  lesion  the  func- 
tion of  the  heart  may  be  little,  if  at  all,  disturbed. 

Practitioners  who  are  not  adepts  in  auscultation  and  feel 
unable  to  estimate  the  value  of  the  various  heart  murmurs 
should  remember  that  the  best  judgment  of  the  conditions 
may  be  gathered  from  inspection  and  palpation.  With  an 
apex  beat  in  the  normal  situation  and  regular  in  rhythm 
the  auscultatory  phenomena  may  be  practically  disre- 
garded. 

A  murmur  per  se  is  of  little  or  no  moment  in  determin- 
ing the  prognosis  in  any  given  case.  There  is  a  large  group 
of  patients  who  present  no  other  symptoms  than  a  systolic 
murmur  heard  over  the  body  of  the  heart,  or  over  the 
apex,  in  whom  the  left  ventricle  is  not  hypertrophied,  the 
heart  rhythm  is  normal,  and  who  may  not  have  had  rheu- 
matism. 

Indeed,  the  condition  is  accidentally  discovered,  often 
during  examination  for  life  insurance. — Osier. 


September,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


THE  SPREAD  OF  DISEASE  .  .  .  AND  RELIGIOUS 

FREEDOM 

(Editorial  in  //  Med.   Soc.  N.  J.,  July) 

With  the  spurious  justification  of  "religious  freedom''. 
New  Jersey  may  soon  be  encouraging  the  spread  of  com- 
municable disease.  Such,  at  least,  will  be  the  State's 
claim  to  fame  if  the  emasculated  version  of  Assembly  Bill 
402  is  finally  enacted  into  law.  In  its  original  form  this 
Bill,  introduced  by  Mr.  Hargrave,  would  allow  no-one 
but  physicians  to  treat  venereal  disease.  The  Christian 
Scientists  succeeded  in  slipping  an  amendment  into  the 
bill  which  would  exempt  them  from  this  restriction,  thus 
allowing  them  to  "treat"  syphilis  and  gonorrhea !  Only 
Senator  Summerill  of  Salem  voted  against  this  amend- 
ment. The  bill  is  now  back  in  the  Assembly,  and  it  may 
be  necessary  for  the  friends  of  public  health  to  withdraw 
A-402  entirely  rather  than  see  it  enacted  in  its  present 
vicious  form. 

The  theory  that  religious  freedom  justifies  faith  heal- 
ing in  venereal  disease  is  utterly  false.  Syphilis  and  gon- 
orrhea are  communicable  diseases,  and  thus  their  control 
is  a  public  health  problem,  not  one  of  private  religious 
opinion.  Second,  it  must  be  understood  that  the  precious 
American  right  to  worship  according  to  one's  own  con- 
science can  not  be  perverted  to  a  permission  to  jeopar- 
dize public  safety.  To  take  an  extreme  but  pertinent  ex- 
ample, could  the  State  allow  a  religious  cult  which  pres- 
cribed assassination  of  non-believers  to  flourish?  Could 
murderers  be  given  immunity  in  such  a  case,  because  their 
crimes  were  dictates  of  their  religion?  The  question 
answers  itself.  Yet  it  is  not  too  strong  to  say  that  the 
faith-healers  will  become  public  menances  if  this  amendment 
is  enacted  into  law.  Carriers  of  syphilis  or  gonorrhea 
who  do  not  want  to  submit  to  medical  care,  will  be  al- 
lowed to  spread  their  infection  freely  while  undergoing 
the  mumbojumbo  of  a  cult  "cure''. 

The  incredible  success  of  this  weird  amendment  can  be 
explained  only  on  the  assumption  that  our  Senators  sim- 
ply did  not  understand  the  implications  of  their  approval. 
They  should  somehow  be  enlightened  before  New  Jersey 
becomes  an  object  of  nation-wide  derision  by  the  enact- 
ment of  the  Christian  Science  Amendment  to  the  Venereal 
Disease  law. 


CHUCKLES 


PERMISSION  NECROPSY 
(O.   T.   Schultz.   Evanfton,   111.,  in  Jl.   of  Med.,  Aug.) 

Only  by  continued  postmortem  studies  can  new  disease 
entities  be  discovered  and  older  observations  be  confirmed, 
elaborated,  and  established  as  fact. 

Only  by  following  the  carefully-studied  patient  to  the 
autopsy  table  can  one  determine  where  and  why  an  error 
in  diagnosis  was  made  or  why  something  may  have  been 
overlooked. 

In  some  of  the  belter  hospitals  tabulations  have  been 
made  of  the  degree  of  agreement  between  clinical  diagno- 
sis and  anatomic  diagnosis.  The  percentage  of  error  is 
highest  in  minor  lesions  that  may  have  been  overshadowed 
by  a  predominant  condition. 

Not  one  death  in  a  hundred  is  subjected  to  postmortem 
examination  in  the  country  at  large.  The  cause  of  death  as 
listed  on  a  death  certificate  is  therefore  incorrect  in  a 
variable  and  not  insignificant  percentage.  The  value  of 
vital  statistics  will  be  increased  in  proportion  to  the  de- 
crease in  the  factor  of  error  in  reported  causes  of  death. 

Early  and  small  cancers  not  recognized  before  death  are 
found  in  a  considerable  proportion  of  deahts  coming  to 
autopsy. 

Heredity  is  an  important  factor  in  disease;  to  what  ex- 
tent cannot  be  determined  until  the  family  history  of  dis- 
ease in  the  ancestrv  of  the  individual  is  better  known. 


Kirkham  Brewer,  during  prohibition  days,  was  in  the 
front  rank  of  bootleggers  and  amassed  a  fortune.  He  still 
hopes  that  prohibition  will  once  more  tighten  its  coils 
around  American  necks.  He  was  admitled  to  the  ward,  a 
pauper,  with  extreme  venous  stasis,  due  to  constrictive 
pericarditis.  As  we  were  discussing  his  case  on  morning 
rounds  he  beckoned  to  me,  "Did  you  tell  those  guys  who 
I  am?"  he  asked.  I  told  him  they  wouldn't  know  if  I  did. 
He  stared  at  me  in  utter  amazement.  "Where  were  they 
all  this  time?  In  Africa?  Mean  to  tell  me  they  never 
heard  of  Kirky  Brewer?"  Suddenly  he  sat  up  with  a  start. 
"I  ain't  no  has-been;''  he  shouted,  "get  this  straight,  I'll 
.  .  .  ."  He  sank  back  on  the  pillows,  exhausted  and  cya- 
nosed.  "Kirky  Brewer  a  has-been,"  he  kept  on  muttering 
feebly. 

The  dismissal  of  John  Holywood's  secretary  cured  his 
wife's  digestive  disturbance. 

The  sterility  of  Mrs.  Hobbs  was  found  to  be  due  to 
dietary  deficiency. 

The  first  case  of  gonorrheal  bursitis  seen  in  the  clinic  in 
a  year  was  in  the  person  of  Christian  Scientist  Hall  Burke. 
Error  of  the  mind. 

— Leaf  from   a   Doctor's  Diary,  Roche  Review. 


ALCOHOLIC  NEURITIS  APPARENTLY  NOT  DUE  TO 

DEFICIENCY  OF  VITAMIN  B1 

(Editorial  in  Amcr.  Jl.  Dig.   Dis.,   Sept.) 

A  few  years  ago  most  enlightened  physicians  were  much 
impressed  by  the  statement  that  neuritis  associated  with 
chronic  alcoholism  was  due  not  so  much  to  the  alcohol  as 
to  the  alcoholic's  tendency  to  go  without  food  and  thus  to 
get  a  Vitman  Bj  deficiency.  The  theory,  then,  was  that  in 
order  to  cure  alcoholic  polyneuritis,  all  one  had  to  do  was 
to  administer  much  Vitamin  B. 

Now  comes  a  report  of  23S  cases  of  alcoholic  neuritis 
treated  through  the  years  which  showed  nothing  to  indi- 
cate that  the  forcing  on  these  patients  of  yeast  extract 
Vitamin  B,  or  liver  extract  shortened  the  period  of  con- 
valescence. The  average  length  of  stay  in  the  hospitals  of 
the  patients  who  were  treated  before  1929,  without  vita- 
mins, was  compared  with  the  stay  of  those  who  were  treat- 
aouarajjrp  lUEDrrrugis  ou  puE  'suiuieha  qjiM  'o?6I  n'.}?  pa 
was  found. 


To  Restore  Charred  Documents. — Treating  the  docu- 
ment with  a  25  per  cent  solution  of  chloral  hydrate  in 
alcohol,  repeating  several  times,  the  document  being  dried  at 
f.0°  C.  between  each  application,  until  a  mass  of  chloral 
hydrate  crystals  forms  on  the  surface.  At  this  stage,  a 
similar  solution,  to  which  10  per  cent  of  glycerine  has  been 
added,  is  applied  and  the  document  dried  as  before.  It 
may  then  be  photographed;  the  most  suitable  type  ot  plate 
being  a  contrasty  non-color  sensitive  one. 

The  method  has  proven  equally  satisfactory  for  type- 
written and  printed  material.  With  certain  modifications  it 
has  also  been  found  to  restore  writing. 


Chronic  sinusitis  may  be  divided  into  the  pure  infec- 
tious type  and  the  allergic  rhinitis  with  sinusitis.  Chronic 
nasal  and  sinus  disease  has  an  allergic  basis  in  the  majority 
of  cases.  Treatment  of  the  infection  by  irrigations  and 
operations  may  result  in  improvement  but  will  often  fail 
to  give  a  permanent  cure.  Treatment  of  both  the  allergy 
and   the  infection   will   give  the  best  results. — Shambaugh. 


526  SOUTHERN   MEDICINE  &  SURGERY  September,   1941 


Southern  Railway's 

SOUTHERNER 


Built  of  high-tensile  steel,  with  sheathing  of  stainless  steel,  THE  SOUTHERN- 
ER which  will  operate  as  three  Diesel-powered  trains,  includes  all  the  latest  refine- 
ments for  the  ultimate  in  safety,  speed  and  comfort.  Each  train  will  consist  of 
Straight,  Partition  and  Baggage-Dormitory  Chair  Cars,  Dining  Car  and  Lounge- 
Tavern-Observation  Unit,  all  reflecting  the  latest  ideas  in  structural  development 
and  modern  styling  and  beauty. 

Passenger  units  have  thermostatically  controlled  heating  and  air  conditioning, 
are  insulated  throughout.  Judicious  use  is  made  of  a  number  of  advancements  favor- 
ing gracious  living.  A  good  part  of  the  luxury  picture  appears  in  the  comfortable 
seating  arrangement  in  all  cars,  the  commodious  and  up-to-date  dining  car  arrange- 
ments and  the  facilities  for  en  route  enjoyment  offered  in  lounge,  tavern  and  obser- 
vation rooms. 

Diesel  locomotives  for  the  trains  are  built  by  the  Electro-Motive  Corporation, 
a  subsidiary  of  General  Motors. 

Particularly  interesting  from  the  standpoint  of  detailed  comfort  planning  is  the 
fact  that  chair  cars  have  twin-rotating,  reclining-type  seats,  cushioned  and  attrac- 
tively finished.  The  dining  car  has  accommodations  for  48  persons  in  satin  metal 
framed  chairs  with  rubber  seats  and  back  cushions.  Settees,  lounge  chairs,  writing 
desk,  card  section  and  refreshment  facilities  have  been  planned  to  fit  the  comfort 
and  utility  requirements  of  passengers  in  the  Lounge-Tavern-Observation  unit. 

A  rich  decorative  treatment  has  been  designated  for  all  units  of  THE  SOUTH- 
ERNER the  basic  colors  being  blue,  green  and  beige  in  light,  medium  and  dark 
tones.  Blue  and  beige  are  distributed  in  straight  chair  car  planning,  each  car  carry- 
ing out  variations  of  the  same  color  treatment  throughout  .  Partition  chair  cars  em- 
phasize beige  and  the  Baggage-Dormitory-Chair  Cars  are  done  in  tones  of  blue. 
Green  is  the  predominating  scheme  in  dining  car  and  Lounge-Tavern-Observation 
units. 

The  whole  scene  is  enriched  with  an  attractive  arrangement  of  photo-murals 
which  have  been  especially  planned  to  heighten  the  atmosphere  of  luxury  and  beauty 
in  THE  SOUTHERNER. 


September.   1941 


SOUTHERN  MEDICINE  &  SURGERY 


527 


PRODUCTS    OF    BAXTER    LABORATORIES 


•      1941      • 

FLORIDA'S  NEWEST  —  FINEST  &  LARGEST 

All-Year  Hotel 


THE     RIVIERA 

Near  Daytona  Beach. 

Ideal  Convention  or  Conference  Headquarters.     Capacity  400. 

The  only  Hotel  Bar  open  all  year  between 
Jacksonville  &  Palm  Beach. 

Radio  and  Fan  in  Every  Room.  Golf  Links.  Artesian  Swimming 
Pool  with  Sand  Beach.  Tennis,  Badminton,  Ping  Pong,  Croquet, 
Horseshoe  and  Shuffleboard  Courts.  Ballroom  and  Convention 
Hall.    Banquet  Facilities.    Spacious  Grounds. 

COOLEST  SPOT  IN  ALL  FLORIDA,  AT  THE  BIRTHPLACE  OF 
THE  TRADE  WINDS.  Where  the  Labrador  (Arctic)  Current 
meets  the  Gulf  Stream,  and  Summer  Bathing  and  Fishing  are 
Superb. 

Write  for  Special  Summer  Rates.  April  to  December. 

Hotel  Riviera,  Box  429,  Daytona  Beach,  Fla. 

MOUNTAINEER,  TAR  HEEL  &  CRACKER 

VACATION  HEADQUARTERS. 


A  SAFE.  COMPLETELY 

closed  technique 

for  preparing 

PLASMA  or  SERUM 


is  provided  by 

BAXTER  EQUIPMENT 

•fc  The  Centri-Vac,  with  its  companion 
container  the  Plasma-Vac,  and  acces- 
sories, provide  a  completely  closed  tech- 
nique, which  is  a  safeguard  against  con* 
tamination  during  blood  collection,  prepa- 
ration of  plasma  or  serum,  storage, 
transportation,  and  administration. 

The  TRMSFISO-MC 

PROVIDES  DEPENDABLE 
VACUUM  FOR  TRANSFUSIONS 


Mark  of  Friendship  to  the  Journal 


SOUTHERN  MEDICINE  &  SURGERY 


September,   1941 


THEY  CAN'T  WAIT  MUCH  LONGER 
Stricken  Civilians  in  England 
and  Allied  Countries 
Need  Your  Help  TODAY! 


*    *    * 


Both  the  first  aid  kits  and  opera- 
ting sets  have  been  approved  as  to 
contents  and  containers  by  physicians 
on  the  Medical  and  Surgical  Supply 
Committee  of  America.  Send  in  your 
contribution  toward  purchasing  a 
unit  today.  Please  make  checks  payable 
to  Arthur  Kunzinger,  treasurer  and 
mail  with  coupon  below. 


MEDICAL  AND  SURGICAL 
SUPPLY  COMMITTEE         OF 

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AVENUE,  NEW  YORK,  CITY, 
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September,    1941 


SOUTHERN  MEDICINE  &  SURGERY 


529 


liilillJliJW****^^^^  r  Help  the  Ameru^an 

••■S-o.™.-'-"'   '""""  fAphnse against «^' **£    Enlist  in  tHe 

r     nosisisthefirstUneof  ^ Rational  prog^  o0.  Use 

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SSo 


PROFESSIONAL   CARDS 


September,   1941 


GENERAL 


Nalle  Clinic   Building 


THE  NALLE  CLINIC 

Telephone — 3-2141    (//  no  answer,  call  3-2621) 


412  North    Church    Street,   Charlotte 


General  Surgery 

BRODIE  C.  NALLE,  M.D. 
Gynecology  &  Obstetrics.. 
EDWARD    R.    HIPP,    M.D. 

Traumatic  Surgery 

PRESTON   NOWLIN,   M.D. 

Urology 


Consulting   Staff 

DRS.   LAFFERTY,   BAXTER   &   PARSONS 
Radiology 
BARRET   LABORATORY 
Pathology 


General  Medicine 


LUCIUS   G.   GAGE,  M.D. 

Diagnosis 


LUTHER   W.   KELLY,   M.D. 
Cardio-Respiratory   Diseases 


J.  R.  ADAMS,  M.D. 
Diseases  of  Infants  &  Children 


W.  B.  MAYER,  M.  D. 
Dermatology  &  Syphllology 


C— H— M   MEDICAL   OFFICES 

DIAGNOSIS— SURGER  Y 

X-RAY— RADIUM 

Dr.   G   Carlyle   Cooke — Abdominal  Surgery 

&  Gynecology 
Dr.  Geo.  W.  Holmes — Orthopedics 
Dr.  C.  H.  McCants — General  Surgery 
222-226  Nissen  Bid.  Winston-Salem 


WADE   CLINIC 

Wade  Building 

Hot  Springs  National  Park,  Arkansas 


H.  King  Wade,  M.  D. 
Charles  S.  Moss,  M.D. 
Jack  Ellis,  M.D. 
Frank  M.  Adams,  M.D. 


Urology 

General  Surgery 

General  Medicine 

General  Medicine 


N.  B.  Burch,  M.D.  Eye,  Ear,  Nose  &  Throat 
Raymond  C.  Turk,  D.D.S.  Dental  Surgery 
A.  W.  Scheer  X-ray  Technician 

Etta  Wade  Clinical  Pathology 

Marjorle  Wade  Bacteriology 


INTERNAL  MEDICINE 


ARCHIE  A.  BARRON,  M.  D.,  F.A.C.P. 
INTERNAL  MEDICINE— NEUROLOGY 
Professional   Bldg.  Charlotte 


JOHN  DONNELLY,  M.  D. 

DISEASES  OF  THE  LUNGS 

324y2  N.  Tryon  St.  Charlotte 


CLYDE    M.    GILMOrvE,    A.  B.,    M.D. 
CARDIOLOGY— INTERNAL    MEDICINE 
Dixie  Building  Greensboro 


JAMES   M.  NORTHINGTON,   M.D. 
INTERNAL    MEDICINE— GERIATRICS 
Medical  Building  Charlotte 


ORTHOPEDICS 


HERBERT   F.   MUNT,   M.D. 
ACCIDENT  SURGERY  &  ORTHOPEDICS 
FRACTURES 

Nissen  Building  Winston-Salem, 


September.   1941 


PROFESSIONAL   CARDS 


531 


NEUROLOGY  and  PSYCHIATRY 


J.   FRED   MERRITT,   M.  D. 

NERVOUS  and  MILD  MENTAL 
DISEASES 

ALCOHOL  and  DRUG  ADDICTIONS 

Glenwood   Park   Sanitarium  Greensboro 


EYE,  EAR,  NOSE  AND  THROAT 


H.  C.  NEBLETT,  M.  D. 

OCULIST 

Phone   3-58S2 

Professional   BIdg.  Charlotte 


AMZI  J.  ELLINGTON,  M.  D. 

DISEASES  of  the 
EYE,  EAR,  NOSE  and  THROAT 

Phones:   Office  992— Residence  761 

Burlington  North   Carolina 


UROLOGY,   DERMATOLOGY   and   PROCTOLOGY 

THE  CROWELL   CLINIC   of   UROLOGY   and   UROLOGICAL   SURGERY 
Hours— Nine  to  Five  Telephones— 3-7101 — 3-7102 

STAFF 

Andrew  J.  Crowell,  M.  D. 

(1911-1938) 

Angus  M.  McDonald,  M.  D.  Claude  B.  Squires,  M.  D. 

Suite  700-711  Professional  Building  Charlotte 


Raymond  Thompson,   M.  D.,  F.  A.  C  S. 


Walter   E.   Daniel,  A.  B.,   M.  D. 


THE  THOMPSON  -  DANIEL  CLINIC 
of 

UROLOGY   &   UROLOGICAL  SURGERY 


Fifth  Floor  Professional  Bldg. 


C.  C.  MASSEY,  M.D. 

PRACTICE  LIMITED 

TO 

DISEASES  OF   THE  RECTUM 

Professional   Bldg.  Chai 


L  D.  McPHAIL,  M.D. 
RECTAL  DISEASES 


Professional   Bldg. 


Charlotte 


WYETT   F.   SIMPSON,   M.D. 

GENITO-URINARY   DISEASES 

Phone   1234 

Hot  Springs  National  Park  Arkansas 


PROFESSIONAL   CARDS 


September,   1941 


SURGERY 


R.   S.   ANDERSON,   M.  D. 

GENERAL  SURGERY 

144  Coast  Line  Street  Rocky  Mount 


R.  B.  DAVIS,  M.  D.,  M.M.S.,  F.  A.  C.  P. 
GENERAL  SURGERY 

AND 
RADIUM   THERAPY 

Hours  by  Appointment 
Piedmont-Memorial  Hosp.  Greensboro, 


WILLIAM    FRANCIS    MARTIN,    M.D. 

GENERAL  SURGERY 

Professional   Bldg.  Charlotte 


OBSTETRICS  &  GYNECOLOGY 


IVAN  M.  PROCTER,  M.D. 

OBSTETRICS  &   GYNECOLOGY 

133   Fayetteville   Street  Raleigh 


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to  societies.  This  service  is  rendered  on  terms  comparing  favorably  with  those  pre- 
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SOUTHERN  MEDICINE  &  SURGERY. 


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tions submitted  to  this  Journal  for  publication. 


Vol.  cm 


JAMES   M.   NORTHINGTON,   M.  D.,   Editor 


OCTOBER,   1941 


Cardiovascular  Emergencies* 

Tinsley  R.  Harrison,   M.D.,  Winston-Salem 
From  the  Department  of  Internal  Medicine  Bowman    Gray  School  of  Medicine  of  Wake  Forest  Collepie 


THE  PURPOSE  of  the  discussion  to  follow 
is  to  deal  with  some  of  the  important 
aspects  of  the  more  common  cardiovascu- 
lar emergencies.  No  attempt  will  be  made  to  dis- 
cuss any  condition  in  detail,  but  interest  will  be 
centered  on  certain  practical  points  in  the  diagno- 
sis and  treatment  of  these  conditions. 

Probably  the  most  common  cardiovascular  emer- 
gency is  an  attack  of  angina  pectoris.  A  great  deal 
of  confusion  has  long  existed  in  regard  to  the  diag- 
nosis of  this  illness,  which  may  exist  even  in  severe 
form,  with  no  objective  abnormalities  on  physical 
examination,  and  even  with  little  or  no  change  in 
the  electrocardiogram.  However,  difficulties  in 
diagnosis  can  usually  be  overcome  by  remembering 
that  any  pain  in  the  neck,  arm,  chest  or  even  the 
upper  abdomen,  which  comes  on  with  exertion  and 
is  relieved  within  a  few  minutes  by  rest,  is  in  all 
probability  angina  pectoris.  In  the  treatment  of 
this  condition  I  would  like  to  emphasize  one  point 
only.  It  has  been  commonly  believed  that  the 
nitrites  have  such  a  short  action  as  to  make  them 
valuable  only  in  the  treatment  of  the  pain  and 
practically  useless  in  its  prevention.  In  recent 
years  new  work  has  shown  that  this  point  of  view 
is  untenable  and  it  is  indicated  that  nitrites  and 
allied  drugs  are  also  of  value  in  preventing  the 
pain.  Most  patients  with  angina  pectoris  can  be 
kept  free  from  severe  attacks  for  weeks  at  a  time 
by  having  them  take  l/200th  to  1  /400th  grain  of 


nitroglycerine  under  the  tongue  every  two  to  every 
three  hours.  When,  as  is  often  the  case,  the  dis- 
ease is  mild,  such  frequent  administration  need  not 
be  carried  out.  but  the  patient  should  be  instructed 
to  utilize  nitroglycerine  before  any  unusual  physi- 
cal or  mental  strain.  Nitroglycerine  is  one  of  the 
few  powerful  drugs  which  is  almost  harmless  and 
patients  may  take  several  tablets  per  day  for  a 
period  of  years  without  developing  any  toxic  symp- 
toms or  without  developing  intolerance  to  the  drug. 
Another  common  cardiovascular  emergency  is 
acute  edema  of  the  lungs.  This  occurs  in  patients 
who  have  some  type  of  heart  disease,  usually  hyper- 
tension, arteriosclerosis  or  deformity  of  the  aortic 
valve,  which  puts  a  predominant  strain  on  the  left 
ventricle.  The  attacks  usually  come  on  in  the  mid- 
dle of  the  night  and  may  waken  the  patient  from 
sound  sleep.  The  seizures  are  attended  by  increas- 
ing dyspnea  and  the  rapid  development  of  moist 
rales  in  the  lungs.  In  the  prevention  of  such  at- 
tacks, digitalis  is  practically  specific.  For  the 
treatment  of  the  attacks  the  methods  of  choice  are 
morphine  used  freely,  and  venesection.  In  case 
the  patient  does  not  respond  immediately,  an  oxy- 
gen tent  should  be  employed  to  prevent  death  from 
asphyxia  while  further  treatment  is  being  insti- 
tuted. Many  patients  who  have  recurrent  attacks 
are  benefited  by  the  frequent  administration  of 
diuretic  drugs.  This  form  of  treatment  is  still  lim- 
ited   by    many    physicians    to    persons    who    have 


'Delivered  before  the  Piedmont   Postgraduate  Clinical   Assembly  at  Ande 


S.  C,  Sept.   10th,   1941. 


CARDIOVASCULAR   EM  ERG  EXC I ES— Harrison 


edema  of  the  legs.  However,  it  should  be  pointed 
out  that  edema  in  this  location  is  much  less  serious 
than  edema  of  the  lungs,  and  that  the  latter  re- 
sponds equally  well  to  diuretic  measures. 

Another  group  of  cardiovascular  emergencies  is  of 
those  which  arise  in  association  with  disturbances 
of  the  rhythm  of  the  heart.  A  sudden  marked 
change  in  rate  in  either  direction  may  induce  grave 
symptoms.  Perhaps  the  most  common  of  such 
conditions  is  auricular  fibrillation,  which  can  be 
recognized  by  the  fact  that  it  is  almost  the  onlv 
condition  which  causes  the  heart  to  beat  both  rap- 
idly and  irregularly.  In  the  treatment  the  physi- 
cian is  faced  with  two  alternatives.  On  the  one 
hand,  he  can  try  to  abolish  the  arrhythmia  com- 
pletely. For  this  purpose,  quinidine  is  the  only 
drug  to  use,  in  doses  of  iy2  to  ll/2  grains  every 
few  hours  until  the  rhythm  suddenly  becomes  reg- 
ular. The  dose  should  then  be  gradually  dimin- 
ished and  finally  omitted  altogether.  Quinidine  is 
the  drug  of  choice  in  patients  who  have  not  had 
cardiac  decompensation  in  the  past,  and  who  have 
auricular  fibrillation  which  has  lasted  only  a  few 
hours  or  a  few  days.  The  drug  is  contraindicated 
when  the  patient  has  or  has  had  congestive  heart 
failure,  when  the  auricular  fibrillation  is  of  long 
duration  and  in  patients  who  have  well  marked 
disturbance  of  conduction,  as  shown  in  the  electro- 
cardiogram. In  the  latter  instances  the  drug  may 
be  dangerous.  Hence,  the  physician  should,  as  a 
rule,  have  an  electrocardiogram  made  before  em- 
ploying quinidine. 

The  other  method  of  treating  auricular  fibrilla- 
tion consists  in  giving  digitalis,  which  slows  the 
heart  but  does  not  cause  it  to  become  regular,  in 
fact  it  favors  the  persistence  of  the  auricular  fibril- 
lation with  increases  in  the  degree  of  block  be- 
tween the  auricles  and  the  ventricles,  so  that  the 
latter  beat  at  a  much  slower  rate.  This  is  the 
method  of  choice  in  treating  patients  with  long- 
standing heart  disease  who  have  had  symptoms  of 
cardiac  decompensation  in  the  past.  It  is  also  the 
method  of  choice  in  treating  any  patient  with 
auricular  fibrillation  of  long  duration.  Ordinarily, 
one  administers  about  IS  cat  units  in  the  first  two 
or  three  days  and  follows  this  with  one  to  two  cat 
units  daily  as  a  maintenance  dose.  Except  in  rather 
rare  instances  the  patient  who  has  once  needed 
digitalis  should  continue  to  take  it  indefinitely. 

Another  condition  which  may  constitute  a  car- 
diovascular emergency  is  paroxysmal  auricular 
tachycardia.  This  is  particularly  common  in 
healthy  young  persons  who  have  no  evidence  of 
organic  heart  disease.  The  heart  rate  suddenly 
changes  from  the  normal  to  a  rate  of  170  or  more. 
The  seizure  lasts  for  a  few  minutes  or  a  few  hours 
or,  much  more  rarely,  for  several  davs.   Under  the 


latter  circumstances  the  circulatory  collapse  may 
set  in,  even  though  the  patient  has  a  structurally 
normal  heart.  The  diagnosis  of  this  condition  can 
usually  be  made  accurately  by  the  history  of 
tachycardia  setting  in  instantly  in  a  person  without 
serious  heart  disease.  The  treatment  consists  of 
vagal  stimulation  of  one  type  or  another.  A  method 
which  is  effective  in  more  than  three-fourths  of 
the  patients  is  pressure  on  first  one  and  then  the 
other,  and  then  both,  carotid  arteries  just  at  the 
highest  point  in  the  neck  at  which  the  pulsation 
can  be  felt.  The  pressure  must  be  rather  firm  and 
it  is  well  to  massage  the  artery  by  moving  the 
fingers  slightly  while  the  pressure  is  kept  up.  An- 
other procedure  which  often  causes  the  attacks  to 
cease  abruptly  is  pressure  on  the  eyeballs.  The 
compression  must  be  sufficiently  firm  to  cause 
slight  pain.  In  stubborn  instances  of  this  disease 
the  attacks  may  sometimes  be  terminated  by  a 
combination  of  two  or  more  of  the  following  pro- 
cedures: 

(a)  Holding  the  breath  in  deep  inspiration 

(b)  Attempting  expiration  with  a  closed  glottis 

(c)  The  induction  of  gagging 

(d)  Any  procedure  which  causes  vomiting,  such 
as  the  use  of  ipecac,  or 

(e)  By  a  dose  of  morphine  large  enough  to  put 
the  patient  to  sleep. 

Attacks  of  paroxysmal  auricular  tachycardia  are 
best  prevented  by  the  administration  of  digitalis, 
one  to  one  and  a  half  cat  units  per  day. 

A  much  rarer  form  of  tachycardia  is  that  in 
which  the  irritable  focus  is  in  the  ventricle — 
paroxysmal  ventricular  tachycardia.  This  usually 
occurs  in  persons  with  advanced  heart  disease,  par- 
ticularly of  the  coronary  type.  It  may  be  induced 
by  digitalis  and  it  occurs  occasionally  in  otherwise 
healthy  individuals.  The  diagnosis  of  ventricular 
tachycardia  at  the  bedside  is  sometimes  difficult. 
Among  the  points  which  are  helpful  are  these:  the 
rate  is  usually  between  130  and  180,  the  rhythm 
is  quite  regular  but  the  loudness  of  the  first  sound 
varies  somewhat  from  beat  to  beat.  Some  of  the 
patients  display  an  occasional  sudden  large  venous 
pulsation  in  the  neck  (it  tends  to  occur  when  the 
auricles  and  ventricles  contract  at  the  same  time). 
In  case  the  physician  suspects  ventricular  tachy- 
cardia but  is  uncertain  of  the  diagnosis  it  is  wise 
to  have  an  electrocardiogram  made  immediately. 
The  condition  is  much  more  serious  than  the  other 
types  of  tachycardia  which  have  been  discussed. 
Digitalis  may  do  harm  by  intensifying  the  attack 
and  favoring  the  induction  of  fatal  ventricular 
fibrillation.  On  the  other  hand,  quinidine  is  prac- 
tically specific  both  in  the  treatment  and  the  pre- 
vention of  the  attacks.    The  drug  may  have  to  be 


October.    1941 


CARDIOVASCULAR   EMERGENCIES— Harrison 


S3S 


given  in  vers'  large  doses  and  occasionally  may 
need  to  be  administered  intravenously. 

A  fourth  type  of  paroxysmal  rapid  action  of  the 
heart  is  auricular  flutter.  This  condition  is  closely 
allied  to  auricular  fibrillation  and  is  usually  a  tran- 
sition state  between  the  latter  and  normal  rhythm. 
It  is  very  difficult  and  often  impossible  to  diagnose 
it  at  the  bedside.  The  treatment  is  essentially  the 
same  as  that  of  auricular  fibrillation. 

All  of  these  various  forms  of  rapid  heart  action 
may  be  differentiated  from  the  ordinary  tachycar- 
dia shown  by  many  ill  patients  by  the  fact  that 
these  ectopic  or  paroxysmal  tachycardias  are  of 
sudden  onset,  the  heart  rate  changing  abruptly 
from  the  normal  to  the  rapid  rate.  The  offset  is 
likewise  apt  to  be  abrupt,  but  the  patient  fre- 
quently does  not  remember  this  because  he  is 
frightened  during  the  attack  and  does  not  recall 
the  events  which  occur  toward  its  end. 

The  sudden  bradycardias  likewise  often  are  re- 
sponsible for  cardiac  emergencies.  Many  healthy 
persons  have,  when  at  rest,  a  heart  rate  of  about 
55.  Occasionally  a  vagotonic  athletic  young  man 
may  even  have  a  resting  heart  rate  of  only  40. 
However,  on  exercise  such  persons  develop  a  grad- 
ual acceleration  of  the  rate.  The  situation  is  quite 
otherwise  in  persons  with  the  Adams-Stokes  syn- 
drome, or  complete  heart  block.  Here  the  rate  is 
usually  45  or  less,  commonly  less  than  40,  and  it 
is  affected  either  very  little  or,  more  commonly, 
not  at  all  by  exercise.  This  point  alone  will  usually 
suffice  to  allow  the  physician  to  recognize  the 
bradycardia  of  true  heart  block.  Other  points 
which  may  be  of  value  are  the  variations  in  the  in- 
tensity of  the  first  sound,  in  spite  of  the  fact  that 
the  rhythm  is  perfectly  regular,  and  the  occasional 
appearance  of  a  marked  pulsation  of  the  juuglar 
vein  at  a  time  when  the  auricles  and  ventricles 
happen  to  contract  together.  In  the  treatment  of 
the  acute  attacks  which  may  be  associated,  of 
course,  with  fainting  spells  and  convulsions,  the 
method  of  choice  is  the  administration  of  minimal 
amounts  of  epinephrine  at  frequent  intervals.  One 
usually  starts  by  injecting  one  minim  and,  keeping 
the  hypodermic  needle  under  the  skin,  massaging 
the  spot,  gradually  injecting  a  little  more  until  the 
heart  rate  becomes  faster.  The  attacks  are  best 
prevented  by  the  use  of  ephedrine  and  of  barium 
chloride.  The  latter  drug  can  be  given  in  doses 
of  yi  to  one  grain  several  times  per  day  and  is 
occasionally  effective  when  all  other  methods  have 
failed. 

Not  all  attacks  of  sudden  great  slowing  of  the 
heart  are  due  to  complete  block.  Much  more  com- 
monly such  seizures  are  the  result  of  reflex  stim- 
ulation of  the  vagus  nerve.  Such  stimulation  may 
arise    from    various    sites   of    the   body,    including 


certain  parts  of  the  gastrointestinal  tract  or  the 
eyeballs.  However,  much  the  most  common  site  is 
the  carotid  sinus,  which  has  a  special  nerve  (the 
nerve  of  Hering)  with  a  particular  influence  on  the 
heart  rate  and  the  blood  pressure.  When  one  sus- 
pects that  a  patient  with  recurrent  attacks  of 
bradycardia  lasting  only  a  few  minutes  had  the 
hypertensitive  carotid  sinus  as  the  cause,  one  can 
usually  prove  or  disprove  the  point  by  having  the 
patient  assume  a  sitting  position,  then  press  firmly 
on  the  carotid  artery  just  behind  the  angle  of  the 
jaw,  first  on  one  side  and  then  on  the  other.  At 
the  same  time  one  listens  to  the  heart  with  a  steth- 
oscope and  observes  whether  extreme  slowing  oc- 
curs. Hypersensitivity  of  the  carotid  sinus  is  one 
of  the  most  common  causes  of  sudden  bradycardia 
associated  with  weakness,  faintness  and  even  with 
attacks  of  unconsciousness.  It  should  be  looked 
for  in  all  patients  complaining  of  these  symptoms, 
and  particularly  so  if  the  patient  mentions  that 
turning  of  the  head  or  a  tight  collar  tends  to  in- 
duce the  attacks.  When  this  syndrome  has  been 
proved  to  exist,  it  can  sometimes  be  satisfactorily 
treated  by  the  use  of  atropine,  ephedrine  or  allied 
drugs.  Some  of  the  patients  are  benefited  by  vita- 
min B].  In  the  severest  cases  a  cure  may  be  ef- 
fected by  removing  a  tumor  of  the  carotid  body 
or  a  lymph  node  pressing  on  the  carotid  artery,  or 
by  simple  denervation  of  the  carotid  artery  by  sec- 
tion of  Hering's  nerve. 

The  conditions  discussed  do  not  by  any  means 
constitute  all  of  the  cardiovascular  emergencies. 
However,  they  do  make  up  a  group  of  fairly  com- 
mon states  and  the  point  which  I  wish  to  empha- 
size particularly  is  that  here,  as  elsewhere  in  med- 
icine, proper  therapy  depends  entirely  on  accurate 
diagnosis.  In  rare  instances  the  use  of  special  im- 
plements, such  as  the  electrocardiograph,  may  be 
necessary.  But  the  physician  who  studies  the  pa- 
tient carefully  can  in  most  instances  make  the 
diagnosis  at  the  bedside  with  no  special  tool  except 
his  stethoscope  to  aid  his  powers  of  observation. 


INSTINCT  IN  THE  CHOICE  OF  DIET 

(Abstract   in    Charleston   Medical  Journal.    1849) 

Mr.  Thomas  Hunt,  berfore  the  Medical  Society  of  Lon- 
don, observes  that  with  regard  to  the  quantity  and  the 
quality  of  the  food,  instinct  is  a  far  better  aid  than  science, 
that  many  cases  of  dyspepsia  originate  in,  or  are  aggra- 
vated  by,  a  rigid  adherence  to  artificial  rules  of  diet,  a  too 
restricted  use  of  the  good  things  which  nature  has  pro- 
vided. It  were  presumptuous  to  dictate  to  the  economy  of 
digestion  what  materials  are  best  suited  to  it.  The  natural 
sensations  of  the  patient  are  far  safer  guides,  both  in 
health  and  in  disease.  In  early  fever,  the  appetites  of  man 
are  far  different  from  those  in  health ;  as  fever  advances 
and  takes  on  new  types,  the  longings  of  the  patient  vary. 
The  author  relates  several  instances  in  which  he  has  known 
disease  of  the  digestive  organs  to  be  cured  by  the  free  in- 
dulgence in  articles  which  are  generally  denounced  as  im- 
proper. 


6  SOUTHERN  MEDICINE  &  SURGERY  October,   1941 

Some  Practical  Aspects  of  Endocrinology* 

Arthur  Groli.man,  Ph.D.,M.D.,  Winston-Salem 

From    the    Department    of     Internal    Medicine.     Bowman   Gray  School  of  Medicine  of  Wake  Forest  College 


EXDOCRIXOLOGY  is  a  relatively  recent 
development  of  medicine.  Like  anv  innova- 
tion it  still  tends  to  be  confused  in  many 
respects.  The  speed  with  which  it  has  developed 
in  recent  years  has  produced  a  mass  of  unproved 
or  partly  proved  literature  which  in  turn  has  led 
to  considerable  confusion  and  unwarranted  claims. 
Clinical  endocrinologv.  in  particular,  is  often  sub- 
ject to  wild  and  vague  theories;  utilizes  forms  of 
therapy  which  have  proved  worthless;  and  indulges 
in  vagaries  which  border  on  sheer  quackery.  How- 
ever, recent  advances  in  the  field  of  endocrinology 
have  placed  the  clinical  aspects  of  the  subject  on 
a  firm  and  scientific  basis.  Both  diagnosis  and 
treatment  can  be  placed  on  as  certain  a  ground  as 
other  well-established  fields  of  medicine.  There  is 
no  need  for  depending  on  speculation,  nor  for 
utilizing  therapy  the  efficacy  of  which  can  not  be 
established  experimentally.  Where  this  can  not  be 
done  one  may  with  assurance  dismiss  the  claims  as 
unworthy  of  serious  consideration. 

Studies  in  endocrinologv  have  thrown  much  light 
on  numerous  problems  that  confront  the  practi- 
tioner dailv.  Such  common  complaints  as  adiposity, 
abnormalities  of  growth  or  menstrual  disturbance, 
as  well  as  numerous  obscure  conditions  formerly 
left  undiagnosed,  misinterpreted  or  designated  as 
hysteria  or  hvpochondriasis,  may  now  be  attributed 
to  certain  endocrinological  dysfunctions.  The  fre- 
quency of  these  disorders  may  be  illustrated  bv  the 
fact  that  among  50.000  patients  at  the  Johns  Hop- 
kins Hospital,  900  suffered  from  diabetes,  400  from 
hvperthvroidism.  100  from  hypothyroidism,  60 
from  adrenal  disorders.  50  from  hvpoparathvroid- 
ism.1  Endocrine  disorders  are  thus  far  from  uncom- 
mon in  everyday  experience. 

One  fundamental  fact  which  has  contributed 
greatly  to  misunderstanding  the  nature  of  endo- 
crine diseases  is  the  belief — shared  by  physiolo- 
gists as  well  as  bv  clinicians — that  each  hormone 
exerts  a  specific  action  in  the  organism.  This  is  a 
wrong  concept  which  leads  to  errors  in  diagnosis 
and  treatment,  as  well  as  in  the  general  conception 
of  endocrine  disease.  Thus,  the  old  view  that  in- 
sulin is  necessary  for  burning  sugar  is  no  longer 
acceptable,  for  carbohydrate  can  be  and  is  metabol- 
ized in  the  absence  of  insulin.  All  of  the  hormones 
exert  basic  functions  in  the  organism  which  involve 
many  reactions  and  affect  many  tissues  and  organs 


in  the  body.  They  are  in  the  nature  of  enzymes 
and  may  be  looked  upon  as  endogenous  vitamins. 
That  is  why  they  manifest  their  dysfunctions  in 
such  a  variety  of  ways  and  why  one  finds  the  hor- 
mones of  the  rat,  for  example,  identical  with  those 
in  the  human,  and  why  one  can  carry  over  to  one 
species  results  of  studies  made  on  members  of  an- 
other species. 

We  are  traditionally  in  the  habit  of  associating 
insulin,  for  example,  with  the  metabolism  of  glucose, 
or  thyroid  hormone  with  oxygen  consumption,  be- 
cause sugar  metabolism  and  the  basal  metabolic 
rate  happen  to  be  strikingly  affected  by  dysfunc- 
tion of  the  pancreas  and  thyroid.  But  we  must 
remember  that  protein  and  fat  metabolism  are  also 
disturbed  in  diabetes,  and  that  the  effects  of  thy- 
roid dysfunction  as  manifested  in  a  derangement 
of  the  heart  may  be  important  from  a  clinical 
standpoint  when  the  change  in  oxygen  consump- 
tion is  of  no  practical  import.  This  point  is  of 
more  than  academic  importance,  because  it  in- 
volves not  only  our  fundamental  concepts  as  ap- 
plied to  diagnosis  but  should  also  vitally  influence 
our  methods  of  therapy. 

Another  example  of  the  error  involved  in  asso- 
ciating too  closely  an  endocrine  gland  with  some 
specific  function  is  exemplified  by  our  ideas  about 
the  pituitary.  This  gland  has  so  long  been  associ- 
ated in  our  minds  with  growth  that  the  claim  has 
been  made  that  the  use  of  pituitary  extracts  will 
induce  growth  in  dwarfism.  As  a  matter  of  fact 
the  available  pituitary  extracts  can  not  be  relied 
on  to  produce  either  gigantism  or  ordinary  growth 
in  the  rat,  much  less  so  in  the  human  patient.  By 
far  the  best  effects  obtained  in  the  treatment  of 
dwarfism  have  been  obtained  by  the  use  of  thyroid 
extract.  Pituitary  dwarfism  is,  indeed,  rather  a 
rarity.  On  the  other  hand  dwarfism  is  frequently 
a  result  of  hypothyroidism,  and  excellent  results 
have  been  obtained  by  administering  the  readily 
available  thyroid  extract  in  treating  these  patients. 
The  idea  that  the  pineal  gland  is  associated  with 
precocious  development  is  another  cherished  idea, 
now  shown  to  be  fallacious.  Precocious  develop- 
ment is  probably  never  a  result  of  pineal  tumor 
unless  it  impinges  on  contiguous  structures,  but  is 
induced  by  other  affections  of  the  cranial  contents. 
The  most  satisfactory  results  in  clinical  endo- 
crinology have  been  obtained  in  the  various  dis- 


*Delivered  before  the  Piedmont   Postgraduate  Clinical  Assembly  at  Anderson,  S.  C,  Sept.  10th,  1941. 


October,    1941 


ESDOCRINOLOG  Y—Gr  oilman 


eases  of  the  thyroid,  either  in  insufficiency  or  in 
hyperactivity  of  this  gland.  Although  the  classical 
type  of  myxedema  is  readily  recognized,  the  lesser 
degrees  of  the  disease  are  frequently  overlooked  in 
diagnosis.  Recent  physiological  investigations  have 
furthered  our  knowledge  of  hyperthyroidism  with 
a  resulting  improvement  in  the  methods  of  treating 
this  condition.  As  a  result  of  the  better  under- 
standing of  the  mechanism  of  action  of  iodine,  and 
of  the  factors  involved  in  the  etiology  of  the  dis- 
order, the  preparation  for  operation  is  much  better 
and  the  result  of  surgical  interference  has  been 
greatly  improved.  As  regards  the  therapy  of  hy- 
perthyroidism, the  use  of  x-rays  has  received  in- 
creasing favor.  The  view  that  this  procedure  in- 
duces an  increased  vascularity  and  leads  to  the 
formation  of  adhesions  is  not  based  on  sound  evi- 
dence. This  method  has  given  excellent  results  in 
the  treatment  of  recurrences,  in  patients  who  re- 
fuse or  are  otherwise  not  amenable  to  operation,  in 
mild  cases  in  which  the  delay  is  not  as  serious, 
and  in  such  patients  in  whom  nervousness  is  the 
most  prominent  symptom  and  constitutional 
changes  minimal. 

Our  advances  in  understanding  of  the  function 
of  the  parathyroid  glands  have  led  to  satisfactory 
treatment  of  parathyroid  insufficiency  and  of  dis- 
eases due  to  an  overproduction  of  the  hormone  of 
these  glands.  Although  an  acute  insufficiency  of 
the  parathyroid  glands  is  readily  recognized  by  the 
presence  of  tetany,  chronic  insufficiency  is  often 
overlooked  because  of  the  rather  mild  and  vague 
symptoms,  with  fatigue,  muscular  weakness,  gas- 
trointestinal irritability,  and  such  changes  as  are 
frequently  misinterpreted  as  manifestations  of 
hysteria  or  hypochondriasis.  Examination  of  the 
blood  and  urine,  however,  can  make  the  diagnosis 
objective;  and  early  recognition  makes  possible 
the  institution  of  treatment  which  not  only  relieves 
the  symptoms,  but  prevents  the  development  of 
mental  retardation,  atrophic  changes  of  the  teeth, 
skin  and  nails,  and  lenticular  opacities  or  cataracts 
which  mark  the  chronic  stages  of  this  disease. 

We  now  recognize  osteitis  fibrosa  cystica  as  be- 
ing only  the  final  condition  induced  by  hyper- 
parathyroidism. Milder  forms  of  this  abnormality 
of  the  parathyroid  glands  may  manifest  themselves 
in  one  of  three  ways:  (1)  The  hypercalcemia 
which  is  characteristic  of  the  disorder  is  frequently 
marked  by  weakness,  anorexia,  loss  of  weight, 
muscle,  joint  and  abdominal  pain,  bradycardia, 
cardiac  irregularities  and  rather  vague  symptoms 
which  are  frequently  undiagnosed  or  erroneously 
attributed  to  neurasthenia.  (2)  The  skeletal  in- 
volvements are  more  easily  recognized  because  of 
the  occurrence  of  generalized  calcification,  cysts, 
Riant-cell    tumors,   pathological    fractures,   skeletal 


deformities  and  epulides.  The  early  recognition  of 
the  disorder  prevents,  however,  the  development  of 
the  skeletal  involvement  noted  in  osteitis  fibrosa 
cystica.  Finally,  (3)  the  abnormal  excretion  of 
calcium  and  phosphorus  which  occurs  in  hyper- 
parathyroidism leads  to  polyuria  and  polydipsia 
and  is  responsible  in  certain  regions  for  three  to 
five  per  cent  of  all  cases  of  renal  calculi.  If  un- 
recognized, these  abnormalities  may  lead  to 
nephrocalcinosis  and  renal  insufficiency. 

Our  new  knowledge  of  carbohydrate  metabolism 
has  led  to  a  recognition  of  a  number  of  disorders 
characterized  by  hypoglycemia.  Besides  hyperin- 
sulinism,  which  is  rather  rare,  fainting,  giddiness 
and  other  obscure  symptoms  frequently  attributed 
to  gastric  ulcer  or  nervous  or  mental  symptoms, 
are  found  to  be  associated  with  the  occurrence  of 
hypoglycemic  reactions.  These  may  be  due  either 
to  functional  overactivity  of  the  pancreas  or  to 
the  presence  of  tumors  in  this  gland;  to  liver  dis- 
ease, which  frequently  does  not  manifest  itself  in 
any  other  way;  or  in  rare  cases  to  disease  of  the 
adrenal  or  pituitary.  Exact  diagnosis  of  these  cases 
is  possible  and  adequate  therapy  may  be  instituted 
once  the  etiology  is  recognized. 

Notable  advances  have  been  made  both  in  the 
diagnosis  and  the  treatment  of  the  various  dis- 
orders associated  with  the  adrenal  glands.  Cases 
of  Addison's  disease  which  previously  had  to  re- 
main undiagnosed  in  life,  due  to  the  absence  of 
some  of  the  so-called  classical  symptoms,  may  now 
be  recognized  by  a  study  of  the  electrolyte  dis- 
orders which  are  present  in  this  disease.  The  treat- 
ment of  these  conditions  has  also  been  greatly 
advanced  by  attention  to  and  correction  of  abnor- 
malities in  salt  and  carbohydrate  metabolism  and 
the  use  of  synthetic  compounds  as  well  as  extracts 
prepared  from  the  glands. 

Perhaps  in  no  field  of  medicine  have  the  ad- 
vances in  endocrinology  shed  so  much  light  as  in 
the  field  of  reproduction.  Studies  on  the  general 
biology  of  sex  have  explained  functions  which  were 
previously  mysterious.  An  entirely  new  theoretical 
basis  for  many  of  the  problems  facing  the  gyne- 
cologist and  which  the  clinician  encounters  in  his 
everyday  work,  have  been  clarified  considerably  by 
the  advances  made  in  the  endocrinological  aspects 
of  reproductive  physiology.  A  number  of  com- 
pounds have  been  introduced  for  the  treatment  of 
these  disorders.  One  of  the  difficulties  which  the 
clinician  faces  is  the  multiplicity  of  compounds 
which  are  offered  him  by  enterprising  manufactur- 
ers, with  unwarranted  claims  and  the  subsequent 
promiscuous  use  of  these  compounds  by  the  un- 
wary practitioner.  The  same  simple  compound  is 
often  presented  to  him  under  a  avriety  of  cacopho- 
nous names,  often  misleading  as  regards  their  origin, 


ENDOCRINOLOGY— Gr  oilman 


October,    1941 


as  for  example  when  substances  prepared  from 
urine  are  sold  with  the  implication  that  they  are 
derived  from  the  pituitary. 

The  empirical  use  of  the  sex  hormones  is  to  be 
deprecated.  It  must  be  remembered  that  these  are 
potent  pharmacological  agents  which  may  be  harm- 
ful if  misused.  We  must  not  forget  that  the  cause 
of  uterine  bleeding  may  still  be  a  malignant  process 
and  that  empirical  use  of  these  preparations  by  the 
general  practitioner  simply  because  they  may  be 
easily  administered  is  no  excuse  for  the  exclusion 
of  malignant  processes  as  the  cause  of  abnormal 
bleeding.  A  complete  study  of  the  case  is  essential 
before  one  can  utilize  rationally  any  particular  en- 
docrine product.  Empiricism  as  the  sole  basis  for 
therapy  is  seldom  justifiable. 

I  have  tried  to  point  out  briefly  to  you  some  of 
the  points  of  practical  value  which  have  resulted 
from  the  scientific  study  of  endocrinology.  We 
need  no  longer  indulge,  as  has  so  frequently  been 
done,  in  vague  theories,  assumptions,  or  unwar- 
ranted beliefs.  We  must  base  our  diagnosis  and 
treatment  on  exact  objective  and  scientific  knowl- 
edge. If  this  be  done,  the  general  practitioner  will 
find  his  ability  to  make  accurate  diagnoses  in  here- 
tofore obscure  conditions  greatly  increased,  and  his 
armamentarium  for  treating  many  conditions  other- 
wise irremediable  gratifyingly  augmented.  There 
still  remain  many  fields  of  the  subject  which  have 
not  been  satisfactorily  investigated.  However,  we 
may  hope  that  as  a  result  of  the  feverish  activity 
in  the  fundamental  studies  in  endocrinology,  our 
knowledge  will  be  gradually  enlarged,  with  the 
probability  of  further  application  to  many  other- 
wise obscure  clinical  problems. 


1.  Grollman,   A.:    Essentials   of   Endocrinology,    T.    B.    Lippincott 
Co.,  Philadelphia,   1941. 


EXTRACTS  FROM   A  LECTURE  ON   DIGITALIS   BY 

DR.  G.  G.  SIGMOND      AS  PUBLISHED  IN 

THE  LONDON  LANCET 

(From  "Reviews  and  Extracts"  in  Southern   Medical  &  Surgical 
Journal,  October,   1838) 

Digitalis  diminishes  the  frequency  of  the  action  of  the 
heart;  hence  the  circulation  through  the  system  becomes 
so  slow  as  to  allow  the  kidneys  much  more  time  to  take 
from  the  blood  the  watery  portion  which  they  secrete:  for. 
says  Dr.  Sigmond,  we  have  no  reason  to  believe  that  these 
organs  are  stimulated  to  any  increased  action  by  the  herb. 

Of  the  use  of  Digitalis  in  Dropsy.  When  it  is  thought 
right  to  employ  it,  be  on  the  guard.  Never  continue  it  too 
long;  and  always  be  wary  in  attempting  to  increase  the 
dose.  It  is  not  a  remedy  to  be  trifled  with.  Where  there 
is  great  general  strength  and  vigour  unimpaired  by  the 
ravages  of  disease  when  the  muscular  fibre  is  tense,  the 
skin  hard  and  dry,  if  the  individual  be  inclined  to  corpu- 
lence, if  the  countenance  be  at  all  indicative  of  determina- 
tion to  the  head,  or  veinous  relaxation,  or  if  the  habit  of 
the  bowels  be  slow  and  difficult  to  be  called  into  action,  it 
will  generally  be  found  useless;  occasionally  injurious.  Dr. 
Withering  first  drew  the  distinction  of  the  cases  of  hydro- 
phic  effusion  in  which  digitalis  would  be  found  unsuccess- 


ful, and  Dr.  S.  believes  the  truth  of  this  distinction  is  con- 
firmed by  the  great  majority  of  medical  men  who  have 
been  in  the  habit  of  employing  it. 

On  the  other  hand,  experience  demonstrated  that  there 
are  states  in  which  it  is  pre-eminently  efficacious.  These 
are,  weak,  delicate,  irritable  constitution,  where  there  may 
be  present  much  laxity  of  fibre,  a  thin,  soft,  smoothe  pale 
skin,  which,  in  the  anasarcous  limb  seems  to  be  trans- 
parent; where,  upon  pressure  on  the  skin,  there  appears  to 
be  no  elasticity  whatever,  but  the  impression  sinks  deeply, 
and  there  is  little  power  of  resistance,  where  the  emacia- 
tion of  the  other  parts  of  the  body  is  very  striking,  when 
the  countenance  is  pale,  when  there  is  feeble  or  intermitting 
pulse,  when  the  constituttion  has  been  much  broken  down, 
more  particularly  if  it  were  originally  strong,  sound  and 
robust,  where  any  indulgence  in  spirituous  liquors,  bad 
habits  of  life,  the  action  of  mercury,  or  any  debilitating 
cause  has  produced  the  mischief ;  in  such  cases  digitalis 
will  be  indicated  in  preference  to  most  diuretics.  It  should 
be  remembered,  however,  that  it  is  merely  the  evacuation 
of  the  hydrophic  fluid  which  is  effected,  and  that  this  is 
not  more  than  one  step  in  the  cure  .of  the  disease,  more 
particularly  if  that  disease  be  connected  with  a  disordered 
state  of  the  viscera,  or  if  it  be  attended  with  paralysis. 

The  disregard  of  the  distinction  of  the  different  states  in 
which  it  is  deleterious  or  beneficial,  has  given  rise  to  many 
contradictory  statements  of  its  diuretic  effects. 

In  hydrothorax  from  any  obstacle  to  circulation,  as 
hypertrophy  of  the  heart,  when  it  is  the  termination  of 
long  protracted  disease  of  the  thorax,  if  it  be  not  accom- 
panied by  disordered  condition  of  the  valves  of  the  heart, 
digitalis  may  be  employed. 

In  ascites  and  in  anasarca,  dependent  on  disordered 
states  of  the  exhalent  vessels,  which  throw  out  a  larger 
quantity  of  fluid  than  can  be  absorbed,  good  effect  is  pro- 
duced by  dinminishing  the  impulse  with  which  the  blood  is 
directed  to  the  capillaries;  and  that  fluid  is  presented  to 
the  kidneys  for  a  greater  length  of  time,  whereby  the  kid- 
neys are  enabled  to  secrete  much  more  than  they  could 
otherwise. 

In  ovarian  dropsy,  digitalis  is  seldom  found  to  suc- 
ceed. 

In  dydrocephalus  in  infancy,  it  is  highly  noxious. 
Many  practitioners  prefer  lowering  the  action  of  the 
system,  when  necessary,  before  the  use  of  digitalis,  by 
ample  depletion.  It  is  true,  he  says,  that  after  venesection, 
digitalis  is  more  diuretic;  but  he  adds,  that  the  most  fatal 
effects  have  occurred  from  giving  the  herb  after  blood- 
letting had  been  practised. 

Deleterious  effects  are  nausea,  vomiting,  purging,  exces- 
sive depression  of  spirits,  fainting.  The  skin  becomes  be- 
dewed with  a  cold  sweat,  tongue  and  lips  swell,  profuse 
salivation  occurs — sometimes  the  action  of  the  kidneys  is 
totally  suspended.  The  pulse  intermits  and  is  slow,  and 
delirium,  hiccough,  cold  sweats,  confused  vision;  sometimes 
convulsions,  and  frequent  faintings  follow,  till  death  closes 
the  scene. 

The  results  occur  after  the  endermic  use  of  this  arti- 
cle. It  is  generally  at  about  the  eighth  dose,  says  Dr.  S., 
that  the  baneful  influence  of  this  herb  is  visible;  and  this 
often  happens,  whether  the  dose  has  been  large  or  small — 
whether  diminished  or  increased;  whether  it  has  been  given 
twice  or  thrice  in  the  course  of  the  day. 


Hypodermic  Medication  100  years  ago.— M.  Lafargue 
has  been  and  is  still  engaged  in  a  series  of  experiments  on 
the  inoculation  of  various  medicinal  agents.  He  has  ascer- 
tained that  the  narcotic  effects  of  morphine  are  readily 
developed  when  the  drug  is  inserted  under  the  cuticle. — 
Bui.  I'Acad.  de  Med.,  via  Southern  Med.  &  Surg.  Jl,  (Au- 
igusta,  Ga.),  1837, 


October.   1941 


SOUTHERN  MEDICINE  &  SURGERY 


Therapeutic  Application  of  the  Various  Insulins* 

Franklin  B.  Peck,    M.D.,  Indianapolis 
From  the  Lilly  Research  Laboratories  and    Diabetic  Clinic,  Indianapolis  City  Hospital 


AFTER  almost  twenty  years  of  accumulated 
experience  with  Insulin,  the  mortality  of 
diabetes  is  found  to  have  mounted  to  ninth 
place  among  the  leading  causes  of  death,  and  the 
magnitude  of  the  problem  of  its  control  is  just 
being  appreciated.  A  growing  concern  about  the 
public-health  aspect  of  all  the  chronic  diseases  was 
expressed  in  the  recent  National  Health  Survey,1 
where  it  was  estimated  that  there  are  now  660,000 
diabetics  living  in  the  United  States.  Other  statis- 
tics indicate  that  this  number  will  reach  1,000,000 
by  1950.  These  figures  represent  between  S  and 
10  diabetic  patients  per  physician,  and  it  seems 
likely  that  all  but  a  relatively  small  proportion  of 
these  cases  are  being  cared  for,  at  least  part  of 
the  time,  by  the  family  doctor.  The  medical  pro- 
fession has  indicated  its  awareness  of  this  situation 
by  the  formation  in  recent  years  of  the  Pennsylva- 
nia Diabetes  Commission,  operating  under  the 
Pennsylvania  State  Medical  Society;  the  Diabetes 
Associations  of  New  York  and  of  Detroit;  the 
Council  on  Diabetes  of  the  Public  Health  Associa- 
tion with  the  Cincinnati  Academy  of  Medicine; 
and  others.  During  the  past  year  the  American 
Diabetes  Association  has  been  formed  and  its  first 
meeting  was  held  just  prior  to  the  A.  M.  A.  meet- 
ing in  Cleveland.  All  these  groups  are  attempting 
to  improve  the  general  level  of  diabetes  therapy 
by  educational  measures  directed  through  the  fam- 
ily physician  to  the  population  at  large.  More 
widespread  application  of  the  knowledge  which  has 
been  accumulated  is  essential. 

Present  Status 
The  present  status  of  control  of  diabetes  can 
best  be  appreciated  by  a  few  statistics.  In  Jos- 
lin's  experience  there  has  been  a  decrease  in  coma 
deaths  from  64  to  4  per  cent,  and  an  advance  in 
the  average  age  of  diabetic  patients  at  death  from 
44.5  to  64.8  years.  General  experience  has  not 
been  so  favorable.  While  the  mortality  rate  for 
diabetes  in  the  United  States  has  trebled  since 
1900,  the  rate  for  tuberculosis  has  steadily  dimin- 
ished, and  the  prophecy  made  by  Dr.  Bolduan 
several  years  ago  that  these  rates  would  soon  cross, 
seems  actually  to  be  fulfilled.  Crude  death  rates 
vary  widely  in  the  different  states  and  areas  of  the 
United  States,  and  probably  vary  equally  widely 
in  different  communities  of  the  same  state.  Recent 
surveys2  emphasize  that  the  statistical  incidence  of 
diabetes  is  highest  where  medical  supervision  is 
closest.   An  analysis  of  183  (one  year's)  deaths  in 


Cincinnati,3  the  records  of  which  indicated  diabetes 
as  the  cause  revealed  that  three-fourths  of  these 
patients  had  never  followed  a  planned  diet,  and 
only  21  per  cent  of  them  had  been  receiving  reg- 
ular injections  of  Insulin.  It  is  obvious  from  such 
figures  that  the  remarkable  improvement  of  statis- 
tics from  certain  well-known  clinics  does  not  rep- 
resent the  status  of  diabetic  treatment  in  the  coun- 
try as  a  whole.  This  must  always  be  the  responsi- 
bility of  the  general  physician. 

Recent  Developments 
The  treatment  of  diabetes  since  Insulin  was  in- 
troduced has  progressed  through  a  number  of  dis- 
tinct phases.  First,  there  was  a  period  of  adapta- 
tion to  Insulin  therapy  of  the  very  low-carbohy- 
drate, high-fat  diets  then  in  common  use.  During 
the  next  several  years,  the  controversy  raged  be- 
tween the  exponents  of  high-fat  diets  and  high- 
carbohydrate  diets.  Since  Protamine  Zinc  Insulin 
was  introduced,  this  question  has  been  displaced 
by  an  agnostic  attitude  in  many  quarters  concern- 
ing the  deleterious  effects  of  hyperglycemia  and 
glycosuria.  Even  many  of  the  more  conservative 
observers  have  relaxed  somewhat  their  vigilant  en- 
deavor to  maintain  reasonably  normal  blood-sugar 
levels  and  prevent  glycosuria.  Since  Soskins'  dem- 
onstration4 that  carbohydrate  utilization  may  pro- 
ceed in  animals  even  in  the  absence  of  Insulin, 
depending  upon  the  height  of  the  blood-sugar  level, 
there  have  been  attempts  to  compel  carbohydrate 
combustion  to  take  place  by  deliberately  inducing 
extreme  hyperglycemic  levels.  It  has  been  suggest- 
ed that  hyperglycemia  and  glycosuria  (in  the  ab- 
sence of  ketosis  or  dehydration)  are  not  responsi- 
ble for  diabetic  complications,  or  for  delayed  heal- 
ing of  wounds,  and  are  not  incompatible  with  rea- 
sonably good  health  and  satisfactory  progress  of 
cases  of  diabetes.  Without  too  great  a  strain  on 
the  imagination,  some  of  these  data  might  be  in- 
terpreted to  mean  that  high-blood-sugar  levels  and 
sugar  wastage  in  the  urine  are  desirable  accom- 
paniments of  this  disease  rather  than  indications 
of  its  poor  control.  A  natural  question  might  be: 
Why  treat  the  diabetic  at  all,  except  insofar  as 
ketosis  is  concerned? 

Within  the  past  year  or  two  important  evidence 
has  accumulated  which  places  the  treatment  of 
diabetes  on  a  much  firmer  foundation.  Two  great 
fundamental  principles  can  now  be  stated:  (a) 
give  enough  carbohydate  to  protect  the  liver  and 


"Presented   before    the    Piedmont    Postgraduate    Clinical    Assembly.   Anderson,  S.  C,   Septe 


THE  INSULINS— Peck 


October,    1941 


(b)  give  enough  Insulin  to  protect  the  islets  of  the 
pancreas.  The  first  of  these  principles  is  based  on 
the  conclusions  reached  by  Mirsky/'  Stadie,6  and 
others,  who  have  pointed  out  the  independence  of 
the  carbohydrate-  and  the  fat-oxidizing  systems. 
Any  phenomenon  which  will  accelerate  glycogen 
depletion  in  the  liver — e.g.,  Insulin  deprivation, 
hyperthyroidism,  hepatitis,  infection,  surgical  pro- 
cedures, gastro-intestinal  disturbances,  vomiting — 
will  result  in  a  secondary  acceleration  of  fat  oxi- 
dation and  the  consequent  production  of  excessive 
amounts  of  acetone  bodies.  The  second  principle 
is  based  upon  the  culmination  of  a  whole  train  of 
investigations  by  Houssay  and  Evans,  leading  to 
the  production  by  Young,  Best,  Long,  Lukens,  and 
others,  of  permanent  diabetes  in  animals  by  means 
of  anterior  pituitary  injections,  and  finally  the  pre- 
vention and  cure  of  this  type  of  diabetes  by  In- 
sulin. If  the  conclusions  from  animal  experiments 
can  be  applied  to  clinical  problems,  renewed  and 
far  greater  emphasis  must  from  now  on  be  placed 
on  the  importance  of  early  and  continuous  mainte- 
nance of  good  clinical  control  of  diabetes.  Allen 
advocated  this  in  1913,  and  again  in  1922,  but  the 
full  significance  of  his  observations  has  just  been 
rediscovered. 

Haist,  Campbell  and  Best,7  of  Toronto,  in  study- 
ing the  factors  which  affect  the  insulin  content  of 
the  pancreas,  have  demonstrated  that  the  produc- 
tion of  diabetes  in  animals  by  administration  of 
pituitary  diabetogenic  substances  may  be  prevent- 
ed by  dietary  means,  or  by  the  administration  of 
large  doses  of  Insulin.  Fasting,  fat  feeding,  or 
Insulin  administration,  in  rats  and  in  dogs,8  leads 
to  a  decrease  in  insulin  content  of  the  pancreas,  but 
without  degeneration  of  the  islet  cells.  Carbohy- 
drate-feeding, on  the  other  hand,  in  the  absence 
of  Insulin,  causes  an  increased  insulin  content  in 
the  pancreas;  however,  this  increase  is  not  sus- 
tained. Dailv  administration  of  Protamine  Zinc 
Insulin  augments  the  effects  of  fasting  and  fat- 
feeding  and  tends  to  prevent  reduction  in  insulin 
content  and  degenerative  changes  produced  by  the 
anterior  pituitary  extract  alone. 

Allen"  demonstrated  many  years  ago  that  par- 
tial pancreatectomy,  sufficient  to  cause  production 
of  diabetes  in  dogs,  is  accompanied  by  progressive 
degranulation  and  hydropic  degeneration  of  the 
beta  cells  in  the  islets  of  the  pancreatic  remnant. 
He  found  that  active  diabetes  is  prerequisite  for 
the  occurrence  of  hydropic  degeneration,  and  that 
the  two  are  parallel  in  degree  and  course.  In  those 
animals  in  a  borderline  state  or  in  early  stages  of 
diabetes,  "a  genuinely  new  formation  of  islands  is 
possible  by  direct  proliferation.  But  when  all  beta 
cells,  new  and  old,  are  exhausted,  it  is  evident  that 


the  regenerative  power  is  also  exhausted,  and  no 
further  production  of  islet  cells  is  possible." 

Lukens  and  Dohan1",  n,  12  found  that  permanent 
diabetes  can  also  be  produced  in  the  cat  by  an- 
terior pituitary  injections  provided  one-half  to 
three-fourths  of  the  pancreas  be  first  removed. 
Permanent  recovery  did  not  occur  in  certain  ani- 
mals treated  with  Insulin.  These  instances  were 
associated  with  infection,  poor  control  of  diabetes 
by  Insulin,  or  with  delay  in  institution  of  Insulin 
therapy  until  sufficient  time  had  elapsed  to  result 
in  irreversible  damage  to  the  islet  cells.  These  ex- 
periments lead  once  again  to  the  assumption  that 
hydropic  degeneration  is  the  early  lesion  of  dia- 
betes. More  recently,13  by  a  carefully  devised  set 
of  experiments,  these  observers  have  shown  that 
hyperglycemia  per  se  is  the  factor  underlying  the 
pathological  changes  in  the  islet  tissue.  Hence  the 
emphasis  that  must  be  placed  on  protection  by 
Insulin  of  the  islet  cells.  Lukens'  observations  sug- 
gest that  the  reason  it  is  not  seen  more  often  in 
cases  of  human  diabetes  may  be  that  the  reversible 
stage  has  been  passed  long  before  patients  reach 
the  autopsy  table.  This  period  is  much  shorter  in 
the  dog  than  in  the  cat,  and  we  do  not  know  how 
long  reversible  changes  are  present  in  the  human. 
Warren14, ls  has  reported  20-odd  cases  of  hydropic 
degeneration  in  humans  and  believes  that  the  lesion 
was  relatively  common  in  pre-Insulin  days,  and 
may  be  largely  modified  now  in  patients  who  have 
received  large  amounts  of  Insulin  a  short  time 
prior  to  death. 

Applied  Physiology 

The  chief  therapeutic  implication  of  these  exper- 
imental studies  is  that  the  factors  which  prevent 
diabetes  from  developing  will  also  prevent  diabetes 
from  progressing.  There  is  proof  that  factors  lead- 
ing to  overactivity  of  the  islet  cells  may  produce 
irreversible  changes;  but  the  resting  procedures — 
fasting,  fat-feeding,  and  control  by  Insulin — pre- 
vent degenerative  changes  from  developing  in  cells 
not  already  affected,  and  permit  restoration  of  cells 
that  have  not  lost  all  recuperative  power. 

In  the  treatment  of  patients,  departures  from 
the  normally  balanced  diet  are  permissible  for  only 
short  intervals,  or  nutritional  requirements  will  be 
unsatisfied.  Starvation  is  not  desirable,  neither  is 
excessive  fat-feeding.  Recourse  must  then  be  had 
to  Insulin  and  Protamine  Zinc  Insulin,  in  conjunc- 
tion with  a  diet  planned  to  satisfy  long-term  nutri- 
tional requirements.  Early  treatment  and  continu- 
ous control  are  the  factors  of  greatest  significance. 
Insulin  and  Protamine  Zlnc  Insulin 

Early  treatment  of  diabetes  should  not  offer 
much  difficulty,  but  continuous  control  is  a  differ- 
ent matter.    One  of  the  problems,  that  of  a  night- 


October,   1941 


THE  INSULINS— Peck 


rising  blood-sugar  level,  may  be  solved  by  use  of  a 
modified  Insulin;  but  here,  too,  lie  certain  diffi- 
culties, which  can  best  be  resolved  by  understand- 
ing the  phvsiological  action  of  the  Insulins. 

In  practical  therapy,  the  unmodified  Insulins, 
whether  of  amorphous  or  crystalline  origin,  may 
be  considered  interchangeable,  the  chief  difference 
being  that  Insulin  made  from  zinc-Insulin  crystals 
has  the  advantage  of  chemical  purity.  Both  are 
preparations  having  a  rapid  effect  which  is  ex- 
erted only  for  a  few  hours,  depending  much  upon  the 


size  of  the  dose.  Clinical  studies10, 1T, 18  indicate 
their  essential  similarity  in  action,  and  blood-sugar 
curves  based  on  observations  made  on  large  groups 
of  animals  are  apparently  identical. 

Protamine  Zinc  Insulin,  on  the  contrary,  is  only 
slowly  effective,  but  its  duration  of  action  exceeds 
twenty-four  hours,  again  depending  somewhat  on 
the  size  of  the  dose.  Wilder's19  blood-sugar  curve 
(Figure  1),  made  on  a  patient  with  severe  diabetes 
who  was  fed  every  two  hours  day  and  night,  has 
been  regarded  by  clinicians  as  illustrative  of  the 
typical  action  of  Protamine  Zinc  Insulin. 


M.B.5.  Female,  ag*e  3Z  yrs. 
Hoars 

O        4        6       12.      16      S.O     £4      26      32.      36 


40 


O     500 

c  400 
^V,  300 
§  -2.00 

o 


100 


"t t  t ft tt  t  tt  t  t  t  t  t  t T t 


4   o    ^ 
o      .§> 


£.4^ 
1.6  *f 
.6    fc> 


t=Feedinc/   179  cc.  of  milk,  cream,  Karo 
mixture      C14.16      R5.41      E6.33 

13£  units    protamine    insulin  with 
z.inc  (1  mg.  per   500  units) 
£iven    at   zero    hour 


Figure  1. — Reproduced  by  courtesy  of  Dr.  Russell  Wilder 
This  curve  shows  a  slow  onset  of  hypoglycemic  effect,  which  reaches  its  maximum  sixteen  to 
twenty  hours  after  the  dose,  then  gradually  wanes  until  completely  expended  thirty-two  to  thirty- 
six  hours  later.  Not  usually  considered  is  the  fact  that  it  represents  an  acute  experiment  with  a 
patient  under  conditions  of  diet  at  wide  variance  from  those  obtaining  under  daily  living  condi- 
tions. With  this  in  mind,  another  interpretation  is  possible,  by  transforming  the  blood-sugar  data 
into  a  dose:effect  curve  (Figure  2). 


542 


THE  INSULINS— Peck 


October,   1941 


Cumulative  curve  transformed  from  blood  sugar  curve  obtained  when 
132  units  of  protamine  insulin  were  given  a  patient  with  blood  sufar 
of  330  who  was  fed  at  2-hour  intervals. 


32    34 


Hours  alter  Prolamine  Zinc  Insulin 


Figure  2. — Cumulative  curve  based  on  Figure  1. 
The  fall  in  blood-sugar  level  in  this  instance  apparently  assumes  the  form  of  a  symmetrical 
frequency  curve  which  in  biological  data  may  be  transformed  into  a  sigmoid  curve  similar  to  that 
obtained  with  dosage: effect  data.  We  do  not  know  whether  the  sigmoid  figure  is  caused  by  pro- 
tamine releasing  Insulin  more  slowly  at  first,  and  again  more  slowly  at  the  last,  due  to  a  diminish- 
ing supply;  or  whether  it  is  due  to  a  variation  in  the  body's  ability  to  utilize  the  Insulin  available 
at  different  times.  The  most  important  factor,  as  far  as  the  present  consideration  is  concerned,  is 
the  proportionate  part  of  the  total  Insulin  effect  that  has  taken  place  at  any  given  time.  For  the 
sake  of  simplicity,  these  proportionate  parts  are  expressed  in  Insulin  units,  calculated  in  four-hour 
periods. 


October,   1941 


THE  INSULINS— Peck 


It  must  be  borne  in  mind  that  these  data  are 
only  representative,  that  they  have  been  calculated 
for  a  particular  experiment,  and  that  they  may  or 
may  not  be  the  actual  number  of  units  released 
from  time  to  time.  Nevertheless,  they  are  in  agree- 
ment with  man)'  clinical  observations  and  because 
of  this  may  necessitate  revision  of  the  conception 
that  Protamine  Zinc  Insulin  has  a  gradually  devel- 
oping period  of  maximum  effect;  since  if  the 
amount  of  Insulin  effective  beyond  twenty-four 
hours  is  added  to  the  amount  available  during  the 
first  four-hour  period  following  another  dose  on  the 
next  morning,  it  is  obvious  that  an  almost  equal 
amount  of  Insulin  will  be  released  during  each 
four-hour  period  on  subsequent  days.  This  assump- 
tion that  Protamine  Zinc  Insulin  releases  its  Insulin 
at  a  fairly  uniform  and  constant  rate  explains  its 
inability  to  prevent  glycosuria  following  ingestion 
of  large  amounts  of  carbohydrate,  the  relative  un- 


importance of  the  time  of  giving  the  dose;  the  rea- 
son true  cumulative  action  does  not  persist  beyond 
the  first  two  or  three  days;  and,  furthermore,  it 
supports  the  conclusions  of  Ricketts,20  which  were 
reached  from  a  totally  different  point  of  view,  that 
Protamine  Zinc  Insulin  regulates  chiefly  the  endo- 
genous carbohydrate  metabolism.  It  has  been  the 
general  experience  that  the  patient  with  mild  or 
moderate  diabetes,  with  a  total  Insulin  requirement 
not  exceeding  30  to  40  units,  does  well  with  Prota- 
mine Zinc  Insulin.  The  islet  tissue  in  such  a  case 
is  still  capable  of  responding  to  the  presence  of 
exogenous  carbohydrate  by  the  production  of  in- 
sulin. The  severe  case  needs  supplementary  rap- 
idly-acting Insulin,  as  originally  suggested  by  Wil- 
der, or  as  an  alternative,  readjustment  of  the  me- 
tabolic load  (food  given  at  the  various  meals)  to 
the  amount  which  can  be  utilized  by  the  amount 
of  Insulin  available  at  that  particular  period.    In- 


cPo° I  1*4.5  Oo%)    1  |     |tq     CIO'/.) 

—  ]  113-^'e     I    )  ft    la     - 


APPROJU/ttAfE  THEORETICAL  AMOUNT  Of  ACTIVE  INSULIN  AVAILABLECp 


AfcAAMATtC) 


Figure  3.—  Approximate  calculated  amounts  of  active  Insulin  available  under  different  methods  of 
administration. 

In  the  first  instance  (solid  line)  three  doses  of  unmodified  Insulin — 20  units  before  breakfast, 
10  units  before  lunch,  and  15  units  before  dinner — each  provides  its  full  activity  at  times  when 
the  food  load  is  greatest.  In  this  instance,  daytime  control  is  good.  The  difficulty  arises  at  night, 
when  the  activity  of  the  earlier  doses  has  been  expended,  resulting  in  loss  of  diabetic  control  and 
a  high  fasting  blood-sugar  level. 


THE  INSULINS— Peck 


October,   1941 


When  Protamine  Zinc  Insulin  alone  is  administered  in  identical  amount  (45  units)  but  in  a 
single  dose  before  breakfast  (circle  line),  the  fasting  levels  are  satisfactory,  but  daytime  control 
is  poor.  The  reason  is  obvious  from  the  calculation  below,  since  the  free  Insulin  available  during 
the  interval  between  breakfast  and  lunch  has  been  sharply  reduced  from  the  20  units  previously 
administered  to  4.5  units.   This  results  in  poor  control  during  the  periods  of  heaviest  food  load. 

If  an  attempt  be  made  to  render  the  urine  sugar-free  during  the  day  by  administering  larger 
doses  of  Protamine  Zinc  Insulin  (dot-dash  line),  the  blood-sugar  curve  is  placed  on  a  lower  plane, 
but  its  shape  is  not  materially  altered.  Under  such  cricumstances,  daytime  control  may  be  fairly 
satisfactory,  but  so  great  a  proportion  of  the  Insulin  is  freed  at  night  that  nocturnal  hypoglycemia 
is  bound  to  result. 

A  practical  solution  of  the  problem  is  the  administration  of  enough  slowly-acting  Insulin  to 
maintain  good  control  during  the  night  without  inducing  hypoglycemia,  and  then  providing  a 
supplementary  dose  of  rapidly-acting  Insulin  large  enough  to  supply  the  required  number  of  units 
of  free  Insulin  during  the  peak  of  the  metabolic  load  (dash  line).  In  the  instance  illustrated  this 
was  accomplished  by  giving  30  units  of  Protamine  Zinc  Insulin  and  15  units  of  unmodified  Insulin 
before  breakfast.  About  3  units  are  released  from  the  dose  given  twenty-four  hours  previously, 
to  which  must  be  added  the  3  units  that  become  available  following  the  dose  given  the  same 
morning,  a  total  of  6  units  that  are  being  supplied  by  Protamine  Zinc  Insulin.  The  addition  of 
15  unit",  of  unmodified  Insulin  brings  the  total  to  21  units  of  Insulin  that  are  to  act  during  the 
interval  between  breakfast  and  lunch.  The  noon  meal  and  the  dinner  are  accompanied  by  6  to  9 
units,  respectively,  of  freed  Insulin,  with  another  9  units  released  slowly  over  the  night  period. 


REGULATION  OF  INSULIN  AND  PROTAMINE  ZINC  INSULIN  DOSES 

CSCHSWAT'C) 

BLOOD  SUGAR      BLOOD  SUGAR  BL0O0  JUGAR.  Bl 


ADJUST  IMSUL1N  BY  THESE  TESTS 


ADJUST  P.Z.I.  DOSE  BY  TESTS  BETORE  BREAKfAST 


Figure  4. — Regulation  of  Insulin  and  Protamine  Zinc  Insulin  Doses. 
The  fasting  blood-sugar  level  is  characteristically  high  in  Insulin-treated  cases,  but  it  is  low- 
ered during  the  day  when  Insulin  is  being  injected  before  meals.  The  fasting  level  of  blood  sugar 
is  low  in  the  case  of  Protamine  Zinc  Insulin,  however,  but  ascends  in  the  day  time,  since  the  active 
Insulin  is  released  too  slowly  to  compensate  for  the  sudden  influx  of  carbohydrate  with  meals. 
Observations  of  the  excretion  of  sugar  at  the  different  periods  of  the  day  as  diagramed  are  very 
probably  the  most  helpful  single  measure  of  diabetic  management  in  gaining  satisfactory  control 
of  the  case. 


October,   1941 


THE  INSULINS— Peck 


S4S 


terpretation  of  these  data  clinically  is  illustrated 
in  the  accompanying  diagram  (Figure  3),  which 
includes  the  calculated  theoretical  amounts  of  In- 
sulin available  during  different  periods  of  the  day 
when  the  patient  is  treated  by  means  of  45  units 
ef  unmodified  Insulin,  45  units  of  Protamine  Zinc 
Insulin  alone,  90  units  of  Protamine  Zinc  Insulin 
alone,  or  by  30  units  of  Protamine  Zinc  Insulin 
with  a  supplementary  dose  of  15  units  of  unmodi- 
fied rapidly-acting  Insulin. 

A  slight  reduction  in  the  amounts  of  food  given 
at  these  times  may  be  advantageous,  and  the  pro- 
vision of  a  small  lunch  at  bedtime,  containing 
some  protein  (such  as  a  sandwich  or  a  glass  of 
milk)  aids  materially  in  readjusting  the  metabolic 
load  to  the  slow  rate  of  release  of  active  antidia- 
betic principle  from  Protamine  Zinc  Insulin. 

Regulation  of  the  dose  of  either  Insulin  or  Pro- 
tamine Zinc  Insulin  must  be  based  on  different 
observations.  If  one  will  bear  certain  principles  in 
mind,  it  is  possible  to  simplify  the  issue.  The  dia- 
gram (Figure  4)  is  a  schematic  representation  of 
the  effect  of  unmodified  and  Protamine  Zinc  In- 
sulin, showing  their  almost  opposite  effects  in  alter- 
ing the  blood-sugar  curve  in  a  severe  case  of  dia- 
betes. 

Summary 

1.  The  majority  of  cases  of  diabetes  are  of  mild 
or  moderate  degree,  and  may  be  satisfactorily  con- 
trolled with  a  daily  dose  of  Protamine  Zinc  Insulin. 
The  patient  with  mild  diabetes,  if  neglected,  does 
poorly;  but  the  victim  of  even  the  severe  case,  if 
carefully  treated,  does  remarkably  well. 

2.  Upon  the  family  physician,  who  sees  most  of 
these  cases  first,  depends  the  early  diagnosis  of 
new  cases,  and  upon  his  management  depends 
largely  the  course  of  the  case — whether  it  is  to 
remain  mild,  or  whether  alternating  bouts  of  ac- 
tivity brought  on  by  failure  to  observe  dietary  re- 
strictions, by  infection,  or  by  delay  in  administer- 
ing Insulin  when  this  is  necessary,  ultimately  con- 
vert the  mild  case  into  one  of  maximum  severity. 

3.  Two  principles  of  treatment  have  been 
evolved:  (a)  enough  carbohydrate  to  protect  the 
liver,  and  (b)  enough  Insulin  to  preserve  the  islet 
mechanism. 

4.  The  physiologic  action  of  Insulin  and  Prota- 
mine Zinc  Insulin  differ  only  in  rate  of  release  of 
active  antidiabetic  principle.  This  factor  is  consid- 
ered from  the  standpoint  of  theoretical  dose:effect 
data,  and  applied  to  the  treatment  of  a  typical 
case. 

Bibliography 

1.  National  Health  Survey,  Bulletin  6,  1939. 

2.  Joslin,  E.  P.:    Universality  of  Diabetes.    J.  A.  M.  A. 
115:2011,  1940. 


3.  Facts  about  Diabetes  in  Cincinnati.  Cincinnati  Acad- 
emy of  Medimine  in  Co-operation  with  the  Council  on 
Diabetes  of  Public  Health  Education.  Jan.,  1941. 

4.  Soskin,  S.,  and  Levine,  R.:  A  Relationship  Between 
the  Blood-Sugar  Level  and  the  Rate  of  Sugar  Utiliza- 
tion.  Am.  J.  Physiol.,  120:761,  1937. 

5.  Mirsky,  I.  A.:    Etiology  of  Diabetic  Acidosis,  in  press. 

6.  Stadie,  W.  C:  Fat  Metabolisms  in  Diabetes  Mellitus. 
J.  Clin.  Investigation,  iP:843,  1940. 

7.  Haist,  R.  E.,  Campbell,  James,  and  Best,  C.  H.:  The 
Prevention  of  Diabetes.  New  England  J.  Med.,  223: 
607,  1940. 

8.  Campbell,  James,  Haist,  R.  E.,  Ham,  A.  W.,  and  Best, 
C  H.:  The  Insulin  Content  of  the  Pancreas  as  Influ- 
enced by  Anterior  Pituitary  Extract  and  Insulin.  Am. 
J.  Physiol.,  129:328,  1940. 

9.  Allen,  F.  M.:  Experimental  Studies  in  Diabetes.  I. 
Hydropic  Degeneration  of  Islands  of  Langerhans  After 
Partial  Pancreatectomy.    J.  Metab.  Res.,  1:S,  1922. 

10.  Ltjkens,  F.  D.  W.,  and  Dohan,  F.  C:  Morphological 
and  Functional  Recovery  of  the  Pancreatic  Islands  in 
Diabetic  Cats  Treated  with  Insulin.  Science,  92:222, 
1940. 

11.  Ltjkens,  F.  D.  W.,  and  Dohan,  F.  C:  Pituitary-dia 
betes  in  the  Cat;  Recovery  Under  Phlorhizin  Treat- 
ment.   Am.  J.  Physiol.,  133:3b&,  1941. 

12.  Lukens,  F.  D.  W.,  and  Dohan,  F.  C:  Pituitary-dia- 
betes in  the  Cat  Treated  by  Low  Diet,  Insulin,  Phlor- 
hizin, and  Adrenalectomy.  J.  Clin  Investigation,  20: 
444,  1941. 

13.  Dohan,  F.  C,  Fish,  C.  A.,  and  Lukens,  F.  D.  W.: 
Introduction  and  Course  of  Permanent  Diabetes  Pro- 
duced by  Anterior  Pituitary  Extract.  Endocrinology, 
25:341,   1941. 

14.  Warren,  Shields:  Pathology  of  Diabetes  Mellitus,  Ed. 
2.    Philadelphia:   Lea  and  Febiger,  1938. 

15.  Warren,  Shields:  Ibid.  pp.  42-46  (Quoted  by  Mc- 
Daniel,  Conn.  Med.  J.,  Dec,  1940). 

16.  Marble,  A.,  and  Vartialnen,  I.:  Crystalline  Insulin. 
J.  A.  M.  A.,  113:1303,  1939. 

17.  Ricketts,  H.  T.,  and  Wilder,  R.  M.:  Solutions  of 
Amorphous  Insulin  and  Solutions  of  Zinc  Insulin  Crys- 
tals; Clinical  Studies  on  Comparative  Speed  and  Dura- 
tion of  Action.   J.  A.  M.  A.,  1310,  1939. 

18.  Duncan,  G.  G.,  Cuttle,  T.  D.,  and  Jewesbury,  E.  C. 
O.:  Observations  on  the  Comparative  Clinical  Values 
of  Zinc  Insulin  Crystals  in  Solution  and  Unmodified 
Insulin.  Bull,  of  the  Ayer  Clinical  Laboratory,  J:293, 
1939. 

19.  Wilder,  R.  M.,  and  Wilbur,  D.  L.:  Diseases  of  Me- 
tabolism and  Nutrition;  Review  of  Certain  Recent 
Contributions.    Arch.  Int.  Med.,  50:329,  1937. 

20.  Ricketts,  H.  T.:  Constancy  of  Action  of  Protamine 
Zinc  Insulin.  Am.  J.  M.  Sc,  201,  (Jan.)   1941. 


Caeserean  Section. — M.  Caste  stated  at  a  recent  meet- 
ing of  the  Academy  of  Medicine  (Paris)  (Feb.  17th,  1838) 
that  some  years  since,  a  woman  was  in  labour  at  the 
hospice  de  perjectionnement,  the  professors  were  all  assem- 
bled, and  the  caesarean  section  resolved  on.  The  crowd  of 
students  was  so  great  that  some  delay  took  place  whilst 
arrangements  were  making  for  their  accomodation,  and 
during  this  time  the  woman's  delivery  took  place  naturally. 

M.  Gimelle  also  stated  that  he  saw,  at  the  hospice  of  M. 
Dubois,  a  small  woman  who  had  five  times  submitted  to 
the  caesarean  section,  and  who  was  delivered  naturally 
the  sixth  time. — Southern  Med.  &  Surg.  Jl.,  1838. 


Lemon  juice,  y2  oz.,  q.  4h,  has  been  much  and  success- 
fully used  at  Guy's  Hospital,  in  the  treatment  of  acute 
rheumatism.  It  is  also  of  much  service  in  obstinate  dys- 
menorrhea.— Charleston  Medical  Journal,  1849. 


SOUTHERN  MEDICINE  &  SURGERY 


October,   1941 


Aging  As  A  Problem  of  Industrial  Health* 

Edward  J.  Stieglitz,  M.D.,  F.A.C.P.,**  Bethesda,  Maryland 


AGING  is  as  old  as  Time.  Everything  that 
exists  ages.  Aging  is  a  part  of  living.  It 
affects  the  processes  of  life.  Yet,  curiously, 
we  know  very  little  about  it.  The  study  of  aging 
as  a  process  has  been  conspicuously  neglected  until 
very  recently.  Philosophers,  biologists  and  physi- 
cians have  been  strangly  content  to  take  the  phe- 
nomenon of  aging  as  a  matter  of  course  and  to 
ignore  the  complex  questions  which  are  raised. 
The  reasons  for  this  long  neglect  are  not  hard  to 
find.  First  of  all,  science  normally  attacks  the 
simpler  problems  first.  Secondly,  and  this  is  true 
even  today,  aging  is  largely  taken  for  granted.  Air 
conditioning  is  now  a  fact  accomplished.  The  time 
has  come  when  the  progress  of  mankind  demands 
energetic  attack  upon  the  problems  of  aging. 

Man  is  a  utilitarian  creature  and  few  indeed  are 
those  scientists  who  seek  truth  with  purely  abstract 
curiosity  free  from  any  practical  motivation.  Fewer 
still  are  those  who  encourage  and  finance  such  pure 
research.  Up  until  recently  the  problems  of  aging 
have  held  largely  academic  and  theoretical  inter- 
ests. This  is  changed.  There  is  urgency  in  the 
need  to  know  more,  much  more,  about  aging.  With 
the  rest  of  the  world,  this  Nation  is  growing  older 
chronologically;  in  the  basic  structure  of  its  pop- 
ulation this  Nation  is  growing  older  faster  than 
is  the  rest  of  the  world.  In  the  virile  days  of 
pioneering,  physical  hardships  and  early  disease 
left  but  few  to  reach  ripe  senescence.  In  the  last 
fifty  years,  preventive  medicine,  sanitation  and 
vastly  improved  pediatrics  have  dramatically  rais- 
ed the  average  age  of  our  population.  This  in- 
crease in  age  continues;  it  was,  in  fact,  accelerated 
in  the  last  decade. 

At  the  turn  of  the  century  the  average  life  ex- 
pectancy at  birth  was  but  47;  today  it  exceeds  63. 
In  1900  only  17  per  cent  of  the  population  of  the 
United  States  were  45  or  more  years  of  age.  In 
1940,  26.5  per  cent  were  over  45,  and  conservative 
projection  leads  us  to  expect  that  in  1980 — only  40 
years  hence — more  than  40  per  cent  of  our  pop- 
ulation will  be  over  45.  Data  from  the  1940  cen- 
sus reveal  that  the  population  of  the  United  States 
as  a  whole  increased  7.2  per  cent  since  1930,  but 
that  the  number  of  persons  aged  65  or  more  in- 
creased 35  per  cent  in  the  last  decade.  There  are 
now  nearly  nine  million  people  of  65  or  more. 


Were  all  these  people  vigorous  and  well  we 
would  have  reason  to  rejoice  complacently  in  the 
benefits  of  advancing  medical  science.  But  they 
are  not  all  healthy.  A  large  and  growing  number 
suffer  from  the  so-called  degenerative  diseases  and 
are  prematurely  disahled  thereby.  These  disorders, 
whose  incidence  rises  with  advancing  years,  are  not 
limited  to  the  senescent.  Senescence  is  a  contin- 
uous process  and  the  prolonged  disability  from 
cardiovascular-renal  diseases,  arthritis,  diabetes 
mellitus,  gout  and/or  cancer  in  those  in  the  fifth 
and  sixth  decade  of  life  is  of  even  greater  moment 
than  the  rising  proportion  of  deaths  due  to  these 
disorders.  The  period  of  greatest  significance  is 
that  from  40  to  60.  The  infants  and  youths  now 
saved  from  diphtheria,  smallpox,  typhoid  fever, 
summer  diarrheas  and  other  infective  diseases  are 
potential  victims  for  the  disorders  of  late  maturity. 
There  are  several  important  distinctions  between 
these  two  groups.  The  diseases  of  youth  are  char- 
acteristically acute,  florid,  self-limited,  brief  and 
exogenous.  The  disorders  of  late  maturity  are 
chronic,  insidious,  progressively  disabling  before 
they  finally  distroy,  and  largely  endogenous. 

The  implications  of  this  handwriting  on  the  wall 
are  so  vast  that  no  apology  is  needed  for  em- 
phasizing the  urgency  and  great  importance  of 
gerontology,  the  study  of  aging.  Advances  in 
medical  science,  the  prevention  and  improved  treat- 
ment of  infective  diseases,  better  pediatric  care 
and  nutrition  and  public  health's  contributions  to 
sanitation  have  tremendously  enhanced  the  chances 
of  survival  through  infancy  and  youth.  The  in- 
creased longevity  of  our  population  can  be  made  a 
splendid  advance  if  length  of  years  be  paralleled  by 
health  and  productiveness;  it  is  also  potentially 
disastrous  if  the  chronic,  progressive  and  disabling 
disorders  of  later  life  are  not  controlled.  The 
older  fraction  of  our  population  represents  an  im- 
mense, but  largely  unutilized  and  unappreciated, 
resource.  These  increasing  millions  of  older  men 
and  women  will  remain  a  problem  and  a  potential 
menace  to  economic  equilibrium  until  we  know 
enough  about  aging  to  maintain  health  into  senes- 
cence and  to  use  wisely  the  capacities  of  those  we 
call  old. 

Gerontology,  the  science  of  aging,  crosses  the 
lines  of  all  divisions  of  thought  and  thus  applies  all 
the  many  methods  of  science  as  instruments  for  its 


*Read  before  the    Symposium 
mond,  Va..  September  11,   1941, 
May  28,  1941. 
"•Consultant  in  Gerontology,   Division  of  Chemotherapy.   Nat 


Industrial    Health,    Department    of    Preventive    Medicine,    Medical    College    of    Virginia.    Rich- 
d  the  Medical  and  Surgical   Section,    Association    of    American    Railroads,    Montreal,    Canada, 


lal  Institute  of  Health,  U.  S.   Public  Health   Service. 


October,   1941 


AGING  &  INDUSTRIAL  HEALTH— Stieglitz 


advance.  This  is  confusing.  But  it  is  possible  to 
bring  some  order  out  of  this  chaos  and  to  orient 
ourselves  in  this  vast  and  uncharted  sea.  With 
these  points  in  mind  we  may  chart  the  courses  for 
many  voyages  of  exploration.  There  is  much  work 
to  be  done. 

Gerontology  may  logically  be  divided  into  three 
major  categories  of  thought: 

1«  The  biology  of  aging  (particularly  of  senes- 
cence). 

2.  The  clinical  problems  of  aging  man,  both 
normal  and  abnormal. 

3.  The  socio-economic  problems. 

The  first  of  these  divisions  of  thought  deals  with 
all  living  matter  and  involves  many  disciplines. 
Unanswered  as  yet  are  such  fundamental  questions 
as:  just  what  happens  to  a  cell  with  aging?,  why 
does  aging  occur?,  what  accelerates  or  retards  it?, 
what  mechanisms  are  involved,  and  why?  The 
elucidation  of  these  basic  questions  may  solve 
many  riddles.  It  is  within  this  sector  that  fall  the 
biochemical,  physiological,  cytological,  botanical 
and  anatomical  investigations  which  are  necessary 
to  define  more  precisely  what  aging  is  and  does. 
For  example,  the  changes  in  cellular  respiration 
brought  about  by  aging  may  indicate  the  road  for 
solution  of  the  problems  of  arteriosclerosis  or  can- 
cer. 

The  clinical  problems  of  senescence  in  man  are 
of  more  immediate  concern,  but  their  solution  will 
depend  greatly  upon  the  advances  in  the  first  cate- 
gory of  thought.  Obviously,  man  ages  either  nor- 
mally or  abnormally.  Normal  aging  brings  many 
changes,  some  so  obvious  as  to  be  conspicuous, 
others  obscure  and  occult,  all  inevitably  progres- 
sive. Normality  is  not  a  fixed  point  but  a  series  of 
variables  which  change  with  age.  Chronologic  age 
as  measured  by  years  and  months  is  by  no  means 
identical  with  biologic  age.  Biologic  age  varies  with 
each  individual;  there  are  many  of  us  physiologi- 
cally older  than  our  elapsed  years  and  a  few  of  us 
physically  younger  than  our  chronologic  age.  Fur- 
thermore, no  individual  is  of  uniform  physiologic 
age  throughout;  different  structures  and  systems 
age  at  different  rates  at  different  times  in  the  life 
span. 

There  is  a  common  misconception  that  senes- 
cence implies  decline  alone.  This  is  distinctly 
erroneous,  for  there  occur  compensatory  increments 
in  certain  functional  capacities.  For  example,  as 
speed  of  reaction  is  lowered  with  age  there  occurs 
a  compensatory  increase  in  endurance.  In  athletic 
performance  there  is  a  positive  correlation  between 
success  in  competition  requiring  endurance  and  full 
maturity.  The  world  records  for  sprints  are  held 
by  very  young  men,  but  the  records  for  the  mara- 


thon have  been  made  by  men  well  over  30.  Far 
greater  differences  in  endurance  and  reaction  to  ex- 
ercise are  found  in  persons  in  the  same  age  groups 
than  are  observed  between  younger  and  middle- 
aged  subjects.  Loss  of  mere  physical  strength  is 
often  compensated  for  by  increased  skill  and  judg- 
ment. Though  ambition  may  become  less  virile, 
pride  in  good  work  well  done  and  the  reestimation 
of  values  which  come  with  maturity  may  compen- 
sate, particularly  if  an  honest  recognition  of  limi- 
tations is  included  in  the  mental  changes  of  aging. 
It  is  not  merely  a  coincidence  that  the  engineers 
of  the  crack  trains,  that  the  captains  of  the  most 
important  ships  and  that  the  directors  of  the 
greatest  industries  are  old  men. 

Abnormal  senescence  introduces  the  problems  of 
those  diseases  whose  incidence  increases  with  ad- 
vancing years,  and  in  whose  etiology  aging  plays 
some  as  yet  ill-defined  role.  It  is  extremely  difficult 
to  draw  a  sharp  line  of  distinction  between  normal 
and  abnormal,  especially  as  normal  is  not  constant. 

The  socio-economic  problems  of  aging  arise  out 
of  the  tremendously  increased  numbers  of  the  aged 
in  our  population.  This  situation  is  wholly  without 
precedent.  Never  before  in  the  history  of  mankind 
has  a  community,  race,  nation,  or  a  culture  been 
faced  with  a  population  structure  such  as  is  devel- 
oping today.  These  increasing  millions  of  elderly 
people  must  either  have  the  opportunity  to  work 
at  occupations  suited  to  their  capacities,  and  thus 
to  support  themselves;  or  the  proportionately  dwin- 
dling group  of  younger  individuals  must  support 
them  in  one  way  or  another.  The  one  answer  im- 
plies productivity,  the  other  rising  and  potentially 
destructive  costs  upon  a  group  which  may  ulti- 
mately become  a  minority.  Thus  the  problems  of 
our  aging  people  are  of  immediate  and  personal 
significance  to  everyone,  as  individuals  or  as  parts 
of  corporate  industry,  or  of  government.  Industry 
is  particularly  concerned,  not  only  because  of  its 
increasing  share  of  the  tax  burden,  but  because  of 
the  increasing  age  of  its  own  personnel.  Manufac- 
turing personnel  directors  have  recently  become 
aware  of  the  implications  in  the  fact  that  the  aver- 
age age  of  their  employees  is  increasing  at  a  sur- 
prising rate — almost  a  year  per  year  in  one  im- 
mense organization. 

The  average  age  of  workers  will  not  diminish. 
The  threat  of  war  has  already  accelerated  these 
problems,  for  youth  is  being  called  to  military 
training.  The  emergency  of  increased  defense  pro- 
duction is  demanding  the  recall  of  many  older 
workers  because  of  their  skill  and  technical  train- 
ing. The  practical  problems  of  aging  personnel  are 
here.  They  involve  both  clinical  medicine  and  per- 
sonnel management.    Much  may  be  accomplished 


AGING  k  INDUSTRIAL  HEALTH— Stieglitz 


October,    1941 


immediately  by  the  more  conscientious  application 
of  existing  knowledge,  while  awaiting  further  re- 
search into  the  fundamentals  of  the  aging  process. 

Industrial  medicine  is  faced  with  two  major 
functions  in  connection  with  the  aging  of  em- 
ployees. The  one  is  diagnostic,  the  other  therapeu- 
tic. Medical  advisors  of  employers  must  have  cer- 
tain basic  inlormation  as  to  the  physical  condition 
of  workers  in  relation  to  age  before  they  can  guide 
management  wisely.  The  foundation  of  any  effec- 
tive program  for  the  safe  utilization  and  conserva- 
tion of  aging  personnel  is  the  periodic  health  in- 
ventory. The  measurement  of  health  is  far  more 
difficult  and  complex  than  the  diagnosis  of  obvious 
disease. 

There  is  no  such  thing  as  a  perfectly  healthy 
body  and  mind.  Health  is  more  than  the  absence 
of  disease.  It  has  quantitative  attributes,  involv- 
ing reserve  capacities.  An  adequate  health  audit 
requires  much  more  than  the  usual  superficial  and 
hasty  physical  examination.  A  comprehensive,  de- 
tailed history,  routine  laboratory  procedures  and 
stress  tests  to  measure  certain  functional  capacities 
are  essential.  The  highest  type  of  diagnostic  acu- 
men and  intelligence  to  make  sound  clinical  corre- 
lation of  all  the  data  are  required  for  the  proper 
evaluation  of  health.  The  medical  examiner  must 
know  that  normal  is  not  fixed,  but  varies  with  age; 
and  he  must  modify  his  interpretations  of  objective 
findings  accordingly. 

Thus,  to  conduct  periodic  health  inventories 
properly  requires  more  time,  and  therefore  more 
money,  than  has  heretofore  been  allocated.  There 
are  many  who  question  the  prophylactic  and  eco- 
nomic values  of  periodic  examinations  in  industry. 
The  objectors  are  of  three  groups:  executives  con- 
cerned with  personnel  management,  physicians  and 
laboring  men.  Physicians  are  perhaps  the  greatest 
obstructionists,  for  they  are  notoriously  lax  in 
applying  the  principles  of  personal  preventive  med- 
icine to  themselves.  No  doctor  can  be  successful 
in  health  maintenance  if  he  does  not  believe  in  it. 
Once  he  is  convinced  of  its  potentialities,  he 
must  apply  it  to  himself  first.  Management  and 
Labor  both  will  acquire  an  increasing  respect  for 
this  method  of  health  maintenance  if  there  be  bet- 
ter application  of  the  information  gained  by  the  in- 
ventory. All  too  frequently  nothing  comes  of  a 
periodic  examination  but  a  record  on  a  card  which 
is  filed  away.  It  is  the  quality  of  the  advice  to  the 
individual  and  its  conscientious  application  which 
determines  the  effectiveness  of  periodic  consulta- 
tions. Labor  will  be  much  less  suspicious  and  re- 
sentful of  periodic  health  surveys  if  it  sees  the 
direct  benefits  of  better  health.  Management  like- 
wise is  more  prone  to  authorize  the  expenses  in- 


volved if  there  be  greater  assurance  that  the  data 
will  be  applied.  It  costs  money  to  train  skilled 
workers  and  the  value  of  employees  increases  with 
the  years. 

The  second  function  of  industrial  medicine  is 
therapeutic — health  maintenance.  Operating  de- 
partments have  inspectors  to  find  flaws  and  defects 
in  equipment  and  also  employ  service  workers  to 
repair  these  defects  and  maintain  equipment  at  the 
maximum  of  efficiency.  So  should  the  medical 
service  include  health  maintenance.  Men,  and 
healthy  men.  are  the  most  important  units  in  any 
organization. 

The  periodic  health  examination  should  not  only 
detect  defects;  it  should  help  correct  them.  Detec- 
tion of  defects  or  disease  which  make  continued 
employment  hazardous,  not  only  for  the  individual 
but  others,  is  an  important  function  in  safeguard- 
ing the  operating  personnel,  the  equipment  and  the 
public.  But  the  major  objective  of  periodic  diag- 
nostic study  is  to  supply  the  data  necessary  for 
the  formulation  of  sound  health-maintenance  ad- 
vice. Diagnosis  exists  for  the  purpose  of  treatment. 
Industrial  medicine  has  grown  immensely  since  its 
beginnings  as  emergency  traumatic  surgery;  now  it 
begins  to  appreciate  the  potentialities  of  preventive 
medicine. 

Preventive  medicine  may  be  either  impersonal 
or  personal.  Industrial  medicine  should  apply  both 
forms.  Impersonal  or  public  health  type  of  activi- 
ties include  sanitation,  quarantine  of  communicable 
disease,  the  control  of  environmental  hazards  such 
as  fumes,  dusts  and  gases:  insect  vectors  of  disease 
(malaria  control);  and,  lastly,  mass  immunization 
against  certain  infective  diseases.  The  energetic  ap- 
plication of  these  methods  has  contributed  greatly 
to  the  magnificent  improvement  in  the  health  of 
youth  and  the  control  of  many  occupational  dis- 
eases. But  such  methods  are  wholly  inappropriate 
to  preventive  geriatrics.  In  the  first  place,  the  ef- 
fectiveness of  public  health  medicine  is  limited  to 
the  prevention  of  diseases  due  to  exogenous  infec- 
tive or  toxic  agents.  Secondly,  it  is  applicable  only 
to  relatively  homogeneous  groups  where  individual- 
ization can  be  minimized. 

Preventive  geriatrics,  on  the  other  hand,  must 
be  applied  individually  and  personally.  With  ag- 
ing comes  increasing  divergence  from  the  mean, 
and  a  group  of  persons  from  forty  to  sixty-five  is 
far  more  heterogeneous  than  is  one  made  up  of 
vounger  persons.  Furthermore,  the  commoner  dis- 
eases of  middle  and  later  life  are  largely  endoge- 
nous. They  arise  from  within.  One  cannot  immun- 
ize people  against  hypertensive  disease,  arterio- 
sclerosis, arthritis  or  cancer  as  one  can  immunize 
school  children  against  diphtheria  or  typhoid  fever. 


October,   1941 


AGING  &  INDUSTRIAL  HEALTH— Slieglitz 


549 


The  diseases  of  youth  are  usually  readily  detected. 
They  are  acute,  conspicuous  and  self-limited.  In 
later  maturity  the  more  frequent  disorders  are  in- 
sidious, obscure,  progressive  and  tend  to  chronicity. 
They  must  be  searched  for  if  they  are  to  be  de- 
tected early,  when  preventive  therapy  can  accom- 
plish most  in  retarding  progression.  All  too  fre- 
quently cure  is  beyond  our  present  hope;  no  ther- 
apy will  cure  hypertensive  arterial  disease,  arth- 
ritis, or  coronary  arteriosclerosis.  But  control  is  a 
feasible  objective.  The  diabetic  patient  is  kept 
vigorous  and  useful  by  adequate  control  of  his  dis- 
ease, though  he  remains  a  diabetic.  Similarly,  hy- 
pertensive arterial  disease  is  amenable  to  therapeu- 
tic control  and  its  progression  can  be  greatly  re- 
tarded if  individual  management  is  instituted  early. 
There  are,  and  can  be,  no  fixed  routine  methods  of 
management  for  the  progressive  disorders  of  later 
years.  Individualization  is  the  keystone  of  the  arch 
of  prophylactic  geriatrics. 

It  is  vitally  important  to  recognize  that  with 
increasing  age  individual  variability  increases.  In- 
dividuality is  a  composite  of  inherited  and  inherent 
characteristics  and  the  accumulative  vicissitudes  of 
existence.  Generalities  concerning  babies  are  far 
more  justified  than  generalities  concerning  the 
same  individuals  forty  or  more  years  later,  for  each 
and  every  person  has  accumulated  a  highly  per- 
sonal set  of  experiences,  infections,  intoxications 
and  mental  actions  and  reactions.  The  greater  the 
age,  the  greater  the  individual  variability.  Though 
the  baby  knows  nothing  and  the  mature  adult,  if 
honest,  may  likewise  admit  knowing  nothing,  the 
latter  should  at  least  suspect  a  great  deal. 

There  are  many  obstacles  to  the  effective  appli- 
cation of  these  ideas.  As  a  clinician,  I  realize  only 
too  well  the  lack  of  methods  of  diagnosis  for  the 
early  discovery  of  degenerative  disease  and  the 
difficulties  of  therapy.  Even  under  ideal  conditions, 
no  guarantee  is  possible.  But  the  greatest  obstacle 
of  all  is  the  inertia  of  mankind  against  practicing 
any  form  of  prophylaxis.  Personal  preventive  med- 
icine involves  personal  effort  on  the  part  of  the 
patient.  Men  resent  restrictions.  They  prefer  tak- 
ing chances  and  then,  when  it  is  too  late,  demand- 
ing miraculous  cures  for  the  ills  engendered  by 
their  own  neglect.  Prevention  lacks  th°  drama  of 
cure.  The  benefits  of  prevention  are  revealed  only 
statistically  and  statistics  have  little  emotional  ap- 
peal to  the  average  mind.  That  personal  prophy- 
lactic medicine  is  effective  has  been  shown  by  the 
increased  health  and  longevity  of  those  insured 
individuals  who  have  availed  themselves  of  the  pe- 
riodic examinations  made  available  by  certain  life 
insurance  companies.  However,  it  is  notable  that 
but  a  very  small  percentage  of  insured  persons  do 


avail  themselves  of  these  opportunities  for  health 
maintenance. 

This  inertia  can  be  overcome  by  education.  This 
will  take  time  and  much  effort.  The  first  principle 
of  pedagogy  is  to  set  a  good  example.  He  who  does 
not  practice  what  he  preaches  can  not  teach. 
Health  maintenance  of  aging  personnel  could  start 
at  the  top,  for  a  number  of  reasons:  1)  The  ac- 
ceptance of  personal  preventive  medicine  sets  the 
necessary  example;  2)  key  men,  carrying  the  heav- 
iest responsibilities,  are  the  most  difficult  to  re- 
place; 3)  the  leaders  are  almost  invariably  older 
men,  because  experience,  which  is  conditioned  by 
age,  is  the  basis  for  their  valued  knowledge  and 
judgment;  and  4)  the  higher  average  age  and 
heavier  burdens  of  responsibility  are  added  men- 
aces to  health.  Furthermore,  it  is  probable  that 
cooperation  in  attaining  the  high  degree  of  thor- 
oughness and  individualization  necessary  to  make 
personal  preventive  medicine  for  mature  adults 
fully  effective  can  be  obtained  more  readily  with 
the  key  men  of  an  organization,  because  of  their 
higher  intelligence. 

It  is  thus  suggested  that  perhaps  an  effective 
means  of  overcoming  the  well-known  resistance  of 
Labor  to  periodic  health  examinations  is  first  to 
makt  available  the  facilities  for  health  mainte- 
nance, or  prophylactic  geriatrics,  to  the  executive 
branches  of  the  organization.  Human  nature  being 
what  it  is,  there  is  high  probability  that  the  work- 
ers will  not  be  long  in  demanding  that  which  they 
fought  against. 

Mention  will  be  made  of  one  or  two  other  prob- 
lems of  management  in  connection  with  aging  per- 
sonnel. It  has  been,  and  still  is,  the  custom  to  use 
chronologic  age  limits  as  criteria  of  employment 
and  of  retirement.  This  is  grossly  illogical.  As 
previously  pointed  out,  physiologic  age  does  not 
necessarily  parallel  chronologic  age.  There  are 
some  men  who  age  prematurely,  even  in  the  ab- 
sence of  disease,  and  who  should  be  retired  long 
before  the  prescribed  chronologic  age  arbitrarily 
used  as  a  standard.  There  are  others  in  whom 
senescence  is  retarded  and  to  whom  senility  never 
comes,  whose  vigor,  intelligence  and  experienced 
judgment  are  retained  long  past  the  usual  retiring 
age.  To  discard  such  men  is  to  waste  extrava- 
gantly valuable  judgment  and  training.  Such  waste 
is  stupid  and  stupidity  is  a  luxury  in  which  we  can 
ill  indulge  now.  The  problem  crystallizes  into  the 
question  how  physiologic  age  may  be  measured — a 
problem  not  solved  yet;  in  fact,  only  just  pro- 
pounded. A  vast  amount  of  work  is  necessary  be- 
fore we  can  hope  to  develop  methods  for  the  accu- 
rate evaluation  of  physiologic  age.  No  single  cri- 
terion can  suffice.    However,  the  experienced  phy- 


AGING  &  INDUSTRIAL  HEALTHStieglitz 


October,   1941 


sician  does  arrive  at  a  general  impression  of  phy- 
siologic age  by  that  peculiar  and  indefinable  some- 
thing we  call  clinical  judgment  and  which  probably 
is  the  subconscious  correlation  of  many  different 
observations.  Crude  as  such  impressions  are,  in  the 
precisely  quantitative  sense,  they  are,  nevertheless, 
far  more  valid  than  arbitrary  rules  of  retirement 
based  on  chronological  age  alone. 

In  job  placement,  thought  must  be  given  to  the 
employee's  future,  as  well  as  to  his  immediate, 
capacities.  Physical  fitness  implies  not  onlv  the 
capacity  to  work  but  continuity  of  productive- 
ness. Youth  is  molded  with  relative  ease;  with 
advancing  years  adaptation  is  more  difficult 
But  it  is  not  impossible.  As  previously  pointed 
out,  aging  brings  compensations  as  well  as  defects. 
Can  not  these  compensatory  characteristics  be 
utilized?  They  can.  It  is  not  necessary  that 
the  aging  mechanic  or  artisan  whose  speed  is 
reduced  but  whose  skill  and  judgment  are  en- 
hanced be  discarded  or  transferred  to  sorting 
bolts  and  nuts  in  the  junk  shop  or  to  watching 
a  gate.  Such  a  transfer  is  equivalent  to  the 
judicial  decision:  "You  are  through — useless. 
You've  worked  hard  and  we'll  feed  you  for  it,  but 
no  longer  may  you  feel  pride  in  your  work  or  have 
the  precious  satisfaction  of  feeling  really  useful." 
All  of  us  know  of  intimate  instances  in  which  such 
premature  retirement  was  but  the  herald  of  a  death 
certificate.  Under  such  blows  even  the  best  men 
quit.  If,  however,  they  may  feel  that  they  are  shar- 
ing in  the  work  to  be  done  and  are  permitted  to 
give  their  best,  it  is  the  best  which  is  obtained. 

Personnel  officers  frequently  spend  much  time 
and  money  in  attempting  to  insure  the  proper 
placement  of  a  new  employee.  Psychological,  phy- 
sical and  aptitude  tests  are  used  to  guide  the  right 
man  into  the  right  job.  This  is  fine,  but  often 
rather  absurd.  All  too  frequently,  after  much  ef- 
fort, the  round  peg  is  fitted  carefully  into  the  round 
hole  and  left  there.  Now  the  hole,  or  job,  remains 
the  same,  but  the  peg,  or  man.  does  not.  He 
changes  with  age.  His  capacities  and  limitations 
change,  his  perspective  is  altered,  his  interests, 
ambitions,  loyalties  and  values  shift  with  the  years 
and  as  time  goes  on  the  original  fit  between  man 
and  job  becomes  more  and  more  incongruous. 
Thus  may  arise  many  of  the  occupational  neuroses 
which  hasten  the  senescence  of  personnel  manage- 
ment. 

The  employee  of  60  and  over  has  important  po- 
tentialities as  a  teacher  of  new  or  younger  em- 
ployees. Industry  is  now  suffering  from  an  acute 
dearth  of  technically  trained  personnel.  The  edu- 
cation of  apprentices  and  the  development  of  finer 
skill,  application  of  accuracy  and  pride  of  work- 
manship can  well  be  a  function  of  the  older  work- 


ers. It  is  saddening  to  see  the  general  lack  of  re- 
spect for  the  dignity  of  work  in  the  younger  gen- 
eration. Perhaps  our  older  men  and  women  will 
welcome  the  opportunity  to  rekindle  this  vitalizing 
spark.  Not  satisfied  to  just  get  by,  they  can  set 
splendid  examples  if  given  the  chance. 

Summary 
It  has  been  impossible  to  do  more  than  indicate 
some  of  the  problems  introduced  bv  aging  and  em- 
phasize the  importance  of  prophylactic  geriatrics  in 
industrial  health.  Time,  work  and  experience  are 
necessary  for  the  solution  of  these  problems.  It 
may  be  useful  to  recapitulate  briefly  some  of  the 
major  ideas  suggested. 

1.  The  problems  of  aging  are  of  immediate  and 
serious  concern  to  all  leaders  of  mankind:  physi- 
cians, industrialists,  educators  and  statesmen.  The 
shifting  age  of  the  population  introduces  economic 
and  sociologic  questions  of  great  urgency.  Th« 
vast  numbers  of  elderly  people  will  remain  and  in- 
crease. 

2.  Research  into  the  fundamental  processes  of 
senescence  is  necessary  for  any  great  advance  in 
the  clinical  practice  of  geriatrics. 

3.  We  need  to  know  much  more  about  the 
changes  in  mental  and  physical  capacities  intro- 
duced by  normal  aging  in  man  to  attack  intelli- 
gently the  socio-economic  problems  now  pressing 
for  solution  and  to  utilize  wisely  the  increasing 
millons  of  older  men  and  women. 

4.  The  gravest  hazard  to  national  economy  lies 
in  the  ever-increasing  toll  of  prolonged  disability 
exacted  by  the  insidious,  chronic  and  progressive 
disorders  of  later  maturity.  Longevity  without 
health  is  not  only  a  personal  tragedy  but  a  serious 
threat  to  national  equilibrium.  The  privilege  of 
longevity  carries  with  it  the  obligation  of  personal 
effort  toward  health  maintenance. 

5.  The  primary  objective  of  prophylactic  geria- 
trics is  not  the  prolongation  of  life,  but  the  con- 
servation of  health  for  those  past  the  meridian.  To 
prevent  aging  would  be  to  arrest  life.  But  we  may 
hope  to  modify  the  consequences  of  aging  and  re- 
tard the  progression  of  diseases  associated  with 
senescence. 

6.  Personal  preventive  medicine,  if  properly 
and  conscientiously  applied,  can  do  much  to  con- 
serve health  in  later  life.  It  must  be  highly  indi- 
vidualized in  both  diagnostic  study  and  therapeutic 
regimen  to  be  effective.  Senescence  and  the  degen- 
erative disorders  of  later  maturity  start  far  earlier 
than  their  symptoms  become  apparent.  These  dis- 
orders must  be  searched  for  if  they  are  to  be  de- 
tected early  enough  to  permit  of  accomplishing 
much  in  the  way  of  prevention. 


October,   1941 


AGING  &  INDUSTRIAL  HEALTH— Stiglitz 


551 


7.  Health  maintenance  for  older  personnel  is  an 
obligation  of  industrial  medicine.  It  is  the  obliga- 
tion of  management  to  encourage  and  support  such 
activities  in  its  medical  departments.  Industrial 
medicine  is  in  a  particularly  advantageous  position 
to  advance  preventive  geriatrics,  for  industrial  phy- 
sicians have  the  privilege  of  examining  and  reex- 
amining at  periodic  intervals  many  thousands  of 
men  and  women. 

8.  The  practice  of  health  conservation  among 
older  personnel  should  start  at  the  top.  We  must 
not  forget  that  the  wisdom  of  older  men  in  posi- 
tions of  great  responsibility  represents  an  invalua- 
ble national  resource.  The  conservation  of  the 
health  of  these  precious  individuals  should  be  an 
integral  part  of  defense  activities.  Furthermore, 
the  stresses  of  responsibility  are  added  menaces  to 
health,  particularly  among  the  aging. 

9.  We  are  all  aging.  Aging  does  not  commence 
when  the  hair  starts  to  gray  or  farsightedness 
forces  bifocal  lenses  upon  us.  Aging  starts  with 
conception  and  continues  throughout  life;  it  is  a 
part  of  living.  As  the  youth  makes  preparation  for 
becoming  an  adult,  so  should  the  adult  prepare  for 
his  later  years.  The  time  to  seek  medical  guidance 
for  the  maintence  of  health  and  vigor  into  the  fu- 
ture is  now. 


FORCEPS—  From  Page  552 

dilate  upon  its  possibilities  for  usefulness,  but  for 
completeness  of  description  I  shall  mention: 

1.  The  ease,  accuracy  and  rapidity  with  which 
ligatures  can  be  passed  through  any  tissue,  at  the 
same  time  crushing  the  structures  and  reducing  the 
size  of  the  pedicle,  thus  minimizing  the  dangers  of 
hemorrhage  and  of  slipping  of  the  ligature; 

2.  The  operator  is  not  dependent  upon  the  skill 
and  dexterity  of  an  assistant  in  catching  the  end  of 
the  ligature  as  in  using  any  of  the  other  carriers 
and  needles; 

3.  The  operator  is  enabled  to  pass  the  ligature 
easily  and  accurately  through  the  desired  structure 
unaided  with  one  hand,  while  controlling  in  the 
same  position  the  mass  to  be  removed  with  the 
other  hand — at  times  a  very  difficult  procedure. 


LIGATURES  AND  SUTURES  OF  DEER'S  SINEW  A 
CENTURY  AGO 

CPauI  F.  Eve,  in  Sou.  Med.  &  Sura.  JL,  June.  1S38) 
A  negro  man  with  a  large  schirrous  tumor  attached  to 
the  left  tonsil  was  brought  to  me  by  Dr.  Joseph  Wardlaw 
of  Abbeville  village.  S.  C.  A  small  tumour  observed  on  the 
left  side  of  the  neck  several  years  ago,  within  the  last  few 
months  had  rapidly  increased  in  size  till  it  weighed  half  a 
pound.  The  operation  was  performed  in  the  Augusta  hos- 
pital on  the  1st  of  December.  1837. 

By  careful  dissection,  aided  much  by  the  light  reflected 
from  a  mirror  into  the  bottom  of  the  wound,  the  tumour 
was  detached  from  its  connections,  the  last  divided  being 


a  fatty  prolongation  to  the  left  tonsil.  The  left  carotid 
and  internal  maxillary  arteries,  as  well  as  the  thyroid  gland, 
were  exposed.  The  ligature  was  applied  to  but  two  arteries, 
one  being  the  superior  thyroideal.  The  sutures  were  re- 
moved on  the  7th,  the  sixth  day  after  the  operation,  and 
the  patient  left  the  hospital  on  the  11th. 

Extract  from  a  letter  of  Dr.  Wardlaw,  dated  Jan.  20th, 
1838:  "The  boy  Middleton,  has  entirely  recovered,  the 
wound  healed  very  kindly,  and  has  left  a  smooth  and  reg- 
ular cicatrix.  He  is  now  in  fine  health,  and  greatly  rejoices 
that  he  has  gotten  rid  of  'the  lump'  as  he  terms  it." 

Remarks. — The  ligature  I  employ  is  animal,  made  at  the 
suggestion  of  Dr.  John  Bellinger  of  Charleston,  of  deer's 
sinew.  I  only  employ  them  for  sutures  when  I  expect  union 
by  the  first  intention — applying  in  all  cases  silk  ligatures  for 
this  purpose  when  suppuration  is  apprehended. 


BORN  WITHOUT  ARMS— PERFORMANCES   WITH 

HIS  TOES 
(Paul   F.    Eve,   M.D.,   Professor  of   Surgery  in  the   Medical   Col- 
lege of  Georgia,   in  Southern   Medical  cr  Surgical  Journal, 
February,  1837) 

This  is  written  after  witnessing  the  wonderful  perform- 
ances of  a  youth,  during  his  visit  to  our  city. 

S.  K.  G.  Nellis  was  born  in  Johnstown,  New  York,  in 
March,  1817.  At  birth  he  was  of  the  natural  size  and  well 
formed,  with  the  exception  he  had  no  arms.  About  two 
years  of  age,  his  spine  became  affected  with  rickets  caus- 
ing great  deformity  of  the  spinal  column. 

On  each  side  where  the  arms  should  have  been  attached 
to  the  body,  there  is  a  small  nipple,  without  an  areola. 
The  clavicles  and  scapulae  appear  to  be  natural,  the  acro- 
mion process  projecting  considerably  outwards  and  ante- 
riorly. His  inferior  extremities  are  well  developed.  The 
right  foot  is  from  a  half  to  three-fourths  of  an  inch  longer 
than  the  left,  which  approaches  somewhat  the  club-foot. 
This  Mr.  N.  attributes  to  the  left  foot  being  turned  on  its 
external  edge,  in  cutting  paper,  etc.  and  to  his  employing 
it  to  hold  the  objects  upon  which  he  operates  with  the 
right.  With  the  big  toe  of  either  foot,  however,  he  can 
throw  a  6-pound  weight  five  yards.  He  can  also  raise  160 
pounds  with  his  teeth.  He  says  he  now  enjoys  excellent 
health. 

His  performances  with  his  toes  are  truly  astonishing — 
strikingly  exhibiting  to  what  extent  by  art  they  can  be 
adapted  to  the  offices  of  the  fingers. 

With  scissors  in  toes,  Mr.  Nellis  will  cut  valentines  and 
watch-papers,  very  ingeniously;  and  will  also  cut  the  like- 
ness of  any  person  very  correctly. 

He  will  make  a  paper  fly-box,  and  fold  a  letter  in  the 
true-love  style. 

He  will  open  and  wind  up  a  watch,  take  out  and  put  in 
the  crystal  with  perfect  safety,  open  penknives,  screw  up 
his  inkstand,  lock  his  desk,  etc. 

With  bow  and  arrow,  he  will  shoot  at  a  quarter  of  a 
dollar.  This  performance  invariably  astonished  the  behold- 
ers, by  the  almost  unerring  aim  with  which  the  archer  uses 
his  bow  and  arrow. 

On  the  violincello,  he  will  perform  an  accompaniment 
truly  astonishing. 

He  will  sing  a  number  of  songs,  and  conclude  his  exhibi- 
tion with  dancing  a  favorite  hornpipe. 


Dr.  Philip  Sync  Physick,  born  in  Philadelphia  1768, 
University  of  Pennsylvania  Professor  of  Surgery,  the  Fath- 
er of  American  Surgery,  died  December  15th,  1837.  "The 
Medical  Societies  of  the  United  States  resolved  that  all 
their  members  wear  mourning  for  thirty  days." — Southern 
Med.  &  Surg.  JL,  1838. 


SOUTHERN  MEDICINE  &  SURGERY 


October,   1941 


An  Automatic  Liga  ture-Passing  Forceps 

E.  Pierre  Mallett,  M.D.,  H.ndersonville,  North  Carolina 

(EDITED    BY    LAURA   JEAN    McADAMS,    M.A.) 


THERE  is  such  a  multiplicity  of  new  in- 
struments or  modifications  of  old  ones  con- 
stantly being  thrust  upon  a  patient  and 
long-suffering  profession  that  one  hesitates  to  sug- 
gest another.  The  most  enthusiastic  and  dextrous 
of  surgeons  would  hardly  care  to  say  that  he  re- 
gards his  methods  and  operative  technique  as  hav- 
ing reached  perfection,  so  that  any  instrument  or 
method  claiming  to  simplify  and  expedite  the 
graver  operations  of  abdominal  surgery  will,  I  am 
sure,  be  regarded  with  polite  interest  if  not  with 
enthusiasm.  This  instrument  is  designed  for  the 
passing  of  ligatures  through  any  structure  desired 
to  be  ligated  and  removed,  but  particularly  those 
structures  deep  in  the  pelvis  where  it  is  difficult  to 
use  the  needle  or  one  of  the  ligature-passing  devices 
available. 

The  greater  advantages  and  additional  factor  for 
safety  from  crushing  the  tissues  of  any  structure 
before  ligating,  as  suggested  by  Dr.  Murphy,  be- 
came evident  to  us  all,  so  that  special  crushing 
clamps  were  devised  by  Ferguson  and  others  for 


this  purpose.  With  most  of  us  the  crushing  of  the 
structures  with  an  ordinary,  heavy  forceps  and  then 
tying  the  ligature  in  the  groove  thus  made,  has 
seemed  satisfactory.  In  this  instrument  I  have  suc- 
cessfully combined  these  features,  so  that  with  one 
movement  the  pedicle  is  crushed  and  the  ligature 
passed  and  is  in  position  to  be  tied. 

The  modus  operandi  is  simplicity  itself.  A  lig- 
ature is  laid  in  the  groove  in  the  lower  blade,  and 
the  ends  caught  in  the  catch  on  the  handle  or  held 
by  the  fingers  of  the  right  hand  as  the  forceps  is 
grasped  for  use  as  is  any  other  forceps.  The  pedi- 
cle of  the  tumor,  broad  ligament,  or  whatever  struc- 
ture is  to  be  ligated  is  grasped  with  the  left  hand. 
The  open  forceps,  being  in  the  right  hand,  is  then 
applied  in  the  same  manner  as  any  other  forceps, 
crushing  the  structures  within  its  grasp.  It  is  held 
closed  momentarily  for  the  crushing  effect,  then 
opened  and  carefully  withdrawn,  when  the  ligature 
will  be  seen  lying  in  the  crushed  groove,  ready  to 
tie,   having   been   automatically   caught    from    the 


lower  blade  and  pulled  through  the  tissues  by  the 
needle  in  the  upper  blade — no  fishing  for  the  liga- 
ture to  pull  through  as  with  the  Peaslee  needle  or 
Cleveland  passer.  The  ligature  is  caught  with  the 
closing  of  the  forceps  blades  and  is  pulled  through 
the  tissue  on  the  opening  and  withdrawing  of  the 
forceps. 


1     The  instrument  with  ligature  in  position  and  ready  to  clamp 
pedicle 

2.  Clamping  pedicle  to   be  crushed  and  ligated 

3.  Pedicle     clamped,     instrument    opened     and     partially     with- 
drawn— showing   ligature  automatically   passed   through   pedicle. 

To   those   familiar   with    the   class  of   work   for 
which  this  instrument  is  intended,  it  is  needless  to 

(To  Page  551) 


October,    1941 


SOUTHERN  MEDICINE  &  SURGERY 


SS3 


Home  Obstetrics* 

Walter  J.  Lackey,  M.D.,Fallston,  North  Carolina 


TEN  YEARS  AGO  a  North  Carolina  obste- 
trician said  he  was  not  interested  in  help- 
ing to  increase  the  knowledge  of  general 
practitioners  as  to  how  to  practice  obstetrics  in  the 
home,  because  the  only  way  to  practice  obstetrics 
was  for  specialists  in  obstetrics  to  have  charge 
throughout  pregnancy  and  conduct  all  deliveries  in 
hospitals.  Maybe  this  would  be  preferable,  though 
there's  a  lot  of  evidence  to  the  contrary.  Maybe  it 
would  be  best  for  everybody  to  ride  in  Cadillacs; 
but  they  are  out  of  reach  of  the  great  majority 
and  this  great  majority  ride  just  as  safely  and  hap- 
pily in  Fords,  Chevrolets  and  Plymouths,  even 
though  in  some  less  degree  of  luxury.  And  the 
same  principle  applies  to  the  conduct  of  obstetrical 
cases  in  the  homes  by  general  practitioners. 

There's  nothing  but  laziness  to  keep  any  one  of 
us  from  making  a  good  general  physical  examina- 
tion soon  after  being  retained  in  a  case  of  preg- 
nancy and  having  a  Wassermann  examination 
made,  and  in  case  of  any  doubt  as  to  pelvic  capac- 
ity, making  pelvic  measurements.  Along  through 
pregnancy  we  can  make  blood  pressure  readings 
and  urinalyses  at  whatever  intervals  we  think  best, 
as  a  routine,  with  additional  examinations  whenever 
symptoms  appear.  Indicated  dental  care  is  insisted 
on,  and  care  of  the  breasts  and  nipples. 

The  doctor  whose  practice  is  largely  rural  has 
fewer  cases  of  vomiting  of  pregnancy.  Our  women 
are  not  so  prone  to  show  the  three  cardinal  symp- 
toms of  pregnancy  as  given  by  an  old  Negro  mid- 
wife: "The  three  'ats' — sick  at  de  stomach,  foamin' 
at  de  mouth,  mad  at  de  husban'." 

It  is  no  great  labor  to  sterilize  sheets,  towels  and 
dressings,  or  to  have  them  sterilized  at  a  nearby 
hospital,  and  to  conduct  the  ordinary  home  deliv- 
ery with  as  scrupulous  asepsis  and  antisepsis  as 
can  be  carried  out  in  a  hospital. 

The  bed  should  be  raised  to  the  desired  level  by 
putting  a  stout  box  or  block  under  each  leg,  and 
kept  from  sagging  by  running  a  board  crossways 
beneath  the  spring  and  over  the  side-rails.  An  in- 
strument-bag with  a  copper  tray  long  enough  to 
hold  forceps  is  standard  obstetrical  equipment. 

The  patient  is  instructed  to  take  a  soap-and- 
hot-water  all-over  bath,  and  a  warm-water  enema 
on  the  appearance  of  labor  pains  before  calling  me. 
I  see  no  reason  for  shaving  the  genitalia  and  do 
not  practice  it.  A  gentle  scrub  for  several  minutes 
with  hot  water  and  green  soap,  a  rinse  with  boiled 


hot  water,  and  another  with  lysol  solution,  is  am- 
ple. A  large  sterile  pad  is  applied  and  secured  in 
place  by  a  bandage,  a  sterile  gown  put  on  the  pa- 
tient and  a  sterile  sheet  placed  under  and  another 
over  her. 

If  much  complaint  is  made  of  the  pains  in  the 
first  stage,  I  do  not  hesitate  to  give  J^th  gr.  mor- 
phine, repeating  as  may  seem  indicated.  My  pref- 
erence for  partial  anesthesia  in  the  second  stage  is 
chloroform,  a  few  whiffs  taken  as  the  pains  come 
on,  the  light  mask  removed  as  they  subside.  I  know 
of  no  trustworthy  reports  of  ill  results  from  such 
practice. 

If  everything  has  been  found  satisfactory  at  pre- 
vious examination,  unless  there  is  some  special  in- 
dication, I  do  not  make  a  vaginal  examination  at 
this  time.  The  patient  is  encouraged  to  eat  any 
wholesome  food  of  her  choice,  especially  sweets,  in 
liberal  quantities. 

Nearly  always  the  bag  of  waters  is  left  to  rup- 
ture at  its  own  discretion.  In  only  a  few  cases  is 
pituitrin  given  and  then  in  very  small  doses.  A 
famous  obstetrician  used  to  say  the  most  important 
equipment  to  take  on  an  obstetrical  case  is  a  pock- 
etful of  good  cigars. 

As  the  perineum  begins  to  bulge  a  fresh  sterile 
gown  and  sheets  are  put  on  and  the.  patient  turned 
crossways  on  the  bed,  each  thigh  and  leg  support- 
ed on  a  chair  turned  down  and  a  pillow  laid  on  it. 
It  is  seen  that  the  room  is  kept  comfortably  warm, 
and  every  provision  made  that  the  baby  not  be 
chilled.  Very  rarely  is  a  forceps  used  before  the 
head  is  right  at  the  outlet.  Then,  in  many  instances 
such  use  hastens  delivery  and  saves  the  perineum. 
When  it  is  seen  that  tearing  is  inevitable,  episio- 
tomy  should  be  done.  A  clean  cut  placed  just 
where  you  want  it  is  much  less  of  an  evil  than  a 
rough  tear  wherever  it  may  happen.  The  best 
place  to  make  the  incision  is  about  an  inch  to  one 
side  of  the  lower  end  of  the  oval — at  about  what 
would  be  5  or  7  on  the  clock's  dial.  The  incision 
should  be  made  with  a  very  sharp  knife  in  a  down- 
ward and  outward  direction  and  it  should  be  re- 
paired immediately  after  the  birth  of  the  child. 
The  best  time  to  find  out  whether  or  not  perineal 
tears  have  resulted  is  between  the  birth  of  the 
child  and  the  birth  of  the  placenta.  In  many  cases 
the  repair  may  be  best  made  at  this  time.  Use 
powdered  sulfathiazol  on  the  lacerations.  I  always 
have  a  good  flashlight  with  me. 


'Presented  to  the  Fall  Meeting  of  the  Catawba  Valley    (N.  C.)     Medical   Society,   at  Morganton. 


SOUTHERN  MEDICINE  &  SURGERY 


October,   1941 


Whatever  the  assistant  obstetrician  may  say, 
you,  yourself,  must  go  over  the  child  carefully  for 
developmental  defects  and  other  things  it  would  be 
embarrassing  to  have  someone  else  call  to  your 
attention.  A  catheter  and  syringe  should  be  on 
hand  against  the  possible  need  for  removing  secre- 
tions from  the  air  passages. 

Until  the  afterbirth  has  come  away  and  the 
mother  had  a  teaspoonful  of  fluid-extract  of  ergot 
the  mother  should  have  the  doctor's  chief  attention. 
Glucose  solution  and  blood  plasma  should  be  avail- 
able against  the  chance  of  excessive  bleeding.  Put 
silver  nitrate  drops  in  the  child's  eyes,  and  feel  if 
it  is  tongue-tied.  Somebody  will  ask  you.  Put  the 
baby  to  both  breasts  as  soon  as  it  has  been  washed 
and  the  cord  dressed.  This  stimulates  uterine  con- 
tractions. A  pad  over  the  uterus  and  a  well-fitting 
abdominal  binder  may  or  may  not  help.  I  use 
them. 

The  mother  has  been  previously  instructed  in 
the  great  advantages  of  breast  feeding,  even  in 
these  days  of  tin  cans,  better-than-natural  foods 
and  electric  refrigerators. 

Instructions  are  given  that  the  baby  have  as 
much  sweetened  water  as  it  will  take  after  each 
putting  to  the  breast. 

Don't  leave  in  less  than  an  hour,  no  matter  how 
well  everything  has  gone.  Routinely  I  pay  four 
post-partum  visits — on  the  second,  the  third,  the 
fifth  and  the  tenth  day,  more  if  the  case  requires. 

It  is  advised  in  each  case  that  the  mother  come 
in  after  two  months  for  examination,  especially  of 
the  cervix.  Many  lacerations  will  have  healed  of 
themselves.  If  there  are  any  remaining  showing 
eversion  or  erosion  they  are  given  appropriate 
treatment. 

The  vast  majority  of  our  families  cannot  afford 
hospital  obstetrics  by  obstetrical  specialists. 

The  vast  majority  of  such  cases  can  be  well 
taken  care  of  by  their  own  family  doctors  in  their 
own  homes. 

Against  the  possibly  greater  chance  of  infection 
in  a  home  delivery,  may  be  fairly  balanced  the 
likelihood  that  any  infection  in  a  hospital  will  be 
more  virulent  than  one  gotten  in  the  home. 

There's  point,  too,  to  this  story: 

A  little  New  York  boy  came  home  after  his  first 
day  in  school  and  made  this  report: 

"The  teacher  asked  me  a  whole  lot  of  questions. 
I  got  along  all  right  until  she  asked  where  I  was 
born.  I  wasn't  going  to  tell  her  at  the  Woman's 
Hospital  and  let  her  think  I  was  a  sissy,  so  I  said, 
'At  the  Yankee  Stadium.'  " 


CLINIC 

Conducted  By 
Frederick    R.   Taylor,   B.S.,    M.D.,   F.A.C.P. 


Paroxysmal  hemoglobinuria  is  a  rare  manifestation  of 
congenital  or  acquired  syphilis.. — R.  B.  Logue,  Atlanta,  in 
Jl.  Med.  Assn.  Ga.,  June. 


Very  early  in  my  practice  I  was  called  to  see  a 
14-mos.-old  baby  in  its  home  at  11:30  p.  m.  The 
immediate  surroundings  were  anything  but  health- 
ful. The  air  in  the  room  was  very  bad.  Seven  peo- 
ple were  in  the  room,  and  although  it  was  a  hot 
night  in  May,  all  the  windows  and  doors  were  shut 
tightly.  The  child  was  wrapped  in  hot  flannel 
clothing  and  drenched  in  sweat.  The  history  show- 
ed that  the  child's  appetite,  sleep  and  bowel  action 
were  normal.  Its  urine  was  reported  as  scantv  the 
day  previously.  The  child  was  said  to  have  had  a 
convulsion  in  which  it  seemed  to  choke,  a  short 
time  before  I  was  called.  His  temperature  was 
103.6,  pulse  190,  respiration  40.  The  throat  was 
negative  except  for  much  mucus.  The  flannels  were 
removed  despite  protests  that  I  would  kill  the  baby. 
Heart,  lungs  and  abdomen  were  negative. 

Next  I  committed  lese  majeste,  high  treason  or 
what  have  you,  by  opening  all  the  windows  and 
letting  in  good  fresh  air.  Finally  I  ran  all  the 
neighbors  out  of  the  room  despite  my  then  youth- 
ful appearance.  Then  I  stayed  around  for  half  an 
hour.  At  the  end  of  this  time  I  found  the  child's 
temperature  98.6,  his  pulse  quieted  down  and  the 
baby  asleep,  so  I  went  home  without  giving  a  "pre- 
scription,'' much  to  the  amazement  of  the  parents, 
and,  no  doubt,  to  the  multitude  that  had  been  as- 
sembled there  when  they  heard  of  it  next  day. 

Diagnosis:  Heat  exhaustion  due  to  too  much 
clothing  and  too  little  air. 

Treatment:    Simple  hygiene. 

Comment:  What  a  horrible  thing  it  would  have 
been  for  that  poor  baby  to  have  been  dosed  with 
castor  oil,  calomel  etc.  according  to  the  customs 
that  were  then  all  too  common  in  medical  practice! 

On  December  13th,  1925,  I  was  asked  by  his 
employer  to  see  a  55-year-old  truck  driver.  On 
learning  that  he  already  had  had  a  physician  in 
attendance  only  the  day  before,  I  requested  that 
he  be  called  first,  and  then  if  he  wished  me  to  see  ' 
the  patient  in  consultation,  I  would  do  so.  The 
employer  was  unable  to  reach  the  original  physi- 
cian on  the  case,  however,  so  brought  the  man  to 
the  hospital  and  asked  me  to  see  him  at  once,  and 
I  did  so.  The  family  and  past  history  were  not 
contributory. 

The  patient  complained  of  swelling  of  the  scro- 
tum. He  stated  that  for  over  two  years  he  had 
had  a  hard  mass  above  and  attached  to  the  left 
testicle  that  had  grown  steadily  and  felt  like  a 
bunch  of  earthworms.  Two  days  before  I  saw  him, 
while  handling  some  crates  something  seemed  to 


October,    1941 


SOUTHERN  MEDICINE  &■  SURGERY 


555 


pop  in  the  region  of  the  mass,  and  it  suddenly  dis- 
appeared and  was  replaced  by  a  soft  fluctuating 
mass  that  filled  the  left  side  of  the  scrotum.  There 
was  no  severe  pain.  He  was  constipated,  but  had 
no  other  gastrointestinal  symptoms.  He  had  a  mild 
backache  which  he  attributed  to  lying  in  bed  for 
two  days,  and  which  was  easily  relieved  by  a  sup- 
porting pillow  under  his  back.  His  physician  had 
seen  him  the  day  before  and  ordered  hot  cloths  to 
the  scrotum  and  said  that  if  he  did  not  improve 
he  would  tap  him  later.  His  employer  felt,  how- 
ever, that  some  immediate  action  was  needed,  so 
brought  him  to  the  hospital.  The  history  was  other- 
wise negative.  Physical  examination  was  negative 
except  for  bad  teeth  and  the  condition  in  the  scro- 
tum. The  left  side  of  the  scrotum  was  very  mark- 
edly distended  with  what  appeared  to  be  largely 
fluid.  The  mass  fluctuated,  but  did  not  transmit 
light.  A  mass  that  felt  like  a  small  bunch  of  earth- 
worms was  also  present,  presumably  the  remains 
of  a  varicocele.  T.  99.6,  p.  72,  r.  20,  b.  p.  128/66. 

Diagnosis:  Hematocele  due  to  rupture  of  vari- 
cocele.   Dental  sepsis. 

Advice:    Surgery,  and  later  dentistry. 

Outcome:  Dr.  J.  T.  Burrus  was  asked  to  see 
him.  He  agreed  with  my  diagnosis  and  next  day 
made  an  incision  along  the  line  of  the  left  sper- 
matic cord  extending  well  into  the  left  side  of  the 
scrotum.  Two  or  three  ounces  of  bloody  fluid  were 
evacuated.  There  was  a  ruptured  varicocele,  but 
also  a  ruptured  hydrocele  of  the  cord.  A  part  of 
the  sac  was  removed  and  the  rest  "bottled."  The 
wound  was  drained.  The  patient  later  developed  a 
septic  temperature  found  to  be  due  to  a  small  scro- 
tal abscess.  This  was  drained  and  the  patient 
made  a  slow  but  uneventful  rtcoverv. 


SURGICAL  OBSERVATIONS 


OF  THE  STATF 

DAVIS  HOSPITAL 
Statesville 


Introduction  of  the  Catheter. — Mr.  Liston  introduc- 
ing the  catheter,  or  bougie,  in  all  cases  in  which  the  ob- 
struction was  not  seated  near  the  orifice  of  the  urethra, 
preferred  the  employment  of  one  hand  only,  the  urethra 
being  left  perfectly  free;  by  pursuing  that  method  the  in- 
strument was  less  likely  to  be  impeded,  the  natural  obsta- 
cles met  with  about  the  sinus  of  the  urethra  being  more 
effectually  and  certainly  avoided,  the  patien  tsuffering  less 
uneasiness,  and  the  operation  being  altogether  more  easily 
and  dexterously  effected  than  when  the  member  was  pulled 
out  and  the  urethra  put  unnaturally  upon  the  stretch. — 
Southern  Med.  &  Surg.  Jl.     (Augusta,  Ga.),  1837. 


The  larvae  of  Trichina  spiralis  are  killed  at  a  temper- 
ture  of  60°  C.  This  temperature  is  not  always  obtained  in 
the  central  portion  of  a  large  roast,  after  hours  in  a  hot 
oven. 

The  syndrome  which  has  been  thought  to  be  typical  of 
clinical  trichinosis  probably  occurs  in  a  very  small  propor- 
tion of  persons  who  become  infested — the  severest  cases. 

It  is  becoming  apparent  that  mild  or  symptomless  cases 
of  trichinosis  are  far  more  frequent  than  are  cases  in  which 
the  typical  syndrome  is  observed. 


NECROSIS  OF  THE  HEAD  OF  THE  FEMUR 
FOLLOWING  DISLOCATION 

A  careful  x-ray  examination  of  every  patient 
who  has  had  a  dislocation  of  the  head  of  the  femur 
will  disclose  an  occasional  case  of  necrosis  of  the 
head  of  the  femur,  even  though  the  fracture  was 
reduced  immediately  after  its  occurrence.  Fortu- 
nately, however,  there  is  usually  regeneration  of 
bone  and,  even  with  a  considerable  necrosis  of  the 
head  of  the  femur,  the  patient  may  ultimately  get 
a  good  result. 

The  reason  for  this  necrosis  is  very  simple.  The 
blood  supply  to  the  neck  of  the  femur  comes  from 
two  sources:  1.  The  blood  vessels  of  the  round  lig- 
aments. These  are  not  particularly  large  but  the 
supply  is  sufficient.  2.  The  principal  blood  supply 
is  from  the  vessels  that  come  up  from  the  neck  of 
the  femur  toward  the  head. 

In  some  dislocations,  it  is  easy  to  see  the  blood 
supply  that  comes  to  the  head  of  the  femur  through 
the  round  ligaments  will  be  destroyed  by  tearing 
of  the  ligaments  and  destruction  of  the  circulation 
at  the  same  time.  Another  source  of  trouble  is  the 
injury  to  the  blood  supply  coming  up  from  the 
neck  of  the  femur.  The  violence  of  a  dislocation 
may  tear  one  of  the  principal  arteries  in  the  area 
and  thereby  cut  off  the  greater  part  of  the  nourish- 
ment from  this  source. 

A  combination  of  these  two  injuries  to  blood 
vessels  will  naturally  cause  great  impairment  to  the 
circulation  of  blood  to  the  head  of  the  femur  and 
it  is  likely  that  a  necrosis  will  result,  perhaps 
weeks  or  months  after  the  accident. 

The  fact  that  these  things  do  occur  should  be 
kept  in  mind  and  every  patient  who  has  a  disloca- 
tion should  have  x-ray  examinations  at  regular  in- 
tervals so  proper  remedial  measures  may  be  insti- 
tuted as  soon  as  evidences  of  beginning  necrosis 
are  shown. 

The  fact  that  necrosis  often  comes  on  weeks  or 
months  afterwards  and  may  be  manifested  only  by 
pain  in  the  hip  joint  itself  is  an  important  fact  to 
remember. 

SEPARATION  OF  THE  NECK  OF  THE  FE- 
MUR FOLLOWING  INJURY  IN  THE 
AGED  AND  INFIRM 
I  was  called  in  consultation  a  number  of  years 
ago  to  see  an  aged  and  very  feeble  lady  who  had 
sustained    a    fall    several    weeks    previously    and 
thought  possibly  she  had  injured  her  hip.   A  doctor 
was  called,  but  none  of  the  usual  tests  revealed  a 


SOUTHERN  MEDICINE  &  SURGERY 


October,    1941 


fracture  or  any  other  bony  injury.  The  doctor, 
however,  used  due  caution  and  had  an  x-ray  pic- 
ture made  by  a  competent  man.  Careful  examina- 
tion of  this  picture  did  not  reveal  any  fracture  of 
the  neck  of  the  femur.  Some  six  or  eight  weeks 
afterwards,  however,  the  patient  developed  pain  in 
the  region  of  this  hip  and  remained  in  bed  a  few 
days.  The  doctor  was  again  called  and  he  noted  a 
typical  fracture  of  the  neck  of  the  femur  which  was 
confirmed  by  x-ray  examination. 

The  relatives  of  the  patient  felt  that  the  fracture 
had  been  overlooked  but  the  doctor  knew  that  it 
had  not  been  overlooked.  Since  both  x-ray  films 
were  available,  I  examined  these  very  carefully  and 
found  that  the  first  did  not  show  any  fracture  or 
bony  injury  at  all,  even  though  the  picture  was  so 
made  that  we  could  compare  the  two  hip  joints. 

What  had  happened  in  this  case  was  that  the 
fall  on  the  hip  had  caused  some  injury  to  the  can- 
cellous tissue  and  possibly  to  the  blood  supply  of 
the  neck  of  the  femur,  and  this  had  been  followed 
by  necrosis  and  spontaneous  fracture.  An  occur- 
rence such  as  this  has  to  my  knowledge  happened 
on  a  number  of  occasions. 

A  patient  who  is  aged,  and  especially  one  who 
has  been  in  bad  general  health  for  a  long  period  of 
time,  may  have  considerable  absorption  of  the  bony 
structure  about  the  neck  of  the  femur,  so  weaken- 
ing it  as  to  cause  it  to  break  when  subjected  to  no 
more  strain  than  that  of  slow  walking.  In  addition 
to  this,  vascular  changes,  such  as  narrowing  of  the 
lumen  of  the  blood  vessels  to  the  hip  joint,  may 
impair  the  blood  supply,  causing  still  further  trou- 
ble. These  two  together  may  cause  a  necrosis  of 
the  weak  part  of  the  neck  of  the  femur  and  result 
in  the  separation  at  the  neck. 

It  is  very  important  to  keep  this  in  mind  because 
of  the  fact  that  many  doctors  in  general  practice 
have  been  called  in  to  see  patients  who  have  sus- 
tained a  fall  and,  upon  making  a  proper  examina- 
tion, found  no  evidence  of  fracture,  naturally  and 
properly  conclude  there  is  none.  As  a  matter  of 
safety,  however,  every  injury  should  be  x-rayed 
when  there  is  any  indication  of  trouble.  Even  this 
may  not  show  an  injury  to  the  bone,  yet  it  will  be 
a  powerful  factor  in  preventing  criticism  later  on 
in  case  a  spontaneous  fracture  occurs. 

THE  TREATMENT  OF  HEMORRHOIDS 
The  majority  of  adults  have  some  sort  of  rectal 
trouble,  usuallv  hemorrhoids,  often  also  a  fissure. 

The  first  symptom  of  rectal  trouble  is  usually 
pain.  However,  it  may  first  be  manifested  by 
slight  bleeding  or  a  prolapse  of  the  hemorrhoids  or 
rectal  polyps.  Sometimes  rectal  trouble  is  first  evi- 
denced bv  itching  which  may  become  very  severe. 
Skin  tags  which  become  inflamed,  or  hemorrhoids 


which  become  acutelv  inflamed,  especially  if  throm- 
botic, may  cause  intense  agony  if  allowed  to  go 
untreated.  A  fissure-in-ano.  though  very  small,  may 
be  sufficient  to  almost  drive  a  patient  wild.  Every 
complaint  of  rectal  trouble  should  receive  careful 
consideration  and  a  very  thorough  examination. 

The  vast  majority  of  rectal  troubles  can  be  diag- 
nosed by  simple  inspection,  palpation  with  the 
gloved  finger,  and  a  careful  anal  examination,  using 
a  rectal  speculum  and  a  good  light. 

When  the  first  symptom  of  rectal  trouble  ap- 
pears not  only  should  a  careful  examination  be 
made  of  the  anal  region,  but  if  there  are  any  sub- 
jective symptoms  whatever  a  thorough  sigmoido- 
scopic  examination  should  be  done  immediately. 

These  examinations  should  not  be  done  hurried- 
ly, but  carefully  and  methodically,  and  above  all 
should  be  thorough. 

The  treatment  of  hemorrhoidal  conditions 
should  be  attended  to  immediately.  Delay  causes 
the  patient  to  suffer  needless  pain  and  may  lead  to 
considerable  permanent  disability,  especially  if 
complications  occur. 

In  women  we  have  other  complications — such  as 
possiblv  a  torn  sphincter  ani  muscle.  There  may 
be  vaginal  discharges  which  create  irritation  about 
the  rectum  and  various  other  things  may  affect  this 
area. 

A  thorough  and  careful  examination  will  often 
disclose  a  number  of  conditions  which  must  be  cor- 
rected in  order  to  effect  a  cure  of  the  rectal  com- 
plaint. 


DIPHTHERITIC   MYOCARDITIS 

(A.  G.  Bower  et  ri,  Los  Angeles,  in  Med.   Times.  Sept.) 

Early  circulatory  failure  occurs  from  the  2nd  to  the  9th  ' 
day  of  the  disease.  The  temperature  is  usually  elevated; 
the  pulse  is  rapid  and  thready;  the  heart  is  almost  never 
enlarged;  sounds  forceful;  a  systolic  murmur  is  frequently 
present;  there  is  usually  no  disturbance  in  rhythm  except 
as  a  terminal  event;  b.  p.  normal. 

Late  circulatory  failure  usually  occurs  from  the  7th  to 
the  14th  day.  Temperature  may  be  normal  or  subnormal, 
vomiting  is  frequent. 

Therapy  in  the  early  stages  of  diphtheria  includes  com- 
plete bed  rest  and  constant  nursing  care,  adequate  dietary 
and  vitamin  regimen,  dextrose  by  vein,  and  insulin. 

In  1927  Gordon  first  used  dextrose  solution  by  vein  rou- 
tinely in  early  toxic  diphtheria. 

Although  myocarditis  has  consistently  been  demonstrat- 
ed clinically  and  at  necropsy,  in  late  circulatory  failure 
evidence  has  been  offered  that  it  is  not  of  primary  consid- 
eration. 

Heart  stimulants  such  as  digitalis  are  contraindicated. 
Pitressin  the  pressor  principle  of  pituitary  extract,  is  most 
-.•aluable  in  late,  of  no  value  at  all  in  early,  circulatory 
failure.  Blood  pressure  readings  are  taken  and  the  drug  is 
injected  in  amounts  of  0.25  to  1  c.c.  subcutaneously  at  suit- 
able intervals  until  the  blood  pressure  remains  normal  or 
higher  than  normal.  During  the  past  few  years  we  have 
added  adrenal  cortex  (eschatin)  in  doses  from  10  to  20  c.c. 
in  order  to  sustain  blood  pressure. 


October,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


DEPARTMENTS 


HUMAN  BEHAVIOUR 

James   K.   Haix,  M.  D.,  Editor,   Richmond,   Va. 


OX  FREEDOM  OF  WORSHIP 

Lately  I  read  in  a  newspaper  a  despatch  from 
my  native  North  Carolina,  for  which  I  have  con- 
tinuing affection  and  admiration,  a  statement  that 
caused  me  distress.  Two  youngsters  had  been 
brought  by  their  digressive  conduct  into  the  crim- 
inal court  room.  The  Judge,  after  having  heard 
the  testimony,  and  probably  after  having  heark- 
ened to  appeals  for  mercy,  sentenced  the  boys  to 
mandatory  attendance  upon  Sunday  school  every 
single  Sabbath  Day  for  the  next  five  years.  And  I 
fell  to  wondering  if  such  a  sentence  might  not  be 
in  conflict  with  that  provision  of  the  fundamental 
law  that  forbids  unusual  and  cruel  punishment.  I 
doubt  not  that  both  the  sentence  of  the  court  and 
their  enforced  attendance  upon  Sunday  school  will 
give  them  a  distaste  for  such  schooling.  They  may 
even  resent  the  religious  instruction  proffered  them 
within  the  church. 

When  I  was  unable  to  buy  gasosline  at  a  filling 
station  in  Morganton  a  few  days  ago  because  the 
time  was  10:10  in  the  morning,  I  was  momen- 
tarily bewildered.  And  then  I  made  an  interroga- 
tor}'. The  attendant  replied  that  gasoline  could  not 
be  sold  from,  10  to  12  in  the  morning  on  Sunday 
without  violation  of  an  ordinance  of  the  town, 
which  would  result  in  a  fine  of  fifty  dollars.  And  I 
asked  if  the  purpose  of  the  particular  municipal 
pronouncement  was  to  enable  the  filling-station  at- 
tendants to  close  their  stations  so  that  they  might 
go  to  church,  or  if  the  purpose  of  the  ordinance 
was  to  make  it  impossible  for  people  to  ride  in  the 
hope  that  if  the  wheels  would  not  turn  people 
would  go  to  church.  He  was  still  scratching  his 
head  when  I  set  forth  for  Richmond  with  a  tank 
only  partially  filled  with  gas.  But  in  John  Cal- 
vin's own  town  of  Statesville  the  filling-station 
youngster  ran  the  gas-tank  over  and  tried  to  sell  me 
additional  gas  to  be  carried  in  a  container.  I  sur- 
mise that  Caledonian  blood  courses  through  his 
tubes. 

I  should  like  to  have  the  opportunity  for  private 
communion  with  the  youngsters  for  whom  Judge 
Stevens  suggested  pabulum  afforded  by  the  Shorter 
Catechism  and  the  Confession  of  Faith  on  each 
Lord's  Day  for  the  next  five  years.  It  may  have 
come  to  pass,  of  course,  that  the  boys  have  already 
induced  His  Honor  to  change  the  adjudgment  to  a 
term  on  the  roads. 

The  law  is  as  fond  of  punishing  as  a  cat  is  of 
milk.  Is  the  application  of  the  punitive  ritual  often 
corrective? 


DR.  TOM  WILLIAMS  RETURNS 

Just  as  I  was  about  to  step  aboard  the  train  a 
few  days  ago  som,e  mail  was  given  to  me  and  on 
one  of  the  letters  I  recognized  instantly  the  kako- 
graphy  of  my  old-time  friend,  Dr.  Tom  A.  Williams. 
When  the  day's  labours  had  been  concluded  in 
New  York — on  the  Lord's  Day,  too,  it  shames  me 
to  confess — I  lifted  up  the  telephone  and  I  was 
delighted  that  his  Scotch  speech  had  no  more 
changed  than  had  his  handwriting  improved.  On 
my  way  to  the  station  I  stopped  at  the  Wolcott 
Hotel,  and  there  we  communed  and  talked  of  other 
days. 

Dr.  Williams  remarked  that  we  had  not  looked 
upon  each  other  for  twelve  years.  I  told  him  that 
he  had  been  lost  to  me  for  at  least  a  decade.  He 
said  that  he  had  been  engaged  most  of  the  time  in 
practice  in  Europe.  When  he  spoke,  perhaps  a 
trifle  complainingly  of  receiving  no  responses  to 
his  letters  to  some  of  us,  I  asked  at  once  if  he  had 
penned  the  letters.  Certainly,  he  would  not  type  a 
personal  letter.  I  made  answer  only  for  myself  by 
reminding  him  that  once  when  I  was  secretary  of 
a  medical  organization  I  told  him  by  letter  if  he 
were  asking  for  a  place  on  the  program  to  speak 
to  me  through  the  machine.  And  he  promptly  sent 
to  me  a  typed  letter  that  was  easily  legible. 

Dr.  Williams  has  one  of  the  most  remarkable 
minds  I  have  ever  known.  His  mempry  is  phenom- 
enal in  orderliness  and  in  tenacity.  His  store  of 
knowledge  is  so  varied  and  so  comprehensive  that 
I  have  long  thought  of  him  as  omniscient,  both 
within  and  without  the  domain  of  medicine. 

When  he  asked  if  I  thought  he  might  be  able  to 
obtain  a  position  in  a  college  in  which  he  could 
teach  mental  hygiene,  I  wondered,  of  course,  why 
he  might  not  teach  anything  else  in  the  curricu- 
lum. But  his  great  store  of  medical  knowledge 
and  his  acquired  skill  should  be  in  daily  use.  He 
knows  and  he  is  gifted  in  the  verbalization  of  his 
knowledge.  He  would  be  happy  to  hear  from  his 
friends  of  other  days. 


SURGERY 


Geo.   H.   Bunch,  M.   D.,  Editor,  Columbia,  S.  C. 


ABSCESS  OF  THE  PANCREAS 

Acute  pancreatitis  is  an  acute  diffuse  inflam- 
mation of  the  pancreas  which  may  differ  consider- 
ably in  degree.  In  favorable  cases  it  terminates  in 
resolution  or  in  chronic  pancreatitis,  in  unfavorable 
cases  in  diffuse  necrosis  of  the  gland.  Because  of 
its  relative  frequency  and  importance  writers  of 
this  generation  tend  to  attribute  as  a  cause  diseases 
of  the  pancreas  which  develop  independently  of  it. 
Although  abdominal  apoplexy  is  caused  by  the  rup- 
ture of  an  atheromatous  arterial  ulcer  developing 


SOUTHERN  MEDICINE  &  SURGERY 


October,   1941 


upon  arterio-sclerosis  as  a  base,  in  the  pancreas  it 
is  considered  to  be  a  symptom  of  acute  hemor- 
rhagic pancreatitis.  This  is  true  although  the  hem- 
orrhage may  not  have  been  preceded  by  fever,  leu- 
cocytosis,  peritoneal  exudate  or  any  of  the  usual 
symptoms  of  acute  inflammation.  And  a  circum- 
scribed abscess  may  develop  in  the  pancreas  as  in 
any  other  gland  without  having  been  preceded  by 
diffuse  inflammation. 

Two  widely  differing  recent  cases  of  abscess  of 
the  pancreas  may  be  briefly  cited  to  show  that  the 
condition  is  not  necessarily  a  complication  or  a 
sequela  of  acute  pancreatitis  and  that  it  should 
always  be  considered  in  the  diagnosis  of  inflamma- 
tory lesions  of  the  abdomen. 

Case  I — An  ambulant  white  boy  aged  4  had  been 
taken  a  week  previous  to  admission  with  pain  about 
the  umbilicus,  nausea  and  vomiting.  On  examina- 
tion a  transverse  tender  mass  in  the  epigastrium 
was  thought  to  be  an  appendix  abscess.  At  opera- 
tion, however,  fluctuation  was  found  in  the  head 
of  the  pancreas  from  a  circumscribed  abscess  con- 
taining thick,  white,  odorless  pus  from  which 
staphylococci  were  identified.  Uninterrupted  con- 
valescence followed  drainage  of  the  abscess.  The 
appendix  was  normal  in  every  way. 

Case  II — A  fairly  corpulent  white  woman  of  70 
years  had  had  progressively  deepening  jaundice  for 
a  month  before  admission.  There  was  no  history  of 
recurring  pain  suggestive  of  biliary  colic  from 
stone.  There  was  leucocytosis  and  fever  of  mild 
degree.  Because  of  the  jaundice  the  dye  for  x-ray 
stud)'  of  the  gallbladder  was  not  given.  The  pre- 
operative diagnosis  was  obstructive  jaundice  from 
cancer  of  the  head  of  the  pancreas  or  from  stone 
in  the  common  bileduct.  At  operation  the  gall- 
bladder contained  thick,  tarry  bile  but  was  with- 
out stones  and  was  grossly  normal.  The  head  of 
the  pancreas  was  enlarged  and  indurated  so  that 
the  terminal  end  of  the  common  bileduct  was  me- 
chanically obstructed  by  it.  Because  it  was  im- 
possible to  learn  by  palpation  alone  if  an  impacted 
gallstone  was  not  osbtructing  the  terminal  common 
duct  the  head  of  the  pancreas  was  opened  and 
probed  and  no  stone  was  found.  The  duct  was 
compressed  by  a  circumscribed  abscess  in  the  head 
of  the  pancreas.  Thick,  white  pus  containing 
staphylococci  was  evacuated.  The  gallbladder  was 
drained  to  provide  an  outside  escape  for  the  bile 
until  the  inflammatory  induration  in  the  head  of 
the  pancreas  would  have  time  to  subside  and  the 
normal  passage  of  the  bile  through  the  common 
duct  into  the  duodenum  could  be  reestablished.  If 
this  does  not  occur  anastomosis  of  the  gallbladder 
to  the  intestine  should  be  done. 


In  neither  of  these  cases,  even  if  the  diagnosis 
had  been  suspected  before  operation,  could  it  have 
been  proven  except  by  surgical  exploration. 


HISTORIC  MEDICINE 


ON  THE  USE  OF  METALLIC  SUTURES  AND 

METALLIC  LIGATURES  IN  SURGICAL 

WOUNDS  AND  OPERATIONS 

It  is  generally  thought  that  J.  Marion  Sims 
originated  the  use  of  metallic  sutures,  certainly  in 
surgical  repair  work.  Here  is  abstracted  an  article1 
which  shows  how  far  from  the  facts  this  general 
idea  is.  This  article  is  by  the  discoverer  of  chloro- 
form anesthesia,  Dr.  James  Y.  Simpson, 'afterward 
Sir  James  Y.  Simpson,  knighted  for  successfully 
delivering  Queen  Victoria,  under  chloform  anesthe- 
sia, of  the  seventh  or  eighth  of  her  nine  children. 
The  good  Queen  took  this  effective  means  of  silenc- 
ing the  clergy  of  the  Anglican  Church,  who  were 
(along  with  the  great  majority  of  the  clergy  of  all 
other  churches)  denouncing  anesthesia  in  labor  as 
a  sinful  interference  with  the  curse  put  upon  wo- 
man, "In  sorrow  thou  shalt  bring  forth  children." 

The  idea  of  employing  metallic  threads  for  sur- 
gical sutures  is  not  modern,  however  much  the 
practice  may  be  deemed  so.  In  his  learned  disser- 
tation on  the  Ada  of  Celsus,  John  Rhodius  alludes 
to  many  different  forms  of  thread,  as  the  "filum, 
lineum,  laneum,  sericum,  xylinum,  aureum,  argen- 
tcum,  jerreum,  plumbeum."  After  speaking  of  the 
employment  of  gold  and  iron  threads  in  the  indus- 
trial arts,  he  alludes  to  the  question  of  these  two 
metallic  threads  being  capable  of  use  in  surgical 
sutures;  and,  evidently  without  ever  having  tried 
them,  he  condemns  them  as  unfit  for  such  a  pur- 
pose. 

During  the  last  century,  however,  metallic  su- 
tures appear  to  have  been  used,  in  some  isolated 
examples.  Purmann,  "Chief  Chirurgeon  to  the 
City  of  Breslau,  in  Germany,"  as  he  is  styled  on 
the  title  page  of  the  English  edition  of  his  Chirur- 
gia  Curiosa,  used  silver  wire  with  alleged  great  ad- 
vantage in  wounds  of  the  tongue.  Needles  of  gold 
and  silver  were  long  preferred  by  most  surgeons  in 
applying  the  twisted  suture  for  the  cure  of  hare-lip. 
In  his  Elements  of  Surgery,  published  in  1 746, 
Mihles  speaks  of  employing  silver  and  gold  threads 
in  the  operation  for  hare-lip  instead  of  pins,  and 
figures  a  needle  fitted  to  draw  those  metallic 
threads  through  the  sides  of  the  cleft  lip. 

The  first  surgeon  in  our  own  times  who  appears 
to  have  used  metallic  threads  in  practice,  was  the 
late  Professor  Dieffenbach,  of  Berlin.  In  a  paper 
on  Staphyloraphy  published  in  1826,  he  has  detail- 


1.  By  Dr.  J.  Y.  Simpson.  Professor  of  Midwifery  in  Univ. 
sity  of  Edinburgh,  in  Medical  Times  &  Gazette,  London,  Tu 
5th,  1858. 


October,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


ed  several  instances  of  that  operation,  in  which  he 
used  leaden  thread  to  unite  the  sides  of  the  divided 
palate.  He  preferred  for  this  purpose  threads  of 
lead  to  threads  of  silk,  as  he  found  the  ends  of  the 
leaden  thread  could  be  made  by  mere  twisting  of 
their  elongated  extremities,  to  bring  into  contact 
the  raw  sides  of  the  wound  more  easily  than  could 
be  effected  by  attempting  to  tie  and  knot  the  end 
of  silk  threads  by  introducing  the  fingers  so  deeply 
within  the  cavity  of  the  mouth.  The  metallic  su- 
ture in  staphyloraphy  has  been  alluded  to  by  many 
later  surgical  writers  (and  modified  by  some),  as, 
for  instance,  Mr.  Liston  in  1831,  Velpeau,  Pan- 
coast  and  others.  Gosset  stitched  together  the  sides 
of  a  vesico-vaginal  fistula  with  gold  wire,  the  gold 
threads  being  left  in  for  twenty-one  days.  In  his 
Practical  Essay  on  Plastic  Surgery,  Mr.  Spencer 
Wells  observes:  "The  lead  suture  is  sometimes 
useful  in  deep  operations.  A  piece  of  soft  lead  wire 
is  armed  at  both  ends  with  a  short  needle.  These 
are  passed,  by  means  of  forceps  or  a  needle-holder, 
from  within  outwards,  and  the  needles  removed. 
The  ends  of  the  lead  wire  are  twisted  together  until 
the  wound  is  brought  into  apposition.  They  are 
then  cut  off.  This  is  the  easiest  suture  to  apply  in 
cases  of  vesico-vaginal  fistula  when  deep-seated. 

In  the  British  &  Foreign  Medical  Review  for 
April,  1846,  it  is  stated  that  platinum  wire  as  a 
suture-thread  has  thus  been  "successfully  employed 
at  Guy's  Hospital  by  Mr.  Morgan."  The  late  Mr. 
Bransby  Cooper,  in  his  Lectures  on  Surgery,  pub- 
lished in  1851,  when  speaking  of  the  treatment  of 
common  surgical  wounds  by  the  interrupted  suture, 
observes  that  "the  interrupted  suture  is  the  one 
more  frequently  used  by  surgeons  and  silk  is  the 
ligature  generally  used;  but  platinum  wire  is  pre- 
ferred by  some  surgeons."  Again,  Mr.  Guthrie, 
when  describing  the  treatment  of  wounds  left  by 
amputation,  directs  that  "the  common  integuments 
of  the  stump  should  be  drawn  together  in  primary 
amputations  by  sutures  formed  of  flexible  leaden 
wire;  by  threads  of  silk,  if  leaden  wire  is  not  ob- 
tainable." 

But  in  America  the  subject  of  metallic  ligatures 
has  met  with  more  attention  than  in  Europe.  In 
1832,  Dr.  J.  P.  Mettauer,1  of  Virginia,  employed 
them  with  perfect  success  in  operating  in  a  very 
aggravated  case  of  laceration  of  the  perinaeum  and 
rectum,  produced  the  year  previously  by  a  long 
tedious  labor.  The  laceration  extended  as  high  as 
three  inches   upwards,  along  the  anterior  wall  of 


1.  Dr.  John  Peter  Mettauer  was  a  distinguished  surgeon  of 
Prince  Edward  Courthouse,  now  Farmville,  in  Southsidc  Virginia. 
His  fame  rested  largely  on  his  success  in  a  large  scries  of  oper- 
ations for  removal  of  cataract,  and  urinary  stone,  his  cures  of 
vesicovaginal  and  rcctovaginallis  fistula  and  his  conduct  at  P.  E. 
C-H.,  of  the  Medical  Department  of  Randolph -Macon  College. 
It  is  said  that  no  person  ever  saw  Dr.  Mettauer  in  life  with  his 
hat  off,  and  that  he  had  his  coffin  made  extra  long  and  was 
buried  with  his  beaver  on  his  head. — J.  M.  N. 


the  rectum.  After  removing  and  denuding  the 
hardened  edges  of  the  lacerated  cleft,  and  the  parts 
exterior  to  them,  Dr.  Mettauer  stitched  carefully 
together  the  abraded  surfaces  with  ligatures  of  lead 
wire.  As  the  ligatures  were  applied  they  were  tight- 
ened, so  as  to  bring  the  abraded  surfaces  in  contact; 
and  then  their  ends  were  twisted  together  and  cut 
off  of  convenient  length.  About  twelve  ligatures 
were  required  to  close  the  wound.  From  time  to 
time  the  ligatures  were  tightened  by  twisting  them. 

Four  years  after  recording  his  first  case  in  the 
American  Journal  of  Medical  Sciences,  Dr.  Met- 
tauer reported  six  additional  instances  in  which 
he  had  operated  for  extensive  lacerations  of  the 
perinaeum.  "In  all  of  those  cases,"  he  states,  "the 
recto-vaginal  wall  was  completely  divided,  so  as  to 
convert  the  two  passages  bounded  by  it  into  one." 
Six  of  the  operations  were  attended  with  complete 
success.  In  the  seventh  case,  the  wound  partially 
tore  open  some  weeks  subsequently  under  the  dis- 
tention produced  by  the  passage  of  "a  large  indu- 
rated mass  of  faeces,  causing  intense  suffering;"  and 
the  patient  had  not  yet  submitted  to  a  second  oper- 
ation for  her  cure.  In  concluding  this  contribution, 
Dr.  Mettauer  observes,  "My  experience  leads  me 
to  believe  that  every  case  of  the  afflictive  accident 
is  completely  remediable.  I  decidedly  prefer  the 
metallic  suture  in  the  treatment  of  this  infirmity. 
With  it  we  are  enabled  to  close  and  confine  the 
denuded  margin  of  the  fissure  with  more  ease  and 
certainty  than  with  the  silken  or  thread  suture. 
And  should  the  least  gaping  of  the  wound  take 
place,  a  few  twists  of  the  free  ends  of  the  wires 
will  enable  us  to  close  it  up  again.  The  leaden 
suture,  too,  does  not  cut  out  as  soon  as  silk  or 
thread." 

In  the  same  year  (1847)  in  which  he  published 
this  second  essay  on  the  cure  of  lacerated  perinaeum 
with  metallic  sutures,  Dr.  Mettauer  published  an 
account  of  some  cases  of  vesico-vaginal  fistula 
which  he  had  treated  on  similar  principles.  In  his 
first  case  the  opening  in  the  back  wall  of  the  blad- 
der was  "fully  the  size  of  a  Spanish  milled  dollar, 
and  nearly  circular."  Its  edges  were  denuded  and 
brought  together  with  eight  leaden  sutures;  and 
after  the  extremities  of  these  sutures  were  twisted 
and  tightened,  the  opening  was  perfectly  closed  in 
every  part  of  it.  A  short,  light,  silver  catheter  was 
permanently  retained  in  the  bladder.  On  the  third 
day  the  wires  were  tightened,  and  again  on  the 
seventh.  On  the  thirteenth  day  the  ligatures  were 
removed,  and  perfect  union  was  found  to  have 
taken  place  along  the  whole  line  of  contact.  The 
cure  was  complete,  and  the  woman  bore  two  chil- 
dren subsequently  without  any  return  of  the  acci- 
dent.   Dr.  Mettauer  operated  in  five  other  cases  of 


SOUTHERN  MEDICINE  &  SURGERY 


October,   1941 


vesico-vaginal  fistula.  In  his  second  case  the  fis- 
tuous  opening  was  diminished,  but  not  obliterated, 
after  eight  operations.  His  results,  however,  on  the 
whole,  were  so  favorable  as  to  induce  him  to  con- 
clude with  the  strong  allegation,  "I  am  decidedly 
of  the  opinion  that  every  case  of  vesico-vaginal 
fistula  can  be  cured,  and  mv  success  justifies  the 
statement." 

Dr.  Marion  Sims,  formerly  of  Montgomery,  Ala- 
bama, now  of  New  York,  published  in  1852  an  es- 
say on  The  Treatment  oj  Vesico-Vaginal  Fistula 
recommended  the  lips  of  the  fistula,  after  they  were 
refreshed  by  the  surgeon's  gnife,  to  be  held  to- 
gether by  threads  of  silver  wire  used  as  a  suture. 
Latterly  a  ''Woman's  Hospital"  has  been  establish- 
ed in  New  York,  principally  for  the  treatment  of 
fistulae  and  other  injuries  resulting  from  parturi- 
tion; and  Dr.  Sims  has,  as  surgeon  to  that  institu- 
tion, had  ample  means  of  proving  the  valuable  and 
happy  results  of  his  treatment.  Speaking  of  silver 
wire  as  a  suture,  he  remarks,  "From  the  day  its 
wonderful  effects  were  witnessed  in  vesico-vaginal 
fistulae  in  1849,  I  have  never  used  any  other  su- 
ture in  any  department  of  surgery;  and  I  declare  it 
(he  elsewhere  observes)  as  may  honest  and  heart- 
felt conviction  that  the  use  of  silver  as  a  suture  is 
the  great  surgical  achievement  of  the  nineteenth 
century." 


THERAPEUTICS 

J.  F.  Nash,  M.  D.,  Editor,  Saint  Pauls,  N.  C. 


VARICOSE  VEINS  AND  ULCERS  CURED  IN 
OFFICE 

Varicose  veins  and  ulcers  are  prone  to  afflict 
the  men  and  women  who  must  be  on  their  feet  if 
they  possibly  can.  Advice  to  stay  in  bed  and  keep 
the  leg  elevated  will  rarely  be  accepted. 

It  is  a  pleasure  to  read  and  to  pass  on  to  others 
a  report1  of  excellent  results  from  treatment  of  a 
large  series  of  cases  by  a  method  requiring  no  hos- 
pitalization and  keeping  no  patient  from  work  for 
more  than  three  days. 

In  the  Surgical  Out-Patient  Department  of  the 
Medical  College  of  Virginia,  we  average  35  or  more 
such  cases  per  afternoon.  We  inject  the  veins  and 
treat  the  ulcers;  when  necessary  we  also  ligate  the 
veins — in  either  case  allowing  the  patient  to  go 
home. 

A  careful  history  and  examination  determine  the 
possibility  of  deep  phlebitis.  In  women  a  pelvic 
examination  should  be  done  and  if  a  tumor  is 
found,  it  should  be  attended  to  before  the  veins  are 
treated,  and  if  there  is  a  pregnancy  only  suppor- 

1.  G.  W.  Horsley,  Richmond,  in  Bui.  Richmond  Acad,  of  Med., 
Sept. 


tive  treatment  should  be  carried  out  until  after 
the  delivery. 

The  patency  of  the  deep  veins  must  be  tested  by 
applying  an  elastic  stocking  or  Ace  bandage  and 
having  the  patient  wear  it  for  several  days.  If  this 
support  affords  relief,  treatment  may  be  started.  If 
the  veins  are  only  superficial  and  do  not  extend 
above  the  knee,  injection  is  all  that  is  necessary;  if 
they  extend  above  the  knee  or  if  the  valves  of  the 
saphenous  veins  are  incompetent,  ligation  must  be 
done.  Saphenous  veins  must  be  ligated  high — all 
of  the  branches  which  enter  the  foramen  ovale — 
and  divided,  or  there  will  be  a  reflux  of  blood  by 
their  tributaries.  If  by  the  tourniquet  test  the 
valves  in  the  communicating  veins  are  incompetent, 
a  second  ligation  may  be  necessary,  either  lower  on 
the  long  saphenous  vein,  or  on  the  short  saphenous 
vein.  These  ligations  may  be  carried  out  as  office 
procedures,  using  novocain  anesthesia.  After  the 
ligation  the  patient  wears  some  kind  of  supportive 
bandage  or  an  elastic  stocking  for  several  weeks. 
If  the  veins  in  the  thigh  are  large,  thread  a  ureteral 
catheter  down  the  vein  before  the  lower  end  is 
ligated  and,  while  gradually  withdrawing  the  cathe- 
ter, inject  several  ex.  of  the  sclerosing  solution  into 
the  vein.  This  will  obliterate  most  of  the  veins 
above  the  knee  and  will  reduce  the  number  of  sub- 
sequent injections  necessary. 

The  injections  are  started  one  week  after  the 
ligation,  or,  if  no  ligation  is  necessary,  as  soon  as 
it  is  determined  that  the  deep  veins  are  open.  I 
have  been  using  monolate  (monoethanolamine 
oleate),  injections  of  2  to  5  c.c,  three  to  five  days 
apart.  After  each  a  small  gauze  pad  is  placed  over 
the  injection  point  and  a  supportive  bandage  is 
applied  from  the  foot  to  the  knee  until  all  veins 
have  been  occluded,  usually  requiring  from  4  to  12 
injections. 

The  results  have  been  gratifying.  This  method 
does  not  require  hospitalization  and  never  more 
than  two  or  three  days  away  from  work. 

We  have  done  more  than  150  ligations  and  6,500 
injections  without  any  fatalities  and  with  only  four 
injection  reactions.  All  of  these  came  when  a  dose 
of  more  than  5  c.c.  of  solution  was  used.  There 
has  been  no  untoward  reaction  to  my  knowledge 
in  the  past  18  months. 

When  there  is  induration  or  ulceration,  ligations 
and  injections  may  be  started  at  once  unless  there 
is  spreading  infection,  in  which  case  the  patient 
should  be  put  to  bed  and  the  infection  treated. 
Ninety-five  per  cent  of  varicose  ulcers  can  be  com- 
pletely healed  by  the  simple  use  of  elastic  adhesive 
bandages.  The  remaining  five  per  cent,  with  edema 
from  the  varicose  veins  and  long-standing  infection 
and  resulting  lymphangitis,  require  that  all  of  the 
old   ulcer  with   the  scar   tissue  be  widely  excised 


October.   1941 


SOUTHERN  MEDICINE  &  SURGERY 


561 


down  to  normal  muscle  and  fascia,  a  full-thickness 
skin  graft  used  and  the  patient  kept  in  bed  until 
the  graft  has  taken  firmly.  A  well-balanced  diet 
with  sufficient  vitamins  is  a  requisite. 

All  of  these  cases  should  be  followed  from  12  to 
18  months,  and  if  any  small  recurrences  are  noted 
injections  should  be  given  immediately. 


TUBERCULOSIS 

J.  Donnelly,  M.  D.,  Editor,  Charlotte,  N.  C. 


THE  CHARLOTTE  TUBERCULOSIS  CLINIC 
The  Charlotte,  N.  C,  Tuberculosis  Clinic  has 
been  in  continuous  operation  under  the  same  med- 
ical supervision  in  connection  with  the  Charlotte 
Health  Department  since  September,  1919.  Actu- 
ally the  clinic  was  a  continuation  of  the  Tubercu- 
losis Dispensary  of  the  North  Carolina  Medical 
College,  the  college  having  been  discontinued  in 
1916.  The  need  for  institutional  beds  to  care  for 
active  tuberculous  cases  kas  first  recognized  in  the 
Dispensary  of  the  Medical  College,  because  of  the 
large  number  of  patients  appearing  there  for  exam- 
ination and  the  rather  high  percentage  of  tuber- 
culous cases  in  need  of  medical  attention  and  hos- 
pitalization found  among  them.  These  institutional 
requirements  were  further  emphasized  in  the  work 
of  the  tuberculosis  clinic  immediately  after  its  re- 
organization in  connection  with  the  Health  Depart- 
ment, and  it  was  with  the  clinic  as  a  starting  point 
that  the  movement  began  which  eventually  resulted 
in  the  building  of  the  Mecklenburg  Sanatorium. 
The  clinic  still  operates  as  a  feeding  point  for  this 
institution. 

For  a  good  many  years  this  clinic  operated  fairly 
successfully  with  very  inadequate  equipment,  this 
handicap  being  due  to  the  very  limited  funds  ap- 
propriated for  its  use.  That  handicap  has  been  to 
a  large  extent  obviated  because  of  the  interest  and 
generosity  of  the  Charlotte  Woman's  Club.  For 
the  past  five  years  this  Club  has  appropriated  each 
year  money  from  their  Seal  Sale  funds  to  add  to 
our  x-ray  and  other  equipment  until  we  now  have 
everything  needful.  This  added  material  includes 
a  fiuoroscope,  a  complete  x-ray  outfit  for  taking 
fiat  films  and  stereos  of  the  chest,  complete  dark- 
room facilities,  and  the  equipment  necessary  for 
pneumothorax  refills.  In  addition  to  this,  the  Wo- 
man's Club  has  provided  a  sufficient  number  of 
films  each  year  to  supply  our  needs  for  the  raying 
of  the  positive  reactors  in  the  tuberculin  skin-test- 
ing of  school  children  and  the  contacts  of  pre- 
viously diagnosed  active  cases. 

Since  its  organization  in  1919  the  clinic  has  been 
conducted  two  afternoons  of  each  week,  one  after- 
noon of  each  month  for  the  past  several  years  hav- 


ing been  reserved  for  the  skin-testing  of  children 
who  are  known  contacts  of  previously  diagnosed 
active  adult  cases.  The  regular  clinic  staff  consists 
of  one  physician,  one  nurse,  and  a  clerical  worker. 
The  physicians  of  the  city  are  requested,  if  they  so 
desire,  to  refer  any  patient  who  is  unable  to  pay 
for  the  services  of  a  physician  and  who  may  be  in 
need  of  an  examination,  to  the  clinic  for  such  a 
check-up.  The  district  Health  Department  nurses 
are  asked  to  send  in  suspicious  cases  who  are  not 
under  the  care  of  a  private  physician  and  to  ob- 
tain sputum  specimens  for  laboratory  examination 
whenever  it  is  indicated.  By  the  latter  procedure, 
we  have  been  able  to  locate  a  number  of  virulently 
infectious  cases  that  might  otherwise  have  been 
missed.  The  follow-up  of  cases  who  are  listed  in 
the  clinic  records  as  observation  cases,  and  who 
fail  to  return  for  subsequent  checking,  is  handled 
by  the  district  nurses,  as  is  also  the  search  for 
contacts  and  under-par  children  who  might  need 
attention. 

The  number  of  new  patients  examined  yearly 
showed  a  gradual  increase  from  1919  until  1930, 
when  the  largest  number,  765,  were  recorded.  Since 
1930,  the  new  registrations  have  remained  fairly 
constant,  the  number  in  1940  having  been  604.  In 
1930  of  the  765  examined,  91  were  diagnosed  as 
active  tuberculosis;  in  1940  of  the  604  examined 
only  32  were  pronounced  positive.  The  following 
total  figures  will  give  an  idea  of  the  volume  of 
work  which  has  been  done  in  this  clinic  since  its 
opening  to  the  present  time. 

Total  No.  new  patients  examined- ...   16,180 

"        "     visits  to  clinic 23,304 

"        "     active  cases  diagnosed....     1,745 
"     nurses'  field  visits 57,480 

An  item  of  interest,  and  an  indication  that  the 
work  in  prevention  of  tuberculous  infection  has 
achieved  results,  is  the  fact  that  of  those  patients 
examined  in  1921,  46.4%  were  active  tuberculous 
cases,  while  in  1940,  of  the  604  examined,  only 
5.3%  were  active  cases.  Since  the  construction  of 
the  Mecklenburg  Sanatorium  all  cases  judged  to  be 
in  need  of  institutional  treatment  are  urged  to  go 
to  the  institution  for  treatment,  and  applications 
for  entrance  are  filled  out  for  them  in  the  clinic. 
The  follow-up  work  for  discharged  sanatorium 
cases  is  also  assumed  by  the  clinic  if  it  is  desired. 

In  1936  the  yearly  routine  tuberculin  skin-test- 
ing of  school-children  was  added  to  the  outside 
activities  of  the  clinic  staff.  This  has  been  valuable 
public  health  tuberculosis  work,  as  the  investiga- 
tion of  the  environmental  conditions  surrounding 
the  positive  tuberculin  skin-reactors  has  assisted  us 
in  locating  many  open  sources  of  infection.  These 
clinics  have  been  conducted  in  grammar  grades 
and   high  schools  of  both  the  white  and  colored 


SOUTHERN  MEDICINE  &■  SURGERY 


October,   1941 


schools.  That  this  activity  is  a  necessary  part  of 
our  tuberculosis  work  we  are  assured,  and  it  will 
be  continued  each  year  as  far  as  our  finances  will 
permit.  The  following  figures  will  indicate  the 
amount  of  this  work  that  has  been  done  in  the  last 
five  years.  All  positive  skin-reactors  are  x-rayed  in 
the  clinic,  and  an  attempt  is  made  to  repeat  the 
x-ray  examination  at  least  once  a  year  in  every 
case  diagnosed  as  a  primary  tuberculous  infection. 

No.  of  school-children  skin-tested 11,952 

(Includes  8,019  whites  and  3,933  Negroes) 

Positive   reactors  x-rayed 1,162 

Primary  lesions  diagnosed  (active  and 

latent) 297 

Adult  type  disease  (2  white,  4  Negro)..  6 
That  the  work  in  prevention  of  tuberculous  in- 
fection has  had  some  effect  is  indicated  by  the 
gradual  yearly  reduction  in  the  percentage  of  posi- 
tive reactors  both  among  the  white  children  and 
the  Negroes.  In  the  first  year  this  work  was  done 
the  white  children  showed  approximately  16% 
positive  reactors,  while  in  1940  this  percentage  was 
8.1.  In  1936,  518  children  of  one  Negro  school 
showed  34.5%  positive  reactors.  In  1941,  569 
children  in  this  same  school  showed  a  percentage 
of  positives  of  13.57% — much  less  than  half  that  of 
1936.  In  addition  to  the  1,162  positive  skin  reac- 
tors among  the  school-children,  we  have  x-rayed  in 
the  last  three  years  502  positive  reactors  among 
contacts  of  known  active  cases,  a  total  of  1,664 
x-rayed  cases. 

In  January,  1940,  recognizing  the  fact  that  such 
a  department  would  be  of  great  help  to  many  dis- 
charged sanatorium  cases,  we  addsd  an  artificial 
pneumothorax  division  to  the  clinic.  Since  its 
opening  320  artificial  pneumothorax  refills  have 
been  given  in  this  department.  This  service  is 
available  for  any  discharged  sanatorium  patient 
who  has  been  getting  this  type  of  treatment  and 
who  desires  the  service,  provided  that  such  patient 
is  financially  unable  to  pay  for  it. 

Although  we  are  much  better  equipped  at  pres- 
ent than  we  were  some  years  ago,  due  to  the  in- 
terest and  generosity  of  the  Charlotte  Woman's 
Club,  we  are  still  somewhat  handicapped  finan- 
cially. One  of  our  principal  needs  is  a  sufficient 
number  of  trained  nurses  for  field  work  in  order 
that  we  may  accomplish  more  effectual  follow-up 
work,  particularly  among  the  children  who  have 
been  found  with  active  or  healed  primary  infec- 
tions, and  in  the  tracing  of  contacts  of  known  ac- 
tive cases. 


DERMATOLOGY 

J.  Lamar  Calloway,  M.D.,  Editor,  Durham,  N.  C. 


Cesarean  Section. — Probably  a  dozen  different  cases 
and  times  are  cited  by  different  writers  as  "the  first  suc- 
cessful cesarean  section."  Much  of  this  diversity  of  state- 
ment hinges  on  the  meaning  intended. 


RECURRING  APHTHOUS  ULCERS  OF  THE 
MOUTH 

Recurring  superficial  ulcers  affecting  the  mu- 
cous membranes  of  the  lip,  mouth  and  tongue  con- 
stitute one  of  the  most  difficult  diagnostic  and  ther- 
apeutic problems  with  which  we  have  to  cope. 
Fortunately  for  the  patient,  in  most  instances  the 
lesions  are  few  and  recur  infrequently.  However, 
there  is  a  group  in  which  some  lesions  are  present 
almost  constantly,  at  times  being  so  extensive  and 
painful  as  to  cause  the  patient  to  be  unable  to  take 
fluids  or  foods  without  extreme  discomfort. 

Most  common  causes  for  lesions  of  this  type 
are — 

1.  Recurring  herpes 

2.  Vitamin  deficiency   (particularly  of  the  vita- 
min B  complex) 

3.  Electrogalvanic  ulcers 

4.  Food  or  drug  sensitivity 

5.  Contacts  due  to  various  dentrifices,  artificial 
plates,  mouth  washes  etc. 

6.  Endocrine  disturbances. 

From  my  observation  recurring  herpetic  ulcera- 
tions are  the  most  frequent  causes  of  shallow 
aphthous  ulcers  of  this  type  and  if  observed  early 
in  the  course  of  development  almost  always  the 
primary  lesion  is  a  group  of  vesicles  on  an  erythe- 
matous base,  which  rapidly  becomes  eroded  and 
forms  a  shallow  ulcer,  that  the  patient  usually  ob- 
serves first  and  for  which  he  seeks  relief.  The  best 
method  for  building  up  virus  immunity  is  by  small- 
pox vaccination,  repeated  until  a  satisfactory 
"take"  is  obtained. 

Although  the  dietary  intake  of  vitamin  B  com- 
plex may  be  adequate,  since  some  individuals  do 
not  metabolize  vitamin  B  satisfactorily,  deficiency 
of  this  vitamin  is  one  of  the  frequent  causes  of 
superficial  ulcerations  of  this  sort,  and  all  such 
patients  should  receive  adequate  dosages  of  the  B 
complex.  A  satisfactory  way  of  administering  it  is 
by  using  one  tablespoonful  of  brewer's  yeast  in 
tomato  juice  three  times  daily. 

Lain  described  electrogalvanic  lesions  of  the 
mouth  occurring  in  patients  with  dissimilar  metal- 
lic fillings  which  produce  a  mild  electrical  current. 
Lesions  of  this  type  can  as  a  rule  be  detected  fairly 
easily  because  of  their  close  proximity  to  fillings. 
This  factor  should  be  considered  in  all  patients. 

It  is  very  rare  that  specific  food  or  drug  inges- 
tion produces  ulceration  of  this  type;  but  this  fac- 
tor, too,  must  be  kept  in  mind.  The  patient  can 
satisfactorily  eliminate  most  of  his  food  or  drug 
factors  by  keeping  a  careful  diary  for  a  period  of  a 


October,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


S63 


month  and  checking  this  against  the  appearance  or 
recurrence  of  lesions.  Intracutaneous  skin  tests  to 
various  foods  are  also  sometimes  helpful. 

Dentrifices,  mouth  washes,  artificial  plates  and 
other  contact  substances  can  usually  be  eliminated 
by  history;  the  use  of  patch  tests  and  local  appli- 
cations will  assist  in  the  evaluation  of  these  factors. 

Moseley  has  recently  reported  a  case  in  which 
endocrine  therapy  was  required  in  order  to  effect 
cure  of  recurring  ulcerations  of  the  mouth  and 
vulva.  It  should  be  stated  here  that  vaginal  mu- 
cous membrane  is  frequently  involved  in  the  same 
manner  and  degree  as  the  buccal. 

Since  these  problems  are  so  hard  to  manage  it  is 
advisable  in  most  cases  to  use  smallpox  vaccination 
and  large  doses  of  vitamin  B  complex,  to  proscribe 
dentrifices  and  substitute  a  plain  saline  mouth 
wash,  and  to  impress  on  the  patient  the  necessity 
for  careful  cooperation  in  keeping  a  diary  to  deter- 
mination of  any  food  and  drug  sensitization.  If 
these  fail  then  intradermal  skin  tests,  endocrine 
therapy  etc.  are  indicated. 


INSURANCE  MEDICINE 


HYPERTENSION  PERSONALITY 

For  this  issue  A.  Ray  Dawson,  M.D.,  Greensboro,  N.  C. 

Assistant  Medical  Director  Jefferson  Standard  Life 

Insurance  Company 

Hypertension  with  its  camp  followers,  coronary 
diseases  and  cerebral  accidents,  is  today  number 
one  on  the  insurance  companies'  list  of  diseases 
causing  economic  loss.  As  is  well  known,  these 
diseases  kill  and  kill  quickly  in  the  middle  forties 
and  beginning  fifties,  at  the  very  peak  of  man's 
economic  productive  capacity. 

In  the  early  twenties,  insurance  statistics  por- 
trayed the  picture  of  coming  events.  In  December, 
1925,  Dr.  Edwin  W.  Dwight,  Medical  Director  of 
the  New  England  Mutual,  wrote  a  classic  on  cir- 
culatory deaths,  titling  his  paper  "The  Next  Job 
in  Preventive  Medicine."  The  following  is  quoted 
from  his  summary:  "The  incidence  of  circulatory 
diseases  is  in  inverse  relation  to  the  amount  of 
physical  exercise  which  the  group  takes  in  the  open 
air;  and,  other  things  being  equal,  it  is  in  direct 
relation  to  the  amount  of  nervous  and  mental 
strain." 

Prior  to  the  twenties,  there  was  born,  later  to 
be  invested  with  vigorous  growth,  the  term  hyper- 
tensive personality.  This  vague  term  is  now  an 
important  part  of  our  medical  thinking.  We  all 
know  something  of  its  meaning,  but  like  that  eel 
caught  off  the  Carolina  Coast,  it  seems  to  slip 
away  from  us  when  we  have  the  most  stable 
ideas  on  the  subject.  However,  in  the  manner  with 
which  the  experienced  fisherman  holds  the  eel  bet- 


ter than  we  amateurs,  some  of  our  professional  as- 
sociates give  us  thoughts  which  cast  light  on  cer- 
tain features. 

In  dealing  with  pathological  personalities,  we 
have  come  to  recognize  two  distinct  reactionary 
types,  each  of  these  types  react  to  environment  in 
a  more  or  less  certain  and  oft-times  predictable 
manner.  The  pattern  seems  to  be  basic  in  the  indi- 
vidual's nature.  The  psychologist  has  termed  these 
two  classes  of  persons  as  introverts  and  extroverts. 
The  psychiatrist  gives  us  as  an  example  of  intro- 
version, the  psychosis,  dementia  precox,  in  which 
low  blood  pressure  and  weakness  toward  the  in- 
fectious diseases,  particularly  tuberculosis,  are  fre- 
quent findings.  He  also  gives  us  an  example  of 
extroversion,  the  paranoid  or  maniac,  depressive 
psychosis,  in  which  high  blood  pressure  and  circu- 
latory diseases  are  the  most  frequent  findings.  We 
know  that  certain  people  react  to  environment  in  a 
regressive  or  "getting-away-from"  manner,  while 
others  walk  in  and  start  fighting.  Even  at  this 
time,  when  such  a  premium  is  put  on  the  fighting 
side  of  our  nature,  it  seems  not  to  be  such  a  good 
idea  when  one  considers  individual  longevity. 
Many  of  our  great  thinkers  have  said  that  beauty 
and  rhythm  are  the  objectives  in  life.  I  believe 
that  we  can  now  get  a  glimpse  of  the  truth  which 
they  spoke.  It  is  not  the  man  who  gracefully  and 
rhythmically  executes  the  latest  steps  who  gets  hot 
under  the  collar  when  social  custom  dictates  that 
he  dance  with  the  hostess  or  the  lady  of  the  even- 
ing. No,  it  is  those  among  us  who  seem  to  awk- 
wardly stumble  through  the  ordeal.  It  isn't  the 
player  with  the  rhythmic  drive  who  on  the  golf 
links  throws  down  the  club  and  cracks  the  air  with 
verbal  utterance.  It  is  that  other  fellow  who  was 
frustrated  in  his  execution.  The  psychoanalyst 
tells  us  that  frustration  in  the  extrovert  or  fighting 
personality  is  the  basis  for  emotional  hypertension. 
The  introverts  who  are  frustrated  react  in  a  "draw- 
ing-away-from"  manner,  and  are  usually  the  neu- 
rotics. The  psychiatrist  and  the  psycho-analyst 
have  treated  some  cases  of  hypertension  and  from 
them  we  get  the  following:  Every  thought  has  an 
energy  component.  If  this  energy  component  does 
not  find  vent  in  physical  activity  or  the  belief  that 
this  dynamism  has  been  carried  through  to  comple- 
tion, there  is  a  build-up  of  energy  within  the  hu- 
man organism  which  is  manifested  by  high  blood 
pressure,  irritability  and  a  general  reaction  on  the 
part  of  the  individual  to  get  done  quickly  the  thing 
that  he  is  about,  for  his  unconscious  is  constantly 
calling  him  back  to  complete  a  drive  which  is,  as 
yet,  unsatisfied. 

Ayman  compared  a  large  group  of  hypertensive 
individuals  with  those  with  normal  blood  pressure. 
He  found  statistically  that  the  hypertensives  were 


SOUTHERN  MEDICINE  &■  SURGERY 


October,   1941 


impulsive,  high-strung,  quick-tempered,  sensitive 
individuals  who  were  fast  walkers,  fast  workers  and 
fast  eaters  with  large  appetites.  They  eat  more, 
they  drink  more,  they  smoke  more,  they  do  more. 
The  hypertensive  is  an  individual  who  has  put  into 
his  work  a  great  deal  of  time  and  effort.  He  will 
impress  you  with  the  fact  that  he  knows  all  the 
anwers  and  he  usually  does.  In  the  big  business 
organizations,  it  is  rare  that  we  find  hypertension 
among  the  presidents.  It  is  the  vice-presidents  or 
the  executive  managers  who  seem  to  fall  heir  to 
this  disease.  It  is  the  business  man  who  Dr.  Allen 
of  Mayo  Clinic  says  is  trying  to  beat  the  escalator. 
In  talking  to  these  people,  I  have  been  impressed 
by  what  I  wish  to  call  their  conversational  short- 
sighted point  of  view.  Dr.  Allen  puts  this  on  a 
broader  scale  and  classes  the  feature  "a  failure  to 
define  objective."  So  frequently  these  persons  are 
not  willing  to  listen.  This  one  fact  presents  the 
greatest  problem  in  therapy.  Their  mind  seems  to 
be  blocked  to  outside  knowledge.  They  must  arrive 
at  conclusions  for  themselves.  In  an  argument,  the 
objective  seems  to  be  to  convince  one  of  their  point 
of  view,  not  to  get  to  the  truth  of  the  subject. 
During  life  insurance  examinations,  these  persons 
display  a  feeling  of  irritation.  They  assume  the 
attitude  that  they  are  completely  well  and  that  the 
examination  is  a  necessary  evil.  They  are  prone  to 
under-estimate  the  severity  or  importance  of  the 
few  diseases  which  they  have  had  during  their  life- 
time, and  they  usually  have  had  but  few.  I  have 
never  felt  that  they  attempted  to  falsify  any  knowl- 
edge but  in  general  they  give  one  the  impression 
that  a  physical  examination  is  an  unnecessary  loss 
of  time  from  their  daily  activities.  To  obtain  from 
them  a  clear  and  concise  history  plus  cooperative 
physical  examination  is  one  of  the  hardest  prob- 
lems facing  the  examiner.  The  hypertensive  is  so 
prone  to  forget,  pass  over  or  belittle  that  slight 
pain  in  the  chest  while  hunting  last  fall  or  that 
attack  of  "indigestion"  when  he  was  at  the  conven- 
tion last  summer. 

He  is  a  sensitive,  head-strong  individual.  He 
doesn't  go  to  the  doctor  and  cry  on  his  shoulder 
every  time  he  has  a  little  pain  or  indigestion.  Sis- 
sies and  weaklings  do  that.  When  he  says  "Oh!  it 
was  nothing  but  indigestion;  I  was  drinking  a  little 
and  eating  too  much.  I  took  a  couple  of  doses  of 
soda;  felt  fine  the  next  day."  He  doesn't  want  to 
talk  any  more  about  it.  To  get  a  clear,  concise  re- 
mainder of  that  history  is  a  challenge  to  the  exam- 
iner, but  so  important  to  life  insurance  companies. 
It  means  the  difference  between  a  normal  life  ex- 
pectancy or  a  life  expectancy  of  but  a  few  years 
even  though  the  physical  findings  today  are  nor- 
mal. They  require  extra  time  while  examining. 
Why   were    those    tonsils    removed   after   reaching 


manhood  and  the  teeth  in  the  late  thirties  or  early 
forties?  Why  that  examination  by  Dr.  Doe?  Why 
that  unusual  vacation?  Remember  they  are  hard 
workers  who  keep  their  "nose  to  the  grindstone" 
and  any  unusual  thing  that  took  them  away  is 
worth  looking  into. 


OPHTHALMOLOGY 

Herbert  C.  Neblett,  M.  D.,  Editor,  Charlotte,  N.  C. 


WHAT  PERCENTAGE  OF  PEOPLE  ARE 
AWARE  OF  THEIR  VISUAL  DEFICIENCY? 

One  who  is  engaged  in  the  daily  practice  of  ex- 
amining eyes  must  be  impressed  with  the  large 
number  of  people  who  have  little  knowledge  of 
their  visual  loss,  or  in  other  words,  how  poorly  they 
actually  see.  The  number  is  fairly  large  when  the 
problem  is  considered  from  the  viewpoint  of  the 
whole  population  from  early  childhood  to  old  age; 
when  this  group  is  broken  up  into  age  periods,  into 
educational,  social  and  economic  classes,  the  num- 
ber in  certain  of  these  groups  is  seen  to  be  amaz- 
ingly high.  It  will  be  understood  that  this  is  not 
a  discussion  of  the  percentage  of  visual  deficiency 
in  the  population,  but  is  an  approximation  of  the 
number  of  people  who  are  not  aware  of  any  appre- 
ciable visual  deficiency  although  it  may  be  consid- 
erable when  reckoned  upon  the  percentage  stand- 
ards of  visual  efficiency. 

Vision  is  said  to  be  normal  when  a  person  can 
read  20/20  on  the  Snellen's  test  chart.  This  is 
equivalent  to  a  visual  efficiency  of  100  per  centum; 
but  there  are  a  larger  number  of  people  who  read 
20/30,  20/40,  20  60  and  20/100  or  slightly  less 
who  carry  on  their  daily  work  oblivious  of  the  fact 
that  they  have  any  limitation  of  visual  acuity.  To 
those  of  us  who  work  in  the  field  of  the  eye  and 
to  many  others  this  situation  may  appear  impossi- 
ble of  existence.  Offhand,  it  might  be  assumed  that 
a  person  should  know  if  he  does  not  see  within  the 
prescribed  limits  of  the  so-called  normal,  20/20. 
Yet,  the  occasion  arises  often  in  the  process  of  an 
eye  examination  wherein  a  patient  will  emphati- 
cally state  he  has  no  difficulty  in  seeing  and  it  is 
found  by  testing  that  his  vision  is  20/100  or  less. 
This  is  more  often  the  viewpoint  of  the  patient 
partciularly  if  he  has  good  to  fair  vision  for  near 
work.  This  is  likewise  often  true  when  vision  in 
one  eye  is  good  and  the  other  blind  or  nearly  so 
that  the  patient  is  oblivious  of  the  fact  that  he  is 
blind  in  one  eye  until  it  is  brought  to  his  attention 
by  accident  or  by  a  visual  test. 

In  grouping  these  cases  it  is  found  that  a  large 
number  of  children  of  preschool  and  school  age  up 
to  10  or  12  years  of  age  may  not  realize  their  visual 
disability  until  it  is  noticed  by   their   teacher  or 


October,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


parents  or  others.  This  is  particularly  true  in  the 
low-grade  simple  type  of  myopia  where  the  condi- 
tion began  at  an  early  age  and  progressed  by  slow 
advancement.  The  same  is  true  in  simple  hy- 
permetropia  of  the  adult  where  the  condition  is 
insidious  and  until  near  vision  becomes  blurred  at 
the  age  of  presbyopia.  In  the  better  educated 
group,  and  among  others  who  use  their  eyes  largely 
at  close  range,  clear  vision  for  distance  to  many  of 
them  is  not  a  consideration.  They  are  primarily 
concerned  with  near  vision.  Of  those  in  the  lower 
economic  and  social  scale,  who  use  their  eyes 
largely  to  determine  theri  position  in  space  and 
with  respect  to  their  daily  environment,  the  major- 
ity have  little  conception  of  very  great  visual  loss 
as  we  understand  visual  efficiency.  The  majority 
of  these  people  have  few  if  any  symptoms  as  result 
of  the  refractive  error  or  of  the  pathological 
changes  responsible  for  the  visual  loss  for  distance, 
and  apply  for  help  only  when  the  period  of  ad- 
vanced presbyopia  supervenes. 

The  problem  that  confronts  us  here  is  what  to 
do  about  the  adult  who  is  unaware  of  his  visual 
defects,  and  who,  in  his  activities  on  our  motor 
highways  and  in  our  industrial  plants,  becomes  a 
menace  to  himself  and  others.  Corrective  methods 
have  long  been  known  and  proposed  but  regulation 
and  enforcement  are  still  wanting. 


GENERAL  PRACTICE 

James    L.    Hamner,    M.  D.,    Editor,    Mannboro,    Va. 

CAUSES  OF  CANCER 

Next  in  human  interest  after  the  question:  If  a 
man  die  shall  he  live  again?,  probably  comes: 
What  is  the  cause  of  cancer?  Few  important  ques- 
tions are  susceptible  of  categorical  answer. 

Rous1  goes  into  the  causation  of  cancer  in  a  very 
helpful  way. 

Men  never  tire  of  discussing  the  relative  shares 
of  heredity  and  environment  in  making  the  indi- 
vidual what  he  is.  It  has  been  shown  that  the  ten- 
dency to  tumors  can  be  bred  in  or  out  of  animal 
families  at  will,  and  the  purposeful  utilization  of 
carcionogenic  (cancer-producing)  agents  to  pro- 
duce cancer  has  established  the  importance  of 
some  of  the  factors  which  determine  the  disease. 

High  in  the  list  is  the  presence  in  the  tissue  of 
potentialities  for  tumor  formation.  The  animal 
body  possesses  such  potentialities  in  enormous 
number,  differing  in  character  with  the  species,  and 
individuals  of  the  same  species  but  of  different 
familial  strains.  Liability  of  an  individual  to  this 
or  that  sort  of  growth  depends  first  upon  whether 
his  tissues  possess  potentialities  of  the  sort  from 


which  that  certain  growth  may  derive.  They  are 
familial;  but  whether  they  are  actually  inherited 
is  still  unsettled.  The  potentialities  of  some  strains 
of  mice  to  have  mammary  cancer  are  conferred 
after  birth,  reaching  the  young  animals  by  way  of 
the  mother's  milk. 

In  order  that  a  tumor  potentiality,  of  whatever 
sort,  may  give  rise  to  a  growth,  it  must  be  worked 
upon  by  one  or  another  of  the  many  agents  which 
we  speak  of  as  carcinogenic.  They  might  better  be 
termed  oncogenic  (tumor-producing)  agents,  since 
they  act  to  change  normal  cells  into  sarcoma  cells, 
endothelioma  cells,  leukemia  cells,  and  so  forth,  as 
well  as  into  cancer  cells. 

Often  the  cell  that  has  been  converted  into  a 
tumor  cell  by  a  carcinogen  becomes  at  once  a  going 
concern;  it  proliferates  and  a  benign  or  malignant 
growth  is  the  result.  But  in  many  cases  the  cell, 
though  rendered  neoplastic,  requires  aid  if  it  is  to 
assert  itself. 

Intercurrent  infection  with  bacteria  often  makes 
a  cancer  more  malignant.  Recently  it  has  been 
found  that  secondary  infection  with  a  virus  caus- 
ing cell  proliferation  may  convert  benign  tumors 
(of  unknown  cause)  into  malignant  tumors;  also 
that  such  infection  may  cause  growths  that  are  pri- 
marily cancerous  to  grow  much  faster  and  assume 
a  different  form. 

Cancer  is  almost  always  the  consequence  of 
many  conditions  and  circumstances  working  to- 
gether for  ill.  The  omission  of  a  single  one  of  these 
factors  may  mean  that  the  disease  will  not  occur. 
In  such  instances  the  missing  factor  must  be  re- 
garded as  the  determining  cause  of  cancer.  Yet 
though  this  is  the  case  it  can  not  be  deemed  the 
actuating  cause  of  the  tumor.  Given  all  necessary 
determining,  contributing  conditions,  what  makes 
a  cell  a  cancer  cell?  To  trace  down  in  the  individ- 
ual case  each  and  all  of  these  responsible  influ- 
ences should  be  the  aim  of  laboratory  worker  and 
clinician  alike. 

The  great  number  of  agents  now  known  which 
cause  cancer,  compared  with  one  another,  are  seen 
to  be  widely  diverse  in  character,  having  little  in 
common  except  their  results.  Yet  one  can  often 
be  substituted  for  another  during  the  long  process 
of  eliciting  cancer,  or  their  actions  can  be  sum- 
mated,  facts  which  indicate  that  they  work  in  the 
same  way  on  the  cells  they  render  neoplastic.  Yet 
they  are  notably  non-specific.  Acting  upon  differ- 
ent kinds  of  animals  or  upon  those  of  one  kind  but 
of  different  familiar  strains,  they  call  forth  tumors 
characteristic,  not  of  the  carcinogen,  but  of  the 
species  or  strain.  Some  of  the  hormones,  when 
present  in  excess,  may  bring  about  changes  in  the 
tissues  on  which  they  act  which  result  in  cancer. 


SOUTHERN  MEDICINE  &  SURGERY 


October,   1941 


Yet  while  substances  formed  within  the  organism 
may  call  forth  tumors,  it  does  not  follow  that  they 
are  the  intrinsic  cause.  Indeed  the  evidence  is 
against  this. 

All  of  the  carcinogens  except  the  tumor-produc- 
ing viruses  vanish  from  the  growths  they  have  en- 
gendered as  these  enlarge,  and  from  the  tumor 
tissue  nothing  resembling  them  which  will  directly 
produce  cancer  can  be  extracted.  The  generality 
of  the  carcinogens  act  indirectly  by  producing 
chronic  tissue  disturbance  on  the  basis  of  which 
tumors  may  arise;  but  they  do  so  only  if  the  tissue 
in  question  possesses  potentialities  for  their  forma- 
tion, these  differing  with  the  species  and  the  fam- 
ily. None  of  the  potentialities  would  ever  become 
a  reality  were  it  not  worked  upon  by  one  or  an- 
other of  the  numerous  agents,  existing  in  nature  or 
produced  in  the  laboratory,  which  have  the  ability 
to  evoke  tumors.  The  agent,  having  done  its  work, 
disappears  from  the  scene. 

The  action  of  viruses  to  evoke  tumors  is  of  quite 
another  kind.  The  neoplastic  viruses  are  not  de- 
pendent for  their  effects  upon  such  tumor  potenti- 
alities as  the  tissue  may  happen  to  possess  but 
they  provide  their  own,  directly  inducing  neoplastic 
change  of  the  cells  upon  which  they  act  and  deter- 
mining the  kind  of  tumor  that  results.  They  ac- 
company the  eels  which  they  have  rendered  neo- 
plastic as  these  multiply  into  tumors,  increase  in 
amount  in  association  with  them,  go  along  with  the 
tumor  tissue  when  this  is  transplanted  into  new 
hosts,  and  can  often  be  recovered  from  it  in  a  state 
to  produce  tumors  of  precisely  the  same  kind  on 
introduction  into  other  individuals.  When  they 
can  not  be  recovered,  their  presence  can  be  dem- 
onstrated obliquely,  as  for  example  by  serological 
tests. 

Though  only  a  few  tumor-producing  viruses  have 
been  discovered,  they  command  attention  as  consti- 
tuting the  only  direct  causes  for  neoplasms  that  are 
now  known.  The  sporadic  incidence  of  human  tu- 
mors decisively  rules  out  the  possibility  that  they 
are  consequent  upon  the  direct  transmission  of 
viruses  from  individuals  carrying  them.  The  lia- 
bility to  mammary  cancer  of  some  strains  of  mice 
is  conferred  on  the  suckling  young  by  way  of  the 
milk;  and  evidence  has  accumulated  that  the  ani- 
mal body  contains  resident  viruses,  just  as  it  con- 
tains resident  bacteria,  which  ordinarily  do  no 
harm.  These  viruses  gaining  entrance  to  the  body, 
perhaps  shortly  after  birth,  may  persist  in  associa- 
tion with  the  cells  of  this  or  that  organ,  and  pro- 
duce no  injury  unless  subjected  to  exceptional  con- 
ditions such  as  the  influence  of  the  carcinogens  can 
provide. 

That  this  much  of  a  positive  character  has  been 
learned  about  cancer,  causation  is  indeed  encour- 


aging. With  this  knowledge  we  can  give  an  answer 
to  those  who  inquire  petulantly:  Why  is  it  you 
doctors  have  never  found  out  anything  about  can- 
cer? And  with  this  knowledge  we  can  save  the 
lives  of  some  of  our  patients  by  cure  and  of  some 
of  them  by  prevention. 


CLINICAL    CHEMISTRY   AND 
MICROSCOPY 

For  this  issue  W.  C.  Thomas,  M.D..  Winston-Salem.  N.  C. 


A  SIMPLE  TEST  OF  CALCIUM  UNBALANCE 
IN  THE  BODY 

The  diseases  involving  disturbances  in  calcium 
metabolism  in  the  body  have  been  investigated  by 
a  great  number  of  men  during  the  past  decade. 
Calcium,  phosphorus,  parathyroid  hormone,  phos- 
phatase, Vitamin  D,  and  serum  protein  have  all 
been  the  subjects  of  unnumbered  experiments. 
The  literature  has  abounded  in  presentations  of  the 
results  of  the  work. 

With  the  advance  in  the  experimental  phases  of 
study,  clinicians  started  to  apply  the  comprehen- 
sive methods  worked  out  upon  some  of  their  ob- 
scure and  distressing  problems.  The  results  were 
promising.  One  investigator,  for  example,  found 
that  from  three  to  five  per  cent  of  renal  stones 
were  caused  by  hyperparathyroidism  and  that  cura- 
tive therapy  should  be  directed  at  the  parathyroid 
glands.  Other  equally  persistent  conditions  were 
found  to  be  based  on  calcium  imbalance.  So 
it  behooves  us  to  seek  out  means  of  diagnosing 
this  underlying  pathologic  state. 

Unfortunately,  because  of  inadequate  chemical 
laboratory  facilities  or  because  of  the  desire  to 
spare  the  patient  the  added  expense  of  such  an 
examination,  there  is  a  tendency  to  forego  complete 
diagnostic  study  in  disorders  of  calcium  metabol- 
ism. And  perhaps  justifiably  so  because  of  the 
expense  and  technical  difficulties  involved.  Recently, 
however,  in  reading  one  of  the  newer  books  on 
endocrinology1,  I  found  mention  made  of  a  test 
which  places  in  the  hands  of  every  practitioner  a 
valuable  weapon  for  his  diagnostic  armamen- 
tarium. 

The  test  was  described  by  Sulkovitch  and  it 
bears  his  name.  It  depends  upon  the  fundamental 
fact  that  variation  in  the  level  of  the  blood  calcium 
is  reflected  in  the  renal  excretion  of  the  substance 
in  the  urine.  So  a  high  calcium  content  of  the 
blood  is  revealed  by  a  high  calcium  content  of 
the  urine. 

THE  SULKOYTTCH  REAGENT 

Oxalic  acid 7.5  grams   (dissolve  in  water) 

Ammonium   oxalate....     2.5   urams   (dissolve  in   water).... 

Glacial    acetic    acid...     5.0  cc. 

Water    q.s.    ad 150.0  cc. 


October,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


The  solid  constituents  should  be  dissolved  in  water 
separately  and  then  the  entire  amount  diluted  with  water 
to  150  c.c. 

THE  TEST 
Add   two   cubic  centimeters   of   freshly   voided   urine   to 
an  equal  amount  of  the  reagent  as  prepared  above. 
INTERPRETATION 
Fine  White  Cloud —  indicates  a  probable  normal  level  of 
the  blood  calcium — between  9-11  mgms.  %. 

Heavy  White  Precipitate —  indicates  a  probable  level  of 
the  blood  calcium  over  11  mgms.  %. 

Failure  of  a  Cloud  to  Form —  indicates  a  level  between 
5-7.5  mgms.  %. 

USE 

1.  In  Diagnosis:.  In  those  patients  suspected  of  having 
an  upset  calcium  metabolism  in  which  an  inexpensive  and 
easily  performed  determination  of  the  relative  status  of  the 
blood  calcium  is  desired.  The  finding  of  an  altered  state 
is  then  an  indication  to  bring  into  play  more  extensive 
studies. 

2.  In  Following  Therapy:  t'here  a  potent  drug  such  as 
dihydrotachysterol  is  used  to  elevate  the  blood  calcium. 
it  is  very  important  to  avoid  any  abnormal  rise  in  the 
blood  calcium,  level.  The  Sulkovitch  test  is  a  very  simple 
method  of  doing  this.  It  is  quite  simple  to  instruct  the 
patient  in  its  use  so  that  he  may  safeguard  his  course 
of  therapy. 


1.  Grollman,    A.,    Essentials    of   Endocrinology,    J.    B.    Li] 
cott  and   Company,    1941 


GENERAL  PRACTICE 

Walter  J.  Lackey,  M.D.  Editor,  Fallston,  N.  C. 


MASSIVE-DOSE   ARSENOTHERAPY  OF 

EARLY  SYPHILIS  BY  INTRAVENOUS 
DRIP  METHOD 

The  accepted  method  of  treating  syphilis  is 
long-continued  and  expensive.  The  long  period  of 
treatment  makes  it  next  to  impossible  to  keep  the 
fact  that  a  certain  individual  has  syphilis  a  secret; 
or  to  effect  more  than  a  haphazard  check  of  spread 
of  the  disease.  A  method  of  rapid  cure  which 
would  sacrifice  nothing  of  safety  or  effectiveness 
would  be  a  boon  to  society. 

Promising  results  are  reported1  from  treatment 
of  a  large  enough  number  of  patients  over  a  long 
enough  time  to  carry  weight. 

Group  1,  studied  in  1933,  consisted  of  25  pa- 
tients, who  were  given  an  average  of  4  Gm.  of 
neoarsphenamine  over  the  course  of  five  days. 

Group  2,  studied  in  1938,  comprised  86  men 
treated  in  the  same  manner. 

Groups  1  and  2  constitute  the  neoarsphenamine 
series  of  1 1 1  patients. 

Group  3,  studied  in  1938  and  1939,  included  157 
patients.  These  men  received  mapharsen  in  doses 
varying  between  400  and  1,100  mg.,  average  700 
mg. 

Group  4,  118  patients  treated  late  in  1939  and 
early  in  1940,  received  1,200  mg.  of  mapharsen. 
Four  are  also  reported  in  the  neoarsphenamine  se- 
ries.   They  were  re-treated  with  mapharsen:  3  for 

1.  Win.  Leifer  at  al,  New  York,  in  //.  A.  M.  A.,  Oct.  4th. 


reinfections  and  1  for  infectious  relapse. 

Neoarsphenamine  was  abandoned  because  of  a 
fatal  complication  of  treatment  and  the  high  inci- 
dence of  peripheral  neuritis. 

In  the  earlier  mapharsen  group,  the  frequent  oc- 
currence of  infectious  relapse  and  the  low  inci- 
dence of  toxicologic  manifestations  led  to  a  gradual 
increase  of  the  dose.  The  initial  amount  of  400 
mg.  was  increased  to  what  seemed  a  safe  and  opti- 
mal total  of  1,200  mg.  administered  over  the  course 
of  five  days.  Group  3  includes  the  patients  who 
were  given  less  than  the  optimal,  safe  dose  of  1,200 
mg.  Group  4  includes  all  who  received  the  optimal 
amount. 

The  ages  of  the  patients  varied  from  13  to  56. 
Forty-six  (12%)  on  admission  were  in  the  sero- 
negative primary  stage.  The  diagnosis  of  syphilis 
in  each  of  these  was  established  by  dark-field  ex- 
aminations. 

In  a  series  of  382  cases  there  was  1  death  from 
treatment.  No  deaths  occurred  with  mapharsen. 
The  minor  toxicologic  phenomena  included  local 
reactions,  primary  and  secondary  fever,  toxicoder- 
mas,  nausea  and  vomiting.  Peripheral  neuritis  oc- 
curred in  one-third  of  the  patients  who  received 
neoarsphenamine,  in  a  negligible  number  of  mild 
paresthesias  in  the  mapharsen  series.  Of  the  grave 
phhenomena  only  the  cerebral  symptoms  were  en- 
countered in  1.8%  of  the  neoarsphenamine  series 
and  in  1.1%  of  the  mapharsen  series. 

Classifying  as  unfavorable  all  questionable  re- 
sults, we  find  that  81%  of  the  patients  had  a  com- 
pletely satisfactory  course.  Including  favorable  re- 
sults from  re-treatment  in  an  additional  15  cases, 
the  total  number  of  satisfactory  results  approxi- 
mates 88%  for  the  entire  series.  With  a  single  ex- 
ception, the  spinal  fluid  of  every  patient  has  be- 
come completely  clear. 

With  the  exception  of  the  infectious  relapse  at 
the  site  of  the  original  inoculation,  no  organic  man- 
ifestation of  syphilis  has  been  noted.  The  patients 
of  series  1  were  re-examined  at  the  end  of  five 
years,  and  many  of  the  patients  of  series  2  have 
passed  three  years  of  observation. 

The  irrevocable  failures  approximate  5%.  A 
definitive  policy  for  re-treatment  might  have  ap- 
preciably lowered  this  percentage. 

The  treatment  of  the  41  patients  with  seronega- 
tive primary  syphilis,  2  of  whom  were  re-treated 
with  massive  dose  of  arsenotherapy,  was  100%  sat- 
isfactory. 

Polyembryony  or  the  development  of  more  than  one 
embryo  from  a  single  egg  is  a  characteristic  found  in  vary- 
ing degrees  in  many  groups  of  animals.  The  identical 
twins,  triplets,  quads,  quints,  and  sextuplets  of  man  are 
representative  of  this  phenomenon.  Polyembryony,  how- 
ever, attains  its  climax  among  the  ants,  bees,  and  wasps. — 
Ciba  Symposia. 


568 


SOUTHERN  MEDICINE  &  SURGERY 


October,    1941 


SOUTHERN  MEDICINE  &  SURGERY 

Official  Organ 

TRI-STATE  MEDICAL  ASSOCIATION  OF  THE 
CAROLINAS  AND  VIRGINIA 

James  M.  Northington,  M.D.,  Editor 

Department  Editors 

Human  Behavior 

James  K.  Hall,  M.D Richmond,  Va. 

Orthopedic  Surgery 
William  Tate  Graham,  M.D Richmond,  Va. 

Urology 

Raymond  Thompson,  M.D Charlotte,  N.  C. 

Surgery 

Geo.  H.  Bunch,  M.D Columbia,  S.  C. 

Obstetrics 

Henry  J.  Lancston,  M.D Danville,  Va. 

Ivan  M.  Procter,  M.D Raleigh,  N.  C. 

Gynecology 

Chas.  R.  Robins,  M.D Richmond,  Va. 

G.  Carlyle  Cooke,  M.D Winston-Salem,  N.  C. 

Pediatrics 

G.  W.  Kutscher,  Jr.,  M.D Asheville,  N.  C. 

General  Practice 

J.  L.  Hamner,  M.D Mannboro,  Va. 

W.  J.  Lackey,  M.D Fallston,  N.  C. 

Clinical  Chemistry  and  Microscopy 

C.  C.  Carpenter,  M.D.  I  ....     ,       _  ,         XT    _ 

>  Winston-halem,  N  C 
R.  P.  Morehead,  B.S.,  M.A.,  M.D.  | 

Hospitals 

R.  B.  Davis,  M.D Greensboro,  N.  C. 

Cardiology 

Clyde  M.  Gilmore,  A.B.,  M.D Greensboro,  N.  C. 

Public  Health 

N.  Thos.  Ennett,  M.D Greenville,  N.  C. 

Radiology 
Wright  Clarkson,  M.D.,  and  Associates.. ..Petersburg,  Va. 

R.  H.  Lafferty,  M.D.,  and  Associates Charlotte,  N.  C. 

Therapeutics 

J.  F.  Nash,  M.D Saint  Pauls,  N.  C. 

Tuberculosis 

John  Donnelly,  M.D Charlotte,  N.  C. 

Dentistry 

J.  H.  Guion,  D.D.S Charlotte,  N.  C. 

Internal  Medicine 

George  R.  Wilkinson,  M.D Greenville,  S.  C. 

Ophthalmology 

Herbert  C.  Neblett,  M.D Charlotte,  N.  C. 

Rhino-Oto-Laryngology 

Clay  W.  Evatt,  M.D Charleston,  S.  C. 

Proctology 

Russell  von  L.  Buxton,  M.D Newport  News,  Va. 

Insurance  Medicine 

H.  F.  Starr,  M.D Greensboro,  N.  C. 

Dermatology 
J.  Lamar  Calloway,  M.D Durham,  N.  C. 

Offerings  for  the  pages  of  this  Journal  are  requested  and 
given  careful  consideration  in  each  case.  Manuscripts  not 
found  suitable  for  our  use  will  not  be  returned  unles  author 
encloses  postage. 

As  is  true  of  most  Medical  Journals,  all  costs  of  cuts, 
etc.,  for  illustrating  an  article  must  be  borne  by  the  author. 


INTERESTING  AND   INSTRUCTIVE  BITS 

FOUND  IN  ABSTRACT  OF  THE 

SCIENCES— 1858-1859 

From  Medical  Times  &■  Gazette,  London:   A  CASE  OF 

labor- 
Two  ounces  of  chloroform  had  been  given 
during  the  Saturday  and  Sunday.  Once  the  patient 
was  nearly  insensible.  On  inquiry  why  this  had 
been  done,  the  medical  attendant  stated  that  he 
did  not  approve  of  it,  but  the  patient  insisted  upon 
having  it.  She  informed  me  that  a  lady  of  her  ac- 
quaintance was  attended  by  "a  chloroform  doctor,'' 
and  that  she  had,  in  consequence  of  this,  contrary 
to  the  advise  of  her  medical  attendant,  insisted 
upon  taking  it.  It  appeared  almost  certain  that  if 
he  had  not  yielded  to  the  wishes  of  his  patient,  she 
would  have  placed  herself  in  other  hands. 

Evidently  there  were  patients  in  those  days,  too, 
who  decided  for  themselves,  and  on  the  advice  of 
neighbors,  what  manner  of  treatment  they  would 
have. 

Dr.  Robert  Hunter  Semple.  in  his  book  on  COUGH 
18S8: 

I  can  not  refrain  from  expressing  an  opinion 
upon  the  propriety  of  sending  away  a  consumptive 
patient  to  a  distant  land,  in  the  hope  of  curing  the 
disease  in  his  lungs.  My  conviction  is  that  not 
only  very  little  good,  but  very  much  harm,  is  gen- 
erally done  by  such  a  proceeding.  A  patient  is  too 
often  torn  away  from  his  home  and  his  relatives, 
to  perish  in  a  foreign  soil:  or,  after  a  brief  sojourn 
in  the  land  of  his  banishment,  to  return  in  a  worse 
condition  than  when  he  went  away.  When  the 
patients  are  fond  of  travelling,  are  able  to  bear  the 
expense  of  it,  and  can  carry  their  relatives  and 
their  household  with  them,  there  may  be  an  ad- 
vantage in  a  trip  to  the  Mediterranean,  or  a  resi- 
dence in  the  south  of  France,  or  a  tour  in  Egypt; 
but,  in  the  great  majority  of  cases,  our  own  coun- 
try affords  as  much  physical  benefit  to  the  sufferer, 
and  is  perhaps  far  more  congenial  to  his  sentiments 
and  his  affections,  not  to  mention  pecuniary  and 
other  domestic  considerations. 

To  mock  the  sufferings  of  a  dying  patient,  by 
the  administration  of  inert  and  useless  globules, 
while  the  adoption  of  a  rational  and  vigorous  plan 
of  treatment  might  restore  him  to  life,  appears  to 
me  to  be  nothing  less  than  to  ridicule  human  mis- 
ery, and  to  welcome  the  approach  of  the  Angel  of 
Death.  I  can  only  hope  that  if  any  honest  homoe- 
path  (if  there  be  such  a  person)  should  meet  with 
a  case  of  acute  laryngitis,  he  would,  at  least  for  the 
occasion,  renounce  his  creed,  and  prefer  the  sacri- 
fice of  a  dogma   to   the  destruction  of  a   fellow- 


October,    1941 


SOUTHERN  MEDICINE  &  SURGERY 


S69 


creature.  I  bv  no  means  coincide  in  the  view  of 
those  that  believe  that  because  bleeding  is  not  gen- 
erallv  so  well  borne  as  it  formerly  was,  therefore 
all  bleeding  and  all  depletion  are  injurious.  I  be- 
lieve, on  the  contrary,  that  in  certain  cases  the 
abstraction  of  blood  is  not  only  justifiable  but  is 
imperativelv  demanded,  and  that  acute  laryngitis 
is  a  case  in  point. 

The  good  doctor  had  the  sense  to  take  into 
consideration  all  the  circumstances  of  the  case  and 
to  individualize,  and  to  put  himself  in  the  place  of 
the  patient. 

From  the  Deutsche  Klinik:  TREATMENT  OF  BURNS 
BY  WARM  BATHS— 

Dr.  Passavant's  experiments  were  made  in  the 
hospital  at  Frankfort  upon  eighteen  persons  who 
had  been  all  more  or  less  seriously  burnt  in  the 
explosion  of  a  firework  manufactory.  The  water, 
which  was  changed  twice  a  day,  or  oftener  if  the 
suppuration  was  abundant,  was  kept  at  27°  Reau- 
mur (93°  F.)  and  at  the  end  of  some  weeks, 
when  the  patients  had  become  tired  of  them,  the 
baths  were  changed  for  fomentations.  Under  their 
use  pain  and  inflammation  very  soon  came  to  an 
end:  the  hardened  tissues  became  soft,  and  the 
eschars  separated  readily;  the  chances  of  irritation 
and  purulent  absorption  became  greatly  diminish- 
ed: and  cicatrization  proceeded  more  rapidly. 

From  Comptes  Rendues:  TREATMENT  OF  WOUNDS 
AND  ULCERS  BY  VENTILATION— 

By  means  of  an  ordinary  bellows,  or  by  some 
special  contrivance  for  producing  a  draught  of  air, 
Dr.  Bonisson  dries  up  the  effused  fluid  and  obtains 
in  this  manner  a  crust  by  which  the  wounds  or 
ulcers  are  covered  and  protected.  The  process  of 
healing,  he  tells  us,  advances  more  favorably,  and 
more  rapidly  under  these  circumstances — subcrus- 
tean  cicatrization  being  to  open  wounds  what  sub- 
cutaneous cicatrization  is  for  closed  wounds.  One 
of  the  advantages  of  this  plan  is  the  saving  which 
it  effects  in  charpie  and  other  dressings. 

From  Glasgow  Medical  Journal:  ON  SHORTENING 
THE  DURATION  OF  LABOR  BY  EXCITATION  OF 
THE  NIPPLES— 

In  order  to  increase  the  action  of  the  uterus, 
and  therebv  hasten  delivery,  Dr.  J.  Gray  advises 
us  to  excite  the  nipple  as  a  labor-pain  comes  on, 
and  continue  the  stimulation  so  long  as  it  lasts. 
This  is  accomplished  by  passing  the  left  hand  gent- 
ly but  continuously  upwards  and  downwards  over 
one  or  other  of  the  nipples;  or  by  simulating  with 
the  fingers  the  act  of  sucking  of  the  infant.  By 
such  manipulation,  he  says,  the  nipple  erects,  and, 
in  virtue  of  reflex  action,  the  uterine  contractions 
increase  in  force;  while  at  the  same  time  the  os 
dilates,  and  the  external  parts  become  relaxed.  Be- 


sides shortening  the  duration  of  labor,  he  finds  it 
has  also  the  effect  of  preventing  hemorrhage.  The 
second  stage  of  labor  completed,  if  the  placenta  be 
not  in  the  passage,  he  still  maintains  at  short  inter, 
vals  the  friction  over  the  nipple,  in  order  that  the 
uterus  may  expel  its  contents;  and  also  resorts  to 
it  in  cases  where  he  has  occasion  to  fear  flooding. 
If,  I  inquired,  the  application  of  the  child  to  the 
breasts  causes  the  womb  forcibly  to  contract,  and 
thus  prevents  flooding,  may  not  a  similar  operation 
artifically  performed  have  the  same  effect  in  pro- 
moting the  contractile  efforts  of  the  uterus  and 
hastening  the  delivery?  That  it  does  so,  very  am- 
ple trial  has  fully  convinced  me.  I  never,  however, 
be  it  remembered,  interfere  in  those  cases  where 
there  are  already  active  uterine  contractions. 

Certainly  this  sounds  sensible.  It  seems  remark- 
able that  numerous  accounts  are  not  to  be  found 
of  trial  of  this  plan,  whether  the  plan  met  with 
success  or  failure. 

From  Medical  Times  &  Gazette,  London:  ON  DELIV- 
ery by  turning  as  a  general  rule  in 
labor- 
Mr.  Figg  attempts  to  show,  not  only  that  de- 
livery by  turning  is  preferable  to  delivery  by  for- 
ceps in  cases  requiring  operative  interference,  but 
that  turning  is  the  rule  to  be  adopted  in  general 
cases.  He  tells  us  that  he  has  attended  sixty  labors 
since  writing  these  papers,  that  only  thre«  of  these 
were  conducted  as  head  presentations,  and  that  of 
the  remainder  two  were  breech  presentations,  and 
fifty-five  delivered  by  turning.  As  the  results  of 
this  astonishing  practice  we  leave  Mr.  Figg  to 
speak  for  himself: 

"With  regard  to  the  children,  they  are  generally 
still  from  two  to  five  minutes,  and  in  some  cases 
for  half  an  hour's  duration.  I  confess  with  hu- 
mility that  I  have  even  broken  four  arms,  which, 
though  they  occurred  in  cases  of  great  pelvic  con- 
traction were  attributable  to  my  own  mismanage- 
ment in  pressing  over  the  shaft  of  the  os  humeri 
instead  of  following  its  line  to  the  elbow.  Should 
you  commit  the  same  error,  with  similar  result,  be 
not  too  candid  to  the  relatives,  but  at  once  by 
your  own  dictum  transubstantiate  the  injury  into 
a  slight  sprain  received  by  the  infant  striking  its 
shoulder  against  the  backbone  of  the  mother  while 
actively  prosecuting  his  uterine  gambols.  It  will 
pass  current,  more  especially  if  you  appeal  to  her 
experience,  when  it  is  sure  to  be  corroborated  by 
a  quotation  of  the  day  and  hour  of  the  occurrence. 
Two  slips  of  pasteboard  applied,  with  a  strip  of 
calico  a  yard  long,  remedies  the  evil  in  ten  days." 
"The  operation  was  ancient,  but  nearly  obsolete, 
and  its  revival  by  Dr.  Simpson  in  particular  cir- 
cumstances led  to  my  adoption  of  it  in  general 
cases." 


SOUTHERN  MEDICINE  &  SURGERY 


October.    1941 


In  a  later  communication,  written  chiefly  as  an 
answer  to  the  strong  objections  of  Drs.  Robt.  Lee, 
Ramsbotham,  and  Oldham,  are  the  following  pas- 
sages: "Permit  me,"  says  Mr.  Figg,  "with  humil- 
ity to  observe,  that  while  physiology,  anatomy,  and 
analogy  enable  me  to  concoct  as  rational  a  theory 
for  the  operation  as  they  can  against  it,  I  bring 
forward  a  formidable  ally  to  my  cause  in  nearly 
eighty-seven  consecutive  cases  of  perfect  convales- 
cence in  mother  and  child,  without  adverting  to  a 
still  greater  number  of  successful  instances  effected 
at  various  intervals  antecedently.  Do  these  gen- 
tlemen impugn  mv  veracity?  Let  them  depute  any 
member  of  the  profession  resident  either  in  Edin- 
burgh, Glasgow,  or  London,  to  visit  the  locality  of 
my  residence,  and  by  impartial  inquiry  of  my  pa- 
tients prove  its  immunity  from  danger  and  their 
satisfaction  as  to  its  adoption."  And  again:  "While 
mv  deliveries  average  two  per  week,  I  have  had  but 
one  death  during  the  year — the  second  child  of  a 
woman  aged  45,  born  to  a  second  husband  after  a 
widowhood  of  fourteen  years." 

Anticipating  obstetrician  Potter,  of  Buffalo, 
by  some  seventy  years. 

From  Gazette  des  Hopiteaux,  Paris:  SUPRAPUBIC 
PUNCTURE  OF  THE  BLADDER— 

A  discussion  upon  this  operation  recently  arose 
at  the  Paris  Surgical  Societv  on  the  occasion  of  the 
presentation  of  a  memoir  by  M.  Fleury,  in  which 
he  stated  that  he  had  often  performed  the  opera- 
tion with  success,  and  considered  it  a  very  easy 
one. 

M.  Chassaignac  said  when  the  abdominal  parie- 
tes  are  very  thin,  and  the  bladder  is  much  dis- 
tended, few  precautions  are  necessary:  but  in  very 
fat  or  verv  muscular  subjects  we  have  then  to  em- 
ploy a  very  long  trocar,  and  to  plunge  it  in  very 
deeply:  and  there  is  danger  of  wounding  the  op- 
posite side  of  the  bladder. 

M.  Lobert  considered  puncture  of  the  bladder  as 
preferable  to  forced  catheterism.  He  leaves  in  the 
canula  for  a  fortnight,  and  then  substitutes  a 
caoutchouc  tube.  He  observed,  also,  that  the  urine 
should  not  be  allowed  to  run  continuously  from  the 
canula.  This  should  be  plugged,  and  only  opened 
every  three  or  four  hours;  otherwise  the  bladder, 
contracting  too  readily  upon  itself,  may  abandon 
the  canula. 

M.  Deguise  could  not  understand  how  anv  diffi- 
culty could  arise  in  introducing  a  catheter  bv  the 
track  of  a  canula  that  had  remained  in  situ  for 
eight  days.  He  introduced  a  catheter  on  the  first 
day.  and  changed  it  on  the  third  or  fourth,  and  he 
had  never  found  any  difficulty  in  so  doing.  He 
considered  the  operation  a  very  easy  one,  provid- 
ing that  a  preliminary  incision  be  made  down  to 


the  linea  alba.  He  employs  a  straight  canula.  The 
trocar  is  to  be  introduced  horizontally,  and  a  gum- 
elastic  catheter  is  to  be  passed  into  the  canula  im- 
mediately on  the  withdrawal  of  the  stiletto,  and 
to  be  fixed  in  situ  when  the  canula  has  been  slid 
awav  upon  it. 

The  stylet,  enclosed  in  the  canula  should  be 
passed  horizontally  above  the  pubis,  instead  of,  as 
is  usually  directed,  downwards  and  backwards. 

It  is  to  be  wondered  whether  or  not  today  supra- 
pubic puncture  could  be  used  much  oftener  to  the 
advantage  of  patients  and  attendants. 


THE  -DISGRACEFUL"  SHOWING  OF  OUR 
YOUNG  MEN 

It  could  have  been  foreseen  that  those  who  have 
never  been  able  to  find  anything  good  in  the  pres- 
ent system  of  rendering  medical  care  would  cry  out 
to  high  heaven  about  the  "disgraceful"  state  of 
health  of  the  nation,  "as  revealed  by  the  enormous 
number"— 30  to  40  to  50% — "of  rejections  for 
army  service." 

The  greater  part  of  the  disgrace  in  this  connec- 
tion lies  in  the  disgraceful  ignorance  of  those  who 
have  never  been  able  to  learn — 

"Whoso  thinks  a  perfect  piece  to  see. 

Thinks  what  ne'er  was,  nor  is,  nor  e'er  shall  be." 

The  great  majority  of  those  who  have  fallen 
short  of  Army,  Navy  and  Air  Service  requirements 
are  gladlv  accepted  as  first-class  risks  by  our  best 
insurance  companies;  and  insurance  companies  are 
not  in  business  to  lose  money,  and  they  know  more 
about  life  expectancy  and  useful  work  expectancy 
than  does  any  other  group. 

One  might  think  from  the  number  of  rejections 
because  of  eye  or  tooth  imperfections  that  modern 
soldiers  are  supposed  to  destroy  the  enemy  with  the 
glare  of  a  Basilisk,  or  to  bite  them  to  death. 

The  most  absurd  of  many  absurd  rulings  is  that 
which  rejects  men  who  have  early  syphilis.  Accept- 
ance would  provide  the  ideal  conditions  for  treating 
the  disease  until  it  is  cured.  There  would  be  no 
risk  of  transmitting  the  disease  to  another  soldier. 
The  syphilitic  soldier  under  treatment  could  render 
just  as  good  service  as  the  nonsyphilitic. 

It  should  astonish  no  one  (1)  that  perfection  is 
a  hope,  not  a  fact;  (2)  that  a  famous  oculist  said 
after  dozens  i  of  years  of  practice  that  he  had  never 
seen  a  pair  of  eyes  capable,  unaided,  of  errorless 
vision;  or  (3)  that  at  least  95  rr  of  us  have  decay- 
ing teeth. 

It  should  astonish  us  that  Governmental  regula- 
tions apparently  are  made  by  persons  who  do  not 
take  it  into  consideration  that  usability,  not  per- 
fection, is  what  we  need  in  our  sooldiers,  and  that 
George  Washington   made   a   pretty   good   soldier 


October.   1941 


SOUTHERN  MEDICINE  &  SURGERY 


S71 


and  died  well  nourished  despite  the  handicaps  of 
a  set  of  false  teeth  good  only  for  dress  occasions, 
and  that  he  had  to  gum  his  meat  for  many  a  long 
vear. 


NEWS 


MIGHT  SAVE  YOU  MONEY 

State  of 

Xorth  Carolina  Before 

County  Justice  of  the  Peace 


Plaintiff, 

SUPERSEDEAS   BOND 


Defendant. 
Whereas  on  the  day  of  , 

the  above  named  plaintiff  recovered  judgment 
aaginst  the  defendant  in  this  Court  for  the  sum 
of  $  and  for  the  costs  of  suit: 

And  whereas  the  defendant  has  appealed  from 
the  said  judgment  to  the  Supreme  Court  of 
,  County: 
Xow,  therefore,  we  and 

suant  to  the  statute,  that  if  judgment  is  rendered 
of  of  the  County 

,  State  of  North  Carolina,  undertake,  pur- 
against  the  defendant  in  the  Superior  Court,  we 
will  pay  the  judgment  together  with  all  costs 
awarded  against  the  defendant. 

(SEAL) 

(SEAL) 

,   above   named 

being  sworn,  says  that  he  is  a  resident  and  free- 
holder in  the  State  of  North  Carolina,  and  worth 
double  the  sum  specified  in  the  above  undertaking 
over  and  above  all  his  debts  and  liabilities  and  ex- 
clusive of  property  exempt  from  execution. 


Sworn  to  and  subscribed  before  me, 
day  of 


this. 


Bond  Approved 


Justice  of  the  Peace. 


Justice  of  the  Peace. 

A  doctor  friend  had  occasion  to  appeal  from  a 
magistrate's  preposterous  decision  recently  and,  be- 
cause he  did  not  know  how  to  draw  a  bond  and 
could  not  purchase  such  a  blank  form,  he  had  to 
pay  a  lawyer  S3. 00  to  write  out  the  form. 

Should  any  reader  find  himself  in  such  case,  he 
can  have  his  secretary  type  off  the  form  given  be- 
low and  save  not  only  the  S3. 00  but  probably  all 
lawyer  fees  as  in  most  instances  in  which  a  plantiff 
knows  he  can  not  win  in  Superior  Court  the  case 
is  never  called  up. 


ANNUAL  MEETING  NINTH  DISTRICT,  N.  C,  MED- 
ICAL SOCIETY 

September  25,  1941,  Vance  Hotel,  Statesville. 

PROGRAM 

1.  3:00  P.  M. — Meeting  called  to  order,  by  Dr.  I.  E. 
Shafer,  District  Councillor,  Salisbury. 

2.  Invocation — Dr.  Harry  Gamble,  Statesville. 

3.  Address  of  Welcome — Dr.  M.  B.  Clayton,  Statesville. 

4.  Response  to  Address  of  Welcome — Dr.  J.  R.  Terry, 
Lexington. 

5.  Officers  Called  to  the  Chairs. 

6.  Election  of  Officers  for  1942. 

7.  Memorial  Service — Dr.  T.  V.  Goode,  Statesville. 

Papers 

1.  The  Plasma  Protein — Its  Physiology  Relative  to  the 
Normal  and  Failing  Circulation,  Dr.  F.  B.  Marsh, 
Salisbury. 

Blood  Plasma — Technical  Discussion,  Dr.  John  Elliott, 
Salisbury. 

2.  The  Etiology  and  Classification  of  Hypertension,  Dr. 
John  R.  Williams,  Winston-Salem. 

3.  The  Protection  of  the  Soldier  Against  Communicable 
Disease,  Capt.  John  W.  R.  Norton,  Fort  Bragg. 
Discussion:   Dr.  James  W.  Davis,  Statesville;   Dr.  C. 
W.  Armstrong,  Salisbury. 

4.  The  Procurement  of  Medical  Officers  for  Active  Duty 
in  the  Army,  Maj.  R.  C.  Tatum,  Headquarters,  First 
Military  Area,  Knoxville. 

5.  Modern  Concepts  of  Vitamin  Therapy,  Dr.  D.  Frank 
Milam,  Durham. 

Dinner  at  7:30. 

Toastmaster — Dr.  James  W.  Davis. 

Motion  Picture — Intravenous  Anesthesia. 

Guest  Speaker — Dr.  L.  G.  Beall,  Black  Mountain. 

Dist.  Councillor — Dr.  I.  E.  Shafer,  Salisbury. 

President — Dr.  W.  D.  McLelland,  Mooresville. 

Vice-Pres.— Dr.  S.  A.  Rhyne,  Statesville. 

Sec'y.-Treas. — Dr.  J.  Sam  Holbrook.  Statesville. 


NORTH   CAROLINA   NEUROLOGICAL   AND   PSYCH- 
IATRIC ASSOCIATION 
Meeting  at  State  Hospital,  Morganton,  October  24th 
Program 

1.  Shock  Therapy 

1.  Metrazol  Therapy— Drs.  R.  H.  Long  &  J.  R.  San- 
ders, State  Hospital. 

2.  Insulin  Therapy — Dr.  Otto  Billig,  Highlands  Hos- 
pital, Asheville. 

3.  Electro-Therapy — Drs.    Griffin    and    Griffin,    Appa- 
lachian Hall,  Asheville. 

The  subject  matter  discussed  in  this  symposium 
is  gathered  from  our  clinical  experience  over  the 
recent  years. 

Drs.  J.  G.  N.  Cushing  and  Mary  Cushing  of 
Pinebluff  Sanatorium  and  Dr.  Hans  Lowenbach  of 
Duke  Hospital  will  open  discussion  of  the  papers 
in  the  order  presented. 

2.  Changing    Trends    in    Therapy — Dr.    John    A.    Rose, 
Bowman  Gray  School  of  Medicine,  Winston-Salem. 

This  discussion  concerns  the  development  of 
direct  personal  treatment  in  the  evolution  of  child 
guidance  clinic  function,  and  also,  shows  how  this 
development  is  affecting  our  ideas  of  dealing  with 
nervous  disorders  in  adults  and  in  the  teaching  of 
clinical  psychiatry  in  medical  schools. 
Intermission — five  minutes 

3.  Encephalitis — Dr.    Paul    Kimm.?I$tiel,    Memorial   Hos- 
pital, Charlotte. 


SOUTH ERX  MEDICINE  &  SURGERY 


October,    1941 


This  discussion  will  be  from  a  pathological  point 
of  view. 

4.  Deficiency  Diseases  of  the  Nervous  System — Dr.  Leo 
Alexander,  Duke  Hospital. 

This  lecture  is  an  outline  of  the  clinical  neuro- 
psychiatric  syndromes,  physical  and  neurological 
signs,  as  well  as  of  the  correlated  pathological  and 
histological  changes,  encountered  in  patients  suffer- 
ing from  deficiency  diseases.  This  clinico-pathologi- 
cal  study  includes  those  deficiency  syndromes  which 
are  primary,  as  well  as  those  which  are  secondary 
to  alcoholism,  diabetes  or  other  intestinal  and  me- 
tabolic disorders. 

5.  Business  meeting. 

6.  Social  Hour.  Host:  Dr.  F.  B.  Watkins  and  Staff  of 
State  Hospital. 

7.  Dinner. 

8.  Round-table  discussion  of  neurological  and  psychia- 
tric examinations  of  the  Draftees.  Led  by  Dr.  J.  C. 
George.  U.  S.  M.  C,  Asheville;  and  Dr.  L.  G.  Beall. 
Black  Mountain. 

Officers 
President — Dr.   Archie  A.   Barron.  Charlotte. 
Vice-President — Dr.  F.   B.  Watkins,  Morganton. 
Secretary-  &  Treasurer — Dr.  Burke  Suitt.  Durham. 


SOUTHERN  PSYCHIATRIC  ASSOCIATION  ELECTS 
HALL 

Dr.  James  K.  Hall,  Richmond,  was  named  president- 
elected  of  the  Southern  Psychiatric  Association  and  Rich- 
mond was  selected  as  the  site  of  the  1942  convention  at 
iss  recent  meeting  at  Nashville.  The  date  of  the  conven- 
tion will  be  selected  later. 

Dr.  Whitman  McConnell.  of  St.  Petersburg,  Fla.,  was 
installed  as  president,  succeeding  Dr.  Arthur  J.  Schwenken- 
berg.  of  Dallas.  Texas. 

The  "swarms  of  hysteria  which  were  expected  to  follow" 
the  air  raids  in  the  British  Isles  have  not  developed,  al- 
though Germany's  bombings  have  caused  an  increase  in 
"certain  psychiatric  disorders."  the  association  was  told. 

The  paper  was  prepared  by  Dr.  Felix  Brown,  registrar 
in  psychological  medicine  at  Guy's  Hospi'al.  London,  and 
read  before  the  association. 


MEDICAL  SOCIETY  OF  VIRGINIA 

At  this  year's  meeting  at  Virginia  Beach  just  concluded 
Dr.  Roshier  W.  Wilier,  of  Richmond,  was  installed  as 
president  and  Dr.  J.  M.  Emmett.  of  Clifton  Forge,  was 
made  president-elect. 

Dr.  Emmett  is  a  native  of  Oxford,  N.  C.  a  graduate  of 
the  Medical  College  of  Virginia,  Richmond,  in  1915,  and 
for  a  number  of  years  maintained  an  office  at  Richmond. 

Dr.  Miller  succeeded  Dr.  Walter  B.  Martin,  of  Norfolk. 
Dr.  Martin  and  Dr.  Carrington  Williams,  of  Richmond, 
were  elected  delegates  to  the  American  Medical  Association 
meeting  in  June.  The  society  voted  to  hold  the  1942  meet- 
ing at  Roanoke  and  elected  the  following  other  officers: 

Dr.  James  W.  Anderson,  of  Norfolk,  Dr.  G.  G.  Scott, 
of  Lynchburg,  and  Dr.  J.  P.  Williams,  of  Richlands.  vice- 
presidents,  and  Miss  Agnes  Edwards  was  re-elected  secre- 
tary-treasurer. 

In  an  address  at  the  morning  session.  Commander  W.  P. 
Jackson,  of  the  United  States  Naval  Reserve,  told  the  so- 
ciety that  the  airplane  had  tremendous  potentialities  for 
spreading  disease  and  urged  careful  regulation  under  direc- 
tion of  competent  health  officers,  with  adequate  equipment 
and  personnel,  for  control. 

Slightly  more  than  half  of  the  men  in  Norfolk  who  have 
been  examined  for  military  service  have  been  rejected  as 
unfit,  Dr.  C.  Lydon  Harrell.  chairman  of  the  local  exam- 
ining beards,  told  the  convention.    Dr.  Harrell  called  the 


unusually  high  percentage  of  rejections,  here  and  elsewhere, 
"a  shame  and  a  disgrace  to  a  civilized  and  cultured  na- 
tion." "The  problem  of  defectiveness  in  our  youth  should 
be  given  careful  study  by  our  health  authorities,"  he  said, 
"and  an  effort  made  to  correct  these  defects  if  possible." 
He  also  suggested  that  it  was  unfair  to  exempt  from  mili- 
tary service  those  with  treatable  and  curable  diseases  or 
ailments.  "Why."  he  asked,  "should  those  with  reparable 
hernia  be  excused  from  service,  or  the  ones  with  well- 
fitted  artificial  teeth  or  other  minor  defective  teeth  that 
are  otherwise  physically  fit.  be  deferred?"  "Many  of  us 
think."  he  continued,  "that  the  ones  with  venereal  disease 
should  be  treated  until  they  have  passed  the  contagious 
stage,  then  be  inducted  into  service.  It  is  just  not  fair  to 
those  that  have  been  called." 


DR.  COPPEDGE  CONFIRMED 
After  much  wrangling  and  litigation.  Dr.  T.  0.  Cop- 
pedge  has  been  confirmed  as  health  officer  of  Nash  County. 
An  act  passed  by  the  last  General  Assembly  of  North 
Carolina  gave  the  commissioners  of  Nash  County  author- 
ity to  approve  or  to  disapprove  the  selection  of  the  county 
board  of  health's  appointment  of  county  physician.  After 
the  county  board  of  health  had  elected  Dr.  Coppedge 
county  physician,  the  county  commissioners  would  not 
approve  the  election.  The  majority  of  the  Supreme  C~urt 
expressed  the  opinion  that  the  state  constitution  forbids 
the  legislature  the  authority  to  enact  local  health  laws. 

Dr.  Alex  W.  Terrell,  son  of  the  late  Dr.  J.  J.  Terrell, 
who  was  known  as  "Lynchburg's  Last  Quaker"  laid  the 
cornerstone  of  the  new  Quaker  Memorial  Presbyterian 
Church  Sunday,  October  12th.  Dr.  Terrell  was  instrumen- 
tal 40  years  ago  in  having  the  present  church  built  on  the 
ruins  of  the  old  Quaker  Meeting  House  where  the  city's 
founder,  John  Lynch,  worshipped.  Dr.  Terrell  is  Lynch- 
burg's oldest  practicing  physician.  The  new  building  is 
being  erected  a  few  feet  from  the  restored  building. 


Dr.  Arthur  E.  Anderson,  of  Wilmington,  has  become 
a  member  of  the  staff  of  the  State  Hospital  at  Morganton 
as  the  first  full-time  dentist  of  that  institution. 


Dr.  Mason  I.  Lowra.nce  announces  the  removal  of  his 
offices  to  215  Doctors  Building.  Atlanta.  Internal  Medicine. 
Allergy. 


Dr.  G.  A.  Hawes  and  Dr.  Hunter  Jones,  Charlotte, 
were  guest  speakers  at  a  meeting  of  Grace  Hospital  Mor- 
ganton. Staff,  the  evening  of  October  6th.  All  physicians 
of  Burke  County  were  invited  to  attend  the  meeting,  held 
at  Hughson  Hall,  with  Dr.  John  W.  Ervin  in  charge  of 
the  program.  Dr.  Hawes  spoke  on  sterility  of  the  male, 
and  Dr.  Jones  discussed  sterility  of  the  female. 


Dr.  Whitehorn  Goes  to  Johns  Hopkins — Announce- 
ment has  been  made  that  Dr.  John  C.  Whitehorn,  profes- 
sor of  psychiatry  at  Washington  University  School  of 
Medicine,  St.  Louis,  has  been  appointed  to  the  chair  in 
psychiatry  and  director  of  the  Henry  Phipps  Psychiatric 
Clhvc  at  Johns  Hopkins  University,  to  succeed  Dr.  Adolf 
Meyer,  who  retires  this  year. 

The  selection  of  Dr.  Whitehorn  for  this  very  important 
post  is  to  be  regarded  as  a  happy  choice.  His  well  estab- 
lished reputation  as  a  clinician,  teacher  and  investigat  r 
predicates  success  in  upholding  the  high  traditions  of  Johns 
Hopkins. 

Psychiatry  still  partakes  somewhat  of  the  weakness  of 
psychology — the  echoes  of  the  schools  have  not  yet  died 
away.  Perhaps  in  no  other  discipline  is  it  so  necessary 
that  a  leader  be  firmly  grounded  in  the  scientific  method 
and   the   technique   of    the    laboratory.     Dr.     Whitehorn's 


October.    1941 


SOUTHERX  MEDICINE  &  SURGERY 


S73 


training,  experience  and  personality  fully  satisfy  this  con- 
dition. 
— The  American  Journal  of  Psychiatry,  July,    1941. 

Dr.  Hugh  C.  Wolfe,  of  Greensboro,  is  the  new  presi- 
dent of  the  North  Carolina  Eye,  Ear,  Nose  and .  Throat 
Society.  Dr.  J.  H.  Fitzgerald,  of  Smithfield,  was  elected 
vice  president,  and  Dr.  Vanderbilt  F.  Couch,  of  Winston- 
Salem,  was  re-elected  secretary-treasurer.  Dr.  Wolfe  suc- 
ceeds Dr.  Milton  R.  Gibson,  of  Raleigh. 


DIED 
Dr.  Nathaniel  Peter  Moss,  76,  Roanoke,  retired  Lafay- 
ette, La.,  banker,  died  in  a  hospital  at  Roanoke  October 
10th,  a  few  hours  after  he  was  stricken  with  a  heart  at- 
tack. Native  of  Lafayette,  he  founded  and  was  for  years 
president  of  the  First  National  Bank  there,  retiring  in 
1925  when  he  came  to  live  in  Roanoke,  where  he  had 
spent  his  summers  for  several  years  prior  to  his  retire- 
ment. 


Dr.   Bert   Reade   Long   was   found   dead  in   his  bed  in 

Greensboro   on   the  morning  of  September  27th.    He  had 

been   for  several   years   a   member   of   the  department   of 
health  of  Greensboro. 


Dr.  C.  A.  Ranson.  of  Falls  Church,  Va.,  one  of  the 
coroners  of  Fairfax  County,  died  of  a  gunshot  wound  Sep- 
tember 20th. 


Dr.  C.  Dudley  Barksdale.  70,  Halifax  County,  Virginia's, 
oldest  practicing  physician  in  point  of  service,  died  Sep- 
tember 20th   at   his  home   near   Sutherlin   after  a   brief  ill— 


Dr.  John  Webster  McGehee,  62,  prominent  physician 
and  distinguished  citizen  of  Reidsville,  died  September 
23rd.  after  a  brief  illness. 


OUR  MEDICAL  SCHOOLS 


Medical  College  of  Virginia 

ADVANCE  NOTICE  OF  THE  FIRST  SESSION  OF  THE 

COLLEGE 

From   the  "Medical   Intelligence"  of  the  Southern  Medical  &■ 
Surgical  Journal   (Augusta,  Ga.),  June,   1838: 

We  have  received  the  circular  of  the  Medical  College  of 
Richmond.  Virginia. 

The  following  is  the  arrangement  of  the  Faculty: 

H.  Johnson,  M.D.,  Professor  of  Anatomy  and  Physi- 
ology. 

John  Cullen,  M.D.,  Professor  of  Theory  and  Practice. 

S.  W.  Chamberlayne,  M.D.,  Professor  of  Mat.  Med.  and 
Therapeutics.  . 

R.  L.  Bohannon,  M.D.,  Professor  of  Obstetrics  and  Dis- 
eases of  women  and  children. 

Aug.  L.  Warner,  M.D.,  Professor  of  Surgery. 

Socrates  Maupin,  M.D..  Professor  of  Chemistry  and 
Pharmacy. 

This  new  Medical  School  is  opened  under  the  auspices 
of  the  Hampden  Sidney  College,  whose  Trustees  have  or- 
ganized and  located  it  in  the  city  of  Richmond.  Its  annual 
session  is  to  commence  on  the  1st  Monday  in  November, 
and  continue  until  the  last  week  in  March,  a  period  of 
five  calendar  months;  and  candidates  for  the  Doctorate 
are  required  to  have  deposited  with  the  Dean,  a  suitable 
essay  by  the  1st  day  of  January. 

Although  of  sound  political  bearing,  pointing  the  citizens 
of  its  own  state  to  what  it  considers  both  their  duty,  and 


present  and  prospective  interest,  the  circular,  considering 
the  usages  of  the  day  in  such  cases  .enjoys  an  honourable 
exemption  alike  from  the  boasting,  and  the  invidious  com- 
parisons and  electioneering  manoeuvres  which  have  too 
often  disgraced  the  annual  announcement  of  some  of  the 
American  Medical  Seminaries. 

It  is  observed  that  the  session  of  lectures  is  extended  to 
five,  instead  of  the  usual  term  of  four  months.  This  is,  of 
itself,  correct.  And  it  is  very  justly  observed,  that  "the 
addition  of  another  month  to  the  ordinary  session  of  med- 
ical lectures,  (which  is  admitted  by  every  physician  to  be 
entirely  too  short)  will  enable  the  professors  to  complete 
the  course  which  would  otherwise  be  imperfect."  But  from 
experience  in  point,  we  are  led  to  apprehend  the  advantages 
thus  offered  will  not  be  duly  appreciated  by  the  medical 
students,  so  long  as  there  are  other  similar  institutions 
which  offer  a  shorter  term ;  but  on  the  contrary,  could  the 
majority  of  medical  students  be  allowed  to  sway  the  col- 
leges in  this  particular,  the  term  would  soon  be  reduced  to 
two  or  three  months.  Students  expect  in  the  inconsidera- 
tion  of  their  youth,  to  "combine  pleasure  with  business, 
and  gain  the  rewards  of  industry,  without  suffering  its 
fatigues,"  and  reap  to  themselves  the  profits  of  a  costly 
profession  without  paying  the  tribute  money  necessarily 
due  to  its  procurement. 

Convocation  exercises  opening  the  one  hundred  fourth 
session  of  the  college  were  held  at  12  noon,  September 
15th,  at  The  Monumental  Church.  President  Sanger  pre- 
sided and  talks  were  made  by  the  four  deans,  the  secre- 
tary-treasurer, the  president  of  the  student  body,  and  the 
president  of  the  college  Y.  M.  C.  A.  Reverend  George 
Ossman,  rector  of  the  church,  gave  the  invocation  and 
benediction. 

Dr.  Lewis  E.  Jarrett,  director  of  the  hospital  division, 
attended  the  annual  meeting  of  the  American  Hospital 
Association,  September  13th-17th,  at  Atlantic  City. 

The  United  States  Public  Health  Service  has  made  a 
grant  of  $3,000  for  the  Saint  Philip  school  of  nursing  and 
§12,350  for  the  college  school  of  nursing. 

The  Crockett  Memorial  Laboratory  was  dedicated  with 
appropriate  exercises  on  the  afternoon  of  September  15th 
at  3  o'clock.  This  laboratory  was  made  possible  by  gifts 
from  friends  and  former  students  of  the  late  Doctor  Crock- 
ett, the  pharmacy  profession  at  large,  and  others.  This 
laboratory  will  be  used  by  junior  and  senior  students  of 
the  school  of  pharmacy. 

Dr.  Thomas  D.  Rowe  received  his  docto'ate  during  the 
summer  and  has  been  made  associate  professor  of  phar- 
macy to  succeed  the  late  Dr.  W.  G.  Crockett  as  head  of 
the  department. 

Dr.  Ralph  A.  Logan,  Dr.  Philip  Modjeski  and  Dr.  E.  P. 
Ferrari  have  joined  the  faculty  of  the  dental  school. 

Dr.  Ann  T.  Swing  has  been  appointed  B.  Armistead 
Shepherd  fellow  in  immunology  for  the  current  session. 

The  second  symposium  on  industrial  health  was  held  at 
the  college,  September  10th-12th.  The  number  in  attend- 
ance exceeded  last  year  and  the  meetings  were  enthusiastic. 
Distinguished  speakers  from  far  and  near  were  gathered  for 
this  program.  It  is  hoped  that  this  important  feature  of 
the  work  of  the  college  may  be  continued. 

It  is  expected  that  the  superb  piece  of  statuary  given  the 
institution  by  Mrs.  Anna  Hyatt  Huntington,  distinguished 
sculptress,  will  be  received  before  very  long ;  the  setting 
for  the  group,  designed  by  Mr.  Charles  F.  Gillette.  Rich- 
mond landscape  architect,  is  practically  completed. 

Dr.  John  M.  Meredith  has  been  appointed  associate  pro- 
fessor of  neurological  surgery,  replacing  Dr.  W.  Gayle 
Crutchfield,  resigned.  Doctor  Crutchfield  has  accepted  the 
professorship  of  neurological  surgery  at  the  University  of 
Virginia. 


SOUTHERN  MEDICINE  tr  SURGERY 


October,   1941 


BOOKS 


A  TEXT-BOOK  OF  PATHOLOGY,  Edited  by  E.  T. 
Bell,  M.D.  Contributors:  E.  T.  Bell,  M.D.,  Professor  of 
Pathology,  B.  J.  Clawson,  M.D.,  Professor  of  Pathology, 
J.  S.  McCartney,  M.D.,  Associate  Professor  of  Pathology 
— all  of  the  University  of  Minnesota,  Minneapolis.  Minn. 
Fourth  edition,  enlarged  and  thoroughly  revised,  published 
1941.  Octavo,  931  pages,  illustrated  with  431  engravings 
and  2  colored  plates.    Cloth.  $9.50  net. 

This  excellent  work  has  been  thoroughly  revised 
and  additions  have  been  made.  It  offers  a  large 
amount  of  entirely  new  material,  forty-one  new 
figures  and  references  to  the  latest  literature  in 
this  field.  Pathological  physiology  has  been  in- 
cluded in  connection  with  the  majority  of  diseases 
in  which  well-established  data  are  available.  A 
conservative  attitude  is  shown  toward  opinions 
which  are  not  yet  widely  accepted.  It  supplies  the 
medical  student  with  a  textbook  which  he  may  use 
during  his  clinical  training  and  supplies  a  useful 
reference  book  to  the  practicing  physician.  The 
authors  feel  that  clinical  medicine  should  be  con- 
sidered   as   a   direct   continuation    of   pathological 


studies  and  not  as  an  abrupt  entrance  into  a  new 
field.  The  illustrations  are  original,  the  arrange- 
ment is  rational  and  the  subject  is  presented  as  a 
living  science  of  the  nature  and  causes  of  disease 
on  which  all  successful  practice  of  medicine  must 
be  based. 


CANCER  OF  THE  FACE  AND  MOUTH— Diagnosis, 
Treatment.  Surgical  Repair,  by  Vilrav  P.  Blair,  M.D.; 
Sherwood  Moore,  M.D.,  and  Louis  T.  Byars,  M.D., 
Saint  Louis.  Illustrated.  C.  V.  Mosby  Co.,  St.  Louis, 
$10.00. 

Cancer  of  the  face,  in  particular,  is  the  cancer 
whose  victims  have  been  most  exploited  by  quacks 
with  their  salves.  The  introduction  by  Dr.  J.  M. 
Finney  is  sufficient  guarantee  of  the  high-class  of 
the  volume,  the  basis  of  which  is  a  close  study  of 
1,500  cases  in  the  past  twenty  years,  in  the  light 
of  reports  of  the  work  of  others  from  all  over  the 
world. 

The  general  consideration  of  cancer  of  these 
parts  lays  a  broad  foundation;  then  follow  chap- 
ters on  principles  of  destruction  of  cancer  and  care 
of  the  patient  as  a  whole. 

Cancer  of  the  face,  of  the  ear,  of  the  nose,  of 
the  orbital  structures,  of  the  lip,  of  the  structures 
within  the  mouth,  of  those  in  and  in  communica- 


BIPEPSONATE 


Calcium   Phenolsulphonate   2  grains 

Sodium  Phenolsulphonate  2  grains 

Zinc  Phenolsulphonate,  N.  F 1  grain 

Salol,  U.  S.  P 2  grains 

Bismuth  Subsalicylate,  U.  S.  P 8  grains 

Pepsin,   U.   S.  P 4  grains 

Average    Dosage 

For  Children — Half  drachm  every  fifteen  minutes  for 
six  doses,  then  every  hour  until  relieved. 
For  Adults — Double  the  above  dose. 

How   Supplied 

In  Pints,  Five-Pints  and  Gallons  to   Physicians  and 
Druggists  only. 


Burwell  &  Dunn  Company 


Manufacturing 
Established 


Pharmacists 
in    1887 


CHARLOTTE,  N.  C. 


Sample   sent   to    any    physician    in    the    U.    S.   on 
request 


Advertisers  is  a  Mark   of  Friendship  to  the  Journal 


October.    1941 


SOUTHERN  MEDICINE  &  SURGERY 


575 


STRATEGIC    OUTPOST 

Our  National  Defense  definitely  includes  improvement  of  the  nutrition  of  the  millions  of  individuals  who 
are  below  par  and  the  prevention  of  nutritional  and  vitamin  deficiencies  in  everyone.  The  most  important 
strategic  outpost  in  the  nutritional  defense  program  is  the  physician's  office  and  the  clinic,  where  patients 
can  be  properly  instructed  regarding  the  "enemy"  forces  that  beset  the  course  of  vitamins  from  the  food 
market  to  our  bodies.  Physicians  (and  their  nurses  and  dietitians)  are  best  qualified  to  explain  that  even 
if  the  right  types  of  foods  are  selected  there  are  always  the  hazards  of  processing,  refining,  and  improper 
cooking,  which  may  rob  us  of  the  full  metabolic  utilization  of  their  original  vitamin  content.  We  earnestly 
suggest  that  physicians  considering  the  advisability  of  prescribing  vitamin  supplements  give  preference  to 
Vi-Penta  Perles  and  Vi-Penta  Drops.  These  Roche  preparations  are  unsurpassed  in  overcoming  the  lassi- 
tude, the  anorexia,  and  the  poor  resistance  that  are  traceable  to  vitamin  deficiency.  Perles:  packages  of  25, 
100  and  250;  Drops:  calibrated  dropper  bottles  of  15  and  60cc.  HOFFMANN -LA  ROCHE,  INC.,  NUTLEY,  N.  J. 


VI-PENTA      PERLES      AND      VI-PENTA      DROPS 


Patronage  of  our  Advertisers 


Mark  of  Friendship  to  the  Journal 


SOUTHERN  MEDICINE  &  SURGERY 


October,    1941 


tion  with  the  nose — all  these  are  dealt  with  elabor- 
ately. Moles,  nevi  and  melanomas  are  treated  of 
with  the  care  their  importance  demands.  Other 
chapters  are  given  to  tumors  of  the  salivary  glands, 
cervical  node  metastases,  anesthesia,  destruction 
by  radiation,  and  follow-up  and  statistics. 

The  general  practitioner,  the  general  surgeon, 
the  dentist  and  the  cosmetic  surgeon  will  find  in 
this  book  the  solution  of  many  of  his  problems. 


IMMUNITY  AGAINST  ANIMAL  PARASITES,  by 
James  T.  Culbertson,  Assistant  Professor  of  Bacteriology, 
College  of  Physicians  and  Surgeons,  Columbia  University, 
1941.    $3.50. 

This  is  a  textbook  written  to  acquaint  those  be- 
ginning the  study  of  immunity  to  the  parasitic 
forms  with  the  fundamental  principles  of  the  sub- 
ject, and  to  give  the  more  experienced  the  vital 
things  to  be  found  in  the  recent  writings  dealing 
with  immunity  in  parasitic  infection.  The  matter 
is  presented  in  a  manner  suited  to  the  needs  of 
the  beginning  student,  which  is  at  the  same  time 
the  manner  suited  to  the  trained  investigator,  and 
the  general  physician  or  veterinarian. 

Contents 
Part  I:   Natural   Resistance  and  Acquired   Im- 
unity 

1.  Introduction 

2.  Natural  Resistance 

3.  Age  Resistance 

4.  Specifically  Acquired  Immunity 

5.  Requisites  for  Immune  Response 

6.  Parasites  Which  Elicit  Immunity 

7.  Mechanisms  of  Specific  Immunity 

8.  Demonstrations  of  Immunity 
Part  II:  Immunity  in  Specific  Diseases 

9.  The  Amcebiases 

10.  The  Leishmaniases 

1 1 .  The  Trypanosomiases 

12.  The  Malarias 

13.  The  Coccidioses 

14.  The  Trematodiases 

15.  The  Cestodiases 

16.  The  Nematodiases 

17.  Response  to  Arthropods 
Part  III:  Applied  Immunology 

18.  Classification  of  Parasites 

19.  Vaccination  against  Parasites 

20.  Diagnosis  of  Parasitic  Infection 
Abbreviations  of  Names  of  Periodicals 
Index 


Hospital.  Second  Edition,  thoroughly  revised,  reset  and 
enlarged ;  including  54  color  plates  and  46  other  illustra- 
tions. J.  B.  Lippincott  Co.,  Philadelphia:  London:  Mon- 
treal.   1941.    $15.00. 

To  those  familiar  with  the  first  edition  of  this 
masterful  work  it  is  hardly  necessary  to  say  that 
this  edition  brings  the  knowledge  of  this  section  of 
Medicine  up  to  the  present.  New  material  has  been 
added  on  the  fractioning  of  liver  extract  and  action 
of  drugs  on  the  blood;  a  new  chapter  on  hemo- 
globinuria and  another  on  hemolytic  anemias;  and 
a  new  section  on  hemoglobin  and  its  derivatives. 
There  is  a  good  deal  of  new  material  on  blood 
transfusions,  blood  banks  and  the  use  of  blood 
plasma.  The  development  of  knowledge  of  vitamin 
K  is  given  in  detail.  Dr.  Lloyd  Carver  of  New 
York  contributes  the  chapter  on  treatment  of  leu- 
kemia. 

Dr.  Kracke's  thought  to  provide  a  section  on 
hematologic  terminology  is  an  illustration  of  the 
thoroughly  practical  nature  of  the  work.  There  are 
sections  on  the  development  and  morphology  of 
blood  cells,  leukocytosis  and  leukopenia,  the  ane- 
mias, the  leukemias,  hemorrhagic  diseases,  hema- 
tologic technic;  and  in  an  especially  useful  chapter 
are  included  a  number  of  the  conditions  which  for 


DISEASES  OF  THE  BLOOD  AND  ATLAS  OF  HEM- 
ATOLOGY: With  Clinical  and  Hematologic  Description  of 
the  Blood  Diseases  Including  a  Section  on  Technic  and 
Terminology,  by  Roy  R.  Kracke,  M.D.,  Professor  of  Bac- 
teriology, Pathology  and  Laboratory  Diagnosis,  Emory 
University  School  of  Medicine,  Pathologist  to  the  Emory 


October,    1941 


SOUTHERN  MEDICINE  &  SURGERY 


577 


the  purposes  of  this  work  must  be  classed  as  mis- 
cellaneous. 

Dr.  Kracke's  rank  as  an  authority  in  this  field 
and  his  ability  to  impart  his  knowledge  of  this  im- 
portant subject  are  attested  by  the  great  demand 
for  him  as  a  speaker  before  postgraduate  assem- 
blies all  over  the  country.  His  clear  expositions 
are  amply  supplemented  by  excellent  pictures. 

Very  few  will  be  the  medical  publications  of  this 
year  so  indispensable  to  the  practitioner  of  medi- 
cine and  or  surgery. 


DR.  COLWELL'S  DAILY  LOG  FOR  PHYSICIANS. 
Reg.  U.  S.  Pat.  Off..  A  Brief,  Simple  Accurate  Financial 
Record   lor   the    Physician's   Desk.     Personal    Property   of 

Dr. .    Published  by  Colwell  Publishing 

Company,  Champaign,  111.    §600. 

Forms  Found  in  the  Physician's  Log: 

In  the  Front  of  the  Book: 

1)  Title  Page;  2)  Calendar;  3)  Instructions 
for  Use;  4)  Illustrated  Forms. 

Daily  Pages. 

Following  Each  Month: 

1)  Inoculations;  2)  Business  Summary;  3)  Ex- 
pense Sheet  One;  4)  Expense  Sheet  Two;  5)  Per- 
sonal Account;  6)  Surgical  Record;  7)  Narcotics: 
7)  Social  Security  Taxes — Appointments;  9)  Util- 
ity Record  Sheet. 

In  the  Back  Part  of  the  Book: 

1)  Obstetrical  Waiting  List;  2)  Notifiable  Dis- 
eases; 3)  Annual  Summary;  4)  Record  of 
Deaths. 

The  foregoing  outline  should  convince  any  doc- 
tor that  this  system  of  bookkeeping  will  be  worth 
many  times  the  cost,  in  the  saving  of  time,  worry 
and  money. 


<ZfM  FINANCIAL 

FIGURES  Siteam'/nm 

The  DAILY  LOG  tells  you  at  a  glance  how 
your  daily,  monthly  and  annual  business  rec- 
ords stand.  Important  non-financial  records, 
too.  It  has  protected  the  earnings  of 
thousands  of  physicians  for  14  yrs. 
A  life  saver  at  income  tax  time ! 
WRITE— for  booklet  "The  Adven- 
tures oj  Doctor  Young  in  the  Field 
oj    Bookkeeping.' 

COLWELL    PUBLISHING     CO. 
University  Ave..  Champaign,  II 


THE  TOPICAL  USE  OF  SULFATHIAZOLE  IN 
DECUBITUS  ULCERS 


In  the  first  case  to  be  reported  we  were  confronted  with 
a  lesion  which  had  failed  to  heal  within  a  period  of  10 
months  of  daily  treatment  with  one  or  more  of  the  gener- 
ally accepted  measures.  There  was  utter  failure  of  re- 
sponse. The  application  of  sulfathiazole  powder  produced 
complete  healing  within  21  days. 

One  case  of  chronic  osteomyelitis;  two  cases  of  trau- 
matic, indolent  ulcers  of  the  feet;  one  of  draining  fistulous 
tracts  in  a  recently  amputated  stump  and  a  stubborn  case 
of  pilonidal  sinus — each  rapidly  and  completely  healed. 

Necrotic  and  purulent  slough  becomes  converted  within 
24  hours  into  a  clean,  healthy-appearing  surface,  which 
provides  the  foundation  upon  which  is  produced  abundant 
granulations. 

Sulfathiazole  powder  in  five  decubitus  ulcers  of  long 
standing,  caused  clearing  up  of  infection  and  the  appear- 
ance of  clean,  healthy  granulation  tissue  healing  of  un- 
wonted rapidity ;  a  series  of  related  lesions  were  treated  in 
a  similar  manner  with  uniform  success.  Remedies  used  in 
these  cases  without  success  include  Dakin's  irrigations,  bal- 
sam of  Peru,  urea  crystals  and  infrared  rays. 


GREETING  CARDS  FOR  THE  DOCTOR 

CHRISTMAS  CARDS,  GENUINE  ENGRAVED 
Designed  especially  for  the  professions.  Choice 
of  design  and  sentiment.  Reasonable  prices. 
Write  for  samples. 

THERMOTYPE  PRINTING  CO. 
61  Beekman  Street  New  York,  N.  Y. 


578 


SOUTHERN  MEDICINE  &  SURGERY 


October,   1941 


FIVE   HUNDRED   CONSECUTIVE   THYROIDECTO- 
MIES 
IR.  B.  McKnight,  M.D.,  Charlotte,  in  N.  C.  Med.  J!.,  Aug.) 
These   toxic   patients   are   put   to   bed   at   absolute   rest, 
sedation  is  given  as  needed   (it  is  seldom  needed  after  the 
first   or   second   injection),   a   high-calorie   diet   is   adminis- 
tered, and — most   important — a  daily  intravenous  injection 
of  500  to  1000  c.c.  of  10  per  cent  glucose  or  dextrose  with 
100  to  150  minims  of  Organidine  is  given.   After  the  second 
or  third  injection  metabolic  studies  are  repeated.    The  clin- 
ical picture  of  improvement  is  the  chief  criterion  for  oper- 
ation.   It  is  unusual  to  keep  a  patient   under  preparation 
more  than  five  days,  and  the  big  majority  are  operated  on 
by  the  third  or  fourth  day  after  treatment  is  begun. 

Careful  studies  essential:   the  hippuric  acid  test  for  liver 
function,   the   cholesterol   content   of   the   blood,   galactose 


tolerance  determinations,  basal  metabolic  rates,  and — the 
most  important  of  all — the  clinical  evaluation  of  the  patient 
and  its  correlation  with  laboratory  data. 

In  this  series  of  500  consecutive  thyroidectomies  there 
has  been  but  one  death.  This  fatality  was  due  to 
bilateral  pulmonary  infarction.  A  roentgenogram  taken 
shortly  before  death  on  the  fifth  postoperative  day  reveals 
this  in  excellent  detail.  So  far  as  I  know,  there  has  been 
but  one  case  of  bilateral  abductor  cord  paralysis  which 
was  permanent.  This  patient  died  in  labor  something  less 
than  two  years  after  thyroidectomy.  There  have  been  sev- 
eral who  have  showed  some  huskiness  of  the  voice  for  a 
period  of  a  few  days  to  a  few  weeks  after  operation ;  these 
cases  have  all  cleared  up,  so  far  as  I  can  determine.  Three 
patients  had  severe  postoperative  hemorrhages  necessitating 
prompt  evacuation  of  the  clots.   All  recovered. 


•      1941      • 

FLORIDA'S  NEWEST  —  FINEST  &  LARGEST 

All- Year  Hotel 


THE      RIVIERA 

Near  Daytona  Beach. 

Ideal  Convention  or  Conference  Headquarters.     Capacity  400. 

The  only  Hotel  Bar  open  all  year  between 
Jacksonville  &  Palm  Beach. 
Radio  and  Fan  in  Every  Room.     Golf  Links.     Artesian  Swimming 
Pool  with  Sand  Beach.     Tennis,  Badminton.  Ping  Pong,  Croquet, 
Horseshoe   and   Shuffleboard   Courts.      Ballroom   and   Convention 
Hall.    Banquet  Facilities.    Spacious  Grounds. 

COOLEST  SPOT  IN  ALL  FLORIDA,  AT  THE  BIRTHPLACE  OF 
THE  TRADE  WINDS.  Where  the  Labrador  (Arctic)  Current 
meets  the  Gulf  Stream,  and  Summer  Bathing  and  Fishing  are 
Superb. 

Write  for  Special  Summer  Rates,  April  to  December. 

Hotel  Riviera,  Box  429,  Daytona  Beach,  Fla. 

MOUNTAINEER,  TAR  HEEL  &  CRACKER 

VACATION  HEADQUARTERS. 


is  a  Mark   of  Friendship   to   the  Journal 


October.    1941 


SOUTHERN  MEDICINE  &  SURGERY 


579 


liiliijillJfcW*'*^^^^^  r  Help  the  Ameru»n 

■■■,!.«.«..'"■'"'    '"""  r  .  fpnse  against  cancer.  H  ^  ^ 

.  j, the  first line o/ defense 'J  ^ram-  «* 

Patronage  of  our  Advertisers  is  a  Mark   of  Friendship  to   the  Journal 


SOUTHERN  MEDICINE  &  SURGERY  October,   1941 


Southern  Railway's 

SOUTHERNER 


Built  of  high-tensile  steel,  with  sheathing  of  stainless  steel,  THE  SOUTHERN- 
ER which  will  operate  as  three  Diesel-powered  trains,  includes  all  the  latest  refine- 
ments for  the  ultimate  in  safety,  speed  and  comfort.  Each  train  will  consist  of 
Straight,  Partition  and  Baggage-Dormitory  Chair  Cars,  Dining  Car  and  Lounge- 
Tavern-Observation  Unit,  all  reflecting  the  latest  ideas  in  structural  development 
and  modern  styling  and  beauty. 

Passenger  units  have  thermostatically  controlled  heating  and  air  conditioning, 
are  insulated  throughout.  Judicious  use  is  made  of  a  number  of  advancements  favor- 
ing gracious  living.  A  good  part  of  the  luxury  picture  appears  in  the  comfortable 
seating  arrangement  in  all  cars,  the  commodious  and  up-to-date  dining  car  arrange- 
ments and  the  facilities  for  en  route  enjoyment  offered  in  lounge,  tavern  and  obser- 
vation rooms. 

Diesel  locomotives  for  the  trains  are  built  by  the  Electro-Motive  Corporation, 
a  subsidiary  of  General  Motors. 

Particularly  interesting  from  the  standpoint  of  detailed  comfort  planning  is  the 
fact  that  chair  cars  have  twin-rotating,  reclining-type  seats,  cushioned  and  attrac- 
tively finished.  The  dining  car  has  accommodations  for  48  persons  in  satin  metal 
framed  chairs  with  rubber  seats  and  back  cushions.  Settees,  lounge  chairs,  writing 
desk,  card  section  and  refreshment  facilities  have  been  planned  to  fit  the  comfort 
and  utility  requirements  of  passengers  in  the  Lounge-Tavern-Observation  unit. 

A  rich  decorative  treatment  has  been  designated  for  all  units  of  THE  SOUTH- 
ERNER the  basic  colors  being  blue,  green  and  beige  in  light,  medium  and  dark 
tones.  Blue  and  beige  are  distributed  in  straight  chair  car  planning,  each  car  carry- 
ing out  variations  of  the  same  color  treatment  throughout .  Partition  chair  cars  em- 
phasize beige  and  the  Baggage-Dormitory-Chair  Cars  are  done  in  tones  of  blue. 
Green  is  the  predominating  scheme  in  dining  car  and  Lounge-Tavern-Observation 
units. 

The  whole  scene  is  enriched  with  an  attractive  arrangement  of  photo-murals 
which  have  been  especially  planned  to  heighten  the  atmosphere  of  luxury  and  beauty 
in  THE  SOUTHERNER. 


October,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


THEY  CAN'T  WAIT  MUCH  LONGER 
Stricken  Civilians  in  England 
and  Allied  Countries 
Need  Your  Help  TODAY! 


*     *      A 


^tfcounmes.) 


Both  the  first  aid  kits  and  opera- 
ting sets  have  been  approved  as  to 
contents  and  containers  by  physicians 
on  the  Medical  and  Surgical  Supply 
Committee  of  America.  Send  in  your 
contribution  toward  purchasing  a 
unit  today.  Please  make  checks  payable 
to  Arthur  Kunzinge",  treasurer  and 
mail  with   coupon  below. 


MEDICAL  AND  SURGICAL 
SUPPLY  COMMITTER  OF 

AMERICA,  420  LEXINGTON 
AVENUE,  NEW  YORK,  CITY, 
LExington    2-3970 

Name    

Address    

City     State     

Amount  of   Contribution  $ 


EMERGENCY   FIRST   AID   KIT 
Cost  $70    (covers   insurance   and  ship- 
ment to  England  and  Allied  Countries.) 


Patronage  of  our  Advertisers  is  a  Mark  of  Friendship  to  the  Journal 


PROFESSIONAL   CARDS 


October,    1941 


GENERAL 


Nail*  Clinic  Building 


THE  NALLE  CLINIC 

Telephone — 3-2141    (//  no  answer,  call  3-2621) 


412  North   Church   Street,  Charlotte 


General  Surgery 

BRODIE  C.  NALLE,  M.D. 
Gynecology  &  Obstetrics.. 
EDWARD   R.   HIPP,   M.D. 

Traumatic  Surgery 

PRESTON  NOWLIN,  M.D. 

Urology 


Consulting  Staff 

DRS.   LAFFERTY,   BAXTER  &  PARSONS 
Radiology 
BARRET   LABORATORY 
Pathology 


General  Medicine 


LUCIUS   G.   GAGE,  M.D. 
Diagnosis 


LUTHER   W.   KELLY,  M.D. 
Cardio-Resptratory   Diseases 


J.  R.  ADAMS,  M.D. 
Diseases  op  Infants  &  Children 


W.  B.  MAYER,  M.  D. 
Dermatology  &  Syphilology 


C— H— M   MEDICAL   OFFICES 

DIA  GNOSIS— SURGER  Y 

X-RAY— RADIUM 

Dr.   G  Carlyle   Cooke — Abdominal  Surgery 

&  Gynecology 
Dr.  Geo.  W.  Holmes — Orthopedics 
Dr.  C.  H.  McCants — General  Surgery 
222-226  Nissen  Bid.  Winston-Salem 


WADE   CLINIC 

Wade  Building 

Hot  Springs  National  Park,  Arkansas 

H.  King  Wade,  M.  D.  Urology 

Charles  S.  Moss,  M.D.  General  Surgery 

Jack  Ellis,  M.D.  General  Medicine 

Frank  M.  Adams,  M.D.  General  Medicine 
N.  B.  Burch,  M.D.  Eye,  Ear,  Nose  &  Throat 
Raymond  C.  Turk,  D.D.S.  Dental  Surgery 
A.  W.  Scheer  X-ray  Technician 

Etta  Wade  Clinical  Pathology 

Marjorie  Wade  Bacteriology 


INTERNAL  MEDICINE 


ARCHIE  A.  BARRON,  M.  D.,  F.  A.  C.P. 
INTERNAL  MEDICINE— NEUROLOGY 
Professional   BIdg.  Charlotte 


JOHN  DONNELLY,  M.D. 

DISEASES  OF  THE  LUNGS 

324H  N.  Tryon  St.  Charlotte 


CLYDE    M.    GILMOixE,    A.  B.,   M.D. 
CARDIOLOGY— INTERNAL    MEDICINE 
Dixie  Building  Greensboro 


JAMES  M.  NORTHINGTON,  M.D. 
INTERNAL    MEDICINE— GERIATRICS 
Medical  Building  Charlotte 


ORTHOPEDICS 


HERBERT   F.   MUNT,   M.D. 
ACCIDENT  SURGERY  &  ORTHOPEDICS 

FRACTURES 
Nissen  Building  Winston-Salem, 


October.    1941 


PROFESSIONAL  CARDS 


583 


NEUROLOGY  and  PSYCHIATRY 


J.   FRED   MERRITT,   M.  D. 

NERVOUS  and  MILD  MENTAL 
DISEASES 

ALCOHOL  and  DRUG  ADDICTIONS 

Glenwood   Park   Sanitarium  Greensboro 


EYE,  EAR,  NOSE  AND  THROAT 


H.  C.  NEBLETT,  M.  D. 

OCULIST 

Phone   3-S8S2 

Professional   Bldg.  Charlotte 


AMZI  J.  ELLINGTON,  M.D. 

DISEASES  of  the 
EYE,  EAR,  NOSE  and  THROAT 

Phones:  Office  992— Residence  761 

Burlington  North   Carolina 


UROLOGY,   DERMATOLOGY   and   PROCTOLOGY 

THE  CROWELL  CLINIC  of  UROLOGY  and  UROLOGICAL  SURGERY 

Hours — Nine  to  Five  Telephones — 3-7101 — 3-7102 

STAFF 

Andrew  J.  Crowell,  M.  D. 

(1911-1938) 

Angus  M.  McDonald,  M.  D.  Claude  B.  Squires,  M.  D. 

Suite  700-711  Professional  Building  Charlotte 


Raymond  Thompson,  M.  D.,  F.  A.  C.  S. 


Walter   E.  Daniel,  A.  B.,  M.D. 


THE  THOMPSON  -  DANIEL  CLINIC 

of 

UROLOGY  &  UROLOGICAL  SURGERY 


Fifth  Floor  Professional 


C.  C.  MASSEY,  M.D. 

PRACTICE  LIMITED 

TO 

DISEASES  OF   THE  RECTUM 


Professional   Bldg. 


Charlotte 


L.  D.  McPHAIL,  M.  D. 
RECTAL  DISEASES 


Professional   Bldg. 


Charlotte 


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GENITO-URINARY   DISEASES 

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October.    1941 


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Vol.   cm 


CHARLOTTE,   N.   C,   NOVEMBER,   1941 


Coronary-Artery    Disease   in   General    Practice 

Ernest  Lee  Copley,  M.D.,  Richmond 


ABUNDANT  EVIDENCE  attests  that  doc- 
tors recognize  and  understand  diseases  of 
the  coronary  arteries  and  their  relation  to 
heart  failure  far  better  than  in  previous  years.  All 
Vital  Statistics  records  show  a  large  increase  in  the 
mortality  from  this  type  of  heart  disease.  After 
giving  all  due  weight  to  the  alleged  strain  and  ten- 
sion of  modern  life,  no  one  believes  there  has  been 
the  rise  in  the  mortality  which  these  statistics 
would  seem  to  indicate.  It  is  obvious  that  physi- 
cians now  are  more  accurately  diagnosing  throm- 
bosis and  occlusion  of  the  coronary  arteries  and 
the  consequent  myocardial  infarction  and  heart 
failure.  Undoubtedly  many  deaths  have  been  cer- 
tified to  have  been  caused  by  simple  heart  failure, 
when  the  actual  cause  of  death  was  myocardial  in- 
farction and  heart  failure.  Coronary  occlusion  and 
the  resultant  myocardial  infarction  constituted  the 
primary  cause  of  death.  Although  many  excellent 
studies1  had  been  made  and  reported,  the  diseases 
of  the  coronary  arteries  were  generally  so  little 
understood  and  appreciated  that,  prior  to  1930,  no 
separate  statistics  were  kept  for  deaths  from  occlu- 
sion of  these  arteries  and  the  resulting  catastrophe 
to  the  heart  muscle. 

The  statistics  from  the  Virginia  Bureau  are  in- 
teresting. For  the  past  eleven  years  they  are  as 
follows: 

Stale  of  Virginia 

White         Colored 

1930 113       13 

1931 

1932 

1933 

1934 

1935 

1936 


107 

28 

203 

44 

328 

50 

391 

93 

455 

121 

609 

135 

1937.. 
1938.. 
1939.. 

1940.. 


719 

143 

846 

156 

1022 

165 

1169 

232 

These  statistics,  under  the  heading,  Diseases  of 
the  Coronary  Arteries,  include  coronary  thrombo- 
sis and  occlusion,  and  heart-wall  infarction.  They 
are  not  classified  and  the  classification  is  not  nec- 
essary. Of  most  importance  for  present  purposes 
are  the  statistics  themselves.  Many  researches2 
have  been  made  in  the  last  few  years  on  the  clin- 
icopathological  correlation  of  the  coronary  artery 
disease  and  occlusion  and  infarction  of  the  myocar- 
dium. Very  significant  to  note  in  the  statistics 
given  is  the  tremendous  increase  in  the  number  of 
deaths  reported  from  a  certain  "new"  type  of  heart 
disease  within  a  decade — no  case  reported  before 
1930,  126  cases  reported  for  the  year  1930,  1401 
for  the  year  1940!  It  is  obvious  that  physicians 
generally  have  in  that  ten-year  period  come  to  rec- 
ognize disease  of  the  coronary  arteries  as  a  primary 
cause  of  death,  and  so  report. 

The  City  of  Richmond  established  its  own  Vital 
Statistics  Bureau  in   1935.    The  statistics  for  the 
past  six  years  for  the  city  are  as  follows: 
Richmond  City 


1935.. 
1936.. 
1937.. 
1938.. 
1939.. 
1940.. 


60 

10 

81 

18 

90 

14 

132 

18 

109 

23 

The  increase  in  the  mortality  for  Richmond  is 
as  great  as  that  of  the  State  as  a  whole.  The  num- 
ber of  deaths  rose  from  46  in  1935  to  150  in  1939. 
There  was  a  slight  decrease  in  1940. 


CORO.XARY-ARTERY  DISEASE  IN  GE.XERAL  PRACTICE— Copley 


November,   1941 


Dr.  Francis  P.  Denny,  health  officer  of  Brook- 
line,  Massachusetts,  reclassified  the  records'1  of  all 
heart  deaths  from  1900  to  1935  in  that  suburb  of 
Boston.  He  found  that  from  1900  to  1904,  the 
records  showed  no  death  ascribed  to  cjronary- 
artery  disease.  Between  1905  and  1903,  the  death 
rate  from  this  cause  was  reported  3.9  per  100,000 
population.  For  the  next  five-year  period  the  num- 
ber of  deaths  so  reported  rose  slowly.  From  1915 
on,  the  rate  increased  rapidly,  so  that  from  1930  to 
1934  a  rate  of  94.6  per  100,000  was  reported  and 
in  1935  the  rate  was  156.6.  Assuming  comparable 
conditions  in  Richmond,  this  city  should  have  re- 
ported a  much  larger  number  of  deaths  from  coro- 
nary-artery disease  than  46  in  1935 — or  even  150 
in  1939. 

A  study  of  the  statistical  reports  dealing  with 
coronary-artery  disease  led  me  to  review  my  own 
case  records.  At  present,  I  have  under  my  care  six 
patients  with  coronary-artery  disease  whose  cases 
I  believe  I  have  correctly  diagnosed.  All  of  thesa 
have  had  the  typical  syndrome  of  coronary  occlu- 
sion with  infarction.  With  one  exception,  the  diag- 
nosis has  been  further  confirmed  by  electrocardio- 
grams regarded  as  diagnostic  of  occlusion  and  in- 
farction. Several  of  these  cases  have  been  treated 
in  local  hospitals  and  the  diagnosis  has  been  con- 
curred in  by  other  physicians.  In  the  one  case  in 
which  I  did  not  make  an  electrocardiogram  the 
initial  attack  and  the  physical  findings  were  as 
typical  as  in  the  other  five  cases.  I  am  therefore 
quite  positive  these  six  cases  have  been  correctly 
catalogued. 

In  the  past  three  years,  I  have  had  three  patients 
who  died  following  what  I  am  sure  was  coronary 
occlusion  with  myocardial  infarction.  The  first  of 
these  was  a  Hebrew,  aged  45.  I  first  saw  him  the 
night  of  November  4th,  1939,  in  profound  shock, 
almost  moribund.  He  gave  the  history  of  having 
had,  for  several  days,  severe  substernal  pain  radiat- 
ing down  both  arms.  The  blood  pressure  readings 
were  very  low,  and  the  radial  pulse  could  not  be 
felt.  He  was  taken  in  an  ambulance  to  a  hospital 
where  he  died  the  next  day.  The  cause  of  death 
was  certified  to  be  acute  coronary  occlusion.  No 
autopsy  was  obtained. 

The  second  patient,  a  man,  aged  61,  I  was  called 
to  see  at  3  a.  m.,  August  2nd,  1940.  He  gave  the 
history  of  severe  substernal  pain  radiating  to  the 
left  shoulder,  which  had  persisted  all  night.  This 
man,  obviously  gravely  ill,  was  perspiring  freely; 
his  blood  pressure  was  90  systolic,  40  diastolic.  I 
informed  the  family  that  I  thought  we  were  deal- 
ing with  a  case  of  coronary  thrombosis  with  occlu- 
sion. He  was  made  comfortable  with  morphine  and 
in  36  hours  was  taken  in  an  ambulance  to  a  hos- 
pital.   In  the  hospital,  he  had  fever  which  ran  a 


low-grade  course,  and  moderate  leukoevtosis.  An 
electrocardiogram  showed  the  tracings  of  a  fresh 
myocardial  infarction.  This  patient  had  a  stormy 
course.  Heart  compensation  was  inadequate  during 
the  entire  period  of  his  illness  which  ended  in 
death  February  19th,  1941.  The  cause  of  death 
was  certified  to  be  coronary  occlusion  with  myocar- 
dial infarction.    No  autopsy  was  permitted. 

The  third  case  was  that  of  a  cobred  man,  aged 
55.  I  had  examined  this  man  from  time  to  time 
and  at  each  examination  his  blood  pressure  was 
high.  Also,  he  gave  a  history  of  substernal  pain 
and  dyspnea  on  exertion,  so  he  was  forbidden  to 
do  laborious  work  and  cautioned  against  anv  kind 
of  exertion.  He  died  suddenly,  July  25th,  1940, 
while  trying  to  catch  a  pig.  I  certified  the  cause  of 
death  to  be  coronary  thrombosis  with  sudden  oc- 
clusion. No  autopsy  was  obtained.  I  believe  these 
three  cases  were  correctly  diagnosed  and  properly 
reported. 

I  treated  other  cardiac  patients  earlier  in  the 
eleven-year  period  covered  by  the  statistics  of  the 
Virginia  Bureau,  some  of  whose  cases  I  am  equally 
certain  were  incorrectly  diagnosed  and  improperly 
reported.    These  cases  will  be  outlined. 

The  first  of  these  cases  is  that  of  a  white  woman, 
aged  49,  obese  and  hypertensive  for  an  undeter- 
mined number  of  years.  I  saw  her  first  at  4  a.  m., 
April  5th,  1934.  She  had  severe  substernal  pain, 
was  dyspneic  and  had  a  very  low  btaod  pressure. 
Morphine  was  given  until  her  pain  and  distress 
were  relieved.  She  was  ordered  to  stay  in  bed  and 
was  visited  almost  daily  for  the  period  of  her  ill- 
ness. Her  condition  appeared  favorable  until 
twenty-three  days  after  the  onset  of  her  illness.  I 
was  then  called  at  midnight  and  found  her  in  con- 
gestive failure.  Neither  the  blood  pressure  nor  the 
pulse  could  be  obtained.  She  died  in  about  two 
hours.  I  certified  the  cause  of  death  to  be  conges- 
tive heart  failure  with  acute  dilatation.  I  feel  cer- 
tain now  that  the  primary  cause  of  the  congestive 
failure  was  coronary  occlusion  with  myocardial  in- 
farction. No  electrocardiogram  was  made  nor  was 
an  autopsy  performed. 

A  colored  man,  aged  65,  was  brought  into  my 
office  in  mid-afternoon  September  28th,  1935.  He 
gave  the  history  of  having  been  seized  with  terri- 
ble pain  under  his  breast  bone  while  walking  along 
the  road  near  his  home.  He  was  unable  to  proceed 
and  lay  down  by  the  roadside  until  friends  came 
and  brought  him  to  mv  office.  He  was  in  shock 
and  had  the  sense  of  impending  disaster.  The  puls^ 
was  weak,  blood  pressure  80  systolic  and  30  dias- 
tolic. He  was  given  morphine  and  ordered  taken 
home  where  he  was  seen  the  next  day.  At  that 
time  he  was  acutely  ill  with  congestive  failure.  On 
the  third  day  of  his  illness  he  died.    I  certified  the 


November,  1941 


CORONARY-ARTERY  DISEASE  IN  GENERAL  PRACTICE— Copley 


587 


cause  of  death  to  be  chronic  myocarditis  with 
myocardial  degeneration.  I  feel  sure  now  the  pri- 
mary cause  of  death  was  coronary  thrombosis  with 
acute  coronary  occlusion.  No  autopsy  was  per- 
formed. 

A  large  colored  woman,  aged  53,  was  brought 
into  my  office  at  midnight  July  5th,  1936,  in  great 
distress  and  fearful  of  impending  disaster.  She  was 
suffering  terrible  substernal  pain  and  begged  for  re- 
lief. I  considered  a  dissecting  aortic  aneurism  as  a 
possible  diagnosis,  but  ruled  it  out  because  there 
was  no  radiating  pain  to  the  abdomen  and  the 
blood  pressure  was  low.  She  rapidly  became  dysp- 
neic.  With  difficulty  she  was  taken  home,  where 
she  became  orthopneic.  I  visited  her  several  times 
daily  for  the  next  three  days.  She  went  down  hill 
so  rapidly  that  I  was  dismissed  for  another  physi- 
cian. Still  a  third  physician  was  called  the  last  day 
of  her  illness  who  signed  her  death  certficate. 
Strangely  enough  he  certified  the  cause  of  death  to 
be  cerebral  apoplexy.  No  autopsy  was  perforated. 
I  am  positive  this  patient  died  of  an  acute  coronary 
occlusion  with  myocardial  infarction. 

I  have  no  doubt  that  in  other  cases  of  mine,  in 
the  light  of  present  knowledge,  a  carefully  elicited 
history  of  the  pain  would  have  revealed  them  to 
be  coronary  heart  cases.  I  feel  certain  the  three 
cases  just  reported  in  abstract  should  have  been 
included  among  those  resulting  from  coronary- 
artery  disease. 

There  are  encouraging  factors  in  the  diagnosing 
of  coronary  artery  disease.  Physicians  treat  with 
more  respect  than  formerly  the  pain  of  what  was 
long  called  acute  indigestion.  Less  bicarbonate  of 
soda  is  given  and  more  time  is  taken  to  obtain  a 
clear  history  of  these  attacks.  The  public  knows 
more  about  the  significance  of  substernal  pain.  The 
electrocardiograph  is  in  reach  of  most  physicians 
and  with  reasonable  study  the  tracings  can  be  read. 
Probably  of  greatest  importance  is  the  study  of  the 
diseased  heart  at  autopsy.  And,  finally,  with  a 
proper  appreciation  and  understanding  of  coronary 
artery  disease  it  is  possible  to  prolong  the  most 
productive  period  of  many  lives. 
Summary 

Statistics  afford  evidence  that  physicians  under- 
stand and  diagnose  the  diseases  of  coronary  arteries 
far  better  than  in  previous  years. 

Twelve  case  records  are  reported  in  some  detail: 
six  of  the  patients  still  living,  their  disease  correctly 
diagnosed;  three  dead,  their  disease  correctly  diag- 
nosed; and  three  dead,  their  disease  incorrectly 
diagnosed  and  improperly  reported. 

Some  of  the  encouraging  factors  in  the  diagnos- 
ing and  managing  of  coronary-artery  disease  are 
pointed  out. 


References 

1.  Herrick,  J.  B.:  Clinical  Features  of  Sudden  Obstruc- 
tion of  the  coronary  Arteries.  Joar.  A.  M.  A.,  Vol.  59, 
1912,  p.  201S. 

Idem:    Thrombosis  of  the  Coronary  Arteries.    Jour.  A. 
M.  A.,  Vol.  72,  1919,  p.  387. 

2.  Blumgart,  H.  L.,  Schlesdjger,  M.  J.,  and  Davis,  D.: 
Studies  on  the  Relation  of  the  Clinical  Manifestations 
of  Angina  Pectoris,  and  Coronary  Thrombosis,  and  My- 
ocardial Infarction  to  the  Pathologic  Findings.  Amer. 
Heart  Jour.,  19,  1-91,  1940. 

3.  Denny,  F.  P.:  The  Increase  in  Coronary  Disease  and 
Its  Cause.  New  England  Jour.  Med.,  Vol.  214,  April 
16th,  1936,  pp.  769-773. 


SCALENUS  ANTICUS  SYNDROME    (BRACHIAL 

NEURITIS) 

(Exum   Walker,   Atlanta,   in  Jour.  Med.   Assoc,   of  Co.,  Aug.) 

The  scalenus  anticus  syndrome  occurs  with  frequency, 
but  often  it  is  not  recognized.  It  is  the  commonest  form 
of  brachial  neuritis,  the  symptoms  of  which  can  be 
promptly  relieved. 

The  symptoms  result  from  mechanical  irritation  of  the 
brachial  plexus  as  it  passes  over  the  first  rib,  between  the 
scalene  muscles.  Contributing  factors  are  movements  of 
the  upper  extremity,  and  local  anatomic  and  postural  rela- 
tionships affecting  the  brachial  plexus. 

If,  in  any  part  of  the  distribution  of  the  brachial  plexus, 
there  is  pain  which  is  aggravated  by  using  the  arm  in  cer- 
tain positions,  and  tenderness  is  present  over  the  supra- 
clavicular region,  the  scalenus  anticus  syndrome  is  the  most 
likely  diagnosis. 

Compression  of  nerve  roots  by  the  herniation  of  a  cervi- 
cal intervertebral  disc,  or  by  arthritis  of  the  cervical  spine, 
produces  a  very  similar  clinical  picture,  and  must  be  dif- 
ferentiated. Other  conditions  to  be  considered  are  spinal 
cord  tumor,  syringomyelia,  Raynaud's  disease,  subacromial 
bursitis,  and  tumor  of  the  brachial  plexus. 

Surgical  section  of  the  scalenus  anticus  muscle  results  in 
prompt  relief  of  pain.  This  can  be  accomplished  through  a 
small  incision,  and  requires  hospitalization  for  only  three 
or  four  days. 


VITAMIN  K 

A  great  number  of  reports  in  a  number  of  journals  credit 
Vitamin  K,  the  anti-hemorrhagic  vitamin,  with  wide  use- 
fulness. It  appears  to  be  necessary  for  prothrombin  for- 
mation, and  this  aids  in  blood  coagulation.  Two  forms, 
from  alfalfa  and  from  putrid  fish  meal,  are  known;  one 
has  been  synthesized.  It  is  produced  also  by  a  number  of 
bacteria  including  those  in  the  intestines.  Apparently  it 
requires  the  presence  of  bile  salts  in  order  to  be  absorbed. 

At  the  present  time  the  indications  for  the  administra- 
tion of  vitamin  K  as  a  prophylactic  measure  appear  to 
be  as  follows:  It  should  be  given  to  expectant  mothers 
shortly  before  delivery.  Its  use  is  indicated  in  cases  of 
intestinal  obstruction,  surgical  short  circuits  of  the  intes- 
tines and  conditions  associated  with  chronic  diarrhea.  It 
is  worthy  of  trial  in  chronic  liver  disease,  but  is  peculiarly 
valuable  in  the  preoperative  and  postoperative  treatment 
of  cases  with  obstruction  of  the  common  bilcduct. 

Vitamin  K  is  of  the  greatest  value  in  the  treatment  of 
hemorrhagic  disease  of  the  newborn,  and  in  bleeding  asso- 
ciated with  obstructive  jaundice.  It  will  probably  be  found 
effective  in  cases  of  bleeding  associated  with  disorders  of 
the  alimentary  tract  when  ascorbic  acid  deficiency  is  not 
the  cause.  It  should  be  tried  in  bleeding  associated  with 
primary  diseases  of  the  liver.  It  is  almost  certainly  not 
effective  in  hemorrhagic  conditions  such  a  hemophilia  and 
purpura  hemorrhagica. 


SOUTHERN  MEDICINE  &  SURGERY 


November,  1941 


The  Basic   Problems   of  Acute  Appendicitis* 

Frederick  Fitzherbert  Boyce,  B.S.,  M.D. 

WITH 

Harry  E.  Nelson,  M.D. 
New  Orleans 


IT  WOULD  BE  in  the  highest  degree  unfortu- 
nate if  the  impression  were  to  become  general 
that  the  problem  of  acute  appendicitis  had 
been  in  any  way  solved  by  the  remarkable  reduc- 
tion in  the  morbidity  and  mortality  of  appendicu- 
lar peritonitis  recently  achieved  by  the  use  of  the 
sulfonamide  drugs.  Spectacular  as  these  results  are, 
they  have  not  altered  a  single  one  of  the  funda- 
mental problems  of  this  disease,  in  the  correct  con- 
cept of  which  peritonitis  is  classified  as  a  regretta- 
ble and  entirely  avoidable  complication  and  not  as 
an  integral  phase  of  the  pathologic  process.  The 
challenge  of  acute  appendicitis  is  exactly  what  Elman 
recently  stated  it  to  be;  it  is  not  the  treatment  of 
the  perforated  organ  and  the  consequent  periton- 
itis, but  the  removal  of  the  acutely  inflamed  appen- 
dix before  these  dire  consequences  come  to  pass. 
The  simplest  way  to  reduce,  and  indeed  practically 
eliminate,  the  mortality  of  acute  appendicitis  is  not 
to  treat  peritonitis  with  sulfanilamide  or  with  any- 
thing else,  but  to  increase  the  proportion  of  cases 
of  uncomplicated  acute  appendicitis  which  come 
the  way  of  the  surgeon. 

Bower  of  Philadelphia  has  probably  done  more 
than  any  person  living  today  to  demonstrate  how 
the  mortality  of  acute  appendictis  can  be  reduced. 
One  hesitates,  therefore,  to  take  issue  with  him  on 
any  matter  connected  with  the  disease.  On  the 
other  hand,  I  can  not  agree  with  him  that  medical 
men  should  cease  to  write  about  and  medical  edi- 
tors should  cease  to  accept  articles  on  acute  appen- 
dicitis and  should  concentrate  all  their  attention, 
instead,  on  rupture  and  peritonitis.  In  one  sense, 
of  course,  his  contention  is  correct.  Peritonitis  is 
the  cause  of  most  deaths  in  acute  appendicitis. 
But  that  situation  does  not  prevail  because  too  lit- 
tle attention  is  paid  to  peritonitis.  It  prevails  be- 
cause too  little  attention  is  paid  to  acute  appen- 
dicitis while  it  is  still  acute  appendicitis.  Appen- 
dicular peritonitis  develops  because  physicians  fail 
to  recognize  the  syndrome  of  uncomplicated  ap- 
pendicular disease,  the  spreading  of  the  gospel  of 
which  has  been  Bower's  chief  contribution  to  the 
subject. 

Some  years  ago  the  Committee  on  Acute  Appen- 
dicitis of  the  Philadelphia  Medical  Society,  at 
Bower's  instigation,  undertook  a  survey  of  the 
presentation  of  acute  appendicitis  in  standard  text- 

*Read  by  invitation  at  the  67th  annual  meeting  of  the  Central   111 


books,  systems  and  monographs.  Some  years  later 
I  undertook  a  similar  survey  for  a  similar  commit- 
tee from  the  Orleans  Parish  Medical  Society.  Both 
committees  arrived  at  approximately  the  same  con- 
clusions. To  quote  my  own  report,  most  descrip- 
tions, if  they  do  not  give  the  impression  that  gan- 
grene, rupture  and  peritonitis  form  part  of  the 
initial  syndrome  of  acute  appendicitis,  are  so  lan- 
guid, so  unemphatic,  that  the  reader — who,  unfor- 
tunately, is  often  a  medical  student  receiving  his 
first  introduction  to  the  disease — gets  no  idea  what- 
soever of  its  urgency.  In  other  words,  the  average 
presentation  of  acute  appendicitis  is  neither  accu- 
rate nor  adequate,  and  this  more  than  half  a  cen- 
tury after  Reginald  Heber  Fitz  published  the  paper 
with  which  the  modern  knowledge  of  acute  appen- 
dicitis begins  and  which  includes  most  of  the  mod- 
ern knowledge  of  acute  appendicitis.  In  this  paper 
the  most  frequent  of  all  surgical  diseases  was  not 
only  elevated  to  its  proper  place  in  the  scale  of 
frequency  but  was  at  the  same  time  correctly  de- 
scribed from  every  aspect,  including  the  therapeu- 
tic. 

There  are  certain  basic  considerations  which 
ought  to  be  included  in  every  discussion  of  acute 
appendicitis.  Practically  all  of  them  are  included 
in  a  text  written  in  1914,  which  we  investigated  as 
part  of  the  study  just  referred  to.  This  particular 
description  states  that  acute  appendicitis  is  fre- 
quent, serious,  alarming,  multiple  in  its  manifesta- 
tions and  phases,  demanding  heroic  measures  for 
its  relief,  as  clearly  a  surgical  disease  as  a  broken 
leg,  a  disease  which  demands  the  services  of  a  sur- 
geon as  soon  as  it  is  suspected  and  in  which  medi- 
cal treatment  is  relegated  in  the  best  practice  to 
the  limbo  of  contemptuous  oblivion.  That  is  the 
sort  of  flat-footed,  unequivocal  plain  speaking 
which  still  ought  to  be  used  about  acute  appendi- 
citis. 
The  Progressive  Pathology  of  Acute  Appendicitis 
Acute  appendicitis  is  an  exciting  disease  and  a 
disease  to  become  excited  about,  if  for  no  other 
reason  than  that  of  its  unpredictability.  It  should 
always  be  conceived  of  from  the  standpoint  of 
pathologic  progression.  It  begins  as  a  strictly 
localized,  intrinsic,  readily  curable  disease.  It  may 
terminate,  if  not  interrupted  by  natural  reversal  or 
by  surgery,  as  a  disease  which  involves,  directly  or 

nois  District  Medical  Society  at  Springfield,  November  6th. 


November,  1941 


THE  BASIC  PROBLEMS  OF  ACUTE  APPENDICITIS—  Boyce-Nelson 


sm 


indirectly,  tissues  and  organs  adjacent  to  and  re- 
mote from  the  appendix,  and  which  may  be  incur- 
able by  surgery  or  any  other  means.  The  serious 
character  of  acute  appendicitis  is  readily  explained 
by  the  structure  in  which  it  originates.  The  appen- 
dix is  a  vestigial  organ.  It  is  a  blind  pouch  which 
may  assume  various  positions  in  relation  to  the 
.  cecum.  It  has  a  terminal  blood  supply.  It  has  an 
obstructive  mechanism  at  the  base.  It  is  filled 
with  infected  contents  even  under  normal  circum- 
stances, and  it  contains  a  large  amount  of  lymphoid 
tissue,  which  is  notoriously  prone'  to  infection. 
These  facts  all  make  it  clear  why,  when  once  the 
disease  has  been  initiated,  the  circumstances  are 
all  in  favor  of  its  assuming  a  progressively  serious 
course. 

Acute  appendicitis  presents  two  distinct  forms. 
The  first  or  infectious  variety  is  frequently  self- 
limited,  though  it  can  not  be  predicted  in  any  given 
case  that  self-limitation  will  occur,  and  Walton's 
statement  that  there  is  no  such  thing  as  subsiding 
acute  appendicitis  bears  tribute  to  this  uncertainty. 
Far  too  little  attention  has  been  paid  to  the  second 
or  obstructive  variety  of  acute  appendicitis.  It  was 
first  described  by  Wilkie  more  than  25  years  ago, 
and  valuable  clinical  and  experimental  evidence  has 
recently  been  contributed  by  Wangensteen  and  his 
associates,  who  point  out  that  in  this  type  of  dis- 
ease both  the  symptomatology  and  the  pathologic 
process  present  the  risk  of  internal  intestinal 
strangulation.  There  is  little  or  no  tendency  to 
spontaneous  reversal  in  obstructive  acute  appendi- 
citis, a  fact  which  ought  particularly  to  be  empha- 
sized because  the  initial  symptoms,  although  fre- 
quency prominent,  are  not  associated  with  a  con- 
stitutional reaction  until  a  number  of  hours  have 
elapsed,  and  therefore  may  be  very  misleading. 
Meantime,  tension  within  the  appendix  increases 
rapidly,  especially  if  a  fecalith  or  other  foreign 
"lody  is  present,  gangrene  and  then  perforation 
occur,  and  the  appendiceal  contents,  swarming  with 
bacteria,  are  spilled  into  a  totally  unprepared  peri- 
tonea] cavity. 

Generally  speaking,  gangrene  is  a  more  favorable 
development  than  perforation,  and  localized  peri- 
tonitis or  appendiceal  abscess  is  a  more  favorable 
development  than  spreading  peritonitis.  Yet  none 
of  these  developments  is  really  favorable  and  it 
speaks  ill  for  our  concept  of  the  disease  that  we 
should  so  regard  them.  The  whole  matter  is  rela- 
tive. Gangrene  and  rupture  are  considered  compli- 
cations of  acute  cholecystitis  and  there  seems  no 
Bod  reaso  nwhy  they  should  not  be  regarded  as 
complications  of  acute  appendicitis  and  not  as 
phases  of  the  integral  pathology.  The  most  im- 
portant consideration  from  the  pathologic  stand- 
point, however,  is  that  any  prediction  as  to  what 


is  going  to  happen  in  any  given  case  is  pure  guess- 
work. The  only  safe  prediction  is  that  if  the  worst 
has  not  already  happened,  it  is  likely  to  occur  soon, 
a  line  of  reasoning  which  is  not  in  the  least  radical 
but  is  based  on  sound  and  thoroughly  established 
facts. 

One  other  point  should  be  made  in  connection 
with  the  pathology  of  acute  appendicitis,  namely, 
that  its  onward  course  is  always  hastened  by  the 
taking  of  purgatives.  The  late  Lord  Moynihan 
said  that  in  all  his  practice  he  never  saw  a  case  of 
ruptured  appendicitis  in  which  purgation  was  not 
only  an  impressive  antecedent  but  also  a  definite 
cause,  and  he  frequently  paid  his  respects  to  what 
he  called  "therapeutic"  peritonitis.  Aside  from  any 
other  damage  it  may  cause,  the  mere  taking  of  a 
purgative  introduces  the  element  of  procrastina- 
tion, of  waiting  and  seeing  what  it  is  going  to  ac- 
complished: what  it  usually  accomplishes  is  per- 
foration and  peritonitis. 

Purgatives,  unhappily,  are  not  always  the  idea 
of  the  patient.  Physicians  are  still  giving  them  for 
abdominal  pain.  Of  1213  patients  with  acute  ap- 
pendicitis who  had  taken  purgatives  at  the  New 
Orleans  Charity  Hospital,  SO  had  taken  them  on 
the  instructions  of  physicians,  and  the  death  rate 
in  that  group  of  cases  was  26  per  cent,  though 
only  one  physician  seems  to  have  diagnosed  the 
condition  as  acute  appendicitis  before  he  ordered  a 
dose  of  salts.  Moreover,  though  it  must  be  granted 
that  the  point  of  view  is  unique,  a  British  physi- 
cian has  recently  violently  defended  the  idea  that 
an  attack  of  acute  appendicitis  can  be  aborted  by 
a  dose  of  castor  oil  at  the  onset.  He  can  properly 
be  classified  with  the  American  physician  who  ad- 
vocates the  postponement  of  operation  in  most  noc- 
turnal cases  of  appendicitis  until  morning,  one  of 
the  reasons  being  that  a  sleepy  operating  crew  does 
not  do  its  best  work. 

The  Ubiquity  of  Acute  Appendicitis 
The  realization  that  acute  appendicitis  is  the 
commonest  of  all  surgical  diseases  is  the  first  essen- 
tial in  diagnosis.  The  cumulative  effect  of  reading 
about  it  in  the  daily  papers  is  more  striking  than 
is  the  quotation  of  hospital  statistics.  Scarcely  a 
week  goes  by  that  an  emergency  appendectomy  is 
not  performed  at  sea  or  that  a  seaman  is  not  flown 
from  ship  to  shore  for  operation.  One  of  the  weekly 
pictorial  magazines,  reporting  the  recent  military 
maneuvers  in  Louisiana,  ran  a  picture  of  an  oper- 
ation for  acute  appendicitis  in  a  field  hospital  at- 
tached to  one  of  the  contending  armies.  That  was 
not  yellow  journalism.  In  April,  1940,  at  the 
height  of  the  ill-fated  Norwegian  campaign,  a  dis- 
patch from  London  told  how  a  squadron  of  Rritish 
cruisers  and  destroyers,  on  duty  in  the  North  Sea, 
for  an  hour  formed  a  protecting  ring  about  a  bat- 


THE  BASIC  PROBLEMS  OF  ACUTE  APPENDICITIS—  Bovce-Neho 


November,  1941 


tleship  on  which  a  seaman  with  acute  appendicitis 
was  having  his  appendix  removed.  There  may  be 
some  argument  as  to  the  wisdom  of  risking  thou- 
sands of  lives  to  save  one  life,  which  perhaps  itself 
was  promptly  lost  in  the  new  exigencies  of  war,  but 
there  can  be  no  argument  as  to  the  ubiquity  and 
urgency  of  acute  appendicitis. 

The  world's  greatest  pugilist  almost  died  from 
appendicular  peritonitis — not  acute  appendicitis — 
two  or  three  years  ago.  Last  year  the  professor  of 
animal  industry  at  Louisiana  State  University  went 
on  a  cattle-rescuing  expedition  into  one  of  the 
flood-stricken  parishes  of  the  state.  A  week  later 
he  was  himself  rescued  by  the  American  Red  Cross, 
desperately  ill  with  acute  appendicitis.  The  coro- 
nation of  the  late  King  Edward  Vllth  of  England 
was  delayed  because  he  was  operated  on  for  an 
appendiceal  abscess.  The  late  President  Ebert  of 
Germany  died  of  the  disease.  One  of  the  recent 
Louisiana  scandal  trials  was  halted  because  the 
chief  of  the  defense  staff  developed  an  attack  of 
acute  appendicitis  while  court  was  in  session  and 
had  to  be  operated  on.  The  City  of  New  York  lost 
sixty  thousand  dollars  because  a  case  in  which  the 
testimony  had  occupied  14  weeks  had  to  be  declar- 
ed a  mistrial,  one  of  the  jurors  developing  acute 
appendicitis  and  requiring  an  emergency  operation 
just  as  it  was  going  to  the  jury. 

Such  instances  can  be  multiplied,  but  they  need 
not  be.  The  point  is  perfectly  clear.  Acute  appen- 
dicitis is  a  very  frequent  and  a  very  urgent  disease. 
It  spares  no  race,  sex,  or  social  station.  It  may 
occur  at  any  age  from  the  cradle,  or,  more  correct- 
ly, the  womb,  to  the  grave.  It  can  occur  at  work, 
at  play,  during  sleep — from  which  it  frequently 
awakes  the  victim — on  land,  on  sea,  and  I  have  no 
doubt  in  the  air,  on  the  golf  course,  at  the  moving 
pictures,  in  church,  in  the  center  of  civilization,  in 
the  heart  of  the  wilderness,  and  in  the  physician's 
office,  where  at  least  two  patients  of  my  acquaint- 
ance developed  their  attacks  while  waiting  to  con- 
sult their  physicians  for  other  complaints. 

The  experiences  of  these  two  patients  demon- 
strate an  important  diagnostic  point,  that  an  indi- 
vidual with  one  disease  can  perfectly  well  develop 
another  in  the  course  of  it.  Failure  to  realize  that 
fact  is  responsible  for  a  great  many  deaths  in  acute 
appendicitis.  In  several  thousand  cases  studied  in 
detail  at  the  New  Orleans  Charity  Hospital,  the 
disease  developed  under  a  great  variety  of  circum- 
stances: with  the  onset  of  and  during  menstruation, 
after  tonsillectomy,  during  the  act  of  defecation, 
immediately  after  taking  a  purgative,  after  the  ex- 
traction of  teeth,  after  an  operation  for  cataracts, 
after  vaccination,  and  in  the  course  of  malaria, 
paratyphoid  and  typhoid  fever,  pneumonia,  influ- 
enza, measles,  and  pelvic  inflammatory  disease,  In 


a  small  but  highly  fatal  group  of  cases  it  followed 
dietary  indiscretions.  What  part  such  indiscretions 
play  in  the  etiology  of  the  disease  is  not  known, 
but  of  the  frequency  of  their  occurrence,  the  diag- 
nostic difficulties  they  introduce,  and  the  number 
of  fatalities  they  cause  there  can  be  no  doubt.  The 
natural  tendency  is  to  resort  to  purgation.  Even 
if  that  dangerous  practice  be  omitted,  delay  is  al- 
most inevitable,  and  is  particularly  serious  in 
young  children  and  in  older  individuals,  in  whom, 
for  many  reasons,  dietary  indiscretions  are  partic- 
ularly frequent'. 

Acute  appendicitis  is  relatively  infrequent  before 
the  age  of  12  years,  and  actually  infrequent  over 
the  age  of  40  years,  though  the  mortality  is  higher 
in  extreme  youth  and  very  much  higher  in  middle 
and  late  life  than  in  adolescence  and  early  adult 
life.  In  4207  cases  studied  at  the  New  Orleans 
Charity  Hospital  over  a  nine-year  period,  individ- 
uals at  the  extremes  of  life  provided  just  over  a 
quarter  of  all  cases  of  acute  appendicitis,  but  well 
over  half  of  the  total  mortality.  Even  more  strik- 
ing it  is  that  individuals  over  39  years  of  age,  who 
provided  just  over  10  per  cent  of  the  total  number 
of  cases,  provided  considerably  over  a  quarter  of 
the  total  deaths,  the  mortality  rising  steadily  with 
each  succeeding  decade. 
The  Diagnostic  Difficulties  of  Acute  Appendicitis 

The  difficulties  in  the  diagnosis  of  acute  appen- 
dicitis usually  come  early  in  the  disease.  In  the 
obscure  case  some  degree  of  hesitation  is  natural, 
but  the  physician  who  is  hesitating  over  a  diagno- 
sis of  acute  appendicitis  should  not  hesitate  too 
long.  The  interval  between  observation  should 
never  be  more  than  four  hours,  and  could  profit- 
ably be  a  great  deal  less,  for  the  disease,  as  Stone 
points  out,  does  not  proceed  on  a  railroad  time- 
table, and  a  great  deal  of  harm  may  be  done  in  a 
short  space  of  time,  particularly  in  the  obstructive 
variety.  A  practical  consideration  is  that  in  the 
interim  between  observations  what  Bower  has 
called  the  "lucid  interval"  and  others  the  "danger- 
ous period  of  calm-'  may  ensue  and  may  confuse 
the  physician  by  the  disappearance  of  symptoms. 
It  may  also  so  relieve  the  patient  and  his  family 
that  they  refuse  operation,  on  the  basis  that  recov- 
ery is  well  under  way. 

Another  important  consideration  in  the  diagnosis 
of  acute  appendicitis  is  that  the  disease  is  atypical 
in  a  very  large  proportion  of  cases.  Some  set  the 
figure  at  25  per  cent.  My  own  experience  and  ob- 
servation would  make  me  set  it  much  higher, 
though  the  exact  proportion  makes  no  difference. 
What  is  important  is  to  recollect  that  although  in 
some  cases  of  acute  appendicitis  certain  symptoms 
appear  in  a  certain  chronological  order,  so  that  a 
lav  person  could  make  the  diagnosis,  in  other  cases, 


November,  1941 


TEE  BASIC  PROBLEMS  OF  ACUTE  APPENDICITIS— Boyce-Nehon 


certain  symptoms  or  signs  are  missing,  or  the 
chronology  is  reversed  or  otherwise  disturbed,  or 
the  whole  clinical  picture  is  bizarre  and  not  at  all 
suggestive  of  appendiceal  disease. 

It  is  curious  that  some  of  the  physicians  who 
have  done  the  most  to  teach  the  essential  consid- 
erations of  acute  appendicitis  have  also  made  dog- 
matic and  incorrect  statements  about  it  which  have 
done  a  great  deal  of  harm.  Thus  Lord  Moynihan 
made  the  unqualified  statement  that  if  pain  be  not 
the  first  symptom,  appendicitis  can  be  excluded.  It 
was  not  the  first  symptom  in  307  of  the  cases  we 
studied  at  the  New  Orleans  Charity  Hospital.  John 
B.  Murphy  insisted  on  a  temperature  elevation  as 
a  cardinal  symptom  of  acute  disease.  Nearly  21 
per  cent  of  the  patients  we  studied  at  Charity  Hos- 
pital were  fever-free.  A  leukocytosis  of  between 
10,000  and  15,000  is  usually  stated  to  be  the  aver- 
age, yet  less  than  a  third  of  the  Charity  Hospital 
patients  fell  into  this  group.  The  mortality  in  all 
of  these  atypical  groups  was  considerably  higher 
than  in  the  typical  group  and  well  illustrates  the 
danger  of  generalizations  in  this  disease. 

Differential  diagnosis  is  frequently  difficult.  J. 
M.  T.  Finney,  St.,  has  listed  40  conditions  which 
he  has  been  called  upon  to  differentiate  from  acute 
appendicitis,  and  one  textbook  mentions  60.  Deav- 
er  listed  acute  abdominal  conditions  in  the  order 
of  intensity  with  acute  pancreatitis  first  and  acute 
appendicitis  last,  though  in  the  order  of  frequency 
he  reversed  the  list  and  put  pancreatitis  last  and 
acute  appendicitis  first.  The  widespread  prevalence 
of  the  disease  makes  it  imperative  that  the  physi- 
cian confronted  with  any  patient  in  whom  it  is  a 
possibility,  however  remote,  should  follow  this  same 
author's  advice  and  think  of  acute  appendicitis 
first,  last  and  all  the  time. 

Elman  has  suggested  a  sound  plan  of  differential 
diagnosis.  First,  the  physician  should  exclude  med- 
ical diseases  which  may  produce  acute  pain,  such 
as  coronary  disease,  primary  peritonitis,  amebic 
dysentery  and  typhoid  fever.  In  this  group  of 
cases  operation  would  be  harmful  and  could  be 
fatal.  Second,  he  should  exclude  other  nonsurgical 
diseases,  such  as  spastic  colitis  and  acute  pelvic  dis- 
ease. In  this  group  operation  would  be  a  mistake 
but  would  have  no  serious  consequences.  Third,  he 
should  exclude  other  surgical  diseases,  such  as  in- 
testinal obstruction,  perforated  peptic  ulcer  and 
perforated  Meckel's  diverticulum.  In  this  group, 
the  diagnosis  would  be  mistaken;  but  surgery  is 
necessary,  and  no  harm  would  be  done  provided  the 
surgeon  made  an  incision  which  enabled  him  to 
recognize  and  remove  the  disease  process  present. 
Not  to  operate  in  acute  appendicitis,  Elman  points 
out,  is  the  really  serious  error.  To  operate  and  find 
an  appendix  normal  and  no  other  lesion   needing 


surgical  attention  is  a  good  mistake,  provided  that 
it  is  not  made  too  frequently  and  that  medical  dis- 
eases have  been  excluded  before  the  exploration  is 
undertaken. 

Before  one  can  diagnose  or  exclude  a  disease, 
one  must  remember  that  it  may  be  present.  In 
acute  appendicitis  this  means  almost  literally  that 
the  only  patient  who  may  not  have  the  disease  is 
the  one  whose  appendix  has  already  been  removed. 
The  physician  who  puts  the  burden  of  proof  on  the 
elimination  of  other  conditions,  particularly  medi- 
cal conditions,  is  entirely  justified  in  recommending 
operation  in  any  given  case  on  the  basis  that  he 
can  not  say  positively  that  the  patient  does  not 
have  acute  appendicitis.  This  is  not  radical  advice. 
The  mortality  which  attends  exploratory  laparo- 
tomy is  nothing  like  the  mortality  which  attends 
the  nonsurgical  treatment  of  acute  appendicitis. 
Furthermore,  as  Elman  has  pointed  out,  the  fre- 
quent argument  between  the  surgeon  and  the  path- 
ologist as  to  the  significance  of  minor  microscopic 
and  even  gross  changes  in  the  appendix  is  futile. 
The  surgeon  who  operates  for  acute  appendicitis, 
even  if  the  diagnosis  is  in  error,  or  if  the  appendix, 
as  is  frequent  in  early  obstructive  appendicitis, 
shows  no  special  changes,  need  feel  no  regret  if  the 
pathologist  returns  a  report  suggesting  that  the  ap- 
pendix need  not  have  been  removed. 

Conservative  Therapy  in  Complicated  Acute 
Appendicitis 

The  treatment  of  acute  appendicitis  needs  no 
discussion.  The  treatment  is  surgical — first,  last, 
always,  and  immediately.  As  more  than  one  writer 
has  put  it,  the  principle  on  which  the  physician 
should  manage  the  case  is  that  the  only  safe  appen- 
dix is  the  appendix  in  a  jar  on  the  laboratory  shelf. 
If  the  premise  of  the  unpredictability  of  acute  ap- 
pendicitis be  accepted,  then  the  corollary  is  imme- 
diate operation  when  the  patient  is  first  seen,  unless 
he  be  certainly  on  the  road  to  recovery,  and  even 
then  the  decision  not  to  operate  immediately  is 
sometimes  bitterly  regretted. 

Generally  speaking,  I  believe  with  Grey  Turner 
that  details  of  technique  can  not  alter  the  outcome 
in  acute  appendicitis  in  any  way  whatsoever. 
Equally  good  results  have  been  reported  with  the 
McBurney  and  the  right-rectus  incision,  and  with 
and  without  inversion  of  the  stump.  None  of  these 
things  makes  a  difference  in  comparison  with  such 
other  points  as  how  soon  the  patient  is  seen  after 
the  onset  of  his  illness,  how  promptly  he  is  oper- 
ated on,  and  whether  or  not  he  has  had  a  purga- 
tive. 

Although  the  complications  of  acute  appendicitis 
are  not  the  subject  of  this  paper,  a  few  words 
should  be  said  about  their  management,  particu- 
larly with  reference  to  so-called  conservative  or  ex- 


THE  BASIC  PROBLEMS  OF  ACUTE  APPENDICITIS— Bow-Nelson 


November,  1941 


pectant  therapy,  which  never,  of  course,  enters  into 
consideration  in  the  management  of  acute  appen- 
dicitis. 

During  certain  periods  of  our  nine-year  study  of 
acute  appendicitis  at  the  New  Orleans  Charity 
Hospital  the  conclusion  has  unfortunately  been  in- 
escapable that  a  moderate  reduction  in  surgical 
mortality  has  been  associated  with  a  clear  increase 
in  the  number  of  non-surgical  deaths.  It  is  fair  to 
say  that  in  at  least  some  of  these  latter  cases  con- 
servative therapy  appears  to  have  been  employed 
on  somewhat  doubtful  indications.  The  method  is 
of  very  questionable  value  in  young  children,  in 
individuals  advanced  in  years,  and  in  Negroes. 
With  due  realization  that  the  institution  of  therapy 
in  relation  to  the  duration  of  illness  is  dangerous, 
its  use  within  the  first  40,  and  certainly  within  the 
first  24,  hours  of  illness  is  questionable.  Speaking 
categorically,  I  have  no  doubt  that  immediate 
operation  in  all  cases  of  acute  appendicitis,  regard- 
less of  when  the  patient  is  seen  or  what  complica- 
tions may  be  present,  will  give  better  results  in  the 
long  run  and  in  the  hands  of  most  surgeon  than 
will  the  practice  of  conservative  therapy  by  men 
who  do  not  thoroughly  understand  its  limitations 
and  implications. 

Harvey  Stone,  who  has  recently  taken  the  un- 
qualified position  that  immediate  operation  is  the 
only  safe  method  in  any  stage  of  acute  appendi- 
citis, has  well  summed  up  the  arguments  in  favor 
of  that  stand.  The  whole  basis  of  expectant  treat- 
ment, he  points  out,  is  the  entirely  unwarranted 
assumption  that  it  is  possible,  without  opening  the 
abdomen,  to  recognize  the  nature  and  extent  of  the 
pathologic  process.  It  is  not  possible.  A  ruptured 
retrocecal  appendix  may  be  clinically  unrecogniz- 
able. The  mass  suspected  of  being  an  abscess  may 
turn  out  to  be  an  unruptured  appendix  surrounded 
by  omentum.  The  diagnosis  of  spreading  periton- 
itis may  be  made  when  the  abdomen  contains  only 
cloudy  fluid  and  the  appendix  is  still  intact.  Arkush 
and  Kosky's  study  supports  these  observations;  in 
48  per  cent  of  the  cases  they  studied  a  preoperative 
diagnosis  of  rupture  was  made,  but  the  appendix 
was  found  at  operation  to  be  unruptured.  If  oper- 
ation had  been  delayed  in  these  cases,  the  appendix 
might  have  ruptured  literally  under  the  surgeon's 
eyes. 

Stone's  second  point  is  the  illogic  of  relying  on 
Nature  to  take  care  of  the  damage  done  by  a  rup- 
tured appendix  without  first  removing  the  source 
of  the  damage;  that  is,  the  leaking  organ  itself.  It 
is  difficult  for  him  to  believe  that  a  properly-car- 
ried-out  operation  is  as  harmful  to  the  patient  as 
is  the  continued  entrance  into  the  peritoneal  cavity 
of  infection  from  a  perforated  viscus.  He  takes 
decided  issue  with  Lehman's  feeling  that  the  estab- 


lishment of  an  abscess  marks  the  end  of  the  dan- 
gerous phase  of  the  disease,  and  that  many  such 
patients,  if  properly  handled,  may  not  require  sur- 
gery at  all.  This  is  certainly  not  the  general  ex- 
perience. 

Stone's  arguments  about  expectant  treatment 
are  in  entire  accord  with  my  own  frequently-ex- 
pressed opinion  that  the  chief  risk  of  peritonitis  is 
the  toxemia  to  which  the  ruptured  appendix  gives 
rise.  That  point  was  first  made  by  Dieulafoy,  but 
not  a  great  deal  of  emphasis  has  been  put  upon  it 
since,  though  it  is  one  of  the  most  cogent  arguments 
against  delayed  operation  at  any  age,  and  partic- 
ularly at  the  extremes  of  life,  when  toxemia  is 
particularly  fatal. 

Elman  has  also  taken  the  position  that  all  the 
surgeon  has  to  decide  in  a  case  of  acute  appendi- 
citis is  whether  the  patient  is  in  such  condition  as 
to  withstand  surgery.  If  he  is,  operation  is  done 
immediately,  regardless  of  the  state  of  his  appen- 
dix. If  he  is  not,  operation  is  postponed  until  his 
condition  is  improved,  and  is  performed  the  mo- 
ment the  reparative  measures  have  had  their  maxi- 
mum effect,  again  without  regard  to  the  state  of 
the  appendix.  In  such  cases,  the  full  therapeutic 
regimen  should  be  carried  out,  including  the  liberal 
use  of  sedatives — with  the  realization  that  they 
may  mask  symptoms — infusions  for  the  mainte- 
nance of  the  proper  fluid  balance,  continuous  in- 
testinal decompression,  postural  drainage,  the  heat 
tent,  oxygen  therapy,  sulfonamide  therapy,  and 
transfusions  of  blood  or  plasma  as  indicated. 

Advice  to  seek  prompt  interval  appendectomy 
should  be  issued  to  the  patient  who  has  had  pre- 
vious conservative  treatment  of  appendiceal  dis- 
ease, whether  it  has  been  nonsurgical  or  surgical 
without  removal  of  the  appendix.  Deferred  appen- 
dectomy, as  Coller  and  Potter  express  it,  implies 
that  appendectomy  is  going  to  be  done.  A  patient 
whose  appendix  is  still  in  situ  after  conservative 
therapy  is  quite  as  liable  to  subsequent  attacks  as 
is  a  patient  who  has  had  recurrent  attacks  of  the 
simple  acute  disease;  the  only  difference  is  that 
the  former  has  used  up  more  of  his  luck.  Of  16 
patients  at  Charity  Hospital  who  had  recurrent  at- 
tacks after  previous  incision  and  drainage  of  the 
appendiceal  abscesses,  in  one  instance  only  three 
weeks  before,  the  death  rate  exceeded  30  per  cent. 

Sulfonamide  Therapy  in  Complicated  Acute 
Appendicitis 
Over  the  nine-year  period  ending  April  1st,  1939, 
4207  surgical  cases  of  acute  appendicitis  and  its 
complications  were  treated  at  Charity  Hospital  of 
Louisiana  at  New  Orleans,  with  a  mortality  of  5.6 
per  cent.  This  figure  represents  the  total  of  four 
cumulative  studies,  in  each  of  which  there  was  only 
a  fractional  variation  in  the  mortality.     The  1492 


November,   1941 


THE  BASIC  PROBLEMS  OF  ACUTE  APPENDICITIS—  Boyce-Nelson 


cases  comprising  the  last  series  (ending  April  1st, 
1939),  in  which  the  mortality  was  S.3  per  cent, 
may  fairly  be  taken  as  typical  of  the  results  achiev- 
ed in  what  might  be  called  the  presulfonamide 
period.  A  series  of  756  cases  analyzed  for  the  pe- 
riod extending  from  January  1st,  1940,  to  June 
1st,  1941,  in  which  the  mortality  was  2.91  per  cent, 
furnishes  an  interesting  comparative  illustration  of 
the  possibilities  of  the  sulfonamide  drugs,  although 
they  were  used  in  only  132  of  the  517  cases  in 
which  the  disease  had  advanced  beyond  the  simple 
acute  stage. 

The  improvement  in  mortality  can  most  readily 
be  shown  by  comparing  the  ratio  of  deaths  to  cases 
in  relation  to  certain  phases  of  acute  appendicitis 
in  the  most  recent  presulfonamide  period  (1492 
cases)  with  the  ratio  in  the  756  cases  recently 
studied,  when  the  use  of  sulfonamide  drugs  had 
become  rather  general  (Table  1). 
Table  1 

Ratio  of  deaths  to  cases  in   two  series  of  cases  of  acute 
Appendicitis* 

Pre- 

sulj onamide  Sulfonamide 

Era  Era 
1492  Cases     756  Cases 

Total  cases  1:19  1:34 

Uncomplicated  cases  1:63  1:120 

Complicated  cases  1:11  1:26 

Appendectomy  only  1:72  1:310 

Appendectomy  and/or  other  procedures  1:4  1:7 

Males  1:20  1:50 

Females   1:17  1:22 

White  1:25  1:42 

Colored    1:11  1:26 

Under  13  years  1:14  1:36 

13-39  years  1:29  1:102 

Over  39  years  1:6  1:8 

Operation  within  12  hours 1:69  1:150 

within  24  hours 1:58  1:55 

within  48  hours 1:15  1:31 

after  48  hours 1:12  1:20 

With  purgation  1:16  1:38 

With  repeated  purgation 1:14  1:17 

•The  nearest  whole  numbers  are  used. 

The  circumstances  in  both  series,  aside  from  the 
difference  in  the  number  of  cases,  were  not  always 
similar.  A  smaller  number  of  patients  took  purga- 
tives and  repeated  them  in  the  more  recent  series. 
Drainage  was  used  in  fewer  cases,  which  increased 
the  proportion  of  simple  appendectomies  perform- 
ed. As  was  to  be  expected  of  cases  in  which 
operations  were  carried  out  by  a  large  number  of 
persons,  the  sulfonamide  drugs  were  not  used  in 
all  cases  in  which  it  seems  they  were  indicated,  and 
neither  the  dosage  nor  mode  of  application  appears 
to  have  been  decided  on  consistently  logical 
grounds. 

In  spite  of  these  facts,  however,  an  improvement 
which,  as  a  rule,  was  striking,  was  shown  in  prac- 
tically every  phase  of  the  756  most  recent  cases, 
and   there  seems  no  doubt  that  most  of  this  im- 


provement was  due  to  the  use  of  the  sulfonamide 
drugs.  The  improvement  achieved,  moreover,  was 
definite  and  not  fractional,  as  any  improvement 
which  had  occurred  over  the  preceding  nine-year 
period  had  always  been.  Finally,  it  was  accom- 
plished in  a  hospital  in  which  conditions  are  admit- 
tedly unfavorable,  in  that  it  receives  patients  of 
the  social  strata  most  likely  to  ignore  illness  until 
it  has  become  serious  and  most  likely  to  treat  it 
unwisely  if  they  do  pay  any  attention  to  it.  To 
cut  the  mortality  in  half  in  a  hospital  of  this  sort 
is  eloquent  testimony  to  the  possibilities  of  sul- 
fonamide therapy  in  appendicular  peritonitis, 
though  it  does  not,  as  I  said  in  the  beginning,  in 
any  way  solve  the  problem  of  acute  appendicitis, 
which  is  to  treat  the  disease  before  the  develop- 
ment of  complications  which  put  the  patient  in 
jeopardy,  no  matter  how  they  are  treated. 
The  Solution  of  the  Problem  of  Acute  Appendicitis 
When  Bower  began  his  work  with  acute  appen- 
dicitis in  Philadelphia  in  the  late  twenties,  the 
mortality  in  the  hospitals  there  was  nearly  6  per 
cent.  Within  five  years  it  had  been  cut  almost  in 
half,  as  the  result  of  the  campaign  of  public  in- 
struction on  the  subject  instituted  by  the  local 
medical  society.  This  result,  which  I  do  not  believe 
has  been  equalled  anywhere  in  the  country  prior  to 
the  use  of  the  sulfonamide  drugs,  bears  out  Hoff- 
man's contention  that  acute  appendicitis  is  a  pub- 
lic-health problem. 

There  can  not  be  very  much  argument  over  that 
point  of  view.  It  would  be  hard  to  think  of  a  dis- 
ease in  which  greater  results  could  be  achieved  with 
a  smaller  expenditure  of  time  and  effort.  In  fact, 
isolated  campaigns  of  education  on  this  subject, 
in  addition  to  the  sustained  campaign  in  Philadel- 
phia, have  demonstrated  such  remarkable  saving  of 
life  as  to  make  one  wish  that  the  large  medical 
foundations  would  devote  a  small  portion  of  their 
funds  to  this  excellent  cause.  The  problem  of  acute 
appendicitis  would  be  solved  and  its  challenge 
would  be  met  if  the  lay  public  could  be  taught  and 
if  physicians  would  remember  (1)  that  any  ab- 
dominal pain  may  be  the  first  symptom  of  acute 
appendicitis;  (2)  that  food,  fluids,  and  particularly 
purgatives,  should  be  absolutely  withheld  in  every 
case  of  abdominal  pain  until  acute  appendicitis  has 
been  excluded  as  a  diagnosis;  and  (3)  that  prompt 
operation  is  the  treatment  for  acute  appendicitis  as 
soon  as  the  diagnosis  is  made  or  is  suspected  with 
good  reason. 

To  revert  to  the  point  with  which  I  opened  this 
discussion,  the  simplest  way  to  reduce  and  indeed 
practically  reduce  to  nullity  the  mortality  of  acute 
appendicitis  is,  not  to  treat  peritonitis  with  sulfan- 
ilamide or  with  anything  else,  but  to  increase  the 
proportion  of  cases  of  uncomplicated  acute  appen- 


THE  BASIC  PROBLEMS  OF  ACUTE  APPENDICITIS— Boyce-Nelson 


November,  1941 


dicitis  which  come  the  way  of  the  surgeon.  That  is 
what  has  been  done  in  Philadelphia,  and  it  is  what 
can  be  done  anywhere  in  the  country  when  physi- 
cians of  any  locality  set  their  minds  and  hearts 
and  energies  to  that  purpose. 
References 

Arkush,  A.  S.,  and  Kosky,  A.  A.:  The  accuracy  of 
diagnosis  of  appendicitis.  /.  Lab.  &  Clin.  Med.,  25:1276- 
1287,  Sept.,  1940. 

Bower,  J.  O.:  The  lucid  interval  and  acute  appendicitis. 
Am.  J.  M.  Sc,  195:529-538,  April,  1938. 

Bower,  J.  O.:  Report  of  the  Pennsylvania  State  Medical 
Society  Committee  on  Appendicitis  Mortality.  Pennsylvania 
M.  J.,  38:257-260,  Jan.,  1935. 

Boyce,  F.  F.:  The  mortality  of  acute  appendicitis.  A 
continuing  study  (4,207  cases)  from  the  Charity  Hospital 
of  Louisiana  at  New  Orleans.  New  Orleans  M.  &  S.  J., 
93:300-306,  Dec,  1940. 

Boyce,  F.  F.,  with  McFetridge,  E.  M.:  The  presentation 
of  acute  appendicitis  in  standard  textbooks  and  systems. 
New  Orleans  M.  &  S.  J.,  89:167-169,  Oct.,  1936. 

Coller,  F.  A.,  and  Potter,  E.  B.:  Treatment  of  appen- 
dicitis associated  with  peritonitis.  /.  A.  M.  A.,  103:1753- 
1758,  Dec.  8th,  1934. 

Deaver,  J.  B.:  The  dramatic  abdomen.  South.  Surgeon, 
1:11-15,  April,  1932. 

Elman,  R.:  The  challenge  of  acute  appendicitis.  Diag- 
nostic and  therapeutic  details  designed  to  reduce  mortality, 
with  special  reference  to  the  delayed  operation.  /.  Mis- 
souri State  M.  A.,  38:107-110,  April.  1941. 

Finney,  J.  M.  T.:  The  acute  abdomen.  New  Orleans 
M.  &  S.  J.,  87:589-600,  March,  1935. 

Fitz,  R.  H.:  Perforating  inflammation  of  the  vermiform 
appendix;  with  special  reference  to  its  early  diagnosis  and 
treatment.    Tr.  A.  Am.  Phys.,  1:107-136,  1886. 

Hoffman,  F.  L.:  The  appendicitis  record  of  1936.  Spec- 
tator, Oct.  28th,  1937,  pp.  6-9,  30. 

Moynihan,  G.  B.  K.:  Essays  on  Surgical  Subjects.  W. 
B.  Saunders  Company,  Philadelphia,  1921.    pp.   143-133. 

Mumford,  J.  G.:  Practice  of  Surgery,  Ed.  2.  W.  B. 
Saunders  Company,  Philadelphia,  1914. 

Murphy,  J.  B.:  Clinics  of;  Acute  appendicitis.  3:1085- 
1102,  Dec,  1914.  4:183-185,  Feb.,  1915.  4:443-446,  June, 
1915. 

Price-Williams,  J.:  Cause  of  appendicitis  (Correspond- 
ence). Brit.  M.  J.,  2:612,  Nov.  2,  1940.  Treatment  of  ap- 
pendicitis (Correspondence). 

Ibid:  2:806,  Dec.  7th,  1940. 

Stone,  H.  B.:  The  management  of  acute  appendicitis. 
Arguments  and  controversies.  Virginia  M.  Month.,  67:655- 
659,  Nov.,  1940. 

Turner,  G.  G.:  Acute  appendicitis.  Brit.  M.  J.,  2:691- 
695,  Oct.  1st,  1938. 

Wangensteen,  O.  H.,  and  Dennis,  C:  Experimental 
proof  of  the  obstructive  origin  of  appendicitis  in  man. 
Ann.  Surg.,  110:629-647,  Oct.,  1939. 

Wilkle,  D.  P.  D.:    Observations  on  mortality  in  acute 
appendicular   disease.     Brit.   M.   J.,    1:253-255,   Feb.    14th, 
1931. 
— 1413  Union  Building 


ACUTE  APPENDICITIS:   A  STUDY  OF  1,006 
CONSECUTIVE  CASES 
(F.  C.  Hill'  &  A.  C.  Fellman,  Omaha,  in  Neb.  Med.  J  I.,  Oct.) 
Creighton  Memorial  St.  Joseph's  Hospital  is  an  institu- 
tion of  500  beds,  about  one-fifth  of  which  are  free,  and 
the  surgery  is  done  by  some  35  men.    This  is  a  study  of 
1,006  consecutive  cases  operated  on  in  the  years  1934  to 
1939.    Only  those  cases  were  used  in  which  the  final  diag- 
nosis of  the  surgeon  was  acute  appendicitis,  and  in  all  of 


the  cases  included,  operation  was  performed.  A  few  pa- 
tients with  acute  appendicitis,  mild,  were  dismissed  from 
the  hospital  without  operation.  There  were  also  three 
cases  which  were  not  operated  on  because  of  the  hopeless 
condition ;  these  are  not  included. 

The  youngest  patient  in  the  series  was  two  months  of 
age,  the  oldest  78.  One-half  of  the  total  number,  and  two- 
thirds  of  the  fatal  cases,  were  of  males.  There  was  a  pre- 
vious attack  of  appendicitis  in  one-third  of  the  entire  series 
and  in  not  quite  one-third  of  the  fatal  cases.  About  90% 
of  all  the  cases  were  simple  acute  appendicitis.  Of  the 
remaining  10%,  80%  were  simply  ruptured  and  20%  were 
ruptured  with  peritonitis. 

The  average  duration  for  all  cases  was  48J  hours.  For 
the  fatal  cases  it  was  over  eight  days,  and  here  is  the  most 
important  cause  of  death  in  appendicitis. 

The  average  temperature  on  admission  was  99.6  for  the 
entire  series  and  100.7  for  the  fatal  cases.  The  average 
white  blood  count  was  16,000  for  the  former,  14,000  for 
the  latter. 

After  pain  in  the  right  lower  quadrant,  nausea  was  the 
next  most  common  symptom,  then  tenderness  in  the  right 
lower  quadrant.  Vomiting  and  distention  was  present  in 
only  42  instances,  and  7  of  these  in  the  fatal  cases.  All  of 
the  cardinal  symptoms  of  acute  appendicitis  (pain  in  the 
right  lower  quadrant,  nausea,  vomiting,  tenderness,  rigidity 
and  leukocytosis)  were  present  in  only  one-third  of  the 
cases. 

Distention  in  acute  appendicitis  makes  us  hesitate  to 
operate.  We  believe  that  in  the  absence  of  distention, 
acute  appendicitis  should  be  operated  upon  regardless  of 
the  duration  of  the  disease  unless  a  palpable  mass  is  pres- 
ent. 

Generalized  rigidity  we  have  not  found  to  be  a  positive 
indication  of  generalized  peritonitis. 

We  believe  that  the  safest  procedure  in  a  case  of  rup- 
tured appendix  is  removal  of  the  appendix,  thus  preventing 
continued  peritoneal  infection. 

The  appendix  was  removed  in  98%  of  the  entire  series 
and  in  83%  of  the  fatal  cases.  In  one-fourth  of  the  cases 
drainage  was  used.  A  purgative  was  administered  in  10% 
of  the  series;  of  the  fatal  cases  23%  received  a  purgative. 

In  the  cases  from  the  Johns  Hopkins  Hospital,  there  was 
no  mortality  in  838  cases  of  simple  acute  appendicitis  and 
in  Omaha  the  mortality  was  1%  for  894  cases.  At  Johns 
Hopkins  the  mortality  was  10%  for  the  ruptured  cases  and 
in  Omaha  it  was  18.75%;  but  for  the  entire  series  the 
mortality  in  Omaha  was  lower  than  at  Johns  Hopkins.  In 
Omaha  10%  were  ruptured  on  admission  and  at  Johns 
Hopkins  36%. 


SYPHILIS  RATE  4.52  PER  CENT 
(//.  A.  M.  A.,  October  18th) 

A  rate  of  45.2  cases  of  syphilis  per  thousand  persons 
examined  was  found  through  physical  and  routine  sero- 
logic blood  tests  of  the  first  million  selectees  and  volun- 
teers called  for  classification  under  the  Selective  Service 
Act  of   1940. 

The  greatest  prevalence  was  reported  by  Florida  and 
South  Carolina,  with  rates  of  170.1  and  156  cases  per 
thousand  respectively.  The  lowest  rate,  of  5.8  per  thous- 
and, was  reported  by  New  Hamphshire.  Seven  Southern 
states  and  the  District  of  Columbia  reported  rates  in 
excess  of  100  cases  per  thousand.  For  the  country  as  a 
whole,  the  prevalence  of  syphilis  among  Negroe  selectees 
and  volunteers  is  thirteen  times  that  for  the  white. 


He  is  rich  who  has  enough  to  be  charitable ;  and  it  is 
hard  to  be  so  poor,  that  a  noble  mind  may  not  find  a 
way  to  this  piece  of  goodness. — Dr.  (Sir)  Thomas  Browne. 


November.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


Present  Status   of  Fever  Therapy* 

Andrew  D.  Taylor,  M.D.,  Charlotte 


IN  THE  PAST  TEN  YEARS  over  650  papers 
and  articles  have  been  published  on  the  treat- 
ment of  disease  by  artificially  induced  fever. 
It  is  the  aim  of  this  paper  to  summarize  these,  and 
to  evaluate  the  results  of  a  few  of  the  recent  and 
more  comprehensive  papers,  and,  in  addition,  to 
offer  some  comments  based  on  my  own  experience 
in  the  Fever  Therapy  Department  of  the  Charlotte 
Memorial  Hospital  and  in  larger  departments  in 
Washington,  New  York  and  Chicago. 

In  our  department  at  the  Charlotte  Memorial 
Hospital  we  use  the  improved  inductotherm  fever 
cabinet.  The  patient's  temperature  is  elevated  by 
electromagnetic  induction  and  maintained  by  an 
insulated  air-conditioned  cabinet.  The  air  in  the 
cabinet  is  warmed,  circulated  and  maintained  at  a 
humidity  approximating  100  per  cent.  An  in- 
dwelling rectal  bulb  is  connected  by  a  wire  to  a 
constant-indicating  electrical  thermometer  at  the 
head  of  the  cabinet  so  that  the  technician  may 
know  at  every  instant  exactly  what  the  patient's 
rectal  temperature  is  without  disturbing  him. 

Hyperpyrexia,  as  induced  by  fever  cabinets,  has 
been  applied  to  more  than  fifty  diseases  in  the  past 
ten  years.  The  results,  in  many  of  these  conditions, 
have  been  disappointing,  whereas  the  benefits  de- 
rived in  other  diseases  proved  this  means  of  therapy 
to  be  of  extreme  value. 

Gonococcic  Infections 

Sinee  the  advent  of  the  sulfonamide  drugs  the 
treatment  of  gonococcic  infections  has  been  greatly 
improved.  The  rapidity  with  which  many  cases 
yielded  to  the  intelligent  administration  of  these 
drugs  obviated,  to  a  great  extent,  the  need  for  the 
use  of  accessory  therapeutic  agents.  However,  sev- 
eral circumstances  indicate  that  we  have  as  yet  no 
specific  cure  for  gonorrhea.  These  circumstances 
are:  (1)  the  persistence  of  the  asymptomatic  car- 
rier, (2)  the  development  of  chemotherapy-fast 
strains  of  the  gonococcus  and,  (3)  the  occurrence 
of  relapse  after  apparent  cure. 

The  carrier  state  is  one  of  the  most  serious  prob- 
lems created  by  chemotherapy.  Under  chemother- 
apy the  urethral  discharge  disappears  in  an  aver- 
age of  three  days.  It  is  difficult  after  this  time  to 
obtain  a  positive  smear,  but  culture  of  the  urine 
and  prostatic  secretions,  when  the  proper  technic 
and  culture  media  are  used,  is  always  positive  for 
the  gonococcus  for  a  period  of  from  two  to  fifty 
days,  with  an  average  of  seventeen  days  for  sul- 
fathiazole-treated    cases.1     Chemotherapy    has   de- 


stroyed the  value  of  the  former  provocative  test. 
The  patient  who  has  gone  into  a  clinically  negative 
phase  under  chemotherapy  can  go  through  alco- 
holic, sexual,  or  exertion  provocation  without  a  re- 
currence of  symptoms,  despite  the  fact  that  cul- 
tural studies  still  give  positive  results.  Hence  the 
asymptomatic  carrier  may  unknowingly  transmit 
his  sulfonamide-fast  strain  to  a  second  person.  The 
second  person,  in  turn,  may  become  an  asympto- 
matic carrier.  Transfer  of  this  organism  to  a  sexual 
partner  may  lead  to  clinical  evidences  of  gonorrhea 
which  will  not  respond  to  chemotherapy.1 

In  a  survey  by  Deese  and  Young  of  2,727  well 
analyzed  cases  only  1,848  (68%)  could  be  classi- 
fied as  immediate  cures,  and  an  additional  four  per 
cent  as  delayed  cures. 

Numerous  investigations  have  demonstrated  the 
value  of  artificial  fever  in  the  treatment  of  gonor- 
rhea. The  best  results  are  now  reported  following 
the  use  of  the  single,  long  fever-session,  combined 
with  the  use  of  one  of  the  sulfonamides.  Belt  and 
Folkenberg  reported  80  per  cent  of  cases  cured  by 
sulfanilamide  or  its  derivatives,  alone.  Of  the  20 
per  cent  of  cases  resistant  to  chemotherapy  they 
cured  87  per  cent  by  a  single,  long  session  of  arti- 
ficial fever,  combined  with  chemotherapy.  By  de- 
termining the  thermal  death  time  of  the  organism 
in  cultures  an  incidence  of  cure  approaching  100 
per  cent  may  be  obtained. 

In  1939  the  Section  on  Urology  of  the  Mayo 
Clinic  reported  that  90  per  cent  of  their  cases  re- 
sponded to  sulfonamides  alone.  The  remaining  10 
per  cent  were  referred  for  fever  therapy.  An  aver- 
age of  1.1  treatments  was  given  resulting  in  a  cure 
in  95.2  per  cent. 

Kendall  and  his  associates  reported  on  the  treat- 
ment of  eighty-three  patients  suffering  from  com- 
plications of  gonorrhea,  resistant  or  intolerant  to 
chemotherapy.  Of  those  refractory  patients  receiv- 
ing fever  therapy  alone  62.5  per  cent  were  cured 
following  a  single  treatment.  When  combined  with 
sulfanilamide  or  Promin*  given  for  eighteen  hours 
before  a  single  fever-session  in  thirty-one  unselect- 
ed  cases,  all  thirty-one  cases  were  cured.  Domestic 
and  business  reasons,  at  times,  may  make  prompt 
and  certain  cure  of  gonorrhea  an  urgent  need.  Fear 
of  divorce  or  loss  of  job,  humiliation  etc.,  may  lead 
a  patient  with  acute  uncomplicated  gonorrhea  to 
seek  the  only  method  whereby  he  could  be  cured  in 

•Promin  is  a  new  sulfonamide  not  yet  released  for  distribution 
( Parke,   Davis  &  Co.) 


•Presented  to  the  meeting  of  the  Mecklenburg  County  (N.  C.)   Medical   Society,   held   at   Charlotte,   October  21st. 


PRESENT  STATUS  OF  FEVER  THERAPY— Taylor 


November,  1941 


twenty-four  to  thirty-six  hours.  Gonorrheal  arth- 
ritis responds  dramatically  to  fever  therapy  and 
should  be  treated  early  to  prevent  permanent  dam- 
age to  the  involved  joint.  Gonorrheal  ophthalmitis 
which  does  not  show  immediate  improvement  under 
chemotherapy  should  be  given  fever  therapy 
promptly  before  the  eye  is  permanently  damaged. 

Bacterial  Endocarditis 

Gonorrheal  endocarditis  is  a  rather  rare  and  for- 
merly almost  hopeless  complication  of  gonorrhea. 
Onlv  about  seven  or  eight  well  authenticated  cases 
have  ever  been  reported  as  recovered. - 

I  have  recently  treated  successfully  a  very  severe 
case  of  acute  gonococcal  septicemia  with  endocar- 
ditis. This  patient  received  three  treatments  at 
temperatures  ranging  between  106.6  and  107°, 
several  different  sulfonamides,  including  Promin* 
(sodium  P-P'  —  diaminodiphenylsulfone  —  di-dex- 
trose  sulfonate)  by  intravenous  injection  following 
the  technic  recommended  by  Kendall  et  al.  as  men- 
tioned. After  another  two  or  three  months  have 
elapsed  I  shall  prepare  a  case  report  on  this  pa- 
tient. His  temperature  has  now  been  normal  for 
eight  weeks.  His  sedimentation  rate  is  normal;  he 
has  gained  twenty-five  pounds  and  is  planning  to 
return  to  work  next  week. 

Recent  reports3  on  the  treatment  of  subacute 
bacterial  endocarditis  by  the  use  of  fever  therapy 
combined  with  chemotherapy  are  at  least  encour- 
aging. Spontaneous  recovery  has  been  reported 
variously  as  occurring  in  from  one  to  three  per  cent 
of  cases.  Of  a  series  in  which  sulfanilamide  was 
used  alone  the  recovery  rate  was  six  per  cent. 
Chemotherapy,  plus  fever  therapy,  has  been  re- 
ported as  successful  in  16  per  cent. 

Phlebitis 

In  acute  or  chronic  phlebitis  three  sessions  of 
artificial  fever  of  only  103.5°  for  three  hours  will 
result  in  prompt  relief  of  tenderness,  pain  and 
edema.  The  course  of  the  acute  illness  is  short- 
ened and  the  disability  of  the  chronic  case  greatly 
reduced.4 

Neuritis  and  Arthritis 

The  gratifying  relief  of  the  intractable,  lancinat- 
ing pains  of  tabes  dorsalis  brought  about  by  fever 
therapy  led  to  its  trial  in  a  variety  of  painful  neu- 
ritic  and  radicular  affections.  Extensive  evidence 
has  shown  that  artificial  fever  is  far  superior  to  any 
form  of  local  heat  production  in  combating  the 
pain  and  relaxing  muscle  spasm.4  Favorable  reports 
include  such  conditions  as  sciatic  neuritis,  brachial 
neuritis,  toxic  infectious  polyneuritis,  herpes  zos- 
ter and  arthritic  disease  with  secondary  neuritis  or 
neuralgia.  Acute  infectious  arthritis  shows  prompt 
and  permanent  benefit.  Chronic  atrophic  or  rheu- 
matoid arthritis  is  usually  benefited  only  tempo- 


rarily if  at  all  and  I  do  not  recommend  fever  ther- 
apy as  a  rule. 

Chorea  and  Rheumatic  Fever 

The  distressing  movements  of  Sydenham's  chorea 
ceased  in  88  per  cent  of  cases,  treated  by  artificial 
fever5 — an  average  of  four  treatments  of  short 
duration.  In  rheumatic  fever  relief  of  pain  and 
swelling  of  joints  was  frequent  and  the  sedimenta- 
tion rate  and  leukocyte  count  were  promptly  re- 
duced.0 In  a  comparative  study  against  a  control 
series  of  cases,  the  fever-treated  group  showed  a 
strikingly  smaller  percentage  of  cases  of  polyar- 
thritis developing,  and  of  deaths  from  rheumatic 
carditis.  Further  analysis  of  the  cases  of  patients 
who  had  heart  disease  showed  that  the  severity  of 
the  cardiac  lesion  was  considerably  greater  in  the 
untreated  group.  The  cases  reported  have  not  been 
in  sufficient  number  to  justify  conclusions.  Acute 
or  chronic  rheumatic  heart  disease  can  be  safely 
treated,  in  many  cases  with  benefit. 

Even  better  results  have  been  reported  in  chorea0 
and  neuritis  when  thiamin  chloride  was  given  in- 
travenously in  conjunction  with  the  fever  treat- 
ments. 

Ocular  Diseases 

Ocular  gonorrhea,  ocular  syphilis  and  stubborn 
cases  of  iritis  are  well  established  indications  for 
fever  therapy.  Cases  of  interstitial  keratitis,  acute 
iritis,  and  acute  exudative  choroiditis  which  have 
resisted  the  usual  forms  of  treatment  may  be  clear- 
ed up  entirely  by  only  two  or  three  treatments.  In 
a  recent  special  article  on  syphilotherapy,7  H.  N. 
Cole  states  that  the  best  known  treatment  for  inter- 
stitial keratitis  is  artificial  fever  plus  vitamin  B-2 
by  mouth. 

Brucellosis 

Several  investigators  have  noted  that  in  a  small 
series  of  cases  of  brucellosis  or  undulant  fever  there 
has  been  a  rather  striking  response  to  fever  ther- 
apy. About  80  per  cent  exhibited  definite  clinical 
remissions  with  prompt  disappearance  of  symp- 
toms.5 8 

Syphilis:  Primary  and  Secondary 

When  artificial-fever  therapy  is  combined  with 
chemotherapy  in  early  syphilis  the  results  are  bet- 
ter than  with  either  alone.  The  dark-field  exam- 
ination will  disclose  no  spirochetes  after  the  first 
fever  session  and  the  patient  is  thus  rendered  non- 
infectious in  a  very  short  while.  The  quantitative 
Kahn  test,  after  a  brief  initial  rise  during  the  first 
week,  shows  less  and  less  evidence  of  syphilis  dur- 
ing the  next  three  to  six  weeks. 

Wassermann-Fast  Syphilis 

Howies0  directed  attention  to  the  fact  that  cases 

which  continued  to  exhibit  a  positive  Wassermann 

in  spite  of  the  usual  anti-syphilitic  treatment  had 

a  focus  of  infection  which  had  become  resistant  to 


November.  1941 


PRESE.WT  STATUS  OF  FEVER  THERAPY— Taylor 


S97 


arsenic  and  heavy-metal  therapy.  A  careful  study 
using  all  available  diagnostic  methods  will  reveal 
most  of  these  lesions  before  clinical  symptoms  de- 
velop. In  asymptomatic  neurosyphilis  not  respond- 
ing to  routine  chemotherapy,  fever  therapy  should 
be  given,  since  accumulated  clinical  evidence  shows 
that  fever  therapy  given  in  this  stage  adequately 
protects  against  clinical  neurosyphilis. 

Paresis 

The  value  of  fever  in  dementia  paralytica  has 
been  well  established  since  1918  when  Wagner  von 
Jauregg  published  his  paper  on  the  dramatic  re- 
sults from  malaria  inoculations. 

When  equally  as  brilliant  results  began  to  be  re- 
ported for  fever  induced  by  artificial  means,  certain 
authorities  in  the  field  of  syphilology  predicted 
that  the  relapse  rate  after  treatment  by  physically- 
induced  fever  would  be  higher  than  that  in  cases 
treated  with  malaria.  In  an  attempt  to  settle  this 
question  a  number  of  clinics  formed  a  group  for 
cooperation  in  the  study  of  this  important  problem. 
The  cooperating  organizations  included  the  Mayo 
Clinic;  Central  State  Hospital,  Indianapolis;  Colo- 
rado Psychopathic  Hospital;  Miami  Valley  Hos- 
pital, Dayton,  Ohio;  Boston  Psychopathic;  Strong 
Memorial,  Rochester,  N.  Y.,  and  a  dozen  others. 
These  clinics  pooled  their  records  for  analysis.  A 
total  of  1,420  patients'  records  were  analyzed. 

Conclusions  as  to  clinical  results  were  based  on 
the  percentage  of  remissions  at  the  end  of  the 
first,  second  and  third  year  of  treatment-observa- 
tion. They  also  classified  their  cases  as  mild,  inter- 
mediate and  severe,  according  to  the  stage  of  the 
disease.  It  will  be  noted  that  the  total  remission 
rate  for  the  three-year  period  was  higher  in  the 
second  two  classifications,  for  the  artificial-fever 
than  for  the  malaria  cases  and  equal  in  the  first  or 
mild  group. 

A  strange  paradox  was  found  in  this  series  in 
the  percentage  of  serological  reversals.  The  group 
report  that  the  reversals  of  both  spinal  fluid  and 
blood  from  positive  to  negative  occurred  twice  as 
frequently  in  the  cases  treated  by  malaria  and 
chemotherapy  as  in  the  cases  treated  by  artificial 
fever  and  chemotherapy.  The  significance  of  this  is 
lessened  by  several  factors:  (1)  according  to  their 
own  figures,  where  no  chemotherapy  was  used  the 
serologic  reversals  were  twice  as  numerous  in  the 
artificial-fever  as  in  the  malaria  group;  (2)  a 
check-up  revealed  that  the  malaria  group  had  re- 
ceived a  greater  amount  of  chemotherapy,  (3) 
many  of  the  cases  included  in  the  artificial-fever 
group  were  those  cases  which  were  treated  during 
the  period  of  experimentation  with  fever  therapy. 
The  optimum  height  and  duration  of  fever  had  not 
then  been  determined,  and  according  to  present 
standards  was  inadequate.    (4)   Since  clinical  suc- 


cess was  not  accompanied  by  complete  serological 
reversal  in  52  per  cent  of  the  cases  it  follows  that 
clinical  success  is  not  necessarily  dependent  on 
serologic  reversal.  They  did  not  include  quantita- 
tive improvement  of  serum  reactions  in  their  sta- 
tistics. 

Among  other  conclusions  from  this  study,  the 
cooperative  group  observed  that  the  death  rate 
during  treatment  and  for  the  period  of  three  months 
after  treatment  was  over  60  per  cent  higher  in  the 
malaria  group  than  in  the  artificial-fever  group. 

Finally  they  found  that  the  rate  of  relapse  was 
only  five  in  a  hundred  for  the  entire  series,  and 
essentially  the  same  for  the  two  types  of  treat- 
ment. 

Ewalt  and  Ebaugh1"  of  the  University  of  Colo- 
rado School  of  Medicine  made  a  comparative  study 
of  artificial  fever  therapy  and  therapeutic  malaria 
in  232  cases  of  dementia  paralytica.  I  shall  quote 
directly  from  their  conclusions: 

"The  follow-up  therapy  in  the  two  groups  has 
been  as  nearly  identical  as  the  vagaries  of  clinical 
practice  will  allow.  The  method  of  therapy  with 
artificial  fever  has  been  safer  and  has  been  produc- 
tive of  better  results.  Improvement  in  the  care  of 
patients  during  malaria  therapy  and  more  attention 
to  follow-up  medication  has  improved  the  results 
of  therapeutic  malaria  in  our  clinic,  although  these 
results  still  remain  inferior  to  those  obtained  with 
artificial-fever  therapy. 

"Patients  with  physical  contraindications  to 
therapeutic  malaria  may,  in  many  instances,  be 
safely  treated  with  artificial-fever  therapy.  The 
serologic  responses  roughly  parallel  the  clinical  re- 
sults in  the  two  series." 

That  is  to  say  that  in  this  study  the  serologic 
improvement  as  well  as  the  clinical  improvement 
had  been  greater  in  the  group  treated  by  artificial 
fever. 

The  Economic  Factors 

The  economic  factors  involved  are  always  im- 
portant. The  patient  to  whom  therapeutic  malaria 
is  given  must  undergo  continuous  hospitalization 
for  at  least  three-and-a-half  to  four  weeks.  Daily 
visits  by  the  physician  must  be  added  to  his  bill. 
He  is  often  weak  and  anemic  after  the  course  of 
treatment  and  must  undergo  a  period  of  convales- 
ence. 

With  the  newer  technic  for  the  treatment  of  de- 
mentia paralytica  by  artificial  fever  the  patient 
may  receive  three  or  four  hours  of  treatment  once 
a  week  and  in  early  cases  is  able  to  return  home 
the  same  day  of  the  treatment,  and  to  work  the 
next  day  if  he  so  desires.  I  have  had  several  who 
could  do  this. 

Recently  I  have  had  three  men  show  dramatic 
clinical  improvement  after  one  treatment.  All  three 


PRESENT  STATUS  OF  FEVER  THERAPY— Taylor 


November,  1941 


had  developed  severe  symptoms  rather  suddenly. 
They  exhibited  tremor,  loss  of  memory,  halting 
speech,  unsteady  gait,  coarse  behavior  habits,  im- 
paired coordination,  and  loss  of  judgment.  The 
day  following  the  first  treatment  each  man  was 
able  to  write  for  the  first  time  in  several  days,  or 
weeks.  Each  could  walk,  talk,  eat  and  carry  out 
coordination  tests  with  relative  ease.  In  two  or 
three  weeks  they  had  returned  home  and  resumed 
at  least  part  of  their  former  occupations.  They 
had  lost  neither  weight  nor  strength.  Think  how 
much  these  men  were  saved  by  not  having  to  be 
committed  to  a  mental  institution! 

Besides  the  clinical  and  economic  advantages  of 
artificial  fever  over  malaria  there  are  others.  ( 1 ) 
There  is  considerable  variety  in  the  response  of 
individuals  to  malaria;  the  degree  of  reaction  is 
unpredictable  and  while  it  can  be  better  controlled 
now  than  formerly  one  can  not  choose  the  hour 
and  duration  and  degree  of  temperature  as  can  be 
done  with  artificial  fever.  (2)  Patients  with  com- 
plicating heart,  lung,  liver  and  kidney  disease  can 
take  carefully  graded  doses  of  artificial  fever  who 
could  not  stand  malaria.  (3)  The  arsenicals  can 
no  tbe  given  during  malaria  treatment.  (4)  Fever 
therapy  seems  to  increase  the  tolerance  of  drug- 
sensitive  individuals  so  that  many  can  take  larger 
doses  without  toxic  reaction.11 

Tabes  Dorsalis 
In  thirty-one  cases  of  tabes  dorsalis,  of  the  most 
severe  type,  many  with  resistant  chronic  symptoms, 
16  (52%)  had  complete  relief  from  all  the  very 
troublesome  symptoms.1-  Eleven  (35%)  had  im- 
provement as  to  all  principal  symptoms,  with  dis- 
appearance of  some  of  them;  while  only  four 
(13%)  were  unimproved.  Neuritic  pains  were  re- 
lieved for  twenty-four  of  the  twenty-eight  patients. 
Gastric  crises  were  completely  or  partially  relieved 
in  eleven  out  of  fifteen  cases.  Many  of  the  patients 
most  benefited  had  failed  of  improvement  under 
treatment  by  other  methods.  Some  were  physically- 
debilitated,  most  of  them  elderly.  In  some  cases 
ataxia  and  urinary  incontinence  also  responded 
with  improvement. 

The  Degree  of  Safety  or  Risk  in  Fever  Therapy 
A  few  years  ago,  in  one  of  North  Carolina's 
leading  hospitals,  in  a  very  brief  time  period,  two 
patients  died  while  taking  fever  treatment.  I  do 
not  know  how  well  the  cases  were  reported,  but  the 
medical  men  from  this  institution  seem  satisfied 
with  the  explanation  that  it  was  to  be  expected  of 
such  a  hazardous  treatment.  I  do  not  know  the 
cause  of  death  in  these  two  cases.  I  do  know  the 
cause  of  two  other  deaths  which  have  been  attrib- 
uted to  fever  therapy  in  two  other  hospitals.  The 
person  actuallv  giving  the  fever  treatment  had  not 


the  proper  training,  was  not  well  enough  acquaint- 
ed with  the  potential  dangers,  was  trying  to  do 
other  things  during  the  treatment,  and  was  not 
properly  supervised.  I  worked  at  one  clinic  in  Chi- 
cago where  treatments  had  been  given  almost  daily 
for  the  past  eight  years  without  one  fatality.  There 
were  no  sequelae. 

Troutman  reported  only  one  death  in  5,500  fever 
sessions  given  to  985  patients.  This  single  death 
occurred  back  in  1936  before  the  newer  technic 
came  into  use.  What  other  major  therapeutic  pro- 
cedure can  claim  a  mortality  rate  so  low? 
Conclusions 

1.  Artificial-fever  therapy,  when  carried  out  in  a 
well  equipped  institution,  by  well  trained 
personnel  under  competent  supervision,  is  a 
procedure  of  relative  safety  and  carries  a  re- 
markably low  mortality. 

2.  Artificial-fever  therapy  is  not  a  specific  that 
will  supplant  other  established  methods  of 
treatment. 

3.  Its  widest  usefulness  is  as  an  adjuvant  to 
other  methods  of  treatment  in  difficult  and 
complicated  cases  where  resistance  to  the 
usual  treatments  is  evident. 

4.  Occasionally  fever  therapy  is  a  life-saving 
measure  where  all  other  methods  have  failed. 

5.  Artificial-fever  therapy  combined  with  chem- 
otherapy will  shorten  the  necessary  period  of 
hospitalization  or  the  period  of  disability  in 
numerous  diseases,  among  them:  syphilis, 
gonococcal  infections,  certain  types  of  asthma, 
arthritis,'  neuritis  and  phlebitis;  undulant 
fever;  rheumatic  fever;  chorea;  lymphogran- 
uloma venereum,  and  endocarditis. 

6.  In  asymptomatic  neurosyphilis  not  respond- 
ing to  routine  chemotherapy,  fever  therapy 
should  be  given,  since  accumulated  clinical 
evidence  shows  that  fever  therapy  given  in 
this  stage  adequately  protects  against  clinical 
neurosyphilis. 

7.  In  paresis  artificially-induced  fever  combined 
with  chemotherapy  is  the  treatment  of  choice. 

References 

1.  Uhle,  C.  A.,  Latowsky,  L.  W.,  and  Knight,  F.:  /.  A. 
M.  A.,  117:249  (July  26),  1941. 

2.  (a)  Freund.  H.  A.,  Anderson,  W.  L.,  and  Lilly,  V. 
S:    J.  A.  M.  A.,  110:549  (Feb.  19),  1941. 

(b)   Davis,  J.  S.,  Jr.:  Arch.  Int.  Med.,  66:418   (Aug.) 
1940. 

3.  (a)  Lichtman,  S.  S.,  and  Bierman,  W.:  /.  A.  M.  A., 
116:281  (Jan.  25),  1941. 

(b)   Bierman,  W.,  and  Baehr,  G.:    /.  A.  M.  A.,  116: 
292   (Jan.  25),  1941. 

4.  Snow,  W.  B.:    Med.  Rec,  148:448  (Dec.  21),  1938. 

5.  Osborne,  S.  L.,  Blatt,  M.  L.,  and  Neyman,  C.  A.: 
J.  A.  M.  A.,  107:98  (Sept.  9),  1936. 

6.  Krusen  and  Elklns:  Section  on  Physical  Therapy 
Mayo  Clinic.  Handbook  of  Physical  Therapy,  J.  A.  M. 
A.,  1939. 

(To  Page  604) 


November,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


Hyperparathyroidism* 

Richard  Z.  Query,  Jr.,  M.D.,  Charlotte 


A  SHORT  WHILE  AGO  two  patients  with 
similar  symptoms  were  admitted  to  a  well- 
known  hospital  in  this  state  and  within  a 
space  of  ten  days  both  had  parathyroid  adenomas 
removed.  This  must  constitute  a  record  for  a  dis- 
ease that  is  very  rare,  or,  what  is  more  probable, 
rarely  diagnosed. 

This  subject  should  be  of  interest  to  everyone 
here  because  the  symptoms  are  so  varied,  multiple 
and  chronic  that,  no  matter  what  type  of  work  the 
physician  does,  he  is  liable  to  encounter  the  dis- 
ease. 

The  relationship  between  the  parathyroid  glands, 
calcium  metabolism  and  pathologic  conditions  of 
bone  has  been  proved  within  the  past  sixteen  years. 
Previous  to  1925,  the  phvsiology  of  parathyroid 
tissue  being  obscure,  medical  science  approached 
the  syndrome  now  recognized  as  hyperparathyroid- 
ism by  describing  merely  its  end  results.  A  path- 
ologic entity  known  as  generalized  osteitis  fibrosa 
cystica  had  been  observed  from  time  to  time  for 
thirty  years  following  von  Recklinghausen's  origi- 
nal description  of  the  condition.  Mention  of  coin- 
cident parathyroid  tumor  was  made  occasionally  in 
the  pathologic  reports  of  osteitis  fibrosa,  but  its 
significance  was  not  suspected.  Experimental  study 
of  the  glands  was  devoted  almost  exclusively  to  the 
effects  of  extirpation.  The  complex  calcium  and 
phosphorus  metabolism  through  which  the  parathy- 
roid dyscrasia  influenced  the  skeleton  was  un- 
known. 

In  1925  the  results  of  three  important  attacks  on 
the  problem  began  to  appear.  Collip  announced 
the  discovery  of  the  parathyroid  hormone  and  the 
preparation  of  a  potent  extract.  This  made  experi- 
mental study  of  parathyroid  activity  possible. 
Mandl  proved  the  etiologic  relationship  of  the 
glands  to  osteitis  fibrosa  cystica.  He  implanted 
parathyroid  tissue  in  a  patient  who  had  osteitis, 
made  him  worse  thereby,  then  removed  the  im- 
plant plus  a  parathyroid  adenoma — and  cured  his 
patient.  Then  Aub  and  his  coworkers,  by  a  series 
of  studies  in  mineral  metabolism,  established  the 
links  by  which  the  glands  and  skeletal  changes  are 
related.  The  medical  profession  has  been  quick  to 
apply  this  knowledge,  and  the  literature  of  the  past 
few  years  contains  numerous  case  reports  includ- 
ing metabolic  studies  on  osteitis  fibrosa  cystica,  the 
classic  form  of  hyperparathyroidism.  There  have 
been  in  addition  excellent  summary  articles  on  the 
subject  by  Barr  and  Bulger,'  Albright  and  Aub,2 
and  Jacobs  and  Bisgard.3 


Most  of  the  cases  of  hyperparathyroidism  re- 
ported have  represented  the  advanced,  classic  form. 
This  type  of  the  disease  offers  no  diagnostic  diffi- 
culties. It  is  one  of  our  chief  objects  in  this  dis- 
cussion to  point  out  that  other  forms  of  hyper- 
parathyroidism are  not  rare  curiosities,  but  condi- 
tions that  every  practitioner  will  meet,  and  not 
infrequently.  The  diagnosis  must  be  considered 
and  ruled  in  or  out  when  any  of  a  whole  list  of 
presenting  symptoms  of  the  most  varied  nature  is 
encountered. 

Hyperparathyroidism  is  a  disease  that  is  usually 
due  to  the  excessive  functioning  of  an  adenoma  of 
the  parathyroid  glands;  however,  certain  cases  pre- 
sent only  hyperplasia  of  all  the  parathyroid  tissue. 
As  a  result  of  the  increased  production  of  the  hor- 
mone, there  is  a  disturbance  in  the  metabolism  of 
calcium  and  phosphorus.  The  easily  measurable 
manifestations  of  this  disturbance  are  an  increased 
serum  calcium  level  and  a  decreased  phosphorus 
level,  and  an  increased  excretion  of  both  elements 
in  the  urine. 

The  bones  are  the  only  storehouse  for  calcium 
and  phosphorus  in  the  body,  so  this  increased  loss 
in  the  urine  leads  to  a  demineralization  of  the 
bones.  They  become  porous  and  later  fibrous  areas 
may  develop  with  cyst  formation.  With  the  in- 
crease in  osteoclasts,  osteoclomas  or  benign  bone 
tumors  may  develop. 

The  increased  excretion  of  calcium  and  phospho- 
rus in  the  urine  not  infrequently  leads  to  the  for- 
mation of  urinary  calculi.  In  some  instances  the 
calcium  phosphate  precipitates  occur  in  the  kidney 
parenchyma.  The  peculiar  manner  in  which  cal- 
cium is  deposited  in  the  kidney  as  revealed  by 
rontgen  rays  presents  a  picture  which  is  probably 
pathognomonic  of  hyperparathyroidism.  It  forms 
delicate  rosette  shadows  which  we  have  not  seen 
described  in  any  other  condition. 

The  replacement  of  so  much  of  the  bone  marrow 
cavity  with  fibrous  tissue  leads  to  a  decrease  in  the 
hemopoietic  elements  and  hence  to  anemia  and  oc- 
casionally leukopenia. 

The  symptomatology  may  be  best  described  by 
dividing  the  cases  into  three  groups:  1)  Those  due 
to  hypercalcemia  per  se.  Just  as  hypocalcemia 
causes  an  increased  excitability  of  nerve-muscle 
apparatus  (tetany),  so  /?y/>«'calcemia  causes  the 
opposite — hypotonia,  lassitude,  constipation,  weak- 
ness, easy  fatiguability  and  weight  loss — the  gen- 
eral symptoms  of  neurasthemia.  2)  Those  due  to 
skeletal  involvement.    These  may  vary  from  cases 


•Presented  to  the  meeting  of  the  Mecklenburg  County  (N.  C.)  Medical  Society,   held  at  Charlotte,  October  21st. 


HYPERPARATHYROIDISM— Query 


November,  1941 


showing  no  symptoms  to  those  in  which  the  skele- 
ton has  to  a  great  extent  lost  its  function.  A  spon- 
taneous fracture  is  often  the  event  that  first  calls 
attention  to  the  disease.  Bone  tenderness  and  bone 
pain,  usually  attributed  to  arthritis,  neuritis  and 
the  like,  have  in  most  instances  been  present  a  long 
time.  Bone  tumors  due  to  cysts  may  be  early 
manifestations.  Bone  deformity  is  usually  a  late 
manifestation,  except  as  regards  the  spine.  There 
may  be  no  skeletal  changes  in  hyperparathyroidism 
demonstrable  by  x-rays.  The  chief  rontgen  evi- 
dences, when  such  exist,  are  pictures  of  increased 
rarefaction,  deformities,  cysts,  tumors  and  frac- 
tures. Only  the  first  of  these  is  fundamental;  the 
other  four  are  secondary.  Being  a  metabolic  dis- 
ease, it  must  exert  its  fundamental  action,  demin- 
eralization,  on  the  entire  skeleton,  if  at  all.  There- 
fore, in  a  doubtful  case,  it  is  essential  to  decide  at 
once  whether  one  is  dealing  with  a  generalized  or 
a  localized  disease.  3)  Those  due  to  hypercalcinu- 
ria  and  hvperphosphaturia.  Polyuria  and  polydip- 
sia are  present  in  almost  all  cases  and  are  usually 
attributed  to  the  increased  excretion  of  phosphorus 
and  calcium  (analogous  to  diabetes  mellitus). 
Renal  colic  or  some  other  manifestation  of  nephro- 
lithiasis may  be  the  first  and  only  symptom.  Any 
case  of  recurrent  renal  stones,  certainly  one  of 
bilateral  renal  stones,  demands  a  thorough  investi- 
gation to  rule  out  hyperparathyroidism.  The 
symptoms,  signs  and  laboratory  findings  of  Bright's 
disease  may  be  present  when  there  is  extensive 
renal  parenchymal  involvement:  however,  this  is 
rather  unusual. 

Once  the  diagnosis  is  suspected,  its  confirmation 
or  exclusion  depends  on  the  chemical  laboratory. 
Hyperparathyroidism  is  almost  unique  in  giving 
the  combination  of  a  high  serum  calcium  and  a  low 
serum  phosphorus  level.  Other  conditions:  e.  g., 
multiple  myeloma  and  metastatic  malignancy,  may 
produce  a  high  serum  calcium;  but  wThen  they  do 
the  serum  phosphorus  also  is  usually  elevated. 
Serum  phosphorus  below  3.5  mg.  per  cent  and  se- 
rum calcium  above  11  mg.  per  cent  should  be  re- 
garded with  grave  suspicion,  especially  if  repeat- 
edly obtained. 

An  increased  urinary  output  of  calcium  and 
phosphorus  is  one  of  the  commonest  manifestations 
of  the  disease,  but  determinations  of  the  excretion 
of  these  elements  are  time-consuming  and  seldom 
necessary. 

The  plasma  phosphatase  level,  probably  an  in- 
dex of  the  degree  of  actual  bone  degeneration  or 
osteoblastic  activity,  is  elevated  in  hyperparathy- 
roidism. The  normal  level  is  2-4  Bodansky  units. 
The  determination  is  of  most  value  in  following 
the  progress  of  a  case. 


Just  as  hyperparathyroidism  mimics  many  con- 
ditions, so  a  number  of  conditions  mimic  hyper- 
parathyroidism. In  our  experience  senile  osteoporo- 
sis, multiple  mveloma  and  metastatic  malignancy 
have  given  more  trouble  in  differential  diagnosis. 
With  careful  studies,  however,  these  can  usually  be 
differentiated. 

The  treatment  is  surgical  removal  of  the  tumor. 
The  chief  operative  difficulty  lies  in  finding  the  tu- 
mor. The  surgeon  should  know  where  to  look  for 
the  normally  situated,  and  the  possible  or  probable 
aberrant,  glands.  Unlike  thyroid  adenomas,  para- 
thyroid tumors  mold  themselves  surprisingly  well 
into  crevices,  as  between  the  esophagus  and 
trachea.  Before  undertaking  this  operation,  the 
surgeon  should  be  well  qualified  in  neck  and  medi- 
astinal anatomy  and  surgery.  There  is  no  time  like 
that  of  the  initial  operation  to  find  the  tumor. 

Case  Reports 

Case  1. — A  34-year-old  farmer  comes  complaining  of 
vague  aching  pains  in  his  lower  back,  legs  and  chest  for 
previous  9  months.  Two  months  ago  his  left  clavicle  was 
fractured  in  a  minor  accident.  He  had  been  extremely 
weak  during  the  entire  illness,  and  lost  25  pounds.  He 
was  poorly  developed,  malnourished,  pale  and  appeared 
chronically  and  seriously  ill.  The  positive  physical  findings 
were  kyphosis  of  the  lumbar  spine,  pallor  of  the  skin  and 
mucous  membranes,  tenderness  over  both  tibiae,  enlarge- 
ment of  right  lobe  of  the  thyroid  to  twice  its  normal  size, 
thickening  and  hardening  of  the  radial  vessels,  generalized 
hypotonia  and  hypoactive  tendon  reflexes. 

The  hemoglobin  was  7.8  gms.  (50%)  ;  red  blood  cells. 
2,500,000;  white  blood  cells,  5,000,  with  a  normal  differen- 
tial count.  The  urine  was  negative  except  for  a  repeatedly 
positive  Bence-Jones  protein.  The  serum  calcium  was  14.6 
mg.%,  serum  phosphorus  2.3mg.%,  the  phosphatase,  26.4 
Bodansky  units.  The  x-ray  pictures  showed  a  severe  de- 
gree of  decalcification  of  all  the  bones  with  areas  of  varv- 
ing  degrees  of  rarefaction.  There  were  pathological  frac- 
tures of  several  ribs  and  the  right  fibula. 

Several  observers  thought  this  a  case  of  multiple  mye- 
loma, especially  in  view  of  the  Bence-Jones  protein  in  the 
urine;  others  leaned  to  parathyroid  adenoma.  After  much 
discussion,  operation  was  done  and  a  parathyroid  adenoma 
removed,  with  relief  of  all  symptoms. 

Case  2. — A  white  housewife  of  49,  complains  of  pains  in 
the  right  chest  and  tiredness  for  a  year's  duration.  She 
had  been  seen  in  another  hospital  10  years  before  where  a 
diagnosis  of  hydronephrosis  on  the  right  with  calcareous 
deposits  in  both  kidneys  was  registered.  At  this  time  a 
serum  calcium  of  12  mg.%  was  reported.  For  the  next 
four  years  she  felt  well  and  did  her  own  housework.  Then 
began  a  dull  pain  under  the  right  shoulder  blade  that 
came  and  went,  and  one  year  later  persistent  pains  in  the 
anterior  chest.  Six  months  before  admission  to  the  hospi- 
tal, she  became  very  weak  and  lost  30  pounds  despite  a 
good  appetite.  She  had  no  polydipsia  or  polyuria.  She 
was  a  small  undernourished  woman,  who  did  not  appear  at 
all  ill.  At  the  left  lower  pole  of  the  thyroid  there  was  a 
round,  firm  nodule  2  cms.  in  diameter.  The  physical  ex- 
amination was  otherwise  quite  negative. 

Red  blood  cells  numbered  3,500,000;  hemoglobin,  10 
gms.  (66%)  ;  white  blood  cells,  6,200,  differential  count 
normal.  The  urine  was  negative.  The  correct  diagnosis 
was  not  suspected  until  a  rontgen-ray  picture  of  the  kid- 
neys showed  these  organs  which  diffuse  mottled  deposits  of 


November,   1941 


HYPERPARATHYROIDISM— Query 


601 


calcium.  All  of  the  bones  showed  a  generalized  loss  of 
calcium.  The  serum  calcium  was  20  mgs.%,  the  phosphorus 
4.7  mg.%.  Repeated  three  days  later,  the  calcium  was  22 
mg.%,  the  phosphorus  4.8  mg.%.  The  phosphatase  was 
23  Bodansky  units.  The  diagnosis  of  parathyroid  adenoma 
was  made  and  operation  advised.  Because  of  a  mild  upper- 
respiratory  infection  with  temperature  of  100°,  operation 
was  postponed  a  few  days.  Rather  suddenly  complaint  was 
made  of  great  weakness  and  nervousness  and,  in  contrast 
to  her  former  cheerfulness,  the  patient  became  tearful. 
These  symptoms  continued  for  the  next  48  hours;  then  she 
suddenly  called  the  nurse  who  found  her  cyanotic  and 
gasping  for  breath.    She  expired  a  few  minutes  later. 

Autopsy  revealed  a  cyst  and  partly  calcined  necrotic 
tumor  of  a  parathyroid  gland.  There  was  widespread  in- 
jury, necrosis  and  calcification  of  the  connective  tissue  in 
the  parenchymatous  organs  and  in  the  arteries.  There  was 
extensive  myocardial  injury  and  necrosis.  Calcification  was 
present  in  the  kidneys  and  myocardium. 

The  autopsy  findings  in  this  patient  parallel  very  closely 
the  pathologic  changes  which  Cantarow,  Stewart  and  How- 
ell describe  in  dogs  poisoned  with  parathormone. 

This  case  has  been  reported  elsewhere  as  one  of  para- 
thormone poisoning. 

Case  3. — A  48-year-old  white  housewife  admitted  to  the 
Charlotte  Memorial  Hospital,  November  27th,  1940,  com- 
plaining of  generalized  pain  of  4-years  duration.  The  pain 
started  in  the  thighs  and  gradually  involved  calves,  arms 
and  chest.  They  were  described  as  being  dull  and  boring. 
There  was  never  any  pain,  swelling,  or  redness  of  the 
joints;  however,  she  had  been  treated  for  arthritis  for  4 
years.  She  had  been  bed-ridden  for  one  year.  For  six 
months  her  fingers  had  been  painful  and  the  tips  had  en- 
larged. For  three  weeks  nausea  and  vomiting  had  been 
troublesome. 

The  patient  appeared  chronically  ill.  The  skin  and  mu- 
cous membranes  were  pale,  bitter  complaint  was  made  of 
pain  in  her  chest  upon  slight  change  in  position.  There 
was  a  1-cm.  nodule  in  the  left  lobe  of  the  thyroid.  There 
was  marked  bowing  of  the  radius  and  ulnar  bones  bilater- 
ally with  a  pronounced  peculiar  enlargement  of  the  distal 
phalanges  of  the  fingers,  which  did  not  appear  to  be  typi- 
cal clubbing. 

The  hemoglobin  was  11  gms. ;  red  blood  cells,  4,300,000; 
whites,  6.000 — differential  count  normal.  The  serum  cal- 
cium was  19  mg.%,  phosphorus  3.S  mg.%.,  phosphatase 
23.2  Bodansky  units. 

X-ray  pictures  showed  generalized  decalcification  with  a 
granular  appearance  of  all  the  bones.  There  were  several 
fractured  ribs.  There  was  a  staghorn  calculus  in  the  right 
kidney  and  bilateral  calcification  in  the  kidney  parenchyma. 

Exploratory  operation  was  done  and  a  parathyroid  ade- 
noma removed.  After  a  rather  stormy  postoperative  course, 
improvement  was  started,  which  has  continued.  She  was 
seen  again  4  months  later,  at  which  time  her  serum  cal- 
cium was  9.14  mg.%,  phosphorus  3.2   mg.%. 

Comment 

Hyperparathyroidism  must  be  considered  as  a 
possible  or  probable  cause  in  cases  presenting  the 
most  varied  symptomatology.  This  is  especially 
true  of  those  bringing  to  mind  the  word  neurasthe- 
nia. 

Although  suspected  from  other  evidence,  the 
final  diagnosis  is  made  on  evidence  adduced  in  the 
chemical  laboratory. 

Rontgenograms  can  only  add  confirmatory  evi- 
dence unless  the  typical  rosettes  of  calcareous  de- 


posit pathognomonic  of    the    disease    are    demon- 
strated in  the  renal  parenchyma. 
References 

1.  Barr,  D.  P.,  Bulger,  H.  A.:    The  clinical  syndrome  of 

hyperparathyroidism.   .4m.  Jour.  Med.  Sc.,  279:449-477 
(April),  1930. 

2.  Albright,  F.,  Aub,  J.  C,  and  Bauer,  W.  J.:     Hyper- 

parathyroidism.   /.   A.  M.   A.,   702:1276-1287    (April), 
1934. 

3.  Jacobs,   J.   E.,   Bisgard,   J.   D.:      Hyperparathyroidism. 

Am.  Jour,  of  Surg.,  38:212-292    (Nov.),   1937. 

4.  Hanes,  F.  M.:    Hyperparathyroidism  due  to  parathyroid 

adenoma,  with  death  from  parathormone  intoxication. 
Am    Jour.  Med.  Sc,  207:85-90  (Jan.),  1939. 


TETANY 
(J.  A.   Schindler,  Monroe,   in    Wise.  Med.  11.,  Oct.) 
The  four  types  of  tetany  are: 

1.  The  parathyroid,  which  occurs  when  parathyroid 
tissue  is  extensively   removed. 

2.  The  infantile,  usually,  though  not  invariably,  asso- 
ciated with  rickets  and  includes  the  tremors  and  cyanotic 
spells  of  the  newborn., 

3.  The  nephritic,  sometimes  seen  with  severe  nephritis 
with  lowering  of  blood  calcium. 

4.  The  tetany  of  alkalosis,  the  only  type  with  a  low 
calcium  content,  most  commonly  seen  with  the  alkalosis 
resulting  from  overbreathing  by  neurotic  women,  relieved 
by  rebreathing  carbon  dioxide  from  a  paper  bag  or  by 
administering  an  acid  salt. 

Treatment  of  the  three  types  due  to  a  low  blood  cal- 
cium.— Milk,  cheese,  butter  and  green  vegetables,  plus 
calcium  chloride,  lactate  or  gluconate.  New  and  appar- 
ently effective  is  the  double  salt  of  calcium  lactobionate 
and  calcium  bromide.  The  best  time  for  oral  administra- 
tion of  calcium  is  two  or  three  hours  after  meals,  when 
the  acidity  of  the  small  bowel  is  increased,  acid  calcium 
phosphate  is  formed  and  more  absorption  occurs.  In  the 
presence  of  gastric  alchlorhydria  the  absorption  of  cal- 
cium is  deficient  and  the  patient  may  show  a  low  blood 
calcium  from  no  other  cause.  Vitamin  D  is  essential  for 
calcium  absorption:  viosterol  and  calciferol  are  potent 
forms;  most  potent  of  all  is  dihydrotachysterol.  The 
level  of  blood  calcium  must  be  carefully  watched  during 
its  administration.  For  this  purpose,  blood  calcium  de- 
terminations are  unnecessary,  since  the  rough  calcium 
determination  devised  by  Sulkowitch  is  adequate. 

The  most  effective  measure  for  raising  the  blood  calcium 
content  is   the   administration   of   parathyroid   hormone. 

Hyperparathyroidism  may  result  from  primary  adenoma 
of  the  parathyroids  or  from  hypertrophy  of  unknown 
cause.  Besides  the  changes  in  bone,  loss  of  appetite,  diar- 
rhea, vomiting  dullness,  drowsiness  and  general  muscular 
flaccidity  are  seen. 

Hypocalcemia  has  been  diagnosed  prior  to  a  blood 
calcium  determination  by  prolongation  of  the  Q-T  interval 
on   the   electrocardiogram. 


Dr.  Wilfred  Pickles,  of  Providence,  tells  us  in  the 
R.  I.  Medical  Journal  for  October:  In  August,  1840, 
workmen  repairing  the  chancel  of  St.  Peter's  Mancrofl 
accidentally  broke  open  a  coffin  which  proved  to  be  that 
of  Sir  Thomas  Browne.  After  a  careful  examination  of 
the  remains  by  an  archaeologist,  the  skull  was  removed 
by  one  of  the  workmen  and  later  found  a  resting  place 
in  the  museum  of  the  Norfolk  and  Norwich  Infirmary 
Here  it  was  exhibited  together  with  these  lines  from  Sir 
Thomas's  Hydriotaphin— "To  he  knaved  out  of  our  graves, 
to  have  our  skulls  made  drinking  bowls,  and  our  bones 
turned  into  pipes  are  tragical  abominations  escaped  in 
burning  burials." 


SOUTHERN  MEDICINE  &  SURGERY 


November,  1941 


Factors  in  the   Diagnosis   and    Treatment   of  Uterine   Cancer* 

John  A.  Kelly,  M.D.,   F.A.C.S.,  New  York  City 
From  the  Service  of  Dr.  William  P.  Healy,  Memorial  Hospital,  New  York  City 


CARCINOMA  of  the  cervix  forms  the  largest 
group  of  malignant  lesions  arising  in  the  fe- 
male genital  tract.  While  rare  cases  are  re- 
ported in  children,  and  young  women  in  the  third 
decade  of  life  are  occasionally  the  victims  of  this 
disease,  over  60  per  cent  of  all  cases  occur  between 
the  fortieth  and  sixtieth  years.  The  symptoms  for 
which  the  patient  usually  consults  her  physician 
are  irregular  vaginal  bleeding  and  vaginal  discharge. 
These  are  symptoms,  of  course,  of  ulceration  and 
infection,  and  in  a  fairly  large  group  of  cases  we 
have  found  these  symptoms  to  have  been  present 
for  over  ten  months  on  the  average  before  the  pa- 
tient sought  any  medical  advice.  Unfortunately 
many  women  over  forty  are  not  alarmed  at  the 
occasional  occurrence  of  irregular  vaginal  bleeding. 
Because  there  are  no  symptoms  in  early  cancer  of 
the  cervix,  and  because  the  symptoms  of  advancing 
disease  are  ignored  for  long  periods  of  time,  it  is 
little  wonder  that  between  70  and  75  per  cent  of 
all  cases  are  in  an  advanced  stage  of  disease  when 
first  seen.  In  the  average  case  the  diagnosis  is 
easily  made  clinically.  The  cervix  is  enlarged,  ul- 
cerated, infected  and  friable.  Bleeding  occurs  from 
slight  trauma;  the  uterus  may  be  partially  or  com- 
pletely fixed  by  parametrial  infiltration.  The  diag- 
nosis should  always  be  confirmed  by  histologic 
study  of  biopsy  specimens.  A  survey  of  the  his- 
tology shows  that  about  97  per  cent  of  all  cases  of 
primary  cervix  cancer  are  of  the  squamous-cell 
type,  or,  as  Ewing  prefers  to  call  them,  epidermoid 
carcinomas.  About  3  per  cent,  of  cervix  gland 
origin,  are  adenocarcinomas.  The  epidermoid  carci- 
nomas are  graded,  after  the  work  of  Ewing,  Bro- 
ders  and  others,  according  to  their  general  cell 
structure.  Those  most  adult  in  character,  showing 
frequent  pearl  formation,  are  grade  I.  Those  show- 
ing most  change  from  the  normal,  anaplastic  or 
embryonal  in  character,  are  grade  III,  while  those 
showing  cell  characteristics  midway  between  these 
groups  are  grade  II.  Over  60  per  cent  of  all  lesions 
of  the  cervix  are  grade  II  epidermoid  carcinomas, 
while  15  per  cent  are  adult  in  structure  and  15  per 
cent  are  anaplastic  in  structure. 

The  extent  of  disease  present  clinically  is  group- 
ed into  four  stages,  under  the  League  of  Nations 
Classification.  Stage  I  is  that  group  of  early  cases 
where  the  disease  is  limited  to  the  cervix.  Group 
IV  embraces  those  hopelessly  advanced  cases  where 
the  uterus  is    completely    fixed,    the    parametrial 


structures  rigidly  held  in  position  with  disease;  the 
bladder  or  rectum  is  invaded,  and  possibly  distant 
metastasis  has  occurred.  The  other  groups  refer  to 
various  stages  of  disease  between  early  and  hope- 
less. 

Treatment  of  carcinoma  of  the  cervix  is  now 
acknowledged  by  all  gynecologists,  at  least  on  this 
continent,  to  be  strictly  a  radiological  problem.  In 
the  past  various  methods  were  used.  Cautery, 
chemicals  and  surgery  have  all  been  advocated  and 
largely  discarded.  Prior  to  the  introduction  of  ra- 
diation therapy  best  results  were  obtained  by  the 
Wertheim  radical  pan-hysterectomy.  Since  only 
the  early,  or  at  most  borderline,  cases  were  sur- 
gically operable,  the  prognosis  for  a  moderately 
advanced  case  was  hopeless.  In  the  hands  of  ex- 
perts, the  Wertheim  operation  had  a  mortality  of 
20  per  cent,  and  of  those  surviving  operation  less 
than  50  per  cent  were  cured  of  their  disease.  The 
best  figures,  those  of  Wertheim  himself,  showed  an 
absolute  cure  rate  of  less  than  19  per  cent,  with  an 
operative  mortality  of  19.5  per  cent.  A  noted 
English  gynecologist  in  1917  reported  an  absolute 
cure  rate  of  10.2  per  cent,  with  an  operative  mor- 
tality of  28  per  cent,  by  Wertheim  hysterectomy. 

For  some  time  past,  at  Memorial  Hospital,  we 
have  carried  out  external  pelvic  x-ray  therapy  prior 
to  the  use  of  radium  in  practically  all  cases  of  car- 
cinoma of  the  cervix.  The  advantages  have  been 
several:  infection  in  the  cervix,  which  is  always 
present,  has  been  cleaned  up;  the  bulk  of  the  pri- 
mary lesion  has  been  reduced;  and,  as  a  result  of 
both  these  effects,  morbidity  due  to  the  manipula- 
tion necessary  to  the  insertion  of  radium  has  been 
markedly  reduced. 

Stripped  of  all  qualifying  factors,  analysis  of  a 
large  series  of  cases  at  Memorial  Hospital  showed 
a  five-year  salvage  of  27.5  per  cent.  The  single 
most  important  factor  was  found  to  be  early  diag- 
nosis. While  the  early  cases  formed  only  15  per 
cent  of  the  total,  nearly  60  per  cent  of  these  pa- 
tients were  alive  and  well  and  free  of  disease  after 
five  years.  On  the  other  hand,  only  22  per  cent  of 
stage  III  cases  survived  the  five-year  period,  and 
only  6  per  cent  of  the  stage  IV,  the  patients  in  the 
most  advanced  group,  lived  five  years. 

It  is  obvious  therefore,  that  with  our  present 
methods  of  treatment,  great  improvement  in  end 
results  will  be  obtained  only  when  the  diagnosis  is 
made  at  an  early  stage  of  the  disease.    Some  im- 


•Delivered  before  the  Piedmont  Postgraduate  Clinical  Assembly,  Anderson,  S.   C,  September  10th,   1941. 


November,  1941 


DIAGNOSIS  AND  TREATMENT  OF  UTERINE  CANCER— Kelly 


provement  will  occur  when  our  patients  report  for 
examination  at  the  time  when  they  first  have 
symptoms  of  discharge  or  bleeding.  Our  end  re- 
sults will  markedly  improve  if  we  are  able  to  estab- 
lish a  diagnosis  before  symptoms  are  evident.  To 
do  this,  we  must  have  our  patients  report  for  care- 
ful pelvic  examination  at  least  twice  each  year  after 
their  40th  year.  Bimanual  examination,  speculum 
examination,  and  biopsy  of  all  suspicious  lesions 
of  the  cervix  should  be  done.  As  a  prophylactic 
measure,  cure  of  all  inflammatory  lesions  of  the 
cervix  is  indicated.  In  96  per  cent  of  all  cases  of 
cervix  cancer  a  clear  history  may  be  obtained  of 
one  or  more  full-term  gestations,  or  of  at  least  one 
miscarriage.  Thus  the  factor  of  cervical  trauma 
and  infection  is  present  in  nearly  all  of  them.  We 
believe  that  the  use  of  the  office  cautery  on  the 
post-partum  cervix,  where  erosion  or  infection  ex- 
ists, will  prevent  the  development  of  some  cervix 
cancers  in  later  life.  This  simple  and  effective 
measure  is  indicated  at  any  time  when  the  cervix 
is  cystic,  eroded,  or  everted. 

Cancer  of  the  body  of  the  uterus  is  far  less  fre- 
quently encountered  than  is  carcinoma  of  the  cer- 
vix, and  it  afflicts  older  women.  The  average  age  at 
which  this  disease  is  found  is  54-55  years.  It  is 
quite  rare  under  40.  Thus,  carcinoma  of  the  corpus 
is  most  frequently  associated  with  the  menopausal 
and  post-menopausal  years  of  life.  The  commonest 
symptom  is  uterine  bleeding.  This  was  present  in 
some  form  in  97  per  cent  of  200  cases  recently  re- 
viewed at  Memorial  Hospital.  In  the  classical  case 
uterine  bleeding  manifests  itself  months  or  years 
after  completion  of  the  menopause.  In  other  cases 
bleeding  may  take  the  form  of  menorrhagia  or 
metrorrhagia  during  the  active  menstrual  life  of  the 
patient. 

The  diagnosis  is  to  be  strongly  suspected  when- 
ever post-menopausal  bleeding  is  the  complaint, 
and  no  lesion  of  the  vagina  or  cervix  is  encounter- 
ed. It  is  to  be  considered  as  a  possibility  in  all 
cases  of  irregular  uterine  bleeding  at  or  near  the 
menopause.  While  the  disease  remains  confined  to 
the  uterine  cavity,  the  diagnosis  can  be  confirmed 
only  by  diagnostic  curettage.  This  procedure  is 
imperative  therefore  in  all  cases  of  post-menopausal 
vaginal  bleeding  where  the  cause  is  not  perfectly 
obvious.  Curettage  should  not  be  long  delayed  in 
any  case  of  menorrhagia  or  metrorrhagia  occurring 
in  a  woman  approaching  middle  life  that  does  not 
quickly  resspond  to  conservative  therapeutic  meas- 
ures. 

It  is  not  always  possible  to  make  a  correct  diag- 
nosis from  the  gross  appearance  of  the  specimen 
obtained  by  curettage.  Positive  diagnosis,  there- 
fore, must  be  made  by  microscopic  study.  Whereas 
most  cervix  cancers  are  of  squamous-cell  origin, 


most  corporeal  cancers  are  glandular  in  origin,  aris- 
ing from  the  glands  of  the  endometrium.  Just  as 
the  histology  of  cervix  cancer  varies,  so  too  does 
that  of  corpus  cancer.  Three  main  classifications 
or  grades  are  recognized,  varying  from  papillary 
adenoma  malignum,  which  is  relatively  low  in  the 
scale  of  malignant  structure,  to  highly  malignant 
anaplastic  adeno-carcinoma.  It  has  been  long  rec- 
ognized that  corpus  cancer  as  a  rule  tends  to  re- 
main localized  to  the  uterus  for  longer  periods  of 
time  before  metastisizing  than  does  cervix  cancer, 
and  it  is  not  uncommon  to  find  the  disease  still 
confined  to  the  uterine  cavity  when  symptoms  have 
been  present  for  months  and  even  years.  There  are 
two  factors  that  have  been  found  to  be  of  prog- 
nostic importance.  First,  when  the  uterus  is  not 
enlarged  the  prognosis  is  good;  and  the  prognosis 
becomes  progressively  worse  with  each  degree  of 
uterine  enlargement.  Secondly,  when  pain  is  com- 
plained of  the  prognosis  is  usually  poor. 

Treatment  of  corpus  carcinoma  has  usually  con- 
sisted of  complete  hysterectomy  by  either  the  va- 
ginal or  the  abdominal  route.  While  the  results  of 
such  surgical  procedures  have  been  vastly  superior 
to  the  results  of  surgical  treatment  of  carcinoma  of 
the  cervix,  careful  statistics  of  many  excellent  clin- 
ics reveal  that  the  five-year  results  were  not  as 
good  as  had  been  hoped  for.  In  an  effort  to  im- 
prove these  results,  radiation  has  been  given  an 
important  place  in  treatment  at  Memorial  Hospital 
for  several  years.  This  consists  of  a  combination 
of  external  x-ray  therapy,  and  intrauterine  irradia- 
tion with  radium  applied  at  the  time  of  diagnostic 
curettage,  or  as  soon  thereafter  as  possible  if  doubt 
exists,  concerning  the  diagnosis.  Six  to  eight  weeks 
after  completion  of  radiation  complete  abdominal 
hysterectomy  is  carried  out  in  every  operable  case 
in  which  no  serious  complication  exists.  When, 
however,  the  patient  is  a  poor  operative  risk,  be- 
cause of  advanced  age,  cardiac  and  renal  disease, 
diabetes  etc.,  reliance  has  been  placed  on  radiation 
alone,  and  with  very  gratifying  results.  Nearly  40 
per  cent  of  all  those  treated  by  radiation  therapy 
alone  were  cured  of  disease,  while  the  end-results 
were  about  15  per  cent  better  in  those  cases  in 
which  hysterectomy  followed  radiation  therapy. 
Because  of  the  late  period  in  life  in  which  this  dis- 
ease usually  occurs,  diseases  other  than  cancer  ca- 
count  for  many  of  the  deaths,  and  this  is  partic- 
ularly true  in  that  group  treated  by  radiation  only. 

Summary 
1.  Carcinoma  of  the  cervix  is  the  commonest 
form  of  cancer  of  the  female  genital  tract.  The 
most  important  factor  in  prognosis  is  the  estab- 
lishment of  an  early  diagnosis.  Care  of  the  cervix 
postpartum  and  inflammatory  lesions  of  the  cervix 


SOUTHERN  MEDICINE  &  SURGERY 


November,  1941 


are  stressed  as  important  in  preventing  the  occur- 
rence of  cervix  cancer. 

2.  Cancer  of  the  corpus  uteri  forms  an  impor- 
tant group  in  diseases  of  women  in  the  menopausal 
years  or  beyond.  The  necessity  for  diagnostic  curet- 
tage is  stressed  in  all  cases  of  post-menopausal 
bleeding,  and  its  importance  is  emphasized  in  cases 
of  irregular  uterine  bleeding  in  the  menopausal 
period.  The  use  of  radiation  therapy,  followed  by 
hysterectomy  in  favorable  risks,  is  advocated.  Ra- 
diation therapy  alone  has  given  good  results  in 
cases  in  which  major  surgery  is  contraindicated. 

—121    East  60th   Street 


CASE  REPORTS 


FEVER— From  p.  598 

7.  Cole,  H.  N.:    /.  A.  M.  A.,  .717:1091  (Sept.  27),  1941. 

8.  Simpson,  W.  M.:  Bull.  New  York  Acad.  Med.,  17:592 
Aug.),  1941. 

9.  Howles,    J.    K.:      Arch.    Physical    Therapy,    20:149 
(March),  1939. 

10.  Ewalt,  J.  R.,  and  Ebaugh,  F.  G.:    J.  A.  M.  A.,  116: 
2474  (May  31),  1941. 

11.  Kendall,  H.  W.,  Rose,  D.  L.,  and  Simpson,  W.  M.: 
J.  A.  M.  A.,  116:351  (Feb.  1),  1941. 

12.  Bennet,  A.  E.,  and  Murray,  D.  L.:    Am.  J.  Syph., 
22:593  (Sept.),  1938. 


HYPERTENSION  AND  RENAL  DISEASE 

(C.  L.  Deming,  New  Haven,  in  //.  Mo.  State  Med.  Assn.,  Oct.) 
Renal  arterial  occlusion,  renal  trauma,  pyelonephritis 
and  urinary  obstruction  are  factors  of  significance  in  rela- 
tion to  hypertension.  The  arterial  circulation  of  each  kid- 
ney must  be  considered  individually. 

Obstruction  to  arteriorenal  circulation  and  obstruction 
to  the  ureter  are  of  equal  significance  as  to  development 
of  hypertension. 

Patients  with  a  proven  unilateral  renal  lesion  with  hy- 
pertension may  expect  relief  of  hypertension  by  a  nephrec- 
tomy when  the  good  kidney  has  a  compensatory  function. 


FELLOWSHIPS  IN  NUTRITION 
Effective  November  1st,  Swift  &  Company  made  avail- 
able a  number  of  fellowships  to   universities   and  medical 
schools,  for  research  in  nutrition. 

To  be  eligible  for  grants,  projects  should  be  aimed  at  one 
of  the  following  objectives: 

1.  The  development  of  fundamental  information  on  the 
nutritive  properties  of  foods. 

2.  The  application  of  this  fundamental  information  to 
the  improvement  of  the  American  diet  and  health. 

Swift  &  Company  is  naturally  interested  in  nutrition 
research  on  meat  and  meat  products,  but  grants  will  not 
be  limited  to  work  in  these  fields.  Any  worthwhile  study 
on  the  nutritive  properties  of  foods  or  the  improvement  of 
diets  will  be  eligible  for  a  grant. 

Each  fellowship  will  be  operative  for  one  year,  unless 
renewed,  and  will  be  granted  in  an  amount  to  be  deter- 
mined by  the  scope  of  the  project.  Placement  of  the  Fel- 
lowships in  Nutrition  will  be  coordinated  by  Dr.  R.  C. 
Newton  and  his  staff  of  the  Research  Laboratories  of  Swift 
&  Company,  Union  Stock  Yards,  Chicago. 


When  I  meet  a  long  Latin  word,  in  a  line  of  quiet  Eng- 
lish, elbowing  its  neighbors  right  and  left,  like  a  motor 
omnibus  raging  down  a  country  lane,  I  stop  it  and  ask  to 
see  its  root.  That  is  the  way  to  take  the  conceit  out  of  all 
such  words. — Stephen  Paget. 


X-RAY  SHADOWS  SIMULATING  STONES 

Walter  E.  Daniel,  M.D.,  Charlotte,  N.  C. 

IT  is  generally  known  that  calcified  lymph 
nodes,  some  pigmented  moles,  phleboliths, 
some  cutaneous  papillomata  and  intestinal  con- 
tents cast  shadows  on  x-ray  films  which  are  diffi- 
cult to  differentiate  from  urinary-tract  calculi.  Two 
cases  will  be  now  reported  in  which  cutaneous 
fibromata  caused  shadows  simulating  renal  calculi. 

Case  I. — This  patient  was  a  26-year-old  white 
woman  who  had  been  in  excellent  health  until  five 
days  before  admission  when  she  began  having  se- 
vere pain  in  the  right  costovertebral  angle  which 
radiated  around  the  abdomen  to  the  bladder.  Nau- 
sea and  vomiting  accompanied  the  pain,  but  no 
fever,  chills,  or  bloody  urine.  The  acute  pain  sub- 
sided in  a  few  hours  leaving  a  residual  soreness  in 
the  right  back  and  flank. 

The  general  physical  examination  was  negative 
except  for  the  abdomen  where  there  was  marked 
tenderness  to  fist  percussion  in  the  right  costover- 
tebral angle  and  tenderness  to  bimanual  pressure 
in  the  right  flank.  Urine  drawn  by  catheter  was 
blood-tinged  and  contained  many  red  blood  cells. 
The  flat-plate  picture  of  the  abdomen  showed  a 
rounded  shadow  two  cm.  in  diameter  in  the  region 
of  the  right  kidney  pelvis  (Fig.  I).  Intravenous 
urography  showed  good  kidney  function  on  both 


Fig.  1 


November,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


sides.  The  right  kidney  pelvis  was  slightly  dilated 
and  in  one  plate  the  shadow  previously  seen  on  the 
flat  plate  could  be  seen  through  the  opaque  me- 
dium. 

During  the  first  few  days  in  the  hospital  the  pa- . 
tient  had  several  typical  attacks  of  kidney  colic 
and  continued  to  pass  urine  containing  red  blood 
cells. 

At  operation  the  right  kidney  and  pelvis  were 
exposed.  The  stone  could  not  be  felt,  so  an  in- 
cision was  made  in  the  rather  large  extrarenal  pel- 
vis and  its  interior  was  examined  with  the  finger. 
No  stone  was  found.  A  catheter  was  then  passed 
down  the  ureter  for  25  cm.  where  it  met  an  im- 
passable obstruction.  The  wound  was  closed  with 
drainage.  While  closing  the  wound  a  small  round- 
ed, soft,  wrinkled,  pedunculated  cutaneous  fibroma 
was  noticed  near  the  upper  end  of  the  incision.  It 
was  removed,  x-rayed,  and  found  to  cast  a  shadow 
identical  with  the  shadow  seen  in  the  right  kidney 
region. 

Nine  days  after  operation  the  incision  stopped 
draining  urine  and  two  days  later  the  patient 
passed  a  very  small  calculus  half  the  size  of  a 
match  head. 

This  patient  had  a  very  small  calculus  in  the 
lower  end  of  the  ureter  which  did  not  show  on  the 
x-rav  films  and  a  cutaneous  pedunculated  fibroma 
which  did  cast  a  shadow  which  was  mistaken  for 
a  renal  calculus. 

Case  II. — This  patient,  a  49-year-old  white  man 
who  had  previously  been  in  good  health,  had  had 
some  soreness  in  the  left  side  of  his  back  for  seven 
days.  The  pain  was  not  severe  and  was  not  typical 
of  renal  colic.  He  brought  an  x-ray  picture  of  the 
abdomen  made  elsewhere  which  showed  a  small 
rounded  shadow  in  the  region  of  the  right  kidney 
and  which  had  the  appearance  of  a  renal  calculus. 

On  physical  examination  there  was  no  definite 
tenderness  in  either  costovertebral  angle  and 
neitherer  kidney  was  palpable.  The  urine  was 
grossly  clear  and  negative.  There  was  a  small 
rounded,  soft,  pedunculated  fibroma  of  the  skin  in 
the  right  costovertebral  angle. 

After  strapping  a  needle  on  the  patient's  back  so 
its  point  was  against  the  fibroma,  another  picture 
was  made  which  showed  the  needle  pointing  to  the 
rounded  shadow  in  the  kidney  region  (Fig.  II.) 

When  this  patient  was  told  that  he  did  not  have 
a  stone  and  would  not  have  to  have  an  operation, 
he  was  so  elated  that  his  pain,  which  had  been 
lessening,  disappeared  entirely.  He  was  discharged 
and  has  had  no  further  trouble. 

These  cases  illustrate  the  fact  that  one  should  be 
careful  in  differentiating  shadows  seen  along  the 
urinary  tract.    Shadows  outside  the  urinary  tract 


Fig.  2 

can  be  ruled  out  by  means  of  cystoscopy,  retro- 
grade and  intravenous  urography,  lateral  and 
oblique  films.  It  is  well  to  remember  the  patient's 
back  and  abdomen  for  moles  and  pedunculated 
fibromata  before  making  the  diagnosis  of  calculus. 

— Thompson-Daniel  Clinic 
Professional  Building 


ECONOMICAL  LIVER  THERAPY 
An  interesting  report  (Am.  J.  M.  Sc,  202:408,  Septem- 
ber 1941)  of  a  comparison  between  the  therapeutic  effec- 
tiveness of  an  extremely  concentrated  liver  extract  ("Retic- 
ulogen"  (Parenteral  Liver  Extract  with  Vitamin  Bl,  Lilly) 
and  less  concentrated  preparations  shows  a  considerable 
saving  to  the  physician  and  hospital  using  the  former.  Forty 
cases  of  pernicious  anemia  were  treated,  thirty-five  for 
periods  of  from  two  to  four  years,  and  control  cases  were 
followed  over  the  same  period.  Red  blood-cell  and  hemo- 
globin levels  were  satisfactorily  maintained,  neural  symp- 
toms were  controlled  or  actually  improved,  and  the  pa- 
tients were  able  to  combat  successfully  many  types  of  acute 
and  chronic  disease  almost  as  effectively  as  the  average 
population.  There  was  no  evidence  that  this  medication 
was  lacking  in  any  protective  factor  since  nearly  all  of  the 
patients  received  as  much  benefit  as  could  be  expected 
from  any  extract. 


VENESECTION  IN  THE  TREATMENT  OF 

ERYTHREMIA 

(A.  A.  Holbrook,  Milwaukee,  in  Wise.  Med.  11.,  Oct.) 

The  withdrawal  of  400  c.  c.  of  blood  may  be  expected 

to  give  prompt  relief  of  headache,  nrevousness,  palpitation 

and    unpleasant   heat   sensations   and   to    reduce    red   cells, 

hemoglobin  and  viscosity,  at  least  temporarily.    If  a  normal 

red   cell   and   hemoglobin   content   are   artifically   produced 

in  a  patient  with  erythremia  he  may  suffer  from   relative 

anemia. 

Studies   before   and   after   venesection   indicate   that   the 
quantity  of  blood  drawn  is  quickly  replaced. 


SOUTHERN  MEDICINE  &  SURGERY 


November,  1941 


SURGICAL  OBSERVATIONS 


OF  THE  STATP 

DAVIS  HOSPITAL 
Statesville 


THE  HUMAN  BEING  AT  HIGH  ALTITUDES  ■ 

Atmospheric,  or  air,  pressure,  which  is  fifteen 
pounds  to  the  square-inch  at  sea  level,  becomes 
less  and  less  as  we  ascend  through  this  blanket  of 
air,  100,  possibly  200,  miles  thick.  The  lessening 
of  pressure  (weight)  as  we  reach  greater  heights 
causes  a  thining,  or  rarefaction  of  the  air,  a  lessen- 
ing of  the  density  of  the  life-supporting  oxygen,  so 
that  even  the  deepest  of  inspirations  repeated  at 
the  ordinary  rate  will  not  supply  sufficient  oxygen, 
and  it  becomes  necessary,  as  the  altitude  increases, 
to  breathe  more  rapidlv  and  more  deeply,  and  that 
the  heart  pump  the  blood  through  the  lungs  more 
rapidlv,  in  order  to  keep  the  economy  supplied 
with  oxygen.  Above  a  certain  point  a  human  being 
cannot  exist  without  an  extra  supply  of  oxygen. 
Aviation  experiments  have  established  almost  the 
exact  limit  of  altitude  at  which  human  beings  can 
survive  without  breathing  from  a  tube  or  chamber 
of  oxygen. 

The  presence  of  carbon  dioxide  in  the  blood 
stimulates  breathing,  and  with  an  increase  in  car- 
bon dioxide  concentration  in  the  blood  the  stimulus 
to  breathing  becomes  more  and  powerful  up  to  a 
certain  point. 

Breathing  pure  oxvgen  through  a  well-fitting 
mask,  gives  a  sense  of  exhilaration  especially  at 
high  altitudes,  and  the  necessity  for  oxygen  under 
artificial  pressure  becomes  more  and  more  urgent. 
After  pure  oxygen  has  been  breathed  for  a  while 
carbon  dioxide  is  eliminated  from  the  blood  and 
from  the  lungs,  and  the  human  mechanism  lacking 
this  natural  stimulant  to  respiration,  the  individual 
will  often  stop  breathing.  In  other  words,  the 
respiratory  mechanism  will  stop  simply  from  lack 
of  excitation  by  this  end-product  of  respiration, 
which  until  comparatively  recently  was  regarded 
as  waste  matter  to  be  got  rid  of  as  rapidly  and 
completely  as  possible. 

Ordinary  nitrogen  is  present  in  the  blood.  While 
this  is  inert  and  harmless  in  ordinary  conditions, 
yet  in  high  altitudinal  atmosphere  the  nitrogen 
will  expand  and  produce  bubbles  and  bring  on  a 
condition  known  as  caisson  disease  or  "the  bends". 

It  has  long  been  known  that  caisson  workers, 
under  such  conditions  as  obtain  in  building  under- 
ground tunnels,  working  under  rivers  where  it  is 
necessary  to  work  under  high  atmospheric  pressure 
in  order  to  keep  back  the  water  and  mud,  must 
have  the  high  atmospheric  pressure  of  the  caisson 
gradually  reduced  so  that  the  body  can  slowly 
adjust  itself  to  the  normal  pressure,  and  so  the 


painful,  possibly  fatal,  caisson  disease  be  prevented. 

In  the  new  airplanes  for  flying  at  high  altitudes, 
superchargers  are  provided  to  feed  the  motors  a 
plentiful  supply  of  oxygen  and  the  cabins  for  the 
pilots  are  constructed  airtight  so  that  oxygen  can 
be  pumped  into  the  cabins  with  the  optimum  per- 
centage of  carbon  dioxide  to  maintain  for  the  crew 
as  nearly  as  possible  the  atmospheric  conditions 
near  sea-level. 

In  preparing  for  a  high-altitude  flight,  pilots 
usually  take  exercise,  using  the  gas  mask.  This 
allows  them  to  breathe  oxygen  and  carbon  dioxide 
but  leaves  out  the  nitrogen.  After  thirty  minutes 
of  this  breathing  with  exercise,  the  nitrogen  may 
be  well  eliminated  from  the  body  and  at  high  alti- 
tudes the  pilots  are  thus  protected,  to  a  great 
extent,  against  the  sudden  expansion  of  nitrogen 
and  the  formation  of  bubbles  in  the  blood. 

Air  combat  of  the  future  requires  planes  that 
can  fly  at  extremely  high  altitudes  and  that  crews 
be  conditioned  bv  special  training  so  that  they  can 
function  normally  under  these  unusual  atmospheric 
conditions. 

Aviation  medicine  is  making  rapid  strides  and 
has  made  possible  the  high-altitude  flying  which 
is  doing  so  much,  and  promises  so  much  more, 
in  the  saving  of  the  world  from  enslavement  by 
Hitler's  Germany. 

PRESACRAL   NEURECTOMY   FOR   THE 
RELIEF  OF  DYSMENORRHEA 

The  majority  of  patients  who  have  a  severe 
idiopathic  dvsmenorrhea  and  have  a  presacral 
neurectomy  get  complete  relief  from  the  painful 
periods;  a  considerable  number  continue  to  have 
pain  of  lesser  degree;  a  very  few  complain  as  be- 
fore. An  odd  thing -it  is  that  after  a  presacral 
neurectomy  patients  will  often  have  pain  during 
one  or  two  of  the  periods  but  after  this  it  usually 
ceases. 

Viewing  a  goodly  number  of  these  patients  over 
periods  of  five  to  twenty  years  has  convinced  us 
that  presacral  neurectomy  will  afford  great  relief 
in  the  vast  majority  of  cases  of  idiopathic  dys- 
menorrhea. Those  who  have  not  obtained  com- 
plete relief  state  that  the  residual  pain  is  negligible. 

In  the  few  instances  in  which  presacral  neurec- 
tomv  has  not  given  relief  from  pain,  and  the 
dysmenorrhea  seems  to  be  about  as  severe  as  ever, 
it  is  probable  that  the  pain  impulses  travel  by 
unusual  nerve  routes,  or  possibly  some  of  the 
presacral  nerves  were  missed  at  the  operation 
directed  to  their  severance. 

Whenever  patients  complain  of  dysmenorrhea 
every  means  should  be  exerted  to  determine  the 
cause  and  if  no  cause  is  found  a  presacral  neurec- 


November,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


607 


tomy  should  be  advised,  if  the  patient  is  in  a 
satisfactory   condition   for  operation. 

There  are  no  after-effects  that  are  disagreeable 
or  harmful.  It  seems  that  some  cases  of  chronic 
constipation  are  improved  and  some  relieved  by 
this  operation,  where  the  constipation  is  due  to 
atony  of  the  lower  bowel. 

As  to  the  danger  of  operation,  when  properly 
performed,  we  consider  it  nil. 

THE  DIAGNOSIS  OF   INTUSSUSCEPTION 

Intussuception  occurs  most  often  in  the  very 
young  and,  while  in  an  occasional  case  relief  may 
come  about  spontaneously,  such  occurrences  are 
very  rare  and  unless  the  intussusception  is  relieved 
the  patient  cannot  recover. 

Owing  to  the  fact  that  many  cases  occur  in 
infants  who  are  so  young  that  they  can  demonstrate 
their  symptoms  only  by  screaming  and  writhing, 
the  diagnosis  is  not  always  easy;  however,  early 
diagnosis  is  necessary  and  a  very  careful  examina- 
tion should  be  made  in  any  instance  of  a  baby 
or  small  child  showing  evidences  of  intermittent 
pain  in  the  belly,  the  doctor  should  bear  intussus- 
ception in  mind. 

The  commonest  symptom  is  this  pain  which,  in 
young  children,  is  evidenced  by  crying  and  often 
little  children  will  scream  if  the  pain  is  particularly 
severe.  The  attacks  of  pain  come  on  suddenly  and 
end  suddenly  at  varying  intervals.  Nausea  and 
vomiting  are  common.  Very  often  the  child  will 
pass  mucus  and  feces  and,  after  the  intussuscep- 
tion is  well  under  way,  there  may  be  flakes  of 
blood  and  sometimes  a  discharge  of  blood  and 
mucus.  This  also  is  one  of  the  most  common  signs 
of  intussusception. 

A  bimanual  examination  with  one  finger  in  the 
rectum  and  the  other  hand  over  the  abdomen 
will  often  enable  one  to  palpate  a  mass  in  the 
lower  abdomen. 

Some  time  ago  I  saw  a  patient  in  which  the  in- 
tussusceptum  could  be  palpated  by  a  finger  in  the 
rectum  as  it  had  gone  down  to  the  point  where  it 
could  be  easily  felt.  In  this  patient  the  intussus- 
ception had  lasted  for  some  time. 

Sometimes  it  is  difficult  to  palpate  the  mass.  We 
have  had  a  number  of  patients  in  whom  the  symp- 
toms are  characteristic  but  in  which  no  mass  could 
be  felt  and  on  opening  the  abdomen  we  have  found 
an  intussusception.  Once  such  a  patient's  symp- 
toms were  fairly  clear  and  we  thought  a  mass  could 
be  palpated  in  the  right  lower  abdomen;  however, 
after  the  patient  was  anesthetized  and  the  abdomen 
opened  there  was  no  intussusception  and  an  ex- 
amination of  the  ileocecal  valve  indicated  what 
apparently  had  been  an  intussusception  which  had 
been  relieved  spontaneously.     The  appearance  of 


the  intestine  indicated  there  had  actually  been  an 
intussusception  which  was  probably  relieved  at 
the  time  the  anesthetic  was  being  given. 

The  only  reliable  relief  for  intussusception  is 
a  surgical  operation  and  this  should  be  done  im- 
mediately. In  a  condition  of  this  kind  delay  may 
be  fatal  to  the  patient  and  increase  the  difficulty 
in  reducing  the  intussusception. 

THE  INCIDENCE  OF  UNDULANT  FEVER 

There  is  far  more  undulant  fever  than  anyone 
has  heretofore  suspected.  Many  patients  have 
undulant  fever  in  mild  form  and  as  the  "specific" 
tests  are  of  doubtful  value  in  many  instances,  diffi- 
culty is  often  found  in  arriving  at  a  diagnosis. 

That  undulant  fever  is  the  cause  of  much  gen- 
eral illness  cannot  be  questioned.  Many  patients 
who  complain  a  great  deal  of  various  aches,  joint 
and  muscle  pains,  and  various  neuritic  symptoms, 
have  as  a  possible  cause  of  this  trouble  an  undiag- 
nosed case  of  undulant  fever. 

The  most  satisfactory  treatment  of  undulant 
fever  in  patients  who  are  able  to  stand  it  is  hyper- 
pyrexia. In  an  experience  of  enough  cases  and" 
over  long  enough  time  to  remove  the  chance  of 
coincidence  explaining  the  sequence  of  events  we 
have  found  this  treatment  highly  satisfactory, 
often  the  condition  clearing  up  after  one  or  two 
treatments. 

Naturally,  it  is  essential  that  fever  therapy  be 
given  by  someone  who  is  experienced  in  its  intri- 
cate technique.  The  treatment  of  undulant  fever 
should  always  be  given  by  those  who  are  familiar 
with  the  disease  and  know  how  to  treat  it. 

The  vaccine  treatment  of  undulant  fever  has 
proved  its  merit  in  a  great  number  of  patients. 
Sometimes  this  is  used  as  a  follow-up  to  fever 
therapy,  or  it  may  be  used  before  fever  therapy. 

Transfusions  of  blood  from  immune  individuals 
give  excellent  results.  In  case  immune  individuals 
are  not  available,  it  is  possible  to  immunize  persons 
against  this  disease  and  when  the  blood  has 
reached  the  highest  titer  blood  transfusions  may 
be  given.  One  of  the  most  important  things  about 
treatment  is  to  continue  it  until  the  patient  is  well 
— at  least  until  the  patient  is  clinically  well. 

Every  doctor  should  be  on  the  alert  for  undulant 
fever. 

THE  TREATMENT  OF  ACUTE  PHLEBITIS 

BY  PARAVERTEBRAL  INJECTIONS  OF 

PROCAINE  SOLUTION 

We  have  found  that  immediate  relief  from  acute 
pain  from  phlebitis  results  from  paravertebral  in- 
jections of  procaine  solution.  After  many  years 
of  exhibition  oT  this  method  of  treatment  we  are 
frequently  almost  startled  at  the  dramatic  way  in 


SOUTHERN  MEDICINE  &  SURGERY 


November,  1941 


which  immediate  relief  of  pain  is  afforded  and  the 
attack  cut  short. 

Usually  the  injections  are  made  along  the  lower 
lateral  aspects  of  the  four  lower  lumbar  vertebrae. 
Immediately  after  injection  it  is  noted  that  the 
affected  leg  becomes  very  warm  and  almost  pink, 
as  compared  to  the  opposite  leg  which  shows  little 
or  no  change.  The  cutting  short  of  the  attack  of 
so  painful  and  potentially  dangerous  a  condition, 
followed  by  rapid  general  improvement,  and  great 
reduction  in  the  chance  of  recurrence  is  gratifying 
to  patient  and  doctor  alike. 

The  injections  are  fairly  easy  to  give  but,  of 
course,  must  be  given  with  great  care,  but  we  have 
never  noticed  any  unfavorable  results. 


DEPARTMENTS 


The  alimentary  tract  ranks  close  to  the  anterior  lobe 
of  the  hypophysis  in  regard  to  the  number  of  active  prin- 
ciples it  is  supposed  to  elaborate.  The  existence  of  three 
gastrointestinal  hormones  is  well  established  by  physiologi- 
cal evidence  adequately  confirmed.  These  are  secretin, 
cholecystokinin,  and  enterogastrone.  The  diagnostic  or 
therapeutic  usefulness  of  these  three  autocoids  has  not  been 
established. — A.  C.  Ivey. 


Not  all  confession  is  of  sins;  and  a  man  may  confess 
his  faith,  his  ignorance,  or  his  love.  Use  the  word  as  we 
will,  it  means  no  more  than  this,  that  he  goes  outside  of 
himself  for  answer,  assurance,  audience.  I  only  want  to 
confess  what  I  have  learned,  so  far  as  I  have  come,  from 
my  life,  so  far  as  it  has  gone. — Stephen  Paget. 


When  carbon  dioxide  enters  the  blood  it  immediately 
passes  for  the  great  part  into  the  red  blood  cell  where  car- 
bonic acid  is  formed.  It  was  almost  inconceivable  that  a 
purely  chemical  reaction,  such  as  this  could  occur  so  rap- 
idly without  assistance  of  an  enzyme.  The  discovery  of 
carbonic  anhydrase  makes  possible  such  a  reaction. — Gur- 
ney. 


There  is  no  agreement  where  cardiac  pain  actually 
originates.  The  pain  of  angina  pectoris  has  been  attributed 
to  irritation  of  afferent  nerve  fibers  in  the  wall  of  the  coro- 
nary arteries  on  the  basis  of  spasms  or  diseases  of  the 
coronary  arteries  or  the  first  portion  of  the  aorta,  to 
arterial  congestion  in  the  coronary  arteries  as  evidenced  by 
the  effect  of  adrenalin,  to  anoxia  of  the  myocardium  with 
resulting  accumulation  of  unknown  metabolic  substances, 
and  to  coronary  insufficiency  on  an  organic  or  functional 
basis. — Lachmann. 


If  a  doctor's  life  may  not  be  a  divine  vocation,  then 
no  life  is  a  vocation,  and  nothing  is  divine. — Stephen 
Pag-t. 


The  annual  meeting  of  the  Association  of  Surgeons  of 
the  Chesapeake  and  Ohio  Railway  was  held  at  White 
Sulphur  Springs,  West  Virginia,  on  October  24th-25th  un- 
der the  presidency  of  Dr.  Clarence  Porter  Jones  of  Newport 
News.  The  new  officers  of  the  Association  are:  President. 
Dr.  T.  W.  Moore,  Huntington,  West  Virginia;  Vice  Presi- 
dent, Dr.  M.  L.  Rea,  Charlottesville,  Virginia;  Secretary, 
Mr.  G.  E.  Meanley  was  re-elected.  The  meeting-place  of 
the  Association  for  next  year  has  not  been  selected. 


INSURANCE  MEDICINE 

For  this  issue  Ennion  S.  Williams,  M.D.,  Richmond,  Va. 
Medical  Director  The  Life  Insurance  Company  of  Virginia 


INSURANCE  HISTORY-TAKING 

Insurance  medical  histories  differ  from  clinical 
histories  in  the  following  ways: 

1.  They  are  of  legal  importance. 

2.  There  is  no  chief  complaint. 

3.  They  must  be  written  for  interpretation  by  a 
third  party. 

4.  Greater  effort  is  required  to  obtain  details 
from  an  applicant  for  insurance  than  from  a 
patient. 

LEGAL   IMPORTANCE 

The  medical  insurance  history  assumes  legal  sig- 
nificance by  being  photographed  and  attached  to 
the  policy  contract.  The  insurance  company  ac- 
cepts the  risk  with  the  understanding  that  the  in- 
formation listed  is  accurate  and  complete.  If  there 
be  misstatement  of  material  importance  the  con- 
tract is  contestible  for  a  variable  period  of  time.  It 
is  the  duty  of  the  history-taker  to  see  that  the 
questions  are  asked  in  a  simple  and  unhurried  fash- 
ion, in  order  that  the  applicant  may  have  ample 
opportunity  to  give  intelligent  and  honest  answers. 
The  history  blank  is  so  arranged  as  to  meet  certain 
legal  requirements  and  the  most  effective  results 
are  obtained  if  its  questions  are  read  exactly  as 
written,  and  the  applicant's  answers  fully  tran- 
scribed. Any  course  short  of  this  may  prove  em- 
barrassing to  both  examiner  and  applicant  should 
court  proceedings  ensue  because  of  material  omis- 
sions in  the  history. 

NO  CHIEF  COMPLALNT 

A  clinical  history  is  built  around  a  chief  com- 
plaint. This  is  used  as  a  focal  point  about  which 
are  developed  corollary  factors  that  guide  the  at- 
tending physician  in  arriving  at  a  working  diagno- 
sis. The  insurance  history,  since  it  never  includes 
a  chief  complaint,  is  developed  around  past  medi- 
cal attention.  The  names  of  attending  physicians 
and  the  dates  of  all  illnesses  are  ascertained  and 
recorded.  Sometimes  an  accurate  statement  of  the 
diagnoses  can  be  obtained;  at  others  the  symptoms 
suffered  are  elicited  and  are  further  clarified  by  in- 
quiries concerning  duration,  hospital  care,  special 
diagnostic  and  laboratory  procedures  and  consulta- 
tions with  specialists.  The  efficient  examiner  is  con- 
stantly on  the  lookout  for  symptoms  of  chronic 
disease-states,  especially  those  commonly  associat- 
ed with  the  chief  cause  of  death. 


November,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


EXPLANATORY  DETAILS  NECESSARY 

Although  the  responsibility  for  accepting  or  re- 
jecting an  insurance  risk  lies  with  the  Home  Office 
of  the  Company,  the  examiner  is  expected  to  do 
more  than  merely  list  the  applicant's  replies  to  the 
questions.  The  companies  do  want  the  applicant's 
exact  answers,  but  this  is  not  all.  Since  the  medi- 
cal examination  report  must  be  interpreted  by  the 
home  office  medical  department,  it  is  necessary 
that  the  examiner  obtain  and  include  in  his  report 
explanatory  details.  This  requires  both  a  broad 
knowledge  of  clinical  medicine  and  a  certain  inter- 
est in  detective  technique. 

Occasionally  there  appears  in  a  report  a  history 
of  medical  treatment  for  indefinite  conditions  such 
as  "pain  in  side,"  "abdominal  pain,"  "indigestion," 
"nervousness"  or  "kidney  trouble,"  without  appar- 
ent effort  to  explain.  This  causes  inconvenience  for 
many  persons.  The  insurance  company  must  file 
the  papers  as  incomplete  and  correspond  further 
with  the  examiner.  The  examiner  is  inconvenienced 
because  of  the  necessity  of  interviewing  the  appli- 
cant the  second  time,  and  the  applicant  does  not 
appreciate  the  additional  bother. 

The  importance  of  developing  a  complete  history 
may  be  illustrated  by  a  review  made  recently  of 
insurance  applicants  who  gave  a  history  of  medical 
treatment  for  nervousness.  Further  investigation  of 
these  applicants  revealed  quite  a  diversity  of  causes 
for  the  nervousness.  Some  of  the  causes  were  im- 
portant in  relation  to  insurability,  while  others 
were  considered  as  merely  temporary  states  and 
were  disregarded. 

Of  130  applicants  who  gave,  primarily,  a  history 
of  treatment  for  nervousness,  29  were  found  by 
further  investigation  to  have  histories  considered 
important  enough  to  indicate  rejection  for  insur- 
ance. These  included  4  cases  of  pellagra,  4  of 
heart  disease,  9  of  arterial  hypertension,  2  of  in- 
sanity, 2  of  spells  of  unconsciousness,  1  of  feeble- 
mindedness, 1  of  severe  birth  injury;  and  cases  of 
paralysis  agitans,  diabetes,  tuberculosis,  toxic 
goiter;  and  in  one  case  the  nervousness  turned  out 
to  be  occasioned  by  the  applicant  giving  birth  to 
an  illegitimate  child. 

Twenty  applicants  were  found  to  have  condi- 
tions justifying  postponement.  These  included  his- 
tories of  recent  "nervous  breakdowns,"  "rundown 
condition,"  menopausal  disturbances,  pregnancy, 
nervous  indigestion,  proposed  operation,  etc. 

Among  the  remainder  considered  insurable  were 
such  conditions  as  the  menopause  (8  cases),  death 
in  family  (5  cases),  overwork  (12  cases),  dysmen- 
orrhea (3  cases),  auto  accident,  childbirth,  amen- 
orrhea, anal  fissure,  chorea  with  recovery,  hives, 
domestic  difficulties,  change  in  work,  financial  dif- 
ficulties, and  moving  from  the  country  to  the  city. 


If  the  investigation  had  been  stopped  without 
attempting  to  determine  the  cause  of  the  nervous- 
ness this  whole  group  of  cases  should  probably 
have  been  rejected,  as  there  were  a  sufficient  num- 
ber of  seriously  impaired  persons  to  give  an  unfa- 
vorable mortality  experience  for  the  group.  An 
exact  history  permits  more  accurate  classification 
of  risks,  thereby  providing  insurance  benefits  for  a 
larger  percentage  of  the  population,  and  salvage  of 
business  for  the  company. 

The  variability  in  significance  of  other  general 
terms  might  be  listed.  Indigestion,  headaches, 
backaches,  kidney  trouble,  dizziness  and  female 
trouble  are  among  the  more  common.  Even  a  his- 
tory of  a  routine  physical  examination  requires  ex- 
planation. When  it  is  clearly  determined  that  this 
examination  was  for  employment,  school,  marriage, 
or  insurance,  the  history  is  obviously  of  no  medi- 
cal importance;  but  there  are  a  certain  few  who 
undergo  these  examinations  owing  to  symptoms  of 
probable  importance.  Tactful  and  skillful  ques- 
tioning on  the  part  of  the  examiner  is  required  to 
disclose  these. 

APPLICANT   VS   PATIENT 

A  patient  desires  to  give  a  full  history  to  his 
attending  physician  in  order  that  he  may  derive 
benefit  from  his  treatment.  An  applicant,  on  the 
other  hand,  wants  his  insurance  and  is  not  unduly 
disposed  to  talk  about  his  illness.  Experience  has 
shown,  however,  that  the  great  majority  wish  to 
give  straightforward,  honest  answers  to  the  medi- 
cal questions  asked.  Ofttimes  they  do  not  know 
which  facts  are  important.  It  is  therefore  neces- 
sary that  the  medical  examiner  skillfully  interro- 
gate in  order  that  a  maximum  of  information  may 
be  obtained  in  a  minimum  length  of  time.  No  set 
of  questions  will  be  adequate  for  all  cases,  but  the 
questions  should  bring  to  light  medical  ministra- 
tions to  the  applicant.  It  will  then  be  the  duty  of 
the  examiner  to  take  these  leads  and  determine 
accurately  the  seriousness  and  the  duration  of  the 
illnesses.  In  some  instances  a  direct  statement 
from  the  attending  physician  will  be  necessary  for 
accurate  evaluation  of  a  given  illness.  A  good  ex- 
aminer, by  intelligent  questioning,  should  make  the 
necessity  of  correspondence  with  attending  physi- 
cians infrequent. 


DERMATOLOGY 

For  this  issue  Paul  G.  Reque,  M.D.,  Durham,  N.  C. 


THE  MANAGEMENT  OF  URTICARIA 

Urticaria,  hives,  nettle-rash,  or  mad  itch,  is  a 
condition  frequently  seen  by  all  physicians.  The 
diagnosis  is  usually  very  easy  with  the  evanescent 
occurrence  of  raised,  itching  and  burning  wheals, 
first  white,  later  becoming  erythematous.  Urticaria 


SOUTHERN  MEDICINE  &  SURGERY 


November,  1941 


usually  occurs  on  the  lower  limbs  and  trunk,  occa- 
sionally on  the  arms.  It  is  of  two  varieties,  the 
acute  and  the  chronic,  the  acute  being  far  more 
common.  In  the  acute  variety,  the  lesions  tend  to 
disappear  in  a  matter  of  minutes  or  hours,  whereas 
in  the  chronic  variety  they  have  been  known  to 
persist  for  months  and  years. 

The  immediate  management  of  the  case  is  of 
chief  concern  to  the  patient  and  is,  therefore,  a 
primary  object  in  treatment.  However,  the  preven- 
tion of  recurrences  is  probably  more  important  to 
patient  and  physician,  and  the  difficulties  involved 
in  finding  the  cause  are  many.  Although  it  would 
seem  that  intracutaneous  testing  should  be  of  ex- 
treme value  in  this  type  of  allergic  manifestation, 
the  opposite  is  true.  The  patch  test  has  little  value 
and  very  little  reliability  can  be  placed  upon 
scratch  or  intracutaneous  testing,  inasmuch  as  the 
patient's  skin  is  usually  very  reactive  and  shows 
dermatographism,  or  the  definitely  positive  tests 
are  so  numerous  that  no  single  item  can  be  select- 
ed. Commonly  there  is  no  history  of  familial  al- 
lergy. In  many  instances  of  acute  urticaria  the 
patient  knows  of  some  unusual  food  or  recent  drug 
ingestion  which  may  be  quickly  selected  as  the 
possible  cause  for  the  urticaria,  and  the  avoidance 
of  the  offending  substance  prevents  further  attack. 
However,  most  of  the  cases  require  exhaustive  phy- 
sical examinations  to  rule  out  foci  of  infection  such 
as  the  tonsils,  the  naso-sinuses,  and  the  genito- 
urinary tract.  Emotional  stress  and  strain  are 
also  factors  which  must  not  be  overlooked.  Endo- 
crine disorders  such  as  hyperthyroidism  and  men- 
strual abnormalities  must  be  carefully  evaluated. 
Urticaria  requires  that  a  careful  history  of  drug 
ingestion  be  obtained.  The  most  commonly  used 
drugs  causing  urticaria  are  salicylates,  iodides  and 
bromides  (particularly  iodized  salt  and  bromosel- 
zer),  the  barbiturates,  morphine  derivatives,  resins, 
phenolphthalein  and  laxatives,  ipecac,  derivatives 
of  quinine,  and  the  arsphenamines.  There  are  other 
drugs  which  produce  urticaria  but  this  list  includes 
the  common  offenders.  Elimination  of  foci  of  in- 
fection requires  dental  examination,  gastrointesti- 
nal studies,  and  stool  examination  for  parasites; 
the  last-named  are  very  common  excitants.  Neo- 
plasms, blood  discrasias,  neurological  and  metabolic 
diseases,  also  bird  and  animal  itch  mites,  brucello- 
sis, all  should  be  borne  in  mind  as  the  possible  ex- 
planation. In  addition  to  this,  foods  are  carefully 
investigated  and  a  diary  may  be  necessary  in  order 
to  incriminate  or  exonerate  certain  uncommonly 
eaten  foods.  Inhaled  substances  such  as  dust  and 
external  contact  with  wool,  silk  and  dyed  materials 
are  again  exciting  factors. 

The  management  of  the  acute  disease  is  a  simple 
one.    A  saline  purge  with  the  use  of  mineral  oil 


before  each  meal,  and  the  administration  of  an 
absorbing  substance  such  as  kaolin  after  meals  will 
afford  relief  in  many  cases  of  urticaria  which  ap- 
parently are  of  gastrointestinal  origin.  In  addition, 
the  use  of  drugs  affecting  the  vegetative  nervous 
system,  such  as  atropine,  adrenalin  and  ephedrine, 
will  prove  effective  in  quickly  terminating  the  acute 
attack.  Autohemotherapy  consisting  of  10  c.c.  of 
whole  blood  from  the  patient's  vein  immediately 
injected  into  the  buttock  may  prove  of  great  help. 
In  the  chronic  cases,  elimination  diets  may  be  em- 
ployed, beginning  with  abstinence  from  wheat,  eggs 
and  milk,  each  for  a  period  of  two  weeks.  Drugs 
of  all  kinds  should  be  forbidden,  other  than  those 
here  specifically  directed  to  be  used.  Calcium  in 
the  form  of  calcium  gluconate  intravenously  and 
by  mouth  is  frequently  soothing.  In  addition  to 
saline  laxatives,  bile  salts  may  stimulate  the  flow 
of  bile  sufficiently  to  help  eliminate  any  possible 
toxic  product  in  the  gallbladder.  When  intestinal 
parasites  are  found,  or  foci  of  infection  discovered, 
they  must  be  removed  before  repeated  attacks  can 
be  controlled. 

Local  treatment  includes  calamine  lotion  with  1 
per  cent  phenol  and  Yi  per  cent  menthol  added  as 
a  cooling  and  antipruritic  measure,  and  starch 
baths  and  oatmeal  baths  given  twice  daily  are 
quite  relaxing.  Other  antipruritics  such  as  2  per 
cent  aluminum  acetate  in  70  per  cent  alcohol  may 
prove  of  great  benefit.  It  must  not  be  forgotten 
that  a  systemic  disease,  syphilis  for  instance,  may 
be  the  causative  factor,  especially  in  the  long- 
standing case. 


OPHTHALMOLOGY 

Herbert  C.  Neblett,  M.  D.,  Editor,  Charlotte,  N.  C. 


THE  INCIDENCE  OF  GLAUCOMA  IN  THE 
UNITED  STATES 

Available  statistical  data  tend  to"  show  that 
glaucoma  simplex  or  compensated  glaucoma  is  in- 
creasing. This  is  the  insidious  type,  practically 
always  bilateral,  and  one  eye  is  usually  more  in- 
volved than  its  fellow.  There  is  rarely  anv 
external  evidence  by  which  its  presence  may  be 
detected  on  ordinary  macroscopic  examination. 
More  often  than  otherwise  the  patient  is  not  aware 
of  its  presence  until  he  notices  a  limitation  of  his 
field  of  vision  and  with  it  a  progressive  lessening 
of  sight.  The  disease  is  then  in  an  advanced  stage. 
To  the  careless  examiner  and  to  the  unitiated  the 
condition  is  too  often  undetected,  and  if  detected 
in  its  incipiency,  which  is  the  period  in  its  exist- 
ence when  treatment  is  effective,  requires  a  con- 
sciousness of  glaucoma  and  careful  analysis. 

This  is  in  contradistinction  to  non-compensated 
or  incompensated  glaucoma  which  is  the  acute  or 


November.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


chronic  congestive  tvpe.  In  this  there  are  imme- 
diate objective  and  subjective  symptoms  sufficient 
to  proclaim  its  presence  because  it  is  always  uni- 
lateral, the  globe  highly  injected,  pain  severe  and 
vision  rapidly  and  markedly  deficient.  It  can  be 
and  frequently  is  contused  with  acute  iritis  from 
which  it  must  be  quickly  differentiated  before 
treatment  of  any  kind  is  instituted.  Prompt  and 
correct  diagnosis  with  early  medical  and  surgical 
treatment  result  in  spectacular  recovery. 

Unfortunately  glaucoma  simplex  is  not  so  amen- 
able to  treatment  even  in  its  incipiency,  and  still 
less  so  if  it  has  not  been  detected  until  the  patient 
becomes  aware  of  a  visual  problem.  Hope  then 
of  controlling  its  progress  or  even  of  saving  what 
vision  is  left  enlists  the  full  cooperation  of  the 
patient  and  all  of  the  ingenuity  and  skill  of  the 
physician  in  charge.  So  difficult,  so  time-consum- 
ing is  the  treatment,  so  unfavorable  the  results  of 
treatment  in  advanced  glaucoma  simplex  that  there 
is  a  trite  saying  among  oculists  ''refer  these  patients 
to  your  enemies". 

The  problem  of  glaucoma  simplex  has  become 
a  national  one  because  it  is  now  recognized  as  one 
of  the  major  causes  of  blindness.  Data  at  hand 
show  it  to  be  the  cause  of  18  to  20  per  cent  of 
blindness  in  the  United  States,  and  from  these 
available  data  it  is  estimated  that  from  1  to  3  per 
cent  of  the  population  have  the  disease  to  some 
degree.  These  data  have  been  amassed  from  many 
private  sources,  from  glaucoma  clinics  recently  or- 
ganized in  several  large  cities,  more  specifically 
from  The  Glaucoma  Clinic  initiated  and  organized 
3  or  4  years  ago  by  Dr.  H.  S.  Gradle  and  his  co- 
workers at  The  Illinois  Eye  and  Ear  Infirmary. 
This  clinic  has  a  full-time  oculist,  nurse  and  clerical 
worker  who  with  the  other  oculists  on  the  hospital 
staff  and  the  Social  Service  workers  of  the  city 
handle  all  the  clinic  glaucoma  cases  in  the  vicinity 
of  Chicago.  Through  this  organization  a  roster  is 
kept  of  all  known  glaucoma  cases,  both  clinic  and 
private,  in  that  area.  From  this  nucleus  and  from 
other  County  Medical  Societies  throughout  the 
State  of  Illinois  oculists  routinely  appear  before 
various  County  Medical  Societies  to  read  papers 
on  this  subject  before  general  meetings.  The  pur- 
pose is  to  create  an  awareness  of  glaucoma  among 
the  whole  profession. 

At  the  recent  meeting  of  the  American  Academy 
of  Ophthalmology  in  Chicago  the  early  diagnosis, 
treatment  and  follow-up  of  glaucoma  simplex  cases 
were  preeminent  in  the  papers  before  the  meeting, 
in  the  special  courses  given  to  its  members,  in  the 
pathological  exhibits  and  in  private  conversations 
among  those  present.  It  was  brought  out  in  these 
discussions  that  the  great  majority  of  glaucoma 
simplex  cases  were  detected  where  the  patient  pre- 


sented himself  to  a  medical  refractionist  for  ex- 
amination of  his  eyes.  It  was  also  emphasized,  as 
has  long  been  known,  that  not  more  than  15  per 
cent  of  the  people  who  wish  to  have  their  eyes 
examined  for  the  fitting  of  glasses  applied  to  the 
medical  refractionist  for  that  purpose.  The  other 
85  per  cent  were  examined  by  the  itinerant  glass- 
fitter,  the  over-the-counter  salesman  and  the  non- 
medical refractionist.  It  is  obvious  from  these 
sources  that  no  reliable  data  on  the  incidence  of 
glaucoma  are  to  be  had.  It  is  therefore  evident 
that  the  incidence  of  1  to  3  per  cent  in  the  general 
population  in  this  country  is  merely  an  approxi- 
mation.    It  is  probably  much  higher. 

The  writer  feels  that  a  problem  which  involves 
so  great  a  local  and  national  economic  loss  from 
partial  and  total  blindness  among  its  people  should 
be  given  the  same  state-wide  recognition  and  con- 
sideration as  any  other  crippling  disease.  Its 
detection,  treatment  and  control  should  be  initiated, 
fostered  and  carried  out  by  oculists.  The  prob- 
lem is  before  us  and  prompt  and  energetic  action 
is  needed. 


HOSPITALS 

R.  B.  Davis,  M.D.,  Editor,  Greensboro,  N.  C. 


HOSPITAL  SHRINKAGE 
It  is  bad  enough  to  be  cheated  out  of  hospital 
collections,  but  it  is  still  worse  to  lose  what  you 
have  already  collected.  Hospital  shrinkage  is  re- 
sponsible for  most  of  the  loss  after  it  is  once  col- 
lected. This  is  divided,  for  the  most  part,  into 
waste  and  neglect  on  the  part  of  the  visiting  staff 
and  the  employees,  and  in  goods  and  supplies 
stolen. 

The  average  hospital  staff-member  does  not  dis- 
cipline himself  in  economy  when  he  is  working  in 
the  hospital,  therefore,  it  is  necessary  to  remind 
him  repeatedly  that  goods  and  supplies  cost  the 
hospital  just  as  goods  and  supplies  cost  him  in  his 
office.  The  failure  to  recognize  this  fact  is  respon- 
sible for  an  enormous  amount  of  waste  in  gauze, 
antiseptics,  disinfectants,  catgut  etc.  The  careless- 
ness and  indifference  on  the  part  of  the  physician 
in  handling  the  surgical  instruments  costs  the  hos- 
pital many  dollars  every  year.  Very  often  he  will 
use  the  wrong  instrument  to  pick  up  gauze,  clamp 
towels  to  the  skin,  or  attempt  to  use  a  small  for- 
ceps where  a  large  one  is  indicated.  It  is  the  writ- 
er's opinion  that  the  waste  by  the  staff  could  be 
largely  prevented,  if  by  a  kind  but  persistent  per- 
suasion, they  could  be  taught  to  be  more  thought- 
ful in  this  respect.  Each  business  administrator  or 
superintendent  might  work  out  his  own  special 
plan    for   accomplishing    this    much    desired    end. 


SOUTHERN  MEDICINE  &  SURGERY 


November,  1941 


The  hospital  staff,  for  the  most  part,  is  the  prod- 
uct of  hospital  training  schools  and  should  have 
been  taught  economy;  but  many  of  the  largest  hos- 
pitals have  neglected  this  training.  This  is  partic- 
ularly distressing  because  of  the  persistence  of  The 
Nurses  Standardization  Committee's  attitude  that 
the  large  hospitals  are  the  only  ones  capable  of 
training  the  nurses.  Be  that  as  it  may,  the  major- 
ity of  the  nursing  staff  in  the  hospital  is  not  as 
economical  as  we  should  like  them  to  be.  They 
are  wasteful  and  extravagant  to  an  alarming  ex- 
tent in  many  cases.  A  small  part  of  this  is  due  to 
the  impatience  of  the  visiting  staff  who  want  to 
appear  so  busy  that  they  can  not  wait  a  minute 
for  the  proper  instrument  or  for  sufficient  prepara- 
tion to  protect  the  bed  linen  or  to  obtain  the  proper 
dosage  of  a  certain  drug.  The  habit  of  leaving  the 
ice-box  open,  leaving  the  faucet  on,  or  letting  the 
light  burn  is  a  common  sin  of  which  most  hospital 
employees  are  guilty.  There  are  some  nurses  and 
some  maids  who  are  naturally  clumsy;  but  then, 
there  are  others  who  are  just  careless  and  who 
break  up  equipment  and  instruments  far  in  excess 
of  the  unavoidable  because  of  their  indifferent  at- 
titude. These  types  of  employees  are  seldom  re- 
formed without  the  help  of  a  salary  deduction  at 
the  end  of  the  month  for  excess  breakage;  but,  for 
the  average  person,  it  is  probably  wiser  to  proceed 
along  the  lines  of  frequent  staff  conferences  at 
which  economy  is  stressed.  The  average  employee 
is  a  decent  person,  and  if  sins  of  omission  and 
commission  are  brought  to  his  her  attention  fre- 
quently each  will  make  improvement. 

When  it  comes  to  shrinkage  due  to  goods,  sup- 
plies, and  food  being  stolen,  here  we  have  a  tre- 
mendous problem,  made  by  short-termed  employees 
who  have  left  their  former  employments  for  the 
reason  that  their  fingers  were  "sticky"  or  that  they 
forgot  to  return  what  they  borrowed.  Some  staff 
doctors  are  responsible  for  instruments  being  miss- 
ing and  this  is  a  difficult  situation  to  deal  with. 
The  doctor  intends  to  return  the  instrument  or  to 
pay  for  the  supplies  he  got  in  the  middle  of  the 
night  or  on  a  holiday.  The  fact  remains,  however, 
that  the  hospital  loses  much  each  year  through 
this  leakage.  One  of  the  best  methods  to  prevent 
it  is  to  have  a  hard-and-fast  rule  that  no  person 
shall  remove  anything  from  the  hospital  without 
signing  in  a  book  for  it.  Once  each  month,  if  not 
more  often,  this  book  should  be  gone  over  by  the 
superintendent  or  business  manager  to  see  if  the 
goods  have  been  paid  for  or  if  the  instruments 
have  been  returned. 

When  it  comes  to  the  problem  of  wilful  taking, 
it  is  not  sufficient  to  discharge  the  employee  and 
let  him  go  at  that.  There  is  a  common  custom 
among  judges  to  let  a  prisoner  go  free  if  he  or  she 


will  get  out  of  town  within  the  next  twenty-four 
hours.  This  is  the  extreme  of  folly.  It  is  obvious 
that  others  come  to  take  their  places  who  have 
received  similar  sentences  from  judges  in  nearby 
towns.  Discharging  hospital  employees  for  stealing 
often  leads  to  their  going  to  another  hospital  and 
repeating  the  dishonest  dealings;  and  often  that 
hospital  will,  in  turn,  follow  the  customary  method 
of  discharging,  and  so  on  ad  infinitum.  The  only 
legitimate  excuse  for  people  taking  something 
that  belongs  to  another  is  when  they  are  hungry 
and  incapable  of  getting  sufficient  to  feed  them- 
selves. This  could  not  be  the  case  of  a  hospital 
employee  who  receives  two  or  three  good  meals 
from  the  hospital  every  day  and  after  that,  if  one 
is  caught  wilfully  stealing,  it  would  be  much  easier 
for  the  hospital  world  if  they  were  summarily 
prosecuted  according  to  law.  Nothing  short  of  this 
is  fair,  either  to  the  hospital  or  to  the  guilty  em- 
ployee, because  leniency  shown  him,  in  many  cases, 
will  only  lead  to  the  opinion  that  crime  does  pay. 


GENERAL  PRACTICE 

James    L.    Hamner,    M.D.,    Editor,    Mannboro,    Va. 


PHYSICAL  THERAPY  COMPARED  WITH 

OTHER  MEASURES  IN  ARTHRITIS 
It  must  be  remembered  that  there  are  several 

important  and  prevalent  types  of  arthritis  and  the 
treatment  for  the  different  kinds  varies  considera- 
bly, whether  it  be  medicinal  or  physical.  This  is 
the  keynote  of  an  article  by  one  of  the  world's 
good  doctors1  with  a  vast  experience  of  arthritis. 

This  experience  has  shown  physical  therapy  to 
deserve  rating  as  one  of  the  most  important  meas- 
ures in  arthritis.  Much  of  it  consists  of  the  appli- 
cation of  heat  in  its  various  forms.  The  most  im- 
portant heat  effects  are  active  hyperemia,  mobiliza- 
tion of  immune  bodies  in  the  infectious  forms  of 
arthritis,  and  sedation.  Massage  and  active  and 
passive  exercises  can  also  be  used.  The  latter  play 
an  essential  part  in  the  treatment  of  spondylitis 
and  the  infectious  forms  of  chronic  arthritis.  Pos- 
tural exercises  have  given  gratifying  results  in  the 
treatment  of  rheumatoid  arthritis. 

Ultraviolet  rays  are  valued  for  their  tonic  fea- 
tures; infrared  afford  a  hyperemic  influence.  Warm 
baths  are  helpful  in  all  forms  of  arthritis.  The  bath 
serves  three  purposes  for  the  convalescent  patient: 
it  strengthens  muscles,  eliminates  stiffness  and  acts 
as  a  general  sedative  and  appetizer.  Short-wave 
diathermy  has  been  disappointing  in  the  treatment 
of  rheumatoid  arthritis,  although  it  is  useful  for 
hypertrophic  arthritis  and  bursitis. 

1.   Russell  L.   Cecil,   in   Archives  of  Physical  Therapy,  October. 


November,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


Although  this  doctor  treats  a  great  many  pa- 
tients with  arthritis,  he  has  never  had  any  physical 
therapy  equipment  in  his  office,  he  having  always 
felt  that  in  all  fairness  it  should  be  used  by  a  spe- 
cialist. 

LIP  CANCER 

Any  crack,  "fever  blister"  or  unexplained  sore, 
especially  if  on  the  lower  lip  of  a  man,  which  does 
not  heal  very  soon — within  four  weeks  according 
to  Hunt1 — must  be  considered  cancer  until  proved 
otherwise  by  biopsy  or  darkfield  examination.  Can- 
cer and  svphilis  can  coexist. 

The  incidence  of  cancer  of  the  lip  can  be  reduc- 
ed by  protection  against  sunburn,  avoidance  of 
burns  by  short  cigarettes  and  hot  pipes;  relief  from 
irritation  by  sharp,  jagged  or  overhanging  teeth; 
and  eradication  of  leukoplakia  and  papillomas. 

The  primary  lesion  of  cancer  of  the  lip  can  be 
destroyed  bv  radiotherapy  or  surgery.  Radiother- 
apy is  generally  preferred  by  this  writer,  because 
of  its  simplicity,  better  cosmetic  results  and  less 
interference  with  function.  Resection  and  plastic 
repair  are  advised  for  the  ulcerating,  destructive 
cancer  and  the  rare  radioresistant  lesion. 

Systematic  follow-up  is  an  essential  part  of 
proper  care. 

Metastasis  occurs  first  to  the  submaxillary  and 
submental  lymph  nodes  and  submaxillary  salivary 
glands,  with  later  extension  to  the  cervical  nodes, 
the  mandible  and  adjacent  structures. 

The  treatment  of  metastasis  is  an  individual 
problem.  The  indicated  management  depends  pri- 
marily on  the  stage  and  secondarily  on  the  grade 
of  the  cancer  as  detailed  in  the  paper. 

The  prospects  of  a  five-year  cure  are  90  to  95 
per  cent  without  apparent  metastases,  33  1/3  per 
cent  with  an  early  single  focus  of  metastasis  in  the 
suprahyoid  structures,  and  only  1  per  cent  after 
metastases  are  present  in  the  cervical  lymph  nodes. 
The  importance  of  early  correct  diagnosis  and 
adequate  treatment  are  obvious.  We  can  all  be  on 
the  lookout,  and  think  of  cancer  when  we  see  a 
sore  or  lump  anywhere,  any  time,  that  does  not 
heal  promptly. 


TUBERCULOSIS 

J.  Donnelly,  M.  D.,  Editor,  Charlotte,  N.  C. 


COR  PULMONALE  AS  A  CONTRIBUTORY 
CAUSE  OF  DEATH  IN  TUBERCULOSIS 

Although  pulmonary  tuberculosis  is  given  as 
the  cause  of  death  in  the  greater  majority  of  the 
deaths  of  individuals  who  have  been  afflicted  with 
the  disease,  the  actual  cause  of  death  in  very  many 


I.   Howard    B.   Hunt, 
Medical  Journal. 


a  recent  issue  of  the   Nebraska   State 


cases  is  not  the  pulmonary  disease,  but  the  effects 
of  this  disease  on  other  vital  organs  of  the  body. 
This  fact  has,  in  the  past  few  years,  elicited  as 
much  interest  and  discussion  as  has  the  pulmonary 
disease  itself.  It  has  often  been  said  that  a  patient 
does  not  die  of  the  disease  tuberculosis,  but  of  a 
complicating  factor,  tuberculous  or  otherwise,  in 
some  other  part  of  the  body. 

In  a  recent  issue  of  the  Bulletin  of  the  Ameri- 
can Academy  of  Tuebrculosis  Physicians  is  an 
article  by  Mahon  and  Grow  offering  a  discussion 
of  these  contributory  causes  of  death,  illustrated 
by  case  histories  and  autopsy  reports.  In  100  con- 
secutive autopsies  in  Fitzsimons  General  Hospital, 
the  following  are  listed  as  the  principal  causes  of 
death:  chronic  cor  pulmonale,  29;  chronic  hema- 
togenous dissemination,  17;  gastrointestinal  tuber- 
culosis, 1 1 ;  tuberculous  and  mixed  infection  em- 
pyema, 9;  hemorrhage  from  a  pulmonary  tubercu- 
lous cavity,  8;  medical  factors  unrelated  to  tuber- 
culosis (such  as  carcinoma,  adenocarcinoma,  car- 
diac lesions,  pneumoconiosis  etc.),  8;  rapidly  pro- 
gressive pulmonary  dissemination,  5;  and  collapse 
therapy  of  tuberculosis,  4.  It  is  notable  that  deaths 
caused  by  chronic  cor  pulmonale  were  considerably 
more  numerous  than  those  in  any  other  category. 
The  fact  that  only  two  spontaneous  pneumotho- 
races  are  noted  in  the  table  is  commented  on  by 
the  authors,  who  state  that  a  great  many  such  ac- 
cidents occurred  in  this  series  of  cases,  but  in  only 
two  cases  was  this  complication  the  immediate 
cause  of  death. 

Since  in  29  per  cent  of  their  series  of  cases  death 
was  by  right  heart  failure,  the  authors  fele  that 
cor  pulmonale  requires  some  emphasis.  Members 
of  the  profession  have  become  familiar  with  the 
fact  that  cardiac  failure  occurs  frequently  as  a  ter- 
minal event  in  older  patients  who  have  suffered 
from  a  fibrotic  pulmonary  condition  for  several 
years.  Physicians  familiar  with  asbestosis,  the 
pulmonary  fibrotic  condition  caused  by  the  inhala- 
tion of  asbestos  dust  over  a  considerable  period  of 
time,  know  that  the  terminal  results  in  many  cases 
of  this  disease  is  progressive  cardiac  failure.  Such 
an  end-result  also  occurs  in  silicosis,  but  not  as 
frequently  as  in  asbestosis.  Furthermore,  acute 
cardiac  failure  occurs  not  infrequently  in  certain 
individuals  known  to  have  suffered  from  a  chronic 
fibroid  tuberculosis  for  a  number  of  years. 

The  authors  note  several  reports,  dating  from 
1792  to  the  present  time,  indicating  that  the  effect 
of  chronic  tuberculosis  on  the  right  heart  has  been 
recognized  for  many  years.  More  recent  studies 
on  this  subject  explain  the  right  heart  strain  as 
caused  by  increased  pulmonary  resistance  in  the 
lesser  circulation  due  to  narrowing  of  the  arterial 
and  capillary  vessels  resulting  in  hypertrophy  and 


SOUTHERN  MEDICINE  &  SURGERY 


November,  1941 


eventual  dilatation  of  the  right  ventricle.  The  au- 
thors give  the  following  as  the  factors  which  cause 
pulmonary  hypertension  in  tuberculosis:  (1)  casea- 
tion and  cavity  formation;  (2)  proliferation  and 
extensive  fibrosis;  (3)  atelectasis;  (4)  mediastinal 
distortion;  (5)  pulmonary  collapse  by  induced  or 
spontaneous  pneumothorax;  (6)  immobility  of  one 
or  both  halves  of  the  diaphragm;  (7)  postopera- 
tive deformity  of  the  chest;  (8)  severe  cough;  (9) 
pleuritis,  obliterative  and  with  effusion;  and  (10) 
emphvsema. 

It  is  stated  that  the  effect  of  extensive  tubercu- 
losis on  the  right  heart  is  similar  to  the  effects  of 
hypertension  in  the  greater  circulation  upon  the 
left  heart.  The  right  heart,  too,  has  a  considerable 
reserve  factor  which  allows  it  to  compensate  for 
considerable  interference  with  the  pulmonary  cir- 
culation, and,  hence,  hypertrophy  of  the  right  ven- 
tricle does  not  always  indicate  failure.  In  some  of 
these  cases  showing  right-heart  failure  there  was 
slight  if  any  hypertrophy.  The  clinical  signs  of  an 
overloaded  right  heart  are  given  as  cyanosis,  dysp- 
nea, orthopnea  and  edema,  and  it  is  stated  that 
they  appear  late  in  the  disease,  often  as  terminal 
symptoms;  and  the  prognosis  is  poor  for  more 
than  one  or  two  years  of  life.  However,  many  pa- 
tients with  an  old  fibrotic  lung  condition,  even  with 
the  development  of  extensive  pulmonary  emphyse- 
ma, live  for  years,  although  handicapped  by  more 
or  less  of  dyspnea. 

The  great  difference  in  the  incidence  of  right- 
heart  failure  in  this  series  of  cases  from  reports 
from  other  institutions  is  noted  as  probably  due  to 
the  fact  that  many  of  these  patients  were  veterans 
of  the  first  World  War  who  are  now  in  the  40-55- 
year  group.  The  patients  dying  of  right  heart  fail- 
ure had  had  their  tuberculosis  an  average  of  8.3 
years,  whereas  the  control  group  without  right 
heart  hypertrophy  had  symptoms  of  tuberculosis 
an  average  of  2.4  years  before  death.  The  type  of 
tuberculosis  which  runs  a  slowly  progressive  course 
is  more  likely  to  cause  pulmonary  hypertension 
and  right  ventricular  hypertrophy.  Also,  right  ven- 
tricular failure  is  due  to  depletion  of  the  cardiac 
reserve,  and  is  more  likely  to  occur  in  older  pa- 
tients. 

The  75  cases  in  this  series  showing  right  ven- 
tricular hypertrophy  were  classified  as  follows: 
(1)  exudative,  (2)  fibrocaseous,  and  (3)  caseous 
pneumonic.  Seven  cases,  or  9.7  per  cent,  were 
classed  as  exudate,  and  none  of  them  showed  right- 
heart  failure  at  death.  Sixty-two  (83.7r;  )  were 
far  advanced  fibrocavernous  tuberculosis,  and  five 
cases,  in  all  of  which  death  was  by  right-heart 
failure,  showed  arrested  fibrosed  lesions.  Forty- 
eight  cases  (66^),  showed  marked  atelectasis  and 
fibrosis  with  hypertrophy  of  the  right  heart,  and 


mediastinal  shift  with  atelectasis  was  present  in  34 
cases.  Pleurisy  with  effusion,  serous  and  purulent, 
was  present  in  18  cases.  Six  cases  showed  none  of 
these  complications. 

Sudden  changes  in  the  pulmonary  circulation 
may  result  in  right-heart  failure.  In  this  series  of 
cases  seven  deaths  from  heart  failure  were  precipi- 
tated by  massive  bronchogenic  spread  of  the  dis- 
ease; in  four  the  cause  was  a  pulmonary  thrombus: 
in  one  a  large  hemorrhage;  in  the  seventh  spon- 
taneous pneumothorax. 

In  this  article  particular  attention  is  given  to 
the  role  played  by  the  gradual  development  of  cor 
pulmonale  in  many  cases  and  the  resulting  right- 
heart  failure.  That  this  condition  is  of  impor- 
tance, particularly  in  the  chronic  fibrotic  or  fibro- 
caseous cases  in  the  older  age  limits,  is  manifest. 
Also,  it  is  possible  that  the  condition  may  assume 
a  greater  degree  of  importance,  since  there  are 
manv  patients  who  have  obtained  an  arrest  of  their 
active  disease  by  means  of  extended  periods  of 
pneumothorax  treatment,  a  procedure  which  has  a 
tendency  to  overload  the  right  heart.  Death  from 
right-heart  failure  is  particularly  frequent  in  cases 
designated  as  tuberculo-asepsis,  in  which  all  sem- 
blance of  tubercle  formation  has  been  replaced  by 
fibrous  tissue.  It  is  worthy  of  note,  also,  that 
hypertrophy  of  the  right  heart  can  not  always  be 
demonstrated  by  the  x-ray  film,  hypertrophy  of 
the  right-heart  muscle  having  been  found  at  au- 
topsy in  cases  in  which  prevous  to  death  the  x-ray 
film  showed  apparently  normal  cardiac  contour. 


GENERAL  PRACTICE 

Walter  J.  Lackey,  M.D.  Editor,  Falbton,  N.  C. 


LESSONS  TO  BE  LEARNED  FROM  REPORT- 
ING OUR  MISTAKES 
Every  doctor  who  sets  up  to  diagnose  disease 
and  treat  patients  would  do  well  to  review  his  mis- 
takes at  least  once  a  year,  and  to  pass  on  the  in- 
formation gained  so  that  he  and  others  may  make 
less  and  less  mistakes  as  time  goes  on.  It  is  easier 
for  a  pathologist  to  report  such  cases,  since  in  few 
of  them  does  a  doctor  in  that  specialty  share  in 
the  responsibility  for  the  mistakes.  Once  in  a  long 
while  a  clinician  takes  his  courage  in  both  hands 
and  makes  one  of  these  valuable  contributions  to 
medical  progress.  A  Mid-Western  professor  of 
medicine1  makes  a  factual  presentation  of  material 
from  500  consecutive  case  histories  of  patients  en- 
tering a  University  Hospital  during  the  previous 
year,  with  maternity  cases  only  excluded  from  the 
consecutive  series.  Not  included  are  technical  yet 
avoidable  operative  errors  since  "little  value  would 


r.  /;.,  Oct. 


November,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


accrue  to  such  a  recital  except  to  the  individual 
who  experiences  such  unhappy  circumstances.'' 

"Lest  the  title  of  our  paper  seem  to  belittle  the 
profession,  we  have  the  temerity  to  suggest  a  simi- 
lar study  be  made  sometime  of  the  laudable  accom- 
plishments found  in  an  equal  series  of  cases." 

Of  the  500  cases  reviewed,  410  showed  a  very 
close  correlation  between  the  diagnoses  offered  by 
the  referring  phvsician  and  the  findings  as  reported 
back  to  him  after  adequate  hospital  stay  and  treat- 
ment. Four  hundred  and  ten  were  discharged  as 
improved;  38  were  unimproved;  20  were  not  treat- 
ed, either  because  no  therapy  was  felt  to  be  of  any 
avail  or  because  no  condition  could  be  found  re- 
quiring treatment,  while  31  died  in  the  hospital. 

Dismissing  410  cases  as  handled  apparently  sat- 
isfactorily from  the  standpoint  of  diagnosis  and 
assuming  that  treatment  accorded  them  was  rea- 
sonablv  adequate  and  free  from  gross  error,  we  are 
left  with  90  cases  to  analyze  more  carefully.  These 
may  be  grouped  into  9  divisions  according  to  the 
nature  of  the  mistake  made. 

Group  1 — Cases  in  which  the  referring  physician 
seems  not  to  have  recognized  or  has  been  unable 
to  cope  with  a  family  or  personal  adjustment  prob- 
lem, financial  or  otherwise,  and  manifested  by  phy- 
sical complaints.  These  are  the  functional  or 
psychic  problems  which  go  unrecognized,  and  are 
treated  for  a  wide  variety  of  complaints  until  some 
particularlv  observing  physician  takes  the  trouble 
to  talk  freely  to  the  patient  or  family  and,  having 
gained  their  confidence,  stumbles  upon  some  fact 
which  turns  out  to  be  the  key  to  the  situation.  One 
must  be  extremely  careful  not  to  label  as  functional 
some  organic  illness  but  the  error  seems  to  be  more 
often  the  converse  of  this.  There  are  18  cases  in 
this  group.   A  few  typical  examples: 

A  man  of  29  was  referred  as  presenting  a  duode- 
nal-ulcer problem.  No  organic  trouble  was  found 
but  the  patient  confessed  a  fear  of  being  drafted, 
which  was  primarily  the  cause  for  his  gastric  com- 
plaints. 

A  woman  of  31  was  referred  to  us  twice,  once 
as  having  gallbladder  disease,  again  as  having  per- 
sistent ulcer.  Maladjustment  with  her  husband 
and  family  was  discovered — all  her  complaints  hav- 
ing originated  shortly  following  her  marriage. 

A  21-year-old  girl  referred  with  vague  history  of 
sinus  complaints.  Complete  studies  including  x-ray 
and  metabolic  readings,  etc.  elicited  nothing  organ- 
ically wrong.  The  case  was  finally  labeled  anxiety 
hysteria  on  the  basis  of  her  being  a  neglected 
daughter,  not  too  attractive,  who  was  endeavoring 
to  get  some  attention  from  the  rest  of  the  family. 

A  woman  of  2  5  referred  to  us  for  a  diagnosis  of 
vague  abdominal  distress,  belching  and  sleepless- 


ness. The  only  pathologic  finding  was  a  small  cerv- 
ical erosion.  She  had  four  children,  had  been 
greatly  over-worked;  and  under  the  strain  of  finan- 
cial reverses  she  had  broken  down.  A  few  weeks  of 
proper  diet  and  psychotherapy  has  put  her  on  her 
feet  without  any  thought  or  gastric  difficulties. 

A  man  of  32  referred  as  having  an  acute  chole- 
cystitis with  history  of  attacks  coming  on  when  he 
bent  over  to  work.  We  were  unable  to  find  any- 
thing wrong  other  than  that  a  definite  neurotic  in- 
dividual had  found  that  he  could  live  on  his  rela- 
tives without  hard  labor. 

Group  II — Cases  in  which  adequate  examination 
would  readily  have  disclosed  the  major  difficulty. 
There  are  12  instances  of  this.  No  funds  were 
available  for  laboratory  and  x-ray  study,  but  does 
this  excuse  the  physician  from  doing  a  prostatic  or 
pelvic  examination  or  making  a  simple  urinalysis? 
Three  instances  of  the  12  will  suffice. 

A  man  of  51  referred  as  having  prostatic  hyper- 
trophy, gave  a  history  of  hematuria,  frequent  uri- 
nation, shutting  off  of  the  stream,  and  loss  of 
weight.  His  doctor  admitted  that  on  examination 
the  prostate  felt  normal.  Examination  in  the  hos- 
pital disclosed  a  carcinoma  of  the  bladder  without 
involvement  or  enlargement  of  the  prostate. 

A  man  of  30  referred  with  hemorrhoids,  gave  a 
history  of  persistent  rectal  bleeding.  Examination 
in  the  hospital  disclosed  an  easily  palpable,  nodular 
mass  in  the  rectum.  Biopsy  showed  this  to  be  a 
carcinoma.  Resection  was  done  and  the  patient  left, 
much  improved. 

A  man  sent  in  with  a  diagnosis  of  blood  dyscra- 
sia.  Examination,  particularly  ophthalmoscopic, 
disclosed  a  loss  of  central  vision  and  a  rather  typi- 
cal picture  of  pituitary  adenoma. 

Group  III — A  group  of  1 1  in  which  dietary  fac- 
tors are  overlooked  or  uncorrected  and  largely  re- 
sponsible for  the  hospitalization. 

A  woman  of  40  referred  as  having  chronic  ap- 
pendicitis with  diabetes  after  a  single  urine  speci- 
men had  been  run  and  showed  sugar.  She  had  been 
placed  on  a  very  rigid  diet  and  alarmed  about  her 
diabetic  state.  Examination  in  the  hospital  showed 
no  glycosuria,  no  hyperglycemia.  There  was  no 
evidence  of  a  chronic  appendicitis.  She  was  very 
constipated  and  had  been  so  for  some  time.  Relief 
nf  this  condition  and  allaying  of  the  fear  of  dia- 
betes resulted  in  recovery. 

A  man  of  40-odd  referred  to  us  as  a  colitis  pa- 
tient, had  been  on  a  diet  inadequate  in  vitamins 
and  oiher  food  essentials.  Studies  disclosed  a  mod- 
erate gallbladder  involvement,  but  when  put  on  a 
fairly  free  diet  with  very  little  restriction,  recovery 
was  quite  remarkable. 


SOUTHERN  MEDICINE  &  SURGERY 


November,  1941 


Group  IV — A  group  of  eight  in  which  gallblad- 
der and  ulcer  symptoms  are  confused.  It  would 
appear  possible  in  the  majority  of  instances  to 
establish  a  diagnosis  by  adequate  history,  physical 
examination,  and  if  necessary  gastric  or  stool  an- 
alyses. Many  a  physician  in  Nebraska  does  not 
attempt  to  carry  out  these  simple  laboratory  proce- 
dures, although  many  others  are  doing  so. 

A  man  of  64  referred  to  the  hospital  as  a  case 
of  perforated  ulcer,  was  found  to  have  a  definite 
disturbance  of  gallbladder  function  but  no  stone. 
There  was  no  evidence  of  ulcer  or  perforation.  He 
was  not  operated  upon  and  under  medical  manage- 
ment made  a  good  recovery.  The  history  was 
clearly  indicative  of  gallbladder  involvement  rather 
than  ulcer. 

A  man  of  27  sent  in  with  a  diagnosis  of  gastric 
ulcer,  was  found  to  have  a  chronically  thickened 
and  adherent  gallbladder  which  was  removed. 
There  seemed  little  suggestion  of  ulcer  either  in  the 
history,  gastric  analysis,  stool  examinations,  or  x- 
ray  studies. 

Group  V,  only  four  cases  which  demonstrate  the 
mistake  of  depending  upon  radiological  evidence 
when  not  supported  by  clinical  findings. 

One  was  referred  to  the  hospital  as  having  a 
lung  abscess,  x-ray  pictures  taken  by  the  home 
physician  showing  this.  In  the  hospital  an  empye- 
ma was  detected  and  after  drainage  a  fistula  de- 
veloped, x-rays  showing  nothing  further  in  the 
lungs.  The  patient  returned  to  the  hospital  after 
an  interval  of  five  months  with  the  fistula  still 
draining.  Further  exploration  detected  cancer  with 
metastis  not  suspected  before. 

A  woman  of  40  years  was  sent  in  for  diagnosis 
of  some  obscure  trouble.  The  home  physician  had 
had  x-ray  studies  both  of  the  gallbladder  and  the 
eastro-intestinal  tract  and  sent  the  patient  to  the 
hospital  with  a  request  for  surgical  exploration. 
There  had  been  loss  of  weight,  epigastric  pain,  and 
a  history  quite  suggestive  of  ulcer.  Our  x-ray 
studies  showed  a  gastric  ulcer  on  the  lesser  curva- 
ture; and  under  medical  management  the  patient 
made  rapid  improvement.  We  quote  this  to  dem- 
onstrate the  inadequacy  of  a  great  many  x-ray 
films  without  desiring  to  go  into  or  cast  any  reflec- 
tion on  the  ability  of  the  general  man  to  do  his 
own  x-ray  work. 

Group  VI,  of  which  there  are  5  cases,  illustrates 
the  temptation  to  temporize  with  a  condition  which 
does  not  yield  readilv  until  too  late  it  is  discovered 
that  cure  is  impossible.  Aside  from  the  physician's 
error  there  are  two  factors  influencing  which  we 
should  mention:  first,  the  question  of  availability 
of  hospital  facilities  for  all  such  patients;  and  sec- 


ondly, the  reluctance  to  be  overcome  on  the  part  of 
the  family  and  patient  at  the  thoughts  of  hospi- 
talization for  apparently  trivial  symptoms. 

A  case  of  a  squamous-cell  carcinoma  of  the  cer- 
vix stage  III,  treated  for  more  than  two  months  by 
the  home  physician  before  attempt  was  made  to 
send  her  to  the  hospital.  A  diagnosis  was  made  by 
the  intern  in  the  admitting  room  on  the  basis  of  a 
large  fungating,  easily  visible  mass. 

A  man  of  38  years  referred  with  a  parotid  cyst 
of  four-years  duration  increasing  in  size  the  pre- 
vious three  months.  A  diagnosis  was  made  in  the 
hospital  of  adenocarcinoma. 

A  man  of  50  years  suffering  for  five  months  with 
malaise,  loss  of  weight  and  vague  abdominal  pain — ■ 
referred  to  the  hospital  as  possible  cancer  of  the 
colon.  He  was  shown  to  have  a  carcinoma  of  the 
kidney  and  when  asked  why  he  did  not  come  to 
the  hospital  sooner  stated  that  no  suggestion  had 
been  made  that  he  needed  such  attention. 

Group  VII. — Permitting  ourselves  to  be  led 
astray  by  current  medical  thought  is  something  we 
are  all  guilty  of.  Three  cases  are  sent  in  for  a 
possible  herniated  intervertebral  disc  which  do  not 
have  the  syndrome  one  really  would  expect.  Some- 
one discovers  a  case  and  talks  about  platybasia  and 
within  a  week  we  receive  requests  for  the  admis- 
sion of  two  such  cases,  neither  of  which  turns  out 
to  have  such  a  condition.  Thus  five  cases  in  this 
group,  to  which  may  be  added  many  instances  of 
the  precribing  of  certain  medications  because  they 
are  in  vogue  and  may  do  some  good.  The  use  of 
sulfathiazole  enemas  and  vitamins  indiscriminately 
are  good  examples.  A  patient  ready  for  dismissal 
was  given  prescriptions  to  take  home  for  $7.50 
worth  of  drugs,  this  amount  representing  nearly 
her  total  financial  resources  for  existence  per  week. 
These  prescriptions  consisted  of  a  liver  prepara- 
tion, hydrochloric  acid,  sulfanilamide,  three  sepa- 
rate vitamins  and  salyrgan. 

Group  VIII — Three  cases  in  which  the  thyroid 
was  blamed  for  symptoms  without  due  cause. 

One  of  these  three  was  a  woman  of  30,  sent  in 
as  having  a  toxic  goitre.  She  had  a  normal  pulse, 
no  visible  tremor  or  goitre  and  a  BMR  of  — 3  re- 
peated several  times.  She  was  of  nervous  disposi- 
tion, had  endocervicitis,  but  nothing  else  of  signifi- 
cance. The  case  might  perhaps  more  properly  have 
been  called  an  anxiety  depression. 

Group  IX — A  miscellaneous  group  of  25  in 
which  the  following  mistakes  seem  discernible  and 
which  time  will  permit  us  only  to  mention. 

Xon-recognition  of  a  pregnancy  beyond  the 
three-months  period — often  associated  with  other 
pelvic  conditions. 


November,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


A  tuberculosis  case  treated  as  cardiac  because  of 
a  predominant  tachycardia. 

Tracheo-bronchial  tuberculosis  treated  in  hospi- 
tal for  several  weeks  in  an  attempt  to  explain  an 
eosinophilia.  Recognition  might  well  have  been 
made  of  the  tuberculosis  from  films  submitted  at 
the  time  of  admission. 

An  undetected  syphilis  called  a  cholecystitis  be- 
cause of  the  presence  of  jaundice.  The  state  pro- 
vides for  a  free  blood  Wassermann. 

A  case  of  nephritis  called  appendicitis,  and  ap- 
pendectomy done. 

A  case  of  allergy  referred  for  nasal  or  sinus 
operation. 

A  diverticulosis  of  the  esophagus  readily  reme- 
died by  surgery  which  was  allowed  to  go  for  five 
years  as  a  thyro-glossal  cyst. 

It  would  appear  that  in  this  series  mistakes  in 
diagnosis  were  made  in  18  per  cent  of  the  cases. 
Mistakes  in  therapy  are  recognized  to  be  more  dif- 
ficult of  evaluation  and  no  attempt  has  been  made 
to  arrive  at  a  percentage  figure  on  these.  It  is 
admitted  that  they  are  common  to  referring  phy- 
sicians and  those  who  care  for  the  patients  in  the 
hospital.  Failure  of  the  physician  to  take  into 
account  all  the  environmental,  social  and  psychol- 
ogical factors  appears  as  the  most  frequent  mis- 
take. 


HUMAN  BEHAVIOUR 

James   K.   Hall,   M.  D.,  Editor,   Richmond,   Va. 


THE  GREAT  NUT-CRACKER 
Is  one's  past  past,  and  does  one's  future  lie 
ahead  of  one?  Hardly.  Yet  nine  of  ten  would 
probably  reply,  if  questioned  about  their  past,  that 
one's  past  life  becomes  as  detached  from  one  as 
completely  as  the  tadpole's  tail  becomes  separated 
finally  from  the  growing  polliwog.  But  the  past  of 
the  human  being  never  becomes  separated  from  the 
individual.  It  becomes  absorbed  into  the  individ- 
ual; lost,  perhaps,  to  the  individual's  consciousness 
of  its  existence,  but  it  becomes  the  larger  part  of 
the  individual;  and  the  dominant  portion  of  the 
mortal  in  motivating  conduct  and  in  stamping  life 
with  happiness  or  with  unhappiness.  Heredity 
gives  the  person  characteristic  physical  form  and 
specific  attributes  and  qualities.  From  the  directing 
and  creating  influences  of  heredity  forces  there  is 
no  escape.  In  each  individual  are  epitomized  the 
record  of  the  responses,  material  and  immaterial, 
of  the  race  of  which  the  individual  is  the  final  rep- 
resentative. 

The  immediate  moment  in  the  life  of  each  mor- 
tal is  a  mere  fiction.  What  is  meant  by  the  present 
is  only  that  portion  of  the  past  that  always  con- 


stitutes a  large  portion  of  one's  present.  No  ex- 
perience in  the  domain  of  the  immaterial  becomes 
wholly  lost.  Each  act  performed  leaves  within  the 
individual  a  record  of  it.  Every  great  emotional, 
intellectual,  and  spiritual  event  in  the  individual's 
life  exercises  some  fashioning  effect  upon  the  per- 
son's character  and  personality.  We  are  each  clay, 
and  the  Potter  is  Heredity,  Destiny,  Fate — all  those 
things  that  one  does,  or  does  not,  become  one's 
master.  We  tend  to  become  what  we  have  been — 
and  are — and  hope  and  yearn  to  be.  But  it  is  as 
utterly  impossible  for  one  to  step  ahead  or  aside 
from  one's  past  as  to  outrun  or  to  hide  from  one's 
own  shadow  on  a  clear  day  or  during  a  night  made 
luminous  by  a  full  moon. 

Parents,  teachers,  physicians,  nurses,  ministers, 
officers,  and  all  others  who  have  to  do  with  man- 
kind during  the  formative  years  should  realize  that 
each  child  and  each  adult  is  unceasingly  engaged 
in  creating  the  kind  of  person  that  the  individual 
is  to  become.  Yesterday  and  the  days  that  preced- 
ed yesterday  are  the  the  most  influential  factors  in 
a  mortal's  life.  Out  of  the  deeds  of  those  days 
come  the  deeds  of  the  individual's  days  that  are  to 
be.  It  is  well  to  live  well  not  only  for  the  sake  of 
the  comfort  of  the  moment,  but  much  more  so  for 
the  sake  of  the  years  that  are  to  be. 

Not  a  day  passes,  hardly,  in  which  I  do  not 
find  my  head  shaking  invisibly  in  unseen  unbelief 
of  the  protesting  statement  of  the  philandering 
potator  that  the  life  ahead  of  him  will  be  a  model 
of  non-toxic  rectitude.  If  he  has  become  hopelessly 
entangled  in  the  network  of  self-destructive  be- 
haviour indulged  in  by  him  for  many  years  then  he 
has  become  the  victim  of  his  own  past,  and  his 
future  will  be  an  extension  of  that  past.  The  reap- 
ing of  the  harvest  comes  after  the  sowing  and  be- 
cause of  the  sowing.  If  one  has  interest  in  one's 
future  one  will  make  use  of  each  day  as  a  prepara- 
tion for  each  tomorrow. 

And,  as  one  emerges  from  childhood,  one  senses 
that  each  tomorrow  and  all  the  tomorrows  that  one 
thinks  of  constitute  a  portion  of  one's  today.  In 
hope,  in  yearning,  in  fear,  in  dread,  in  purpose,  in 
striving,  each  of  us  who  is  living  today  is  living 
also  tomorrow.  How  much  of  sleeplessness  and  of 
uneasiness  and  of  suspense,  dread  and  anxiety  have 
their  origin  in  one's  attitude  toward  those  tomor- 
rows? If  one  could  look  back  upon  one's  life 
without  reproach  of  self,  and  into  the  future  with- 
out fear  of  one's  failure,  how  much  more  tolerable 
each  today  would  be  for  each  of  us!  But  betwixt 
yesterday  and  tomorrow  we  are  each  impinged 
upon  and  relentlessly  pressed  upon  as  a  nut  is  held 
by  the  jaws  of  the  cracker,  one  on  either  side. 
And  sometimes  the  nut  is  cracked;  and  not  infre- 
quently a  mortal  is  broken,  too,  cracked,  fragmen- 


SOUTHERN  MEDICINE  &  SURGERY 


November,  1941 


tized,  disintegrated.  The  jaws  of  the  cracker  come 
sometimes  upon  the  mortal  with  such  force  that 
the  individual's  resistance  is  insufficient.  The  indi- 
vidual's estimation  of  his  yesterdays  and  of  his 
tomorrows  may  be  too  much  for  him.  He  may  dis- 
integrate and  fall  apart. 

The  ideal  life  would  be  without  regret  of  the 
yesterdays  and  without  apprehension  about  the  to- 
morrows. Has  such  a  life  ever  been  lived?  By 
whom? 

I  think  I  know  that  the  egotist,  in  his  constant 
intumescence  of  himself,  is  only  trying,  and  per- 
haps without  realizing  what  he  is  about,  to  develop 
a  delusion  about  himself  sufficientlv  pleasant  to 
himself  to  enable  him  to  continue  to  live  with  him- 
self, instead  of  plunging  into  Biscayne  Bay  or 
swallowing  a  package  of  Rough  on  Rats.  Most 
egotists,  in  the  audienceless  examination  room, 
stripped  of  sartorial  investment  and  reduced  to  so- 
matic nakedness,  are  brought  likewise  to  emotional, 
mental  and  spiritual  nudity.  In  such  circumstances, 
the  most  pachvdermatous  megalocephalic  usually 
confesses  himself  to  be,  even  in  his  own  opinion, 
only  a  Lilliputian.  I  often  think  of  proclaiming  hab- 
erdashery and  of  sparkling  jewels  as  an  expensive, 
pathetic  and  futile  effort  at  substitution  for  what 
is  lacking  within  the  personal  calvarium.  One  may 
fail  in  the  vital  struggle  because  one  is  one's  self. 
But  failure  is  inescapable  if  one  attempts  to  be 
another. 

Mental  hygiene  suggests  that  wholesome  living, 
like  honesty,  is  the  better  policy.  I  have  respect 
for  the  potency  of  the  characterful  individual,  but 
I  respect  also  the  influence  of  the  individual's  past, 
in  fashioning  the  individual's  future.  A  fatalistic 
sort  of  biological  predeterminism  is  silently  but 
busily  and  powerfully  and  constantly  engaged  in 
each  of  us  in  fabricating  the  architecture  of  our 
future  behavior.  In  that  sense  Teach  mortal  is  self- 
made.  One's  attitude  towards  one's  past  mav  be 
modified,  either  at  a  religious  revival  or  in  silent 
communion  with  one's  self.  But  the  individual's 
past  has  become  a  part  of  history,  and  it  can 
neither  be  obliterated  nor  modified.  It  is  irrevoca- 
bly fixed.  Yet  the  surgeon,  the  internist,  the  teach- 
er, the  court,  the  minister,  and  often,  of  course,  the 
psychiatrist  is  each  expected  to  reform  a  life  that 
the  individual  has  spent  his  life  in  malforming. 
There  is  probably  more  medical  than  poetic  truth 
in  the  oriental  quatrain: 

The  Moving  Finger  writes;  and.  having  writ. 
Moves  on:  nor  all  your  Piety  nor  Wit 
Shall  lure  it  back  to  cancel  half  a  Line, 
Nor  all  your  Tears  wash  out  a  Word  of  it. 

The  majestic  and  solemn  lines  do  not  constitute 
a  pessimistic  wail.  They  state  a  truth,  prevalent 
undoubtedly  throughout  the  universal  domain.  Re- 


spect for  truth  and  acceptance  of  it  may  not  al- 
ways be  comforting,  but  such  an  attitude  always 
reflects  intelligence  and  courage. 


SURGERY 


Geo.   H.   Bunch,   M.   D.,  Editor,   Columbia,   S.   C. 


MINERAL  OIL  AS  A  LAXATIVE  AFTER 
LAPAROTOMY 

We  think  it  fundamental  that  the  alimentary 
tract  should  be  kept  at  rest  for  at  least  two  days 
after  laparotomy.  If  there  has  been  intraperitoneal 
infection,  intestinal  resection  or  much  operative 
trauma  postoperative  feeding  should  be  delayed  for 
a  longer  time.  Except  after  surgery  of  the  large 
bowel  the  first  two  or  three  bowel  movements 
should  be  induced  by  enemas.  They  do  not  cause 
intestinal  peristalsis  and  they  mechanically  empty 
the  lower  bowel  without  causing  gas  pains. 

In  most  patients  after  laparotomy  obstipation 
has  to  be  combatted  in  some  way  during  the  period 
of  enforced  bed  rest.  In  them,  unless  there  is  con- 
traindication, the  patient  may  be  given  an  enema 
or,  if  he  prefers,  his  choice  of  a  laxative  drug  for 
daily  evacuation. 

Patients  who  continue  constipated  more  or  less 
indefinitely  during  prolonged  convalescence  and 
after  dismissal  from  the  hospital  often  become  real 
therapeutic  problems.  In  them,  almost  as  a  rule, 
whether  it  is  first  prescribed  by  the  physician  or 
not,  mineral  oil  is  given  as  a  routine.  In  cases 
that  have  had  diffuse  peritonitis  from  any  cause,  in 
those  that  have  had  intraperitoneal  drainage  there 
are  apt  to  be  intestinal  adhesions  which  may  cause 
acute  obstruction  if  peristalsis  is  too  actively  stim- 
ulated by  catharsis.  In  the  aged,  because  of  its 
blandness.  and  in  cases  of  diverticulitis  of  the 
colon,  mineral  oil  is  often  given  over  long  periods. 

It  is  important  to  know  that  the  administration 
of  liquid  petrolatum  in  any  form  over  a  prolonged 
time  may  not  be  innocuous.  Although  considered 
to  be  inert,  unabsorbable  and  acting  only  as  an 
intestinal  lubricant,  it  has  objections  which,  for 
prolonged  use,  more  than  offset  these  advantages. 
Thoroughly  mixed  in  the  intestine  with  the  digest- 
ing food  the  oil  dissolves  the  fat  soluble  vitamins 
and  by  preventing  their  absorption  deprives  the 
patient  of  these  vital  food  elements.  In  this  wav 
the  patient  develops  a  vitamin  deficiency  even 
though  taking  a  well  balanced  proper  diet.  Mixed 
with  oil,  the  passage  of  the  food  through  the  intes- 
tine is  so  rapid  that  there  is  not  sufficient  time  for 
digestion  to  be  completed.  Due  to  the  continuous 
flow  of  oil  through  it  the  sigmoid  colon  can  no 
longer  exercise  its  function  of  being  a  terminal 
storage  place  for  the  completion  of  absorption  be- 


November.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


fore  the  discharge  of  its  contents.  The  sigmoid  be- 
comes coated  with  a  layer  of  dirty  oily  feces  which 
mechanically  impairs  absorption.  Prolonged  ad- 
ministration causes  "mineral  oil  indigestion,"  a  clin- 
ical syndrome  characterized  by  avitaminosis,  ano- 
rexia and  loss  of  weight. 

Finally,  although  the  stools  are  liquid,  after  the 
administration  of  oil  elimination  is  imperfect.  The 
defecation  reflex  is  not  adequately  stimulated  by 
oily  stools  and  sphincteric  control  soon  becomes 
impaired  so  that  the  patient  may  not  be  aware  of 
the  trickle  of  oil  that  continuously  drools  from  the 
anus.  It  is  impossible  to  maintain  proper  hygiene 
under  such  conditions  and  local  skin  irritation  fol- 
lows. 

Reference 
Morgan:     Liquid   Petrolatum   Purgatives.   J.  A.  M.  A., 
Aug.  18,  1941. 


PUBLIC  HEALTH 

N.  Thomas  Ennett,  M.D.,  Editor,  Greenville,  N.  C. 


MILESTONES  IX  NORTH  CAROLINA 

PUBLIC  HEALTH 

(Continued  from  last  month) 

1886 — The  Health  Bulletin  made  its  appearance  in 
April.  A  pamphlet  on  Care  of  Eyes  and 
Ears,  by  Dr.  Richard  H.  Lewis,  was  printed 
and  distributed. 

1887 — Much  interest  and  discussion  in  the  Board 
membership  and  throughout  the  state  this 
year  centered  about  the  necessity  for  pro- 
viding some  safe  method  of  drinking  water 
and  sewage  disposal. 

1888 — Yellow-fever  epidemic  in  Florida  and  refu- 
gees to  Western  North  Carolina  demon- 
strated value  of  a  Board  of  Health  to  cope 
with  situation.  Annual  appropriation,  $2,- 
000. 

1889 — The  chief  item  of  interest  and  importance 
to  the  cause  of  public  health  was  a  state- 
wide Sanitary  Convention  held  in  Raleigh 
February  6th.  It  was  largely  attended  bv 
physicians  and  others  from  many  cities  and 
towns  who  were  much  concerned  about  the 
problems  of  a  pure  water  supply  and  sewage 
disposal.  The  Board  published  an  exhaus- 
tive paper  by  Dr.  H.  T.  Bahnson,  of  Salem, 
President  of  the  Board,  entitled:  The  Pub- 
lic Water  Supply  of  Towns  and  Cities  in 
North  Carolina. 

Providing  refuge  for  hundreds  of  people 
who  had  fled  from  their  homes  farther  south 
on  account  of  yellow  fever  was  a  grave  prob- 
lem. 

1890 — A  widespread  epidemic  of  influenza,  or  la 
grippe,  spread  over  the  state  in  January. 
The  epidemic  appeared  first  in  Russia  about 


Nov.  1st,  1889.  By  Dec.  15th,  1889,  200,- 
000  cases  were  reported  in  New  York  alone. 
It  struck  North  Carolina  in  the  first  week 
in  January  and  in  two  weeks'  time  it  was 
reported  to  be  raging  in  68  counties. 

1891 — Influenza  continued  to  be  present  in  all 
sections  of  the  state  throughout  the  year. 
The  conjoint  session  met  in  Asheville  on 
May  27th.  Dr.  Thomas  F.  Wood  was  re- 
elected Secretary  and  Treasurer  for  a  term 
of  six  years. 

1892 — Dr.  Thomas  F.  Wood,  the  Secretary  of  the 
Board,  died  August  22nd.  Dr.  Richard  H. 
Lewis  elected  Secretary  to  succeed  Dr. 
Wood,  September  7th;  annual  appropria- 
tion, $2,000. 

1893 — Legislative  provisions:  (1)  Laws  improving 
the  reporting  of  contagious  diseases,  (2)  the 
protection  of  school  children  from  epidem- 
ics, (3)  protecting  the  purity  of  public  wa- 
ter supplies,  and  (4)  regulation  of  common 
carriers.  Legislature  provided  that  Governor 
appoint  five  of  the  nine  members  of  the 
Board  of  Health,  that  the  State  Medical 
Society  elect  four,  and  that  the  term  of  of- 
fice of  the  members  of  the  State  Board  of 
Health  be  six  years.  Pamphlet  on  quaran- 
tine and  disinfection  was  prepared  and  re- 
printed by  many  of  the  state  papers.  An- 
nual appropriation,  $2,000. 
— A  number  of  public  health  conferences  were 
arranged  and  held  in  different  towns  of  the 
state.  Bulletin  was  increased  from  a  mailing 
list  of  800  to  1,200.  Annual  appropriation, 
$2,000. 

Dr.  Albert  Anderson  and  Dr.  W.  T.  Pate 
were  elected  bacteriologists  for  the  Board. 
Annual  appropriation,  $2,000. 

(To  be  continued) 


1894 


1895 


iese  data  abstracted  from  the  Twenty^... 
ed  "The  Chronological   Development"  of  Puhl 


Khth    Biennial   Relwrt 
"     1th  Work 


THERAPEUTICS 

J.  F.  Nash,  M.  D.,  Editor,  Saint  Pauls,  N.  C. 


:}<'■ 


ASTRONE,  PRESENT  CONCEP- 


ENTERO- 1 
URO- 

TIONS:  THE  MEULENGRACHT  i«.  THE 
SIPPY 


The  issue  for  October  oj  the  American  Journal 
of  Digestive  Diseases  carries  a  series  of  articles 
dealing  with  those  similar  or  identical  hormones — 
one  from  intestinal  extracts,  the  other  from  urine; 
winding  up  with  an  article  comparing  the  results 
of  the  time-honored  Sippy  method  of  treating  pep- 
tic ulcer,  with  the  newer  Meulengracht  method. 


620 


SOUTHERN  MEDICINE  &■  SURGERY 


November.  1941 


From  the  first  of  these  articles1  we  learn  about 
the  steps  in  the  development  of  our  present  con- 
ceptions: 

Ewald  and  Boas,  in  1886 — observed  that  olive 
oil  added  to  starch  paste  inhibited  gastric  secretion 
and  delayed  evacuation.  Quigley.  et  al,  in  1934, 
apparentlv  demonstrated  the  action  of  a  specicfic 
hormone — enterogastrone.  Lim,  et  al,  found  en- 
terogastrone  in  intestinal  extracts  and  in  blood  of 
animals  fed  fats.  Parenteral  injection  of  enterogas- 
trone was  shown  to  be  effective 

We  mav  emphasize  that  enterogastrone,  .through 
its  marked  influence  on  gastric  motility  and  secre- 
tion normallv  suppresses  the  rate  of  gastric  secre- 
tion and  evacuation.  Thus  it  minimizes  trauma  to 
the  pvloric  sphincter  region  and  retards  peptic- 
ulcer  development.  There  is  a  possibility  that  en- 
terogastrone and  urogastrone  may  prove  to  be  iden- 
tical or  to  arise  from  a  common  source. 

The  second2  gives  the  status  praesens: 

Normal  urine  contains  a  substance  which  inhib- 
its gastric  secretion  and  motility.  Enterogastrone 
is  extracted  from  the  mucosa  of  the  small  intestine. 
Since  it  has  not  been  established  that  the  two  fac- 
tors are  identical,  the  name  urogastrone  was  given 
to  the  substance  obtained  from  urine. 

Preparations  are  now  available  which  are  capa- 
ble of  inhibiting  the  gastric  secretory  response  of 
the  dog  to  histamine  in  doses  of  less  than  one 
milligram.  An  effective  dose  is  obtained  from  ap- 
proximately 600  c.c.  of  urine.  Purification  has  not 
yet  progressed  to  the  stage  of  crystallization  or 
chemical  identification. 

When  sufficiently  pure,  and  when  available  in 
sufficient  quantities,  it  is  hoped  that  urogastrone 
will  provide  an  effective  and  serviceable  method  for 
completely  controlling  gastric  acidity,  without  re- 
striction or  modification  of  the  diet,  and  without 
the  continual  administration  of  alkaline  or  neutral- 
izing agents.  Whether  a  method  capable  of  such 
results  will  prove  to  be  therapeutically  effective,  it 
will  be  the  province  of  the  clinician  to  decide. 

The  next  in  order3  states  the  facts  as  to  the  ef- 
fect of  urine  extract  on  peptic  ulcer: 

The  many  factors  that  must  be  considered  in 
evaluating  results  of  therapy  in  peptic  ulcer  scarce- 
ly need  repetition:  the  natural  life-cycle  of  the 
disease  with  its  many  remissions  and  recurrences: 
the  psychic  effect  upon  physician  and  patient  alike 
of  new  therapeutic  procedures:  psychologic  and 
environmental  problems:  associated  and  intercur- 
rent diseases. 


of   Present  Conceptions,  J.   P. 

2.  Present  Status  of  Urogastrone,  J.   S.  Gray,   Chicago. 

3.  The  Effect  of  Urine  Extract  on   Peptic  Ulcer,   D.  J.  Sand- 
weiss  et  al.,  Detroit, 


Rontgenological  evidence  of  healing,  in  patients 
with  duodenal  ulcer,  does  not  parallel  clinical  prog- 
ress. The  only  basis  on  which  comparisons  can  be 
made  are  symptoms.  These  are  notoriously  capa- 
ble of  misinterpretation  bv  physician  and  patient 
alike. 

The  63  patients  consisted  of  48  clinic  patients 
and  15  private  patients,  41  of  whom  were  Jewish 
and  22  were  non-Jewish:  10  were  negroes.  Forty- 
seven  were  men  and  16  women  ranging  in  age  from 
14  to  63  years. 

All  patients  had  rontgenologically  proved  ulcers: 
58  duodenal  ulcers;  3  gastrojejunal  ulcers  and  2 
gastric  ulcers.  The  average  duration  of  ulcer  symp- 
toms prior  to  onset  of  treatment  was  1 1  years.  All 
patients  had  been  previously  treated  ambulantly 
either  at  the  clinic  or  by  competent  physicians, 
each,  for  several  ulcer  recurrences.  Sixteen  of  the 
patients  had  22  hospital-bed-rest  managements.  Ten 
additional  patients  were  confined  to  a  hospital  at 
one  time  or  another,  for  a  total  of  13  hemorrhages. 
One  patient  was  operated  on  for  closure  of  a  per- 
foration and  3  were  subjected  to  gastroenteros- 
tomy. 

There  were  two  groups  of  patients:  an  unselect- 
ed  group  and  a  group  of  patients  who  had  failed 
to  respond  to  the  usual  diet-alkali-antispasmodic 
management.  All  were  permitted  to  continue  what- 
ever dietary  or  medical  management  had  previous- 
ly been  elected  by  them  or  prescribed  by  their 
physicians.  Urine  extracts  wrere  administered  sub- 
cutaneously  or  intramuscularly,  daily  or  on  alter- 
nate days  during  the  first  week  in  doses  of  yi  to  2 
mg..  twice  weekly  for  the  ensuing  2  or  3  weeks  and 
once  weekly  thereafter.  Length  of  treatment  rang- 
ed from  one  month  to  many  months,  averaging  two 
months.  No  medication  was  prescribed  other  than 
what  they  had  been  taking  before  this  treatment 
was  instituted  and  mineral  oil.  All  patients  were 
treated  ambulantly.  If  treatment  was  discontinued 
and  symptoms  recurred,  injections  were  reinstitut- 
ed.  whenever  possible.  The  63  patients  were  thus 
treated  for  a  total  of  83  ulcer  attacks. 

Total  % 
Improved 
(Attacks) 

Diet:alkali  series    72 

Urine-extract   series   89 

While  the  percentage  of  relapses  within  six 
months  and  one  year  is  approximately  the  same  as 
obtained  in  a  similar  series  treated  with  diet  and 
alkalis,  the  patients  treated  with  urine  extract  en- 
joyed a  more  liberal  diet.  It  is  probable  that  a 
combination  of  diet,  alkalis  and  urine  extract  ther- 
apy might  produce  even  more  encouraging  results. 
Whether  larger  doses  of  a  more  highly  concen- 
trated extract  will  produce  still  better  results  is  a 


November.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


621 


matter  for  further  clinical  trial.  Aside  from  local 
reactions  at  the  site  of  injection  after  each  of  the 
first  two  or  three  injections,  no  untoward  or  detri- 
mental effects  have  followed  urine-extract  therapy. 

Then  we  have4  the  informative  comparison: 

The  Sippv  was  the  offical  treatment  of  the  Peter 
Bent  Brigham  Hospital  for  fifteen  years  until  Jan- 
uary 1st.  1940.  at  which  time  it  was  decided  to  try 
the  Meulengracht  treatment. 

Our  former  regimen  started  patients  on  hourly 
doses  of  four  grams  of  calcium  carbonate  or  two 
grams  of  magnesium  oxide  throughout  the  24  hours 
for  2-3  days  and  then  transferred  them  to  the  reg- 
ular Sippv  regimen.  If  a  hypersecretion  or  contin- 
uous secretion  was  suspected,  powders  were  con- 
tinued throughout  the  night  for  another  2-3  days 
after  food  was  started.  In  the  milder  cases,  the 
milk  feedings  might  be  started  from  the  very  be- 
ginning. During  the  15  years  in  which  this  regi- 
men was  in  force  we  treated  approximately  450 
ulcer  patients  with  hematemesis  or  melena,  with  a 
mortality  of  the  usual  six  per  cent. 

The  Sippv  method  of  treatment  neutralizes  the 
gastric  contents  if  properly  carried  out.  Although 
neutralization  was  the  reason  which  led  Sippv  to 
institute  this  treatment,  it  also  introduces  some- 
thing continuously  into  the  stomach  and  gives  food 
somewhat  sooner  than  the  starvation  method  of 
treatment.  Therefore,  this  method  is  more  like  the 
Meulengracht  treatment  than  M.  himself  was  using 
before  he  started  feeding  his  patients.  One  might 
well  consider  then  whether  other  things  being 
equal,  one  should  expect  much  greater  improve- 
ment by  the  M.  treatment  over  the  S.  as  is  found 
over  the  starvation  treatment. 


4.  A  Comparison  of  the  Results  of  the  Meulengracht  and  thc 
Sippy  Therapies  in  the  Care  of  Bleeding  Peptic  Ulcers.  E*.  S. 
Emery.  Jr.,   Boston. 

THE  MANAGEMENT  OF  SOME  MINOR  SUR- 
GICAL LESIONS  OF  THE  FINGERS 
AND  TOES 

An  article'  just  come  to  hand  sensibly  takes  ac- 
count of  this  problem  and  helps  toward  its  solu- 
tion. 

A  thorough  i  nderstanding  of  the  common 
lesions  of  the  digits  is  of  great  importance  to  all 
of  us  in  the  active  practice  of  medicine.  We  can 
do  much  in  preventing  the  development  of  major 
lesions,  reducing  the  disability  of  the  patient  and 
facilitating  early  return  to  full  w.irk. 

Furuncles  and  carbuncles  are  usually  due  to 
the  staphylococcus  aureus,  and  painful  from  tension 
in  tissues  which  are  not  distensible.  Rest  on  a 
splint  and  the  application  of  moist  wet  boric  acid 
dressings  have  stood  the  test  of  time  until  there  is 
localization  of  the  lesion.  If  the  core  is  not  dis- 
charged a  small  incision  in  the  center  may  facili- 
tate drainage  and  hasten  recovery.    The  carbuncle 

1.   C.   \V.   McLaughlin,  Jr.,  Omaha,   in  Net.   Med.  Jl.,  Oct. 


requires  more  extensive  incisions.  Carbuncles  and 
recurrent  furunculosis  demand  investigation  of 
carbohydrate  metabolism. 

Chronic  staphylococcus  infections  must  be  dif- 
ferentiated from  chancre,  sporotrichosis  and  blasto- 
mycosis. A  dark-field  examination  excludes  the 
first  and  study  of  a  drop  of  the  wound  secretions 
mixed  with  4  per  cent  KOH  rules  out  the  other 
two  conditions.  Examination  of  the  exudate  from 
the  base  of  the  ulcer  shows  staphylococci.  These 
ulcers  respond  promptly  to  daily  cleansing  with 
alcohol  followed  by  the  application  of  10  per  cent 
ammoniated  mercury  ointment. 

Eponychia,  covered  by  cuticle  onlv.  requires 
use  of  a  sharp  scalpel,  without  anesthesia.  The 
application  of  moist  boric  dressings  for  24  hours 
usually  results  in  complete  relief. 

Paronvchiae  ('Tun-arounds")  represent  more 
extensive  infections  of  the  tissue  at  the  base  of 
the  finger  nail.  Novocain.  5  per  cent,  without 
adrenalin,  is  injected  along  each  side  of  the 
digit.  The  distal  portion  of  the  nail  is  left  in- 
tact to  be  displaced  by  the  new  nail.  The  drain  is 
removed  in  48  hours  allowing  the  flap  to  fall  back 
in  place  over  the  matrix,  moist  boric  acid  dress- 
ings continued  for  three  or  four  days. 

Splinters  embedded  deep  under  the  nail  are  best 
approached  by  cutting  a  deep  V  in  the  nail,  grasp- 
ing the  end  of  the  splinter  with  a  mosquito  or 
splinter  forceps.  If  the  finger  has  been  trauma- 
tized by  unsuccessful  efforts  to  remove  the  foreign 
body  anesthetize  by  local  nerve  block  before  re- 
moval. 

In  case  of  a  felon  the  doctor  is  never  justified 
in  waiting  for  fluctuation.  Ethyl  chloride  locally 
should  never  be  used  for  anesthesia  in  these  lesions. 
Use  either  digital  block,  or  pentothal  sodium  bv 
vein.  Using  a  tourniquet,  the  distal  pulp  space 
is  opened  bv  a  lateral  incision  which  may  ex- 
tend halfway  around  the  finger  tip  or  completely 
circumvent  the  distal  phalanx  to  form  a  U  incision. 
The  knife  must  sever  all  the  fibers  in  the  distal 
pulp  space  and  permit  adequate  drainage  of  the 
loculi.  Rubber  dam  is  placed  in  the  wound  for 
48  hours.  Continuous  boric  acid  packs  are  used 
for  three  or  four  days  after  which  a  dry  dressing 
is  adequate.  Infection  present  for  s°veral  days 
before  advice  is  sought  may  mean  osteomyelitis 
with  ultimate  necrosis  of  the  diaphysis.  The  se- 
questrum will  separate  and  be  extruded. 

The  commentator  would  depend  on  sulfanilamide 
by  mouth,  thorough  incision  and  irrigations  of  the 
wound  with  .8  per  cent  sulfanilamide  to  give  earlier 
and  just  as  happy  response. 

Puncture  wounds  of  doctors"  finger  tips  contami- 
nated by  septic  material  require  that  the  operator 
immediately  remove  his  gloves  and  cleanse  the 
wound  under  running  water.     Free  bleeding  is  to 


SOUTHERN  MEDICINE  &  SURGERY 


November,   1941 


be  encouraged  and  if  the  wound  is  a  deep  one  it 
should  be  well  cauterized  with  a  sharp-pointed  stick 
dipped  in  pure  phenol.  If  this  accident  occurs 
in  the  course  of  a  surgical  procedure,  fresh  sterile 
gloves  may  then  be  put  on  and  the  operation  com- 
pleted. Should  infection  develop  it  is  to  be  treated 
by  complete  rest,  voluminous  continuous  moist 
boric  packs  and  sulfanilamide.  Surgical  incision 
is  to  be  avoided  unless  there  is  localization  with 
the  formation  of  pus. 

Ingrown  toe  nails  require  a  properly  fitting  shoe. 
In  mild  cases  daily  packing  of  the  sulcus  between 
the  nail  edge  and  the  adjacent  tissue  with  cotton 
soaked  in  half  alcohol  and  half  iodine  may  prevent 
more  serious  infection.  The  nails  should  always 
be  cut  transversely  in  a  straight  line  and  the  nail 
edges  permitted  to  grow  out  to  points.  The  ma- 
jority of  cases,  with  deeply  buried  nail  edges  and 
infection. — Under  digital  nerve  block  anesthesia 
a  segment  of  the  lateral  edge  of  the  nail  2  to  3  mms. 
wide  is  removed  with  the  underlying  matrix.  If 
both  sides  of  the  nail  are  involved,  a  bilateral  pro- 
cedure is  carried  out  and  the  wounds  loosely  packed 
with  vaseline-gauze  packing.  This  is  removed  in 
24  hours  after  thoroughly  soaking  the  toes  in  warm 
saline  solution.  Shoes  can  usually  be  worn  with 
comfort  in  three  to  four  days.. 

Trimming  of  corns  with  a  razor  blade  is  to  be 
condemned.  Soak  feet  in  warm  soap  suds  for  20 
minutes  the  first  night  of  treatment. 

Apply  a.  m.  and  p.  m.  for  three  days: 

Salicylic    acid    ~ 2.6 

Flex  and  nonflex  collodion     aa 8. 

Again  soak  feet  for  20  minutes  in  warm  soap 
suds  and  water. 

Careful  trimming  of  excessive  callus  with  a 
sharp  scalpel,  removing  if  possible  the  firm  central 
portion,  repeat  two  or  three  times  if  necessary  to 
effect  complete  relief. 

Soft  corns  are  best  treated  by  well  fitting  shoes, 
soaking  feet  each  night  in  warm  soda  bicarbonate 
solution,  and  gently  scraping  away  the  excessive 
epithelial  tissue  at  intervals,  wearing  between  toes 
small  pledget  of  cotton  sprinkled  with  boric  acid 
powder  or  bismuth  subnitrate.  Excision  may  be 
required. 

Plantar  callus  and  plantar  warts  are  usuallv  seen 
on  the  heel  or  the  ball  of  the  foot  occasionally  on 
the  base  of  the  great  toe,  mav  appear  as  a  localized 
area  of  callus.  The  treatment  of  these  lesions  is 
best  entrusted  to  a  competent  radiologist.  About 
six  weeks  is  required  for  the  callus  to  soften  and 
disappear  but  the  ultimate  results  are  superior  to 
surgical  excision. 

A  compress  of  a  sulfonamide  solution  may  be 
substituted  for  boric  acid  solution,  in  most  in- 
stances to  advantage. 


GENERAL  PRACTICE 

James    L.    Hamner,    M.D.,    Editor,    Mannboro,    Va. 


LUDWTGS  AXGIXA 

When  we  are  confronted  with  Ludwig's  angina 
we  need  to  know  what  to  do  right  away.  An  arti- 
cle1 here  abstracted  is  much  to  the  point. 

Streptococci,  predominantly  hemolytic  are  the 
causative  organisms  in  most  cases,  occurring  alone, 
often  with  the  staphylococcus  or  occasionally  with 
the  pneumococcus.  The  portal  of  entry  of  infection 
may  be  a  lesion  anywhere  about  the  lower  lip, 
tongue,  floor  of  the  mouth,  gums  and  teeth  of  the 
lower  jaw,  tonsils  or  pharynx.  Infections  incurred 
about  the  lower  molars,  particularly  following  ex- 
tractions, are  the  most  common  source.  A  massive 
swelling,  often  bilateral,  always  brawny  and  tender 
but  rarely  fluctuant,  involves  the  suprahyoid  re- 
gion, being  extreme  in  the  submaxillary  area.  The 
overlying  skin  is  conspicuously  free  of  inflamma- 
tion, showing  only  edema.  The  tongue  is  swollen 
and  pushed  upward.  The  patient  experiences  pain 
and  difficulty  on  attempting  to  open  his  mouth. 
Deglutition  and  speech  are  trying  and  often  impos- 
sible. 

The  aims  of  treatment  are  to  establish  an  air- 
way, to  relieve  tension,  to  provide  drainage,  and  to 
combat  the  infection  through  supplementary  meas- 
ures. The  wound  should  be  left  open  and  packed 
with  iodoform  gauze  which  is  left  in  place  from 
12  to  24  hours.  The  most  dependable  means  of 
providing  an  adequate  airway  is  to  perform  trache- 
otomy. For  anesthesia,  the  intravenous  anesthetic 
agents  evipal  soluble  and  pentothal  sodium  offer 
great  advantages.  As  an  adjunct  to  surgery,  sul- 
fanilamide is  of  great  value  in  hemolytic  strepto- 
coccus cases;  that  is  to  say,  in  most  cases. 


1.  Ashbel  C.   Willi; 


-S\,  G.  &  O.,  Feb. 


NAILING   A   MALICIOUS  FALSEHOOD 

Someone  is  spreading  rumors  among  our  customers  that 

this  company  is  owned  or  controlled  by  Sterling  Products. 

Inc.,  of  Wheeling,  West  Virginia,  who  have  been  cited  by 

our  government   for  Nazi  affiliations. 

This  company  has  not.  and  never  has  had,  any  connec- 
tons  whatsoever  with  that  concern  and  it  is  merely  our 
misfortune  that  the  names  are  similar. 

STERLING   PRODUCTS    CORPORATION 
333   Fourth  Ave..  N.  Y.  C. 


November,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


SOUTHERX  MEDICINE  &  SURGERY 

Official  Organ 

TRI-STATE  MEDICAL  ASSOCIATION  OF  THE 

CAROLINAS  AND  VIRGINIA 

James  M.  Northinc.ton,  M.D.,  Editor 

Department  Editors 

Human  Behavior 

James  K.  Hall,  M.D Richmond,  Va. 

Orthopedic  Surgery 
Willlam  Tate  Graham,  M.D Richmond,  Va, 

Urology 

Raymond  Thompson,  M.D Charlotte,  N.  C. 

Surgery 

Geo.  H.  Bunch,  M.D Columbia,  S.  C. 

Obstetrics 

Henry  J.  Langston,  M.D Danville,  Va. 

Ivan  M.  Procter,  M.D Raleigh,  N.  C. 

Gynecology 

Chas.  R.  Robins,  M.D Richmond,  Va. 

G.  Carlyle  Cooke,  M.D Winston-Salem,  N.  C. 

Pediatrics 

G.  W.  Kutscher,  Jr.,  M.D Asheville,  N.  C. 

General  Practice 

J.  L.  Hamner,  M.D Mannboro,  Va. 

W.  J.  Lackey,  M.D Fallston,  N.  C. 

Clinical  Chemistry  and  Microscopy 

C.  C.  Carpenter,  M.D.  |  ,„.    ,      c  .        K,   „ 

'>  Winston-Salem,  N.  C. 
R.  P.  Morehead,  B.S.,  M.A.,  M.D.  J 

Hospitals 

R.  B.  Davis,  M.D Greensboro,  N.  C. 

Cardiology 

Clyde  M.  Gllmore,  A.B.,  M.D Greensboro,  N.  C. 

Public  Health 

N.  Thos.  Ennett,  M.D Greenville,  N.  C 

Radiology 
Wright  Clarkson,  M.D.,  and  Associates.. ..Petersburg,  Va. 

R.  H.  Lafferty,  M.D.,  and  Associates Charlotte,  N.  C. 

Therapeutics 

J.  F.  Nash,  M.D Saint  Pauls,  N.  C. 

Tuberculosis 

John  Donnelly,  M.D Charlotte,  N.  C. 

Dentistry 

J.  H.  Guion,  D.D.S Charlotte,  N.  C. 

Internal  Medicine 

George  R.  Wilkinson,  M.D Greenville,  S.  C. 

Ophthalmology 

Herbert  C.  Neblett,  M.D Charlotte,  N.  C. 

Rhino-Oto-  Laryngology 

Clay  W.  Evatt,  M.D Charleston,  S.  C. 

Proctology 

Russell  von  L.  Buxton,  M.D Newport  News,  Va. 

Insurance  Medicine 

H.  F.  Starr,  M.D Greensboro,  N.  C. 

Dermatology 
J.  Lamar  Calloway,  M.D Durham,  N.  C. 

Offerings  for  the  pages  of  this  Journal  are  requested  and 
given  careful  consideration  in  each  case.  Manuscripts  not 
found  suitable  for  our  use  will  not  be  returned  unles  author 
encloses  postage. 

As  is  true  of  most  Medical  Journals,  all  costs  of  cuts, 
etc.,  for  illustrating  an  article  must  be  borne  by  the  author. 


THE  PLACE  OF  THE  HOSPITAL  IN  THE 
CARE  OF  PATIENTS 

Hospital,  hospitable,  hostelry,  hospice,  hotel — 
all  have  a  common  derivation  from  hospes,  a  guest. 
The  primary  idea  is  one  of  affording  shelter,  an- 
ciently shelter  and  food  to  those  in  need  at  no  cost. 

Fifty  years  ago  it  was  a  common  thing  for  mor- 
tality rates,  medical  and  surgical,  to  be  published 
in  two  lists — "In  Hospital,"  "In  Home" — and  in- 
variably the  rate  in  hospital  was  very  much  the 
higher.  Until  long  after  the  War  Between  the 
States  hospitals  for  persons  other  than  the  indigent 
were  great  rarities,  especially  so  in  this  section  of 
the  country;  and  many  of  us  can  remember  when 
most  of  the  knowledge  of  hospital  conditions  was 
derived  from  memories  of  conditions  in  the  military 
hospitals  of  1861-1865,  and  how  difficult  it  was  to 
get  many  in  need  of  hospital  care  to  accept  it. 

In  recent  years  it  has  come  about  that  it  is  diffi- 
cult to  keep  people  out  of  hospitals.  Folks  in  gen- 
eral seem  to  believe  that  calling  a  structure  a  hos- 
pital endows  it  with  magical  powers  for  restoring 
health,  that  there  is  no  other  way  by  which  the 
sick  can  be  saved.  What  more  natural  than  that 
hospitals  would  begin  to  feel  that  theirs  is  first 
place  in  the  care  of  the  diseased  and  injured,  and 
to  act  on  that  feeling? 

By  odd  coincidence  about  two  years  ago  there 
appeared  in  one  column  of  the  Charlotte  News  a 
statement  that  if  anyone  should  need  a  bed  in  a 
Charlotte  hospital  that  night,  he  or  she  would  have 
to  do  without,  as  every  bed  was  full;  while  another 
column  carried  a  picture  of  a  boy  sitting  up  in  a 
bed  in  a  hospital,  and  under  the  picture  a  state- 
ment that  the  boy  was  taken  to  the  hospital  from 
his  home  in  the  city  because,  in  going  into  a  dark 
basement  he  felt  something  stick  in  him  and 
thought  he  had  been  bitten  by  a  snake.  One  can 
but  wonder  what  could  have  been  done  for  the  boy 
in  a  hospital  that  could  not  have  been  done  just  as 
well  and  safely  at  home,  even  had  it  been  known 
that  a  snake  had  bitten  him.  It  could  be  safely 
wagered  that  at  least  20  per  cent  of  the  beds  in  our 
hospitals  that  very  night,  when  there  was  no  room, 
were  occupied  by  persons  who  would  have  been  just 
as  well  off  in  health  and  a  good  deal  better  in 
pocket  if  they  had  been  in  their  own  beds  at  home. 

In  a  recent  issue  of  one  of  our  high-class  lay 
monthlies1  a  former  member  of  the  faculty  of  the 
University  of  London  Medical  School-  writes  to 
insist  that  in  the  rendering  of  medical  and  surgical 
care  the  patient  comes  first,  the  doctor  second,  the 
nurse  third,  the  hospital  fourth;  that  hospitals  are 


1.  The  Atlantic  Monthly  for  August. 

2.  Miles  Atkinson,  M.D.,  New  York. 


SOUTHERN  MEDICINE  Sr  SURGERY 


November,   1941 


provided  for  the  sick  and  their  doctors,  not  the 
sick  and  the  doctors  for  the  hospitals;  that  without 
doctor  and  patient  there  would  be  no  need  for  the 
hospital,  which,  at  a  pinch,  both  can  still  do  with- 
out. 

The  hospital  administrative  staff,  we  are  told, 
in  their  anxiety  to  find  the  means  of  supporting  the 
building  and  their  desire  to  make  it  function  effi- 
ciently, are  apt  to  assume  for  themselves  an  au- 
thority to  which  they  are  not  entitled. 

Certain  troubles  in  this  regard  seem  to  be  quite 
general: 

A  whole  train  of  fallacies  has  arisen — that  the 
bigger  the  building,  the  finer  the  hospital;  the 
larger  the  staff,  the  better  the  work;  the  longer  the 
rules,  the  greater  the  efficiency;  and  that  all  ener- 
gies should  be  devoted  to  the  task  of  keeping  the 
machine  running.  The  administration  rules  the 
roost.  The  patient,  instead  of  being  the  first  con- 
sideration, tends  to  take  second  place,  with  doctors 
and  nurses  as  also-rans.  It  is  apt  to  be  forgotten, 
in  the  exigencies  of  finance,  that  the  reputation  of 
a  hospital  depends  upon  the  calibre  of  its  staff,  not 
upon  the  luxury  of  its  housing. 

Two  major  causes  have  produced  this  sad  state 
of  affairs.  The  increasing  scope  of  modern  medi- 
cine has  led  to  the  demand  for  more  equipment 
and  for  more  expensive  equipment,  while  an  ap- 
preciation of  the  evils  of  overcrowding  in  wards 
has  necessitated  an  increased  allowance  of  bed 
space  per  patient.  The  cost  per  patient  has  there- 
fore increased  by  leaps  and  bounds.  An  institution 
which  has  been  planned  without  regard  to  expense 
finds  it  difficult  to  reorganize  on  a  less  pretentious 
scale.  Large  and  elaborate  buildings  are  solid  ob- 
stacles. 

Big  hospitals  have  many  and  grave  disadvan- 
tages. The  argument  for  them  is  that  they  are 
more  economical  and  more  efficient.  They  are  cer- 
tainly impressive,  but  their  economy  and  efficiency 
are  more  doubtful. 

To  one  accustomed  to  the  hospitals  of  Europe, 
these  palaces  are  breath-taking.  He  gazes  in  awe 
at  the  spacious  halls,  the  numberless  elevators,  the 
lavish  equipment,  the  profusion  of  secretaries,  help- 
ers, orderlies,  which  combine  to  give  an  impression 
of  wealth  beyond  his  wildest  dreams.  Coming  on 
expensive  drinking  fountains  at  frequent  intervals 
he  is  disappointed  to  find  that  they  gush  forth  only 
cool  clear  water,  not  some  rare  Tyrrhenian  wine, 
for  the  effect  is  Old  Roman  in  its  grandeur.  All 
this  is  very  well  when  you  can  afford  it,  though 
even  so  it  savours  of  ostentation.  Nowadays  this 
lavishness  often  hides  an  empty  purse  and  a  con- 
tinual struggle. 


The  idea  that  the  aggregation  of  many  institu- 
tions in  one  building,  the  substitution  of  a  single 
management  and  administration  for  many,  would 
effect  economies  which  would  more  than  offset  the 
extravagance  of  setting  has  proved  to  be  a  delu- 
sion. Efficiency  suffers  in  these  big  medical  centers. 
Individual  departments  get  so  large  that  they  be- 
gin to  approach  autonomy,  to  become  more  and 
more  self-contained.  The  medical  center  is  no 
longer  a  large  general  hospital,  but  an  agglomera- 
tion of  small  special  hospitals  aggregated  in  one 
place,  with  all  their  objectionable  features  aggra- 
vated thereby.  The  greatest  of  these  is  the  one  that 
applies  to  all  specialism — the  narrow  viewpoint.  In 
the  general  hospital  of  moderate  size,  all  the  staff 
members  know  each  other;  they  work  together  as 
a  family.  Patient  and  doctor  alike  profit  from  the 
cooperation.  In  the  super  hospitals  the  staffs  are 
so  big  that  half  of  them  do  not  know  the  other 
half.  In  getting  from  one  department  to  another 
in  these  vast  buildings  requires  time  and  a  passion 
for  geography.  Not  only  do  the  doctors  get  lost, 
but  so  do  the  patients.  We  treat,  not  James  Smith, 
but  No.  2677774. 

Consider  a  patient  who  needs  some  small  proce- 
dure which  can  be  called  surgical,  if  you  are  so 
minded,  for  instance,  puncture  of  a  nasal  antrum  to 
determine  the  presence  or  absence  of  infection, 
really  a  diagnostic  procedure,  but  it  is  often  classed 
as  a  minor  operation  and  has  to  be  paid  for  as 
such.  In  all  probability  that  patient  pays  to  the 
hospital  a  clinic  fee,  an  x-ray  fee  for  an  examina- 
tion which  is  indefinite  in  its  results,  and  a  minor 
operation  fee  to  establish  a  diagnosis. 

Or  again,  the  doctor  may  be  particularly  inter- 
ested in  some  case  and  would  like  to  have  some 
investigations  made,  special  treatments  instituted — 
things  unnecessary  to  the  adequate  care  of  the  pa- 
tient, but  perhaps  important  in  the  discovery  of 
new  facts  about  disease.  This  becomes  expensive 
unless  regulations  can  be  waived — and  regulations 
are  apt  to  be  rigorously  followed,  for  they  mean 
money. 

The  private  patient,  too,  complains  that,  for  a 
price  well  within  the  range  of  hospital  charges,  he 
can  get  better  accommodation,  food,  service  and 
general  amenities  in  a  first-class  hotel  than  he  can 
in  a  hospital.  His  personal  tastes  are  catered  to  in 
a  hotel,  and  he  is  treated  as  an  individual  instead 
of  as  simply  one  of  a  number  of  necessary  evils. 
Now,  granted  that  the  circumstances  which  lead  a 
person  to  a  hotel  are  very  different  from  those 
which  lead  him  to  a  hospital,  yet  his  essential  re- 
quirements are  much  the  same.  And  this  suggests 
that  hospitals  might  be  well  advised  to  make  more 
use  of  men  trained  in  hotel  work.    Of  the  few  that 


November,   1941 


SOVTHERN  MEDICINE  &  SVRGEXY 


625 


do  this,  patients  are  loud  in  their  praise,  and  these 
hospitals  make  money. 

In  the  last  twenty  years  or  so  it  has  become  the 
practice  in  some  institutions  to  employ  a  certain 
number  of  full-time  salaried  physicians  whose  du- 
ties are  largely  teaching  and  administrative.  In- 
stead of  refusing  to  see  private  patients,  or  refusing 
fees  if  for  some  reason  they  are  compelled  to,  these 
whole-time  physicians  often  take  fees  and  turn 
them  over  to  the  hospital,  which  applies  the  money 
towards  its  general  expenses.  Every  consultation 
fee  so  taken  by  a  whole-time  man  maintained  by 
an  institution  is  one  less  available  to  outside  con- 
sultants who  are  dependent  upon  private  fees  in 
order  to  live. 

Another  widespread  practice  that  is  generally  ac- 
cepted, though  it  is  difficult  to  see  why,  is  that  of 
working  the  pathological  laboratories  and  x-ray  de- 
partments at  a  profit  which  goes  into  the  funds  of 
the  institution.  The  pharmacist  too  has  a  justifia- 
ble complaint  against  the  hospitals.  The  wholesale 
drug  houses  all  have  a  special  hospital  rate  for 
drugs  that  is  considerably  below  the  wholesale 
price  the  outside  pharmacist  must  pay.  The  hos- 
pital pharmacy  is  thus  enabled  to  dispense  medi- 
cines to  the  poor  at  a  very  low  rate,  which  is  well 
and  good,  but  to  the  better-endowed  patients  they 
charge  a  price  sometimes  even  in  excess  of  what 
would  be  paid  outside.  Thus  both  wholesalers  and 
retailers  are  being  forced  to  contribute,  willy-nilly, 
to  hospital  funds. 

In  view  of  facts  like  these,  there  is  every  reason 
for  the  feeling,  widespread  among  thoughtful  and 
farseeing  members  of  the  profession,  that  the  doc- 
tors are  not  only  held  responsible  for  the  medical 
care  of  patients  but  forced  to  contribute  to  the 
financial  support  of  the  hospitals. 

It  is  to  be  hoped  that  there  will  be  no  more  of 
these  huge  structures,  costly  to  build  and  costly  to 
maintain.  The  functional  life  of  a  hospital  building 
today  is  estimated  at  no  more  than  thirty  years, 
and  may  soon  be  less  than  that  if  the  rate  of  med- 
ical progress  continues.  What  good,  then,  to  put 
up  palaces?  Rather  erect  as  economically  as  possi- 
ble structures  that  will  last  efficiently  their  allotted 
span  and  can  without  compunction  be  torn  down 
when  their  usefulness  has  ended. 

Let  them  be  smaller  and  let  there  be  more  of 
them,  scattered  at  many  strategic  points  rather 
than  congregated  at  one.  Hospitals  should  be  scat- 
tered and  staffs  concentrated,  small  staffs  doing 
more  work  in  fewer  institutions. 

Some  special  hospitals  must  remain,  for  special 
reasons.  Patients  with  acute  infectious  diseases  are 
not  suitable  inmates  of  the  ordinary  general  hos- 
pital, even  though  it  is  possible,  if  need  arises,  to 
nurse  them  there  without  risk  to  others.   Bed  isola- 


tion, however,  is  a  troublesome  business  and  re- 
quires careful  training  and  attention  to  detail.  Tu- 
berculosis will  need  to  remain  segregated  in 
county  and  state  sanatoria.  Mental  diseases  re- 
quire special  buildings  because  of  the  special  diffi- 
culties of  their  care,  though  probably  these  should 
be  attached  to  general  hospitals  in  order  that  all 
facilities  may  be  readily  available  for  the  investiga- 
tion of  their  manifold  problems.  Radium  and  ra- 
diation therapy  must  be  concentrated  in  the  larger 
institutions  or  sometimes  in  one  special  hospital 
which  may  serve  a  large  area,  and  this  not  only 
bceause  of  the  high  cost  of  apparatus  and  the  limi- 
tations of  its  applicability,  but  also  because  of  the 
special  techniques  required  for  its  handling  and  its 
grave  dangers  in  inexperienced  hands. 

This  observer  and  commentator  concludes  that: 
The  hospitals  are  in  a  parlous  state  and  some- 
thing very  soon  will  have  to  be  done  about  it. 
Half-hearted  measures  are  of  no  use.  The  time  has 
come  for  the  large  view,  for  the  facing  of  facts,  for 
drastic  measures. 

That  the  situation  as  regards  hospitals  is  as  bad 
as  this  article  pictures  it,  few  will  agree.  That 
much  of  its  content  is  deserving  of  serious  atten- 
tion, few  will  deny.  It  seems  manifest  that  one  of 
the  most  serious  troubles  in  our  modern  society  is 
that  we  are  ruled  in  all  our  affairs  by  stupid  slo- 
gans; and  one  of  the  stupidest  and  most  serious  of 
these  is,  "You  get  what  you  pay  for."  Those  of  us 
who  saw  service  in  the  Kaiser's  war  learned  that 
patients  recovered  just  as  certainly,  just  as  prompt- 
ly, just  as  happily,  in  hospitals  built  and  operated 
on  the  Ford  plan  as  in  those  built  and  operated  on 
the  Lincoln  plan.  But  in  civilian  hospitals  there 
are  no  evidences  of  this  fact  having  been  learned. 


COMPENSABILITY   IN  HEART  DISEASE 
CONDITIONS 

About  heart  diseases  and  back  injuries,  as  com- 
pensable conditions,  most  doctors  feel  and  confess 
much  uncertainty.  Few  of  us  welcome  opportuni- 
ties to  testify  in  such  cases.  Too  frequently  we  are 
obliged  to  say  we  do  not  know,  not  infrequently 
that  we  have  no  opinion,  one  way  or  the  other,  at 
all  satisfactory  to  ourselves. 

In  the  paragraphs  to  follow  is  abstracted  an  arti- 
cle' which  may  be  very  helpful  in  such  cases.  Law- 
yers, including  those  on  the  bench,  have  much  re- 
spect for  the  printed  opinions  of  professional  men 
of  the  big  cities. 

A  good  many  very  positive  statements  are  made 
on  subjects  which  had  been  very  hazy  in  the  edi- 
tor's mind.    May  they  be  of  much  service  to  our 


I.  A.    M.    Master,   Nc 


B»l.    ,V.    Y.   Acad,   of  Med., 


SOUTHERN  MEDICINE  &■  SURGERY 


November,  1941 


readers,  in  their  Compensation  Law  cases  and  in 
their  ordinary  practice. 

The  interval  between  an  effort  or  accident  and 
the  onset  of  symptoms  is  usually  short;  the  latter 
are  delayed  in  only  a  few  instances. 

In  spite  of  the  quantity  of  experimental  work 
performed  in  the  past  few  years  the  cause  of  ordi- 
nary high  blood  pressure  or  essential  hypertension 
remains  obscure.  We  know  that  there  is  a  familial 
tendency  and  a  frequent  associtaion  with  obesity 
and  glandular  disturbances.  It  is  a  chronic  condi- 
tion which  comes  on  gradually  and  often  without 
symptoms,  and  is  not  compensable.  This  applies 
also  to  enlargement  of  the  heart  and  hardening  of 
the  arteries,  both  of  which  result  from  or  accom- 
pany high  blood  pressure.  Cardiac  enlargement 
and  arteriosclerosis  develop  over  a  period  of  years 
and  can  not  be  related  to  any  particular  event  or 
effort.  The  term  chronic  myocarditis,  which  has 
been  applied  loosely  to  this  type  of  heart  disease, 
should  be  discarded.  Instead  one  should  specify 
chronic  disease  of  the  coronary  arteries  with  scar- 
ring of  fibrosis  of  the  heart  muscle.  When  high 
blood  pressure  or  hardening  of  the  arteries  have 
developed  after  a  number  of  years,  several  compli- 
cations may  occur. 

A  stroke  may  be  produced  in  three  ways.  The 
commonest  is  rupture  of  a  small  artery  in  the 
brain  resulting  in  hemorrhage;  secondly,  a  clot  or 
thrombosis  may  form  locally  in  a  small  blood  ves- 
sel; thirdly,  a  clot  may  be  dislodged  from  a  dis- 
eased heart  and  an  embolus  may  settle  in  the 
brain.  All  three  of  these  result  in  damage  to  brain 
tissue  and  may  be  followed  by  loss  of  conscious- 
ness and/or  paralysis  which  may  be  very  brief  or 
may  persist.  Neither  dislodgement  of  a  clot  from 
the  heart,  cerebral  hemorrhage  or  thrombosis  is 
probably  related  to  effort.  It  is  necessary  to  ex- 
amine each  case  carefully  for  evidence  of  previous 
high  blood  pressure  and  arteriosclerosis.  If  these 
have  been  present  the  stroke  may  be  merely  coin- 
cidental to  the  effort.  Trauma  to  the  head,  with- 
out fracture  of  the  skull,  can  produce  concussion 
and  contusion  of  the  brain  and  subdural  hemor- 
rhage with  neurological  signs  and  symptoms.  Al- 
though a  stroke  may  seem  to  be  the  result  of  an 
accident,  it  may  have  caused  the  accident. 

In  a  state  of  hypertension  and  arteriosclerosis 
the  heart  may  be  unable  to  maintain  a  normal 
blood  circulation.  The  patient  has  difficulty  in 
breathing,  the  lungs  may  be  congested,  the  liver 
enlarged  and  the  ankles  swollen,  sometimes  for 
long  periods  without  the  patient's  being  aware. 
Heart  failure  is  a  natural  sequence  in  the  course 
of  heart  disease.  When  there  has  been  long-stand- 
ing heart  disease,  or  when  there  is  acute  involve- 
ment of  the  heart,  as  in  rheumatic  fever,  coronary 


occlusion  and  many  infections,  an  unusual  exertion 
may  strain  the  heart  so  as  to  cause  heart  failure. 
The  commonest  factor  of  heart  failure  in  chronic 
heart  disease  is  infection,  not  effort.  Heart  failure 
immediately  follows  strain,  there  is  sudden  conges- 
tion of  the  lungs  or  edema;  it  is  rare  to  find  con- 
gestion of  the  liver  and  swelling  of  the  legs. 

"Acute  dilatation  of  the  heart,"  if  it  occurs  at 
all,  is  merely  one  sign  of  sudden  heart  failure. 

Angina  pectoris  is  merely  a  term  applied  to  pain 
over  the  heart  region.  There  are  many  causes  out- 
side the  heart  of  pain  in  this  location — ulcer  of  the 
stomach,  rheumatism  of  the  spine,  neuritis,  gall- 
bladder disease,  shingles.  In  the  heart,  disease  of 
the  valves  and  of  the  aorta,  as  occurs  in  syphilis 
may  produce  heart  pain,  but  the  usual  cause  of 
angina  pectoris  is  hardening  of  the  arteries  and 
interference  with  their  ability  to  supply  the  heart 
muscle  with  blood.  Persons  with  coronary  artery 
disease  may  feel  pain  beneath  the  breast  bone  or 
sternum  when  they  walk  or  are  emotionally  upset, 
because  the  narrowed  arteries  are  unable  to  supply 
the  greater  blood  flow  required  bv  the  heart.  The 
pain  usually  lasts  only  a  short  time  and  is  relieved 
by  rest  or  nitroglycerin.  The  attack  of  pain  results 
from  a  temporary  insufficiency  of  blood  flow 
through  the  already  diseased  coronary  arteries  and 
not  from  any  new  damage  in  the  artery  induced  by 
the  effort. 

The  problem  is  frequently  complicated  by  the 
fact  that  the  patient  denies  any  symptoms  prior 
to  the  exertion. 

Coronary  occlusion  or  thrombosis  is  the  heart 
attack  which  is  characteristic  and  usually  easy  to 
diagnose.  It  also  produces  typical  changes  in  the 
electrocardiogram.  It  occurs  most  often  between 
the  ages  of  50  to  60  years,  but  one-third  the  cases 
occur  before  SO.  The  great  majority  of  patients 
have  had  high  blood  pressure  and  angina.  An  at- 
tack is  the  result  of  a  sudden  complete  obstruc- 
tion of  one  of  the  coronary  arteries  by  a  clot  cut- 
ting off  the  blood  supply  to  a  large  area  of  the 
heart,  causing  death  of  the  affected  muscle-cardiac 
infarction.  A  dot  does  not  form  in  a  coronary 
artery  unless  that  artery  is  already  hardened  or 
diseased. 

In  a  series  of  1700  attacks  of  coronary  oc- 
clusion detailed  histories  have  revealed  that  the 
attack  began  practically  always  during  sleep,  rest 
or  some  routine  activity,  during  or  directly  after 
unusual  strain  in  only  two  per  cent. 

Such  cases  are  conveniently  divided  into  three 
groups — laborers  and  workers,  storekeepers  and 
business  men,  and  professional  persons.  The  pro- 
portion of  each  of  these  groups  was  practically  the 
same  as  in  the  general  population  of  New  York 
City.   Obstruction  of  a  coronary  artery  takes  place 


November.   1941 


SOUTHERN  MEDICINE  &  SURGERY 


in  the  natural  course  of  coronary  artery  disease, 
and  is  not  caused  by  exertion  even  if  the  latter  is 
unusual. 

It  takes  time  for  the  occlusion  to  form  and  in 
some  patients  the  final  obstruction  happens  to  take 
place  in  the  course  of  their  work,  but  it  is  not 
brought  on  by  it.  This  explains  the  lesser  degrees 
of  pain  several  days  or  weeks  prior  to  the  acute 
attack. 

Cardiac  infarction  may  occur  without  coronary 
occlusion.  The  hardened  coronary  arteries  are  too 
narrow  to  permit  an  increase  of  blood  to  flow 
through  them  which  is  required  when  the  patient 
exerts  himself  or  becomes  excited.  As  a  result  of 
not  receiving  enough  blood  and  oxygen  the  muscles 
become  necrotic  or  infarcted.  This  results  in  pain 
and  even  in  death.  This  is  coronary  insufficiency 
with  infarction  or  necrosis  of  the  heart  and  may  be 
caused  by  effort,  excitement  or  trauma. 

An  operation,  even  if  minor,  may  be  followed  by 
heart  involvement.  This  is  usually  due  to  coronary 
insufficiency  but  in  some  cases  it  is  possible  that 
coronary  occlusion  is  induced  by  operation. 

Rheumatic  fever  usually  first  attacks  in  child- 
hood or  adolescence;  recurrences  are  very  common. 
During  the  acute  stage  there  is  an  acute  endo-  and 
myocarditis.  In  some  cases  a  chronic  deformity  of 
the  valves  gradually  takes  place  over  months  or 
years.  If  a  murmur  is  discovered  following  some 
unusual  strain  it  is  almost  certain  that  the  murmur 
antedated  the  exertion  by  many  months. 

Syphilis  often  results,  after  a  number  of  years, 
in  deformity  of  the  aorta  valve  or  in  disease  of 
the  aorta,  in  which  a  bulge  or  aneurysm  may  form. 
These  changes,  due  solely  to  the  disease  and  not  to 
occupation,  effort  or  trauma,  occur  very  insidiously 
and  gives  rise  to  symptoms  only  after  the  lesion  is 
fully  developed.  Rupture  of  such  an  aneurysm 
may  possibly  result  from  severe  trauma,  but  not 
from  effort. 

The  heart  and  large  blood  vessels  may  be  trau- 
matized as  a  result  of  external  injury  directly  to 
the  chest  or  indirect  to  the  abdomen,  with  or  with- 
out penetration  of  the  wall.  Usually  there  is  blood 
in  the  pericardial  sac. 

It  is  unlikely  that  effort  can  produce  changes  in 
the  valve  even  if  it  was  previously  diseased;  but 
trauma  of  the  heart  may  cause  rupture  of  a  valve, 
though  very  rarely  indeed. 

A  blow  against  the  chest  or  abdomen  may  cause 
functional  derangement  or  bruise  of  the  heart.  In 
the  former  there  are  no  anatomical  changes,  but, 
as  in  concussion  of  the  brain,  there  is  a  physiologi- 
cal disturbance  in  the  function  resulting  chiefly  in 
irregularities  in  rhythm.  If  the  impact  of  the  chest 
wall  against  the  heart  is  more  forecful,  damage  in 
the  heart  muscle  may  result,  chiefly  hemorrhages 


and  lacerations.  It  is  likely  to  result  from  the  chest 
striking  forcefully  against  a  steering  wheel.  When 
the  heart  is  bruised,  its  failure,  with  congestion  of 
the  lungs,  may  set  in  acutely  and  result  in  death; 
or  it  may  be  more  gradually  evidenced  by  swelling 
of  the  liver  and  legs. 

Trauma  never  precipitates  coronary  occlusion  or 
thrombosis. 

Repeated  attacks  of  pain  or  persistent  angina 
pectoris  over  months  or  years  should  not  be  at- 
tributed to  injury  to  the  heart  except  in  the  rarest 
cases. 

Rarely  trauma  may  produce  an  infection  and 
result  in  blood  poisoning  with  infection  of  the  heart 
valves,  that  is,  an  acute  malignant  endocarditis. 
This  is  the  only  type  of  endocarditis  which  is  com- 
pensable. 

A  person  with  heart  disease  may  sustain  an 
accident  as  a  result  of  temporary  disability  due  to 
the  disease,  the  accident  may  erroneously  be  con- 
sidered the  cause  of  the  heart  condition. 

An  irregularity  of  the  heart  rhythm  may  set  in 
suddenly  during  heavy  work  or  after  unusual 
strain.  The  most  common  serious  irregularity  is 
auricular  fibrillation.  If  it  persists  heart  failure  is 
likely  to  ensue.  The  irregularity  usually  sets  in 
without  any  precipitating  factor,  it  may  follow  an 
effort  or  injury  in  which  case  it  is  compensable 
even  if  the  heart  was  abnormal. 

Paroxysmal  tachycardia  is  particularly  apt  to 
occur  in  persons  with  normal  hearts.  Premature 
beats  following  severe  exertion  or  excitement  have 
very  little  significance. 

Carbon-monoxide  poisoning  does  not  produce 
classical  coronary  occlusion  or  thrombosis. 

In  effort  syndrome  chest  pain  may  be  quite  se- 
vere. It  occurs  in  persons  constitutionally  nervous. 
Acute  symptoms  may  be  precipitated  by  an  acci- 
dent, a  fright,  or  an  unpleasant  task. 

In  determining  compensability  following  effort 
or  trauma  it  is  essential  to  obtain  a  very  complete 
arid  accurate  history  as  soon  after  the  effort  or 
trauma  as  the  condition  of  the  patient  permits. 


DOCTOR  CHARLES  DEWITT  COLBY 
On  the  23rd  of    September,    after    nearly    two 
years'  forced  retirement  from  practice  because  of 
illness,    Dr.   Charles   DeWitt   Colby   breathed    his 
last. 

Charles  Colby  was  born  at  Jackson,  Michigan, 
October  23rd,  1865.  He  was  graduated  in  medicine 
by  the  University  of  Michigan  in  the  Class  of 
1892.  The  high  quality  of  his  work  at  Michigan 
gained  him  appointment  as  chief  of  staff  of  the 
University  Nose  and  Throat  Clinic. 

In  1898  Dr.  Colby  served  as  assistant  surgeon 
to   the  31st    Michigan   Volunteer   Infantry  in   the 


SOUTHERN  MEDICINE  &  SURGERY 


November,  1941 


Spanish-American  War.  He  saw  service  at  Chicka- 
mauga  Camp,  in  Puerto  Rica  and  in  Cuba.  When 
he  was  mustered  out  with  his  regiment  in  June, 
1899,  he  had  been  promoted  to  the  rank  of  Major 
Surgeon  and  was  given  by  his  Commanding  Gen- 
eral a  Special  Order  citation  for  his  valuable  ser- 
vice in  the  army.  A  special  course  in  the  Army 
Medical  School  was  pursued  to  graduation  from 
that  institution  in  1905. 

In  1911  Dr.  Colby  removed  to  Asheville  and 
associated  himself  with  the  late  Dr.  W.  L.  Dunn 
in  research  and  private  practice  in  tuberculosis.  In 
this  field  he  contributed  to  the  advancement  of 
knowledge  and  ministered  to  thousands  of  patients. 
His  profound  knowledge  of  the  disease,  tuberculo- 
sis, and  of  the  psychology  of  patients  in  general 
and  of  tuberculous  patients  in  particular,  made  it 
inevitable  that  he  would  be  extraordinarily  suc- 
cessful in  his  chosen  work.  He  early  associated 
himself  with  his  fellow-doctors  in  local,  state,  reg- 
ional and  national  medical  societies,  and  was  an 
unusually  faithful  attendant  on.  and  contributor 
to,  their  sessions. 

While  he  recognized  some  of  the  advantages  of 
socialized  medicine,  he  was  ever  an  ardent  advo- 
cate of  organized  medicine,  and  the  role  played  by 
the  family  doctor  in  the  home  and  in  society  at 
large.  While  welcoming  the  new  methods  of 
diagnosis  and  treatment  according  to  their  proved 
value,  he  never  ceased  to  follow  the  well-tried  and 
proven  paths. 

Lure  of  the  out-of-doors,  not  need  for  treatment 
for  tuberculosis,  brought  Dr.  Colby  to  North  Car- 
olina. For  years  he  walked  the  mountains  and  val- 
leys of  Buncombe,  studying  her  skies,  her  plants, 
her  minerals  and  her  people,  until  he  came  to  be 
an  authority  on  all  these  subjects,  and  the  under- 
standing friend  and  loved  doctor  of  a  multitude  of 
mountain  folks. 

Besides  his  widow,  Dr.  Colby  leaves  a  son, 
Charles,  Jr.,  now  a  senior  medical  student  at  Duke, 
to  carry  on  the  medical  tradition. 


DOCTOR  HENRY  NORRIS 
In  the  early  morning  of  October  6th,  Dr.  Henry 
Norris  died  suddenly  at  his  plantation  home  on 
Waccamaw  Neck  in  the  coastal  country  of  South 
Carolina.  A  few  hours  earlier  he  had  arrived  at 
Litchfield  Plantation  bv  plane  from  his  summer  res- 
idence in  Maine,  where  he  had  been  in  declining 
health  for  a  number  of  months.  A  great  man,  a 
skillful  surgeon,  and  a  beloved  character  has  passed 
on  and  the  hearts  of  a  multitude  of  friends  are 
filled  with  grief  and  sorrow.  He  came  from  an 
illustrious  ancestry  in  Philadelphia  where  a  num- 
ber of  the  Norris  family  have  brought  lustre  and 
fame  to  the  medical  profession. 


Henry  Norris  was  born  May  27th,  1875,  the  son 
of  Joseph  Parker  and  Isabel  (Fry)  Norris  of  Phil- 
adelphia. He  received  his  M.D.  degree  from  the 
University  of  Pennsylvania  in  1896  and  was  interne 
in  the  University  Hospital  1896-98.  During  1898 
he  continued  his  studies  in  Berlin.  On  August  3rd, 
1898.  he  married  Miss  Ethel  Bowman  Wheeler  of 
Philadelphia,  and  to  this  union  were  born  Susan 
W.,  Henry,  Jr..  Ethel  Stuart  and  Charles  Norris. 
From  1900  to  1906  he  was  Instructor  in  Surgery 
at  the  University  of  Pennsylvania,  doing  special 
work  with  the  late  Dr.  Charles  Frazier  and  Dr. 
Joseph  Price.  He  was  a  member  of  the  Philadel- 
phia College  of  Surgeons,  Pediatric  Society,  etc. 

In  1906,  together  with  Dr.  M.  H.  Biggs,  he  was 
founder  of  the  Rutherford  Hospital  at  Rutherford- 
ton.  N  C.  At  that  time  there  was  no  hospital 
between  Asheville  and  Charlotte,  and  surgery  as  a 
specialty  was  in  its  infancy  in  North  Carolina. 
Both  men  were  well  trained  surgeons  and  success 
crowned  their  efforts  from  the  beginning.  As  the 
years  went  by  many  thousands  of  patients  sought 
relief  at  their  hands  and  the  Hospital  won  an  en- 
viable reputation. 

As  a  former  member  of  the  famous  City  Troop 
of  Philadelphia,  Dr.  Xorris  was  always  interested 
in  military  science.  In  1916  he  commanded  a  med- 
ical detachment  of  the  North  Carolina  National 
Guard  on  the  Mexican  border.  Later  he  went  to 
France  with  the  30th  Division  and  became  Divi- 
sion Surgeon.  He  was  detached  from  the  Division 
to  head  an  Operating  Team  in  evacuation  and 
mobile  hospitals.  He  returned  to  the  U.  S.  A. 
gravely  ill  but  after  a  number  of  months  resumed 
his  work  at  the  Rutherford  Hospital.  His  great 
generosity  and  charity  brought  happiness  and  re- 
lief to  a  multitude  of  poor  and  needy  and  he  was 
loved  by  all  who  were  fortunate  enough  to  know 
him. 

Aside  from  his  busy  life  in  the  profession,  he 
was  a  tireless  worker.  He  found  time  to  better  the 
community  in  which  he  lived  and  took  a  leading 
part  in  all  helpful  civic  work.  His  hobbies  were 
dogs,  hunting  and  fishing  and  into  his  hospitable 
home  came  friends  from  many  parts  of  the  country 
to  join  with  him  in  these  sports. 

In  1925  he  purchased  a  large  plantation  on  Wac- 
camaw Neck  near  Georgetown,  S.  C.  and  retired 
from  active  practice.  At  Litchfield  Plantation  he 
and  his  charming  family  entertained  their  many 
friends.  Dr.  Norris  soon  learned  that  there  were 
many  hundreds  of  Negroes  in  the  community  too 
poor  and  too  far  away  to  obtain  medical  attention. 
He  gave  them  his  time  and  substance  and,  together 
with  friends,  built  a  small  hospital  for  these  people 
where  they  could  be  treated  absolutely  free. 


November.   1941 


SOUTHERN  MEDICINE  &  SURGERY 


We  salute  him  for  the  magnificent  life  he  led, 
the  jov  and  happiness  he  gave  to  so  many  people, 
and  the  heads  of  a  host  of  friends  are  bowed  in 
profound  sorrow  at  his  passing. 

— R.  H.  CRAWFORD.  M.D., 
Rutherford  Hospital. 


NEWS 


The  Thermal  Belt  (N.  C.)  Medical  Society  met  at 
th  Cleveland  Hotel.  Shelby,  on  Thursday,  October  16th,  at 
6:30  p.  m.  After  dinner  at  7:00  p.  m.,  the  following  pro- 
gram was  rendered: 

Effective  Therapy  in  Chronic  Alcoholism,  Dr.  T.  B. 
Mitchell.  Shelby — Discussion  by  Dr.  W.  J.  Lackey,  Falls- 
ton. 

The  Local  Use  of  Sulfonamides,  Dr.  William  St.  J. 
Jervey,  Tryon. 

The  Parenteral  Use  of  Sulfonamides,  Drs.  L.  W.  Hagna 
and  Paul  McBee,  Marion. 

Observation  in  China.  Dr.  L.  L.  Wilkinson,  Rutherford- 
ton. 

H.  C.  Thompson,  M.D.,  Sec. 


Dr.  B.  M.  Kacax  announces  the  removal  of  his  offices  to 
1207  West  Franklin  street,  Richmond.  Practice  limited  to 
pediatrics. 


Dr.  Robert  L.  Garrard  announces  the  opening  of  offices 
in  Greensboro.  X.  C,  for  practice  in  Neurology  and 
Psvchiatrv. 


DIED 

Dr.  C.  C.  Orr,  Jr..  31.  died  October  27th  at  his  home  in 
Beverly  Hills,  Asheville,  N.  C.  Born  in  Asheville  in  1909, 
the  son  of  Dr.  and  Mrs.  C.  C.  Orr,  he  was  graduated  from 
Asheville  High  School  in  1925  and  received  his  B.S.  degree 
at  Davidson  where  he  was  a  member  of  the  O.  K.  D. 
fraternity.  He  also  was  a  member  of  Scabbard  and  Blade, 
honorary  military  fraternity,  and  Kappa  Sigma,  social 
fraternity.  He  was  president  of  the  college  glee  club  at 
Davidson  during  his  senior  year.  Dr.  Orr  was  graduated 
in  medicine  from  the  University  of  Virginia  in  1933.  At 
Virginia  she  was  made  a  member  of  Phi  Beta  Kappa,  A. 
O.  A.  and  Phi  Beta  Pi  fraternities  and  of  "The  Raven" 
society.  He  interned  in  surgery  at  the  University  for  two 
years  and  then  went  to  the  Mayo  Clinic  at  Rochester, 
Minn.,  to  serve  a  three-year  fellowship  in  surgery.  He 
remained  at  Rochester  for  nine  months  and  then  was 
called  back  to  Virginia  to  serve  a  surgery  residency.  In 
1939  he  gave  up  the  residency  because  of  ill  health  and 
returned  to  Asheville.  where  he  practiced  medicine  with 
his  father  lo  the  limit  his  health  permitted. 

Surviving  are  the  parents  and  a  brother,  Dr.  Robert  B. 
Orr,  of  Boston. 


Dr.  Jesse  Martin  Shackelford.  72.  founder  of  Shackelford 
Hospital,  Martinsville,  died  at  his  home  at  Martinsville  on 
October  2nd,  following  a  paralytic  stroke  suffered  a  few 
days  before. 


Col.  Michael  A.  Dailey,  59,  chief  surgeon  of  the  Army's 
Third  Corps  Arta,  was  instantly  killed  October  27th  when 
the  car  in  which  he  was  riding  was  struck  by  the  Balti- 
more   and    Ohio's    Royal    Blue   streamliner   at    a   crossing. 


Dr.  Louis  Klein,  director  of  clinical  research  at  Hoff- 
mann-LaRoche,  Inc.,  Nutley,  died  October  24th  after  a 
heart  attack  at  his  home  at  Upper  Montclair,  at  the  age 
of  56.  Dr.  Klein  had  been  clinical  research  director  at  the 
pharmaceutical  plant  since  1935.   For  15  years  before  join- 


ing the  Nutley  concern  he  was  associated  with  the  Parke- 
Davis  Co.  in  New  York  and  Detroit.  At  Hoffmann-La- 
Roche  he  also  was  editor  of  the  Roche  Review. 


Dr.  James  G.  Trant,  60  years  of  age,  a  graduate  of  the 
Medical  College  of  Virginia  1906,  died  at  his  home  in 
Richmond  on  October  29th. 


Dr.  Menas  Sarkis  Gregory,  64.  neurologist  and  former 
director  of  the  Bellevue  Hospital  psychiatric  division,  died 
November  2nd  while  golfing.  Prominent  as  a  psychiatric 
consultant  and  instructor,  he  serevd  at  Bellevue  for  30 
years.  During  his  tenure,  which  ended  in  1934,  he  was 
shot  and  wounded  by  a  maniac  during  an  examination. 


Max  Broedel,  71,  recognized  as  founder  of  the  art  of 
medical  illustration  in  this  country,  died  October  26th  after 
several  weeks  illness.  He  became  anatomical  artist  at  the 
Hopkins  Medical  School  in  1894,  was  made  associate  pro- 
fessor of  art  as  applied  to  medicine  in  1911,  and  retired  in 
June,  1940. 

Born  in  Leipzig,  Germany,  June  8,  1870,  Broedel  was 
educated  at  the  Academy  of  Fine  Arts  there  and  the  Uni- 
versity of  Leipzig. 


OUR  MEDICAL  SCHOOLS 

Medical  College  of  Virginia 

Dr.  Sidney  S.  Negus,  professor  of  chemistry,  attended 
the  Fiftieth  Anniversary  celebration  of  the  University  of 
Chicago. 

Dr.  William  B.  Porter,  professor  of  medicine,  has  been 
re-elected  a  visiting  professor  on  the  faculty  of  the  Uni- 
versity of  Puerto  Rico. 

Dr.  Harry  Walker,  associate  professor  of  medicine,  has 
been  elected  to  membership  in  the  American  Clinical  and 
Climatological  Association. 

Dr.  Lee  E.  Sutton,  Jr.,  professor  of  of  pediatrics,  at- 
tended the  annual  meeting  of  the  American  Academy  of 
Pediatrics  in  Boston. 

A  group  of  three  bears,  in  stone,  by  Mrs.  Anna  Hyatt 
Huntington,  has  been  received;  the  setting  in  the  court- 
yard of  the  new  hospital  has  almost  been  completed.  This 
group  is  the  gift  to  the  college  of  Mrs.  Huntington  and  her 
husband,  Mr.  A.  M.  Huntington.  Funds  for  the  landscape 
treatment  were  by  an  anonymous  friend  of  the  institution. 

The  college  acted  as  host  to  the  Association  of  Amer- 
ican Medical  Colleges,  October  27th-29th,  and  the  intensive 
effort  of  many  made  this  a  notable  occasion.  This 
group  can,  necessarily,  meet  but  once  in  a  generation  in 
one  place  and  the  college  and  Richmond  are  very  proud 
that  they  were  here  for  this  meeting. 

Alumni  of  the  School  of  Medicine  held  a  well-attended 
dinner  at  the  Cavalier  Hotel  during  the  recent  meeting  of 
the  Medical  Society  of  Virginia.  Dr.  T.  Dewey  Davis, 
president  of  the  Alumni  Association,  presided.  Dr.  P.  St. 
L.  Moncure,  who  had  made  local  arrangements  most  ac- 
ceptably, assisted  with  the  meeting  and  spoke  briefly. 
Other  speakers  were  Dr.  W.  L.  Harris,  member  of  the 
Board  of  Visitors  of  the  college;  Dr.  Roshier  W.  Miller, 
member  of  the  faculty,  and  President  W.  T.  Sanger. 

Alumni  of  the  School  of  Medicine  of  the  Washington, 
D.  C,  Chapter  met  October  3rd  at  The  Mayflower.  Dr. 
C.  C.  Coleman,  professor  of  neurological  surgery,  address- 
ed the  group  at  a  luncheon  meeting.  President  W.  T.  San- 
ger also  attended  the  meeting  and  spoke  briefly. 

Dr.  J.  M.  Northington,  of  Charlotte,  North  Carolina, 
represented  the  college  at  the  inauguration  of  Dr.  John  R. 
Cunningham  as  president  of  Davidson  Colegc,  Davidson, 
North  Carolina.  October  16th-17th. 


SOUTHERN  MEDICINE  &■  SURGERY 


November,  1941 


Duke 

At  the  beginning  of  the  autumn  quarter,  there  were  262 
medical  students — 76  first-year.  62  second-year,  and  124 
juniors  and  seniors;  and  169  pupil  nurses  were  enrolled. 

From  October  16th-17th  the  Annual  Post-Graduate  Sym 
posium  on  Problems  of  Civil  and  Military  Emergencies  was 
held,  in  which  the  following  participated:  Dr.  George  J. 
Heuer,  of  Cornell  Medical  College;  Dr.  John  Scudder,  of 
the  College  of  Physicians  and  Surgeons.  Columbia  Univer- 
sity; Dr.  J.  E.  M.  Thomson.  Lincoln,  Nebraska;  Dr.  Ham- 
Stack  Sullivan,  of  the  Washington  School  of  Psychiatry ; 
Dr.  Alfred  R.  Shands,  Medical  Director  of  the  Alfred  I. 
duPont  Institute  of  the  Nemours  Foundation.  Wilmington. 
Del.;  Dr.  John  F.  Fulton,  of  Yale  University;  Dr.  Philip 
D.  Wilson,  of  Columbia  University;  Dr.  Frank  D.  Dick- 
son, of  the  University  of  Kansas;  Dr.  Wilder  G.  Penfield, 
Director  of  the  Montreal  Neurological  Insiitute;  Dr.  T.  T. 
Mackie,  of  the  College  of  Physicians  and  Surgeons,  Co- 
lumbia University;  Dr.  Alvan  L.  Barach.  Columbia  College 
of  Physicians  and  Surgeons;  Dr.  George  E.  Bennett,  of  the 
Johns  Hopkins  University ;  Dr.  John  M.  Converse,  Plastic 
Surgeon  at  the  American  Hospital  in  Britain;  Captain 
Charles  S.  Stephenson,  of  the  U.  S.  Naval  Medical  School ; 
Dr.  Russell  L.  Cecil,  of  Cornell  University  Medical  School. 


BOOKS 


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BILLS? 
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good  your  delinquent  and  hard  to  collect  ac- 
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MEDICAL  BOOKS 
Room  1808 
125  West  40th  Street  New  York  City 


OMISSIONS  FROM  OCTOBER  BOOK  REVIEWS 

P.  574— A  TEXTBOOK  OF  PATHOLOGY,  edited  by 
E.  T    Bell,  M.D.    Lea  &  Febiger,  Philadelphia.    $9.50. 

P.  576— IMMUNITY  AGAINST  ANIMAL  PARA- 
SITES, by  James  T.  Culberson,  Columbia  University 
Press,  Morningside  Heights,  New  York  City. 


DISEASES  OF  THE  VEINS  AND  LYMPHATICS  OF 
THE  LOWER  EXTREMITY,  by  C.  H.  Yerovitz,  M.D.; 
A  Manual  of  Veins  and  Lymphatics  of  the  Lower  Extrem- 
ity for  Students  and  Practitioners.  The  Christopher  Pub- 
lishing House,  Boston.    1941.    $6.00. 

It  is  said  that  one  out  of  six  adults  are  afflicted 
with  varicose  veins.  Certainly  it  is  a  very  common 
and  very  troublesome  disease  condition.  The  book 
is  based  on  the  author's  fifteen  years  of  experience 
in  the  Varicosity  Clinic  of  Saint  Vincent's  Charity 
Hospital,  in  Cleveland.  It  is  emphasized  that  not 
all  ulcers  on  legs  showing  varicose  veins  are  vari- 
cose ulcers. 

The  chapter  on  thrombophlebitis,  its  prevention 
and  cure,  is  especially  well  done.  The  description 
of  the  use  of  leeches  in  the  treatment  is  instructive 
and  entertaining.    Minute  directions  are  given  for 


ASAC 

15%,  by  volume  Alcohol 
Each   f!.   oz.    contains: 

Sod.uni  Salicylate,  U.  S.  P.  Powder 40  grains 

Sodium   Bromide,  U.  S.  P.  Granular 20  grains 

Caffeine.    U.    S.    P 4  grains 

ANALGESIC,    ANTIPYRETIC 
AND    SEDATIVE. 

Average    Dosage 

Two  to  four  teaspoonfuls  in  one  to  three  ounces  nl 
water   as   prescribed   by   the   physician. 

How  Supplied 
In  Pints.   Five  Pints  and   Gallons  to   Physicians   and 
Druggists. 

Burwell  &  Dunn  Company 

Manufacturing    *tj~^j^     Pharmacists 
Established    Ugj^P      '"    tSS7 

CHARLOTTE,  N.  V. 


November,   1941 


SOUTHERN  MEDICINE  &  SURGERY 


(TWO    HEAPING   TEASPOONFULS) 

of  CAL-C-TOSE 

contains    all 
these  vitamin  values 


2000    U.  S.  P.    Units.     As   much   vitamin  A 
as  in    3   ounces   of   good    quality    butter. 


150  International  Units.     As  much  vitamin 
B,  as  in  7  slices  of  whole  wheat  bread. 


In  ADDITION  to  a  full  protective 
complement  of  the  essential  vitamins 
A,  Bi.  B2,  C.  and  D.  Cal-C-Tose  'Roche' 
contains  skimmed  milk  protein, 
dibasic  calcium  phosphate,  and  other 
valuable  minerals.  Added  l"  milk, 
Cal-C-Tose  makes  a  rich,  appetizing, 
chocolate-flavored  drink  that's  bound 
to  tickle  the  palate  of  the  most 
finicky  patient.  It  i-  delicious  served 
either  as  a  "hot  chocolate"  or  as  a 
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SOUTHERN  MEDICINE  &  SURGERY 


November,  1941 


determining  the  patency  of  the  different  sets  of 
veins. 

A  valuable  diagnosis  chart  differentiates  five  vas- 
cular diseases  of  the  lower  extremities.  A  historical 
note  recounts  the  evolution  of  the  operative  treat- 
ment of  varicose  veins,  another  the  evolution  of 
the  injection  treatment. 

This  book  is  written  in  plain,  straightforward 
language,  evidently  by  one  familiar  with  the  details 
of  his  subject.  There  is  no  redundancy.  The  author 
gives  you  his  opinions  on  diagnosis  and  on  treat- 
ment without  waste  of  words,  and  without  that 
multiplicity  of  means  for  accomplishing  an  end 
which  denotes  an  author's  lack  of  confidence  in  any 
means.  A  remarkably  good  covering  of  the  sub- 
ject. 


INFANTILE  PARALYSIS:  A  Symposium  Delivered  at 
Yanderbilt  University,  April,  1941.  Published  by  The  Na- 
tional Foundation  for  Infantile  Paralysis,  Inc.,  120  Broad- 
way, New  York  City. 

This  book  is  a  printing  of  six  lectures  delivered 
at  Vanderbilt  University  April  7th,  8th,  9th,  14th, 
15th  and  16th,  1941,  under  the  auspices  of  The 
National  Foundation  for  Infantile  Paralysis. 

Subjects  of  the  Lectures  are: 

Lecture  1.  History  of  Poliomyelitis  Up  to  the 
Present  Time,  by  Paul  F.  Clark,  Ph.D.,  Professor 
of  Bacteriology,  The  University  of  Wisconsin  Med- 
ical School;  Lecture  2.  The  Etiology  of  Poliomy- 
elitis, by  Charles  Armstrong,  M.D.,  Senior  Sur- 
geon, United  States  Public  Health  Service;  Lecture 
3.  Immunological  and  Serological  Phenomena  in 
Poliomyelitis,  by  Thomas  M.  Rivers,  M.D.,  Direc- 
tor, The  Hospital  of  The  Rockefeller  Institute  for 
Medical  Research;  Lecture  4.  The  Pathology  and 
Pathogenesis  of  Poliomyelitis,  by  Ernest  W.  Good- 
pasture, M.D.,  Professor  of  Pathology,  Vanderbilt 
University  School  of  Medicine;  Lecture  5.  Ths 
Epidemiology  of  Poliomyelitis,  by  John  R.  Paul, 
Professor  of  Preventive  Medicine,  Yale  University 
School  of  Medicine;  Lecture  6.  Treatment  and  Re- 
habilitation of  the  Poliomyelitis  Patient,  by  Frank 
R.  Ober,  M.D.,  John  B.  and  Buckminster  Brown 
Clinical  Professor  of  Orthopedic  Surgery,  Harvard 
University  Medical  School. 

As  a  whole  the  lectures  give  in  brief  the  knowl- 
edge we  have  of  this  disease. 

A  comprehensive  bibliography  is  carried  for  the 
use  of  those  who  wish  an  encyclopedic  knowledge 
of  the  subject. 


OCCUPATIONAL  DISEASES:  Diagnosis,  Medicolegal 
Aspects  and  Treatment,  by  Rutherford  T.  Johnstone, 
A.B.,  M.D.,  Director  of  the  Department  of  Occupational 
Diseasts,  Golden  State  Hospital,  Los  Angeles,  California; 
Formerly  Assistant  Professor  of  Medicine,  University  of 
Pittsburgh  School  of  Medicine.  Illustrated.  W.  B.  Saun- 
ders Company,  Philadelphia  and  London.    1941.    $7.50. 


Occupational  diseases  and  injuries  make  up  a 
larger  and  larger  part  of  the  practice  of  medicine 
and  surgery  as  machinery  multiplies.  As  compen- 
sation laws  are  put  on  the  statute-books  and 
more  and  more  cases  get  into  court  because  of  real 
or  alleged  occupational  diseases,  it  comes  about 
that  a  doctor  needs  to  know  the  law  as  well  as  the 
medicine  of  such  diseases. 

Part  I  concerns  itself  with  Workmen's  Compen- 
sation; Part  II  with  ill  effects  of  Gases,  Solvents 
and  Fumes;  Part  III  with  Metals;  Part  IV  with 
Dusts;  Part  V  with  Backs  and  Hernias;  Part  VI 
with  Dermatosis;  Part  VII  with  Occupational  Can- 
cer, Heat  and  Electrical  Injuries  and  Caisson  Dis- 
ease; Part  VIII,  The  Medicolegal  Relationship  of 
Trauma  to  Disease,  Malingering  and  The  Pre- 
employment  Examination. 

An  Appendix  gives  a  Table  of  Toxic  Thres- 
holds of  Common  Industrial  Substances. 

Few  indeed  will  be  the  readers  of  this  book- 
notice  who  do  not  stand  in  need  of  just  the  kind 
of  information  as  is  to  be  had  from  this  excellent 
book. 


DOCTORS    ANONYMOUS:    The   Story   of    Laboratory- 
Medicine,  by  William  McKee  German,  M.D  ,  with  an  in- 


November.   1941 


SOUTHERN  MEDICINE  &  SURGERY 


troduction    by    Paul    de    Kruif.     Duell,    Sloan    and   Pcarce, 
New  York.    1941.    $2.75. 

An  entertaining  book  to  those  who  like  melo- 
dramatic writing. 

The  "anomymous"  doctors  are  pathologists.  The 
various  activities  of  doctors  practicing  in  this  spe- 
cialty and  something  of  its  history  are  narrated  in 
typical  Hollvwoodese — the  very  same  style  as  that 
de  Kruif  uses  in  the  preface,  and  everywhere  else 
that  the  reviewer  has  seen  his  output. 


IXFAXT  NUTRITION:  A  Textbook  of  Infant  Feeding 
for  Students  and  Practitioners  of  Medicine,  by  William 
McKim  Marriott,  B.S.,  M.D.,  Late  Professor  of  Pedia- 
trics. Washington  University  School  of  Medicine;  Physician 
in  Chief.  St.  Louis  Children's  Hospital;  Revised  by  P.  C. 
Jeans,  A.B.,  M.D.,  Professor  of  Pediatrics,  College  of 
Medicine,  State  University  of  Iowa.  Third  edition.  The 
C.  V.  Mosby  Company,  3523-25  Pine  Boulevard,  St.  Louis. 
1941.    $5.50. 

Dr.  Jeans  was  associated  with  Dr.  Marriott  for  a 
number  of  years,  and  so  is  well  qualified  to  revise 
Dr.  Marriott's  books  for  newer  editions.  Clinical 
and  laboratory  research  of  the  past  score  of  years 
has  built  on  a  solid  basis  a  well-nigh  perfect  struct- 
ure of  knowledge  of  infant  nutrition.  Than  Dr. 
Marriott  was,  or  Dr.  Jeans  is,  no  one  is  able  to 
speak  with  more  authority. 


OFFICE  ENDOCRINOLOGY,  by  Robert  B.  Green- 
blatt,  B.A.,  M.D..  CM.,  Professor  of  Experimental  Medi- 
cine. University  of  Georgia  School  of  Med'cine.  Univ. 
of  Ga.  School  of  Medicine,  Augusta,  Ga.     1941.     $2.00. 

This  is  a  printing  in  an  abbreviated  form  of  a 
series  of  lectures  by  the  author  to  a  post-graduate 
in  Office  Endocrinologv.  The  100-pages  of  text 
will  clarify  for  any  attentive  reader  a  particularly 
cloudy  subject  of  great  importance.  The  author  is 
qualified  to  speak  with  authority,  and  he  has  put 
into  a  booklet  all  that  is  known  on  this  subject 
which  can  be  translated  into  every-day  usefulness 
to  patients.     It  is  a  high  achievement. 


THE  AVITAMINOSES:  The  Chemical.  Clinical  and 
Pathological  Aspects  of  the  Yitamin  Deficiency  Diseases,  by 
Waiter  H.  Eddy,  Ph.D..  Professor  of  Physiological  Chem- 
istry, Teachers  College,  Columbia  University ;  and  Gilbert 
Dalldort,  M.D..  Pathologist  to  the  Grasslands  and  North- 
ern Westchester  Hospitals,  Westchester  County.  New  York. 
Second  edition.  The  Williams  and  Wilkins  Company,  Bal- 
timore.    1941.     S4.50. 

The  ready  acceptance  of  the  first  edition  and  the 
increase  in  knowledge  of  the  subject  have  required 
the  present  publication. 

It  is  perhaps  possible  for  a  physiologist  and  a 
pathologist  to  write  a  more  reliable  book  on  the 
clinical  application  of  these  sensational  food  prod- 
ucts, vitamines,  than  could  the  clinician,  himself. 

Here  is  presented  a  reliable  office  and  bedside 
guide  to  better  management  of  the  cases  of  a  large 
number  of  our  patients. 


FROM  CRETIN  TO  GENIUS,  by  Dr.  Serge  Yoron- 
off.  Alliance  Book  Corporation,  212  Fifth  Avenue,  New 
York.    1941.    $2.75. 

Among  the  arresting  chapter  heads:  The  Soul 
and  the  Mind;  From  Cretin  to  Genius;  The  Role 
of  Chance  in  the  Creative  Process;  The  Origin  of 
Genius;  The  Struggles  of  Genius;  From  Genius  to 
Cretin. 

The  book  is  an  odd  mixture  of  rather  excited 
statements  of  well  known  facts,  and  rather  aston- 
ishing would-be  explanations  of  these  facts.  Those 
who  love  to  be  mystified  and  dabble  in  "super- 
naturalism"  will  find  the  volume  interesting. 


SYNOPSIS  OF  THE  PREPARATION  AND  AFTER- 
CARE OF  SURGICAL  PATIENTS,  by  Hugh  C.  Ilgen- 
fritz,  A.B.,  M.D.,  Instructor  in  Surgery,  Louisiana  State 
LTniversity  School  of  Medicine;  and  Rawley  M.  Penick, 
Jr.,  Ph.B..  M.D.,  F.A.C.S.,  Professor  of  Clinical  Surgery, 
Louisiana  State  University  School  of  Medicine;  with  a 
foreword  by  Urban  Maes,  M.D.,  D.Sc,  F.A.C.S.,  Professor 
of    Surgery    and    Director    of    the    Department,    Louisiana 


GREETING  CARDS  FOR  THE  DOCTOR 

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SOUTHERN  MEDICINE  &  SURGERY 


November,  1941 


State  University   School  of  Medicine.     The   C.   V,  Mosby 
Company,  3523-25  Pine  Boulevard,  St.  Louis.    1941.    $5.00. 

The  foreword  tells  us  that  the  greatest  advances 
in  surgery  of  recent  years  have  been  made  in  pre- 
operative and  postoperative  care,  that  much  of  the 
future  progress  will  result  from  cooperation  between 
the  research  and  the  practicing  surgeon. 

The  volume  is  offered  as  a  guide  to  the  care  of 
surgical  patients  throughout  their  stay  in  hospital. 

Subjects  deemed  worthy  of  special  consideration 
include  fluid  and  electrolyte  balance;  shock;  trans- 
fusion; general  preoperative  measures,  among  them 
permission  and  reassurance;  general  postoperative 
measures,  from  those  oxygen  administration  and 
blood  chemistry  values. 

Fifty-five  well  chosen  illustrations  supplement 
the  text  to  make  of  this  volume  an  excellent  guide 
to  proper  care  of  the  surgical  patient  from  the  time 
he  enters  the  hospital  until  he  leaves;  and  the 
faithful  carrying  out  of  directions  here  given  will 
add  to  the  patients'  comfort,  shorten  hospital  stay, 
lessen  complications  and  sequelae,  and  reduce  the 
hazard  to  life. 


DISEASES  OF  WOMEN,  by  Harry  Sturceon  Grossen, 
M.D.,  F.A.C.S.,  Professor  Emeritus  of  Clinical  Gynecology, 
Washington  University  School  of  Medicine;  and  Robert 
James  Crossen,  A.B.,  M.D.,  Assistant  Professor  of  Clinical 
Gynecology  and  Obstetrics,  Washington  University  School 


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of  Medicine.  Ninth  edition,  entirely  revised  and  reset,  with 
1127  engravings,  including  45  in  colors.  The  C.  V.  Mosby 
Co.,  3523-25   Pine   Boulevard,  St.   Louis.      1941.     S12.50. 

The  first  edition  appeared  in  1907,  the  ninth 
in  1941.  Each  has  represented  the  best  in  knowl- 
edge of  the  subject  for  its  time.  Chapter  heads 
are:  Anatomy  and  Physiology;  Gynecologic  Ex- 
amination and  Diagnosis;  Treatment  Measures; 
Diseases  of  the  External  Genitals  and  Vagina;  Re- 
laxation and  Fistulae;  Displacement  of  the  Uterus; 
Inflammatory  and  Metabolic  Disturbances  of  the 
Uterus;  Non-malignant  Tumors  of  the  Uterus; 
Cancer  of  the  Uterus;  Pelvic  Inflammation;  Other 
Diseases;  Diseases  of  the  Ovary  and  Parovarium; 
Malformation;  Sterility  and  Sexual  Disturbances; 
Miscellaneous  Disturbances:  The  Lower  Intesti- 
nal Tract  in  Relation  to  Gvnecology;  Invasion  of 
the  Peritoneal  Cavity;  After-Treatment  in  Opera- 
tive Cases;  Medicolegal  Points  in  Gynecology. 

On  matters  of  established  fact  the  authors,  of 
large  experience  and  a  comprehensive  knowledge  of 
the  e  perience  of  others  in  their  class,  speak  with 
the  finality  of  clear  conviction.  On  matters  more 
or  less  speculative,  they  speak  guardedly,  some- 
times merely  quoting  others,  and  offering  no  com- 
ment. 

Crossen  remains  an  Old  Reliable  in  the  Field  of 
Gynecology. 


BETTER  NURSING  FOR  AMERICA,  published  by  the 
Public  Affairs  Committee,  presents  in  narative  form  the 
Nation's  urgent  need  for  nurses,  and  describes  the  services 
nurses  are  rendering  in  every  field.  Obtainable  from  the 
Nursing  Information  Burean  of  the  American  Nurses' 
Association.  1790  Broadway,  New  York  City.  Price  10c. 
Liberal  discounts  on  quantity  orders, 
nurses  are  rendering  in  every  field. 

Some  400,000  registered  nurses — it  is  said  at 
work  in  hospitals,  homes,  camps  and  schools,  and 
there  is  need  for  30,000  more. 

The  need  is  that  young  persons  of  superior  abil- 
ity enter  good  nursing  schools. 


riOW  How  You  Stand 
Compared  with  Last  Year  / 


.  .  .  You'd    know    exactly,   at   a   glance,   if   you 
were  using  the  DAILY  LOG.    It's  the  SIMPLI- 
FIED, thoroughly   ORGANIZED   system   of  of- 
fice   bookkeeping.     Includes   in    one    neat    volume 
every    essential    business    record    of 
your  practice.  Important  non-finan- 
cial   ones,    too.     It's    a    treasure    at 
income  tax  time ! 

WRITE — for    illustrated    booklet 
"The    Adventures    of    Dr.    Young 
in  the  Field  of  Bookkeeping". 
COLWELL    PUBLISHING    CO. 
143  University  Ave.,  Champaign.  111. 


The 


l|P^]D>AniLY  EOdS 


November.   1941 


SOUTHERN  MEDICINE  &  SURGERY 


635 


THE  DEVELOPMENT  OF  THE  SCIENCES:  Second 
Series,  by  Oystek  Ore,  Frank  Schlesinger,  Henry  Mar- 
genau,    John    Arrend    Timm,    Chester  Ray  Longwell, 

LORANDE     LOSS     WOODRUFF,     WALTER     RlCHARD     MrXES     and 

John  Farquhar  Fulton  ;  edited  by  L.  L.  Woodruff. 
Yale  University  Press,  New  Haven:  London,  Humphrey 
Milford.   Oxford  University  Press.    1941.   $3.00. 

It  is  in  a  masterful  way  that  these  Yale  profes- 
sors present,  each  his  own,  the  stories  of  the  devel- 
opment of  Mathematics,  of  Astronomy,  of  Physics. 


of  Chemistry,  of  Geology,  of  Biology,  of  Psych- 
ology, and  of  Medicine  as  the  progenitor  of  the 
Sciences. 

We  doctors  know  too  little  of  the  subject-matter 
and  of  the  history  of  the  sciences  which  make  up 
so  much  of  Medicine.  Most  of  the  little  of  this 
history  we  know  deals  with  the  superficial  aspects. 
Here  are  set  forth  matters  substantial  and  funda- 
mental that  all  of  us  ought  to  know  about. 


•      1941      • 

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Radio  and  Fan  in  Every  Room.  Golt  Links.  Artesian  Swimming 
Pool  with  Sand  Beach.  Tennis,  Badminton.  Ping  Pong,  Croquet, 
Horseshoe  and  Shuffleboard  Courts.  Ballroom  and  Convention 
Hall.    Banquet  Facilities.    Spacious  Grounds. 

COOLEST  SPOT  IN  ALL  FLORIDA,  AT  THE  BIRTHPLACE  OF 
THE  TRADE  WINDS.  Where  the  Labrador  (Arctic)  Current 
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636 


SOUTHERN  MEDICINE  &  SURGERY 


November,  1941 


FUNCTIONAL  PATHOLOGY,  by  Leopold  Lichtwitz, 
M.D.,  Chief  of  the  Medical  Division  of  the  Montefiore 
Hospital;  Clinical  Professor  of  Medicine,  Columbia  Uni- 
versity, New  York.  An  extensive  bibliography  follows  each 
chapter.  570  pages;  198  illustrations,  charts  and  tables; 
index.  Cloth,  $8.75  postpaid.  Grune  &  Stratton,  Inc.,  443 
Fourth  Avenue,  New  York. 

Functional  Pathology  is  offered  by  the  author  as 
a  term  for  the  science  which  analyzes  the  mechan- 
ism of  symptoms  and  signs  of  disease. 

From  the  choice  of  these  subjects  for  discussion 
in  the  light  of  his  definition  of  his  choice  of  a  name 
for  the  work,  it  may  well  be  gathered  that  the  au- 
thor has  written  an  unusual  and  instructive  book. 


Among  the  subjects  given  one  or  more  chapters 
are:  General  Endocrinology:  Heat  Regulation,  Hy- 
perthermia. Hypothermia:  Regulation  of  Metabol- 
ism; Functional  Pathology  of  the  Thyroid  Gland: 
Mechanism  of  the  Manifestation  of  Graves'  Dis- 
ease and  the  Interrelations  between  the  Thyroid 
and  the  other  Endocrine  Glands;  Mechanism  of 
Defense;  Mechanism  of  Arthritis;  Mechanism  of 
Obesity;  Disorders  of  the  Skeleton;  Mechanism  of 
Pluriglandular  Diseases;  Essential  Hypertension; 
Mechanism  of  Blood  Diseases;  Mechanism  of 
Bright's  Disease;  Mechanism  of  Hepatic  Disorders. 


AMERICAN      L 

>m.  JUNIOR  RED,  ©R©^ 


November,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


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Southern  Railway's 

SOUTHERNER 


Built  of  high-tensile  steel,  with  sheathing  of  stainless  steel,  THE  SOUTHERN- 
ER which  will  operate  as  three  Diesel-powered  trains,  includes  all  the  latest  refine- 
ments for  the  ultimate  in  safety,  speed  and  comfort.  Each  train  will  consist  of 
Straight,  Partition  and  Baggage-Dormitory  Chair  Cars,  Dining  Car  and  Lounge- 
Tavern-Observation  Unit,  all  reflecting  the  latest  ideas  in  structural  development 
and  modern  styling  and  beautv. 

Passenger  units  have  thermostatically  controlled  heating  and  air  conditioning, 
are  insulated  throughout.  Judicious  use  is  made  of  a  number  of  advancements  favor- 
ing gracious  living.  A  good  part  of  the  luxury  picture  appears  in  the  comfortable 
seating  arrangement  in  all  cars,  the  commodious  and  up-to-date  dining  car  arrange- 
ments and  the  facilities  for  en  route  enjoyment  offered  in  lounge,  tavern  and  obser- 
vation rooms. 

Diesel  locomotives  for  the  trains  are  built  by  the  Electro-Motive  Corporation, 
a  subsidiary  of  General  Motors. 

Particularly  interesting  from  the  standpoint  of  detailed  comfort  planning  is  the 
fact  that  chair  cars  have  twin-rotating,  reclining-type  seats,  cushioned  and  attrac- 
tively finished.  The  dining  car  has  accommodations  for  48  persons  in  satin  metal 
framed  chairs  with  rubber  seats  and  back  cushions.  Settees,  lounge  chairs,  writing 
desk,  card  section  and  refreshment  facilities  have  been  planned  to  fit  the  comfort 
and  utility  requirements  of  passengers  in  the  Lounge-Tavern-Observation  unit. 

A  rich  decorative  treatment  has  been  designated  for  all  units  of  THE  SOUTH- 
ERNER the  basic  colors  being  blue,  green  and  beige  in  light,  medium  and  dark 
tones.  Blue  and  beige  are  distributed  in  straight  chair  car  planning,  each  car  carry- 
ing out  variations  of  the  same  color  treatment  throughout  .  Partition  chair  cars  em- 
phasize beige  and  the  Baggage-Dormitory-Chair  Cars  are  done  in  tones  of  blue. 
Green  is  the  predominating  scheme  in  dining  car  and  Lounge-Tavern-Observation 
units. 

The  whole  scene  is  enriched  with  an  attractive  arrangement  of  photo-murals 
which  have  been  especiallv  planned  to  heighten  the  atmosphere  of  luxury  and  beautv 
in  THE  SOUTHERNER. 


November,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


639 


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CHARLOTTE,   N.   C,   DECEMBER,    1941 


The   Local   Use   of  Sulfonamides* 

William  St.  Julien  Jervey,  M.D.,  Tryon,  North  Carolina 


FOR  SEVERAL  REASONS  my  remarks  on 
the  local  use  of  sulfonamides  are  going  to  be 
brief.  In  the  first  place  the  material  I  had 
hoped  to  receive  from  the  Charity  Hospital  of 
Louisiana  did  not  arrive  and  this  is  the  only  place 
I  have  actually  seen  any  extensive  use  of  these 
drugs  topically.  Secondly,  Drs.  Hagna  and  McBee 
are  to  follow  me  and  I  am  not  sure  how  much  their 
discussion  will  overlap  mine. 

At  Charity  Hospital  before  I  left  in  July  inves- 
tigations on  the  use  of  sultanilamide  intraperito- 
neally  and  in  traumatic  surgery  had  been  exten- 
sive. Sulfathiazole  was  being  used,  but  compara- 
tive estimates  had  not  been  made.  The  general 
opinion  there  was  that  the  results  with  both  these 
drugs  was  satisfactory  beyond  expectations.  Since 
I  have  been  unable  to  get  any  statistics  from  there, 
I  have  gone  through  recent  literature  which  most 
of  you  have  probably  already  seen,  with  the  result 
that  this  discussion  will  be  unique  only  in  its  com- 
plete lack  of  originality. 

One  of  the  most  striking  reports  I  found  was 
from  Roosevelt  Hospital,  New  York  City,  on  a  se- 
ries of  almost  1000  cases  of  acute  appendicitis, 
compiled  over  a  period  of  six  years,  1935  to  1940 
inclusive.  Onlv  those  cases  which  were  grossly 
acute  at  the  operating  table  were  considered.  The 
management  of  these  cases  was  identically  the 
same  throughout  this  period  except  for  the  use  of 
sulfanilamide  powder  intraperitoneally  during 
1940.  In  the  first  five  vears  of  this  series — i.e., 
the  period  without  the  us°  of  sulfanilamide — a 
total  of   741   patients  with  acute  suppurative  ap- 


pendicitis was  operated  on.  The  mortality  rate  was 
20  (2.7%),  the  majority  directly  attributable  to 
peritonitis.  In  1940  there  was  a  total  of  204  cases, 
29  per  cent  of  which  received  sulfanilamide  in  the 
peritoneum,  without  a  fatality.  In  14  of  these 
cases  the  drug  was  continued  by  rectum  or  by  vein ; 
but,  since  it  was  also  used  thus  in  many  of  the 
group  in  the  previous  five-year  period,  the  mor- 
tality reduction  was  attributed  to  the  intraperito- 
neal implant.  These  investigators  feel  that  suffi- 
ciently large  intraabdominal  applications  will  make 
unnecessary  the  systemic  use  of  the  drug. 

In  preparing  the  drug  for  use  it  is  commonly 
placed  in  test-tubes  in  4-,  6-  and  8-Gm.  quantities, 
then  snugly  stoppered  with  cotton.  Moist  heRt,  as 
in  the  autoclave,  converts  the  crystals  into  rock- 
like masses.  Sterilization  by  placing  in  an  oven  at 
120°  for  30  minutes  results  in  a  fine  powder. 
Varying  amounts  were  scattered  over  the  perito- 
neum and  some  sprinkled  between  the  walls  on 
closure. 

Sulfanilamide  blood  levels  showed  an  immediate 
rise,  averaging  7  mgm.  per  cent  in  15  hours  after 
operation.  The  fall  in  blood  level  was  also  rapid 
except  in  the  cases  where  large  amounts  were  used 
in  the  muscle  layers.  This  group  of  investigators 
recommended  an  average  adult  dose  of  8  Gm.  in- 
traperitoneally and  4  Gm.  in  the  abdominal  wall: 
in  cases  of  appendiiceal  abscess  with  a  rapid  loss 
of  the  drug  due  to  drains,  as  much  as  20  Gm.  has 
been  used  withotu  ill  effects. 

No  definite  toxic  effects  were  observed,  though 
cyanosis  was  frequent.    One  case  of  jaundice  was 


'Presented  to  The  Thermal  Belt  (N.  C.)   Medical  Society  meeting  at  Shelby,  October  16th. 


THE  LOCAL  USE  OF  SULFONAMIDES— Jervey 


December,  1941 


encountered;  this  seemed  to  be  secondary  to  a 
streptococcus  peritonitis  and  cleared  up  under  con- 
tinued administration  of  the  drug.  There  were 
some  cases  in  which  a  continued  fever  was  attrib- 
uted to  sulfanilamide.  Ages  in  the  group  ranged 
from  one  to  72  years.  Of  those  cases  in  which  sul- 
fanilamide was  used,  in  45  per  cent  there  was  a 
diffuse  peritonitis.  In  one  case  at  secondary  appen- 
dectomy two  months  later,  the  peritoneum  appear- 
ed normal  and  there  was  no  evidence  of  adhesions. 

Drains  were  used  in  these  cases  as  much  so  as 
they  had  been  used  in  the  previous  five  years.  The 
group  in  New  Orleans  believe  they  are  getting 
better  results  following  appendectomy  or  perforat- 
ing abdominal  wounds  when  they  close  without 
drainage  except  in  those  cases  contaminated  by 
large  amounts  of  feces  or  extremely  thick  and 
copious  pus.  In  many  of  the  cases  which  they 
closed  tight  with  excellent  results,  the  absence  of 
a  drain  before  the  use  of  sulfanilamide  powder 
would  have  been  considered  criminal  neglect. 

Most  of  my  information  on  the  use  of  sulfona- 
mides in  orthopedic  surgery  has  been  borrowed 
from  reports  of  Key  of  St.  Louis,  who  has  done  a 
great  deal  of  work  with  both  sulfanilamide  and 
sulfathiazole  locally,  and  is  now  using  a  mixture 
of  the  two  powders.  It  has  been  found  that  the  two 
drugs  are  dissolved  independently;  i.e.,  a  saturated 
equeous  solution  of  sulfanilamide  will  take  into  so- 
lution just  as  much  sulfathiazole  as  will  the  same 
quantity  of  pure  water.  He  recommends  the  joint 
use  of  the  two  powders,  not  only  because  of  their 
varying  action  on  different  organisms,  but  also 
because  of  the  fact  that  sulfathiazole,  while  not 
attaining  as  high  a  concentration  as  sulfanilamide, 
will  last  longer  because  of  its  slower  absorption 
and  excretion.  Both  drugs  are  well  tolerated  and 
do  not  apper  to  interfere  with  healing  in  patients 
or  in  experimental  animals.  He  uses  them  in  both 
clean  and  infected  cases,  regarding  all  cases  as  po- 
tentially infected  regardless  of  technique.  In  243 
clean  cases,  using  one  or  both  drugs,  he  had  no 
postoperative  infections.  By  the  use  of  as  much 
powder  as  can  be  placed  in  the  wound  without 
interfering  with  coaptation  (usually  1-5  Gms.) 
there  is  no  appreciable  delay  in  healing.  A  high 
local  concentration  is  thus  maintained  for  48  hours 
of  sulfanilamide  (has  been  measured  at  over  600 
mg.  '',  )  and  a  somewhat  longer  period  with  sul- 
fathiazole. The  rate  of  absorption  and  excretion 
varies  with  the  amount  used,  surface  area  and 
blood  supply. 

Of  contaminated  wounds  the  percentage  that 
can  be  closed  successfully  by  primary  suture  after 
complete  debridement  has  been  greatly  increased 
by  the  use  of  sulfonamides,  though  their  use  does 
not  in  any  sense  lessen  the  importance  of  adequate 


debridement  and  immobilization.  Those  wounds 
which  are  considered  poor  risks  for  primary  closure 
heal  more  rapidly  and  with  minimal  infection  if 
the  drug  is  packed  in  the  wounds  and  dusted  over 
them. 

The  British  have  obtained  their  best  results  in 
the  handling  of  extensive  wounds  of  the  extremities 
in  war  casualties  from  the  use  of  routine  irrigation, 
debridement  and  immobilization  if  necessary;  then 
packing  the  wound  full  of  sulfanilamide  powder, 
covering  with  sterile  vaseline  gauze  and  taping  the 
wound  heavily  to  approximate  the  edges  as  nearly 
as  possible.  This  dressing  is  not  disturbed  for  five 
days,  at  the  end  of  which  time  the  wounds  are 
rather  consistently  clean,  granulating  and  suitable 
for  suture. 

In  civil  practice  in  this  country  one  source  re- 
ports a  5-per  cent  incidence  of  infection  following 
compound  fractures  with  the  use  of  sulfanilamide, 
as  compared  with  27  per  cent  in  cases  in  which  the 
management  was  otherwise  the  same.  Another  re- 
ports a  similar  reduction  of  from  54  to  5.6  per  cent 
and  a  reduction  in  average  hospitalization  time 
from  37.7  days  to  6.8  days. 

In  contaminated  cases  in  which  debridement  is 
prompt  Key  does  not  consider  it  necessary  to  use 
the  drug  orally.  In  those  cases  in  which  there  has 
been  delay,  or  the  adequacy  of  the  debridement  is 
in  question,  he  uses  full  doses  of  sulfathiazole  or- 
ally. If  there  is  no  evidence  of  infection,  after  two 
days  the  drug  is  discontinued.  Acutely  infected 
wounds  must  be  left  open  and  serum  administered 
as  indicated.  In  these  cases  packing  large  quanti- 
ties of  the  powder  in  the  wound  gives  good  results, 
though  not  nearly  so  satisfactory  as  those  in  which 
the  drug  can  be  closed  in  the  wound.  In  acute 
pyogenic  osteomyelitis  or  arthritis  Key  advocates 
drainage  of  the  focus,  then  the  implantation  of  a 
liberal  amount  of  sulfathiazole  (or  a  mixture  of  the 
two)  into  the  wound,  then  packing  with  vaseline 
gauze;  with  oral  administration  additional.  In  a 
few  of  the  less  severe  cases  of  pyogenic  joint  in- 
volvement he  has  implanted  the  powder,  then 
closed  and  immobilized  the  joint,  and  had  a  useful 
joint  result. 

A  recent  report  from  Chicago  on  the  use  of  sul- 
fanilamide locally  after  mastoidectomy  is  of  inter- 
est here  chiefly  because  of  the  comparative  results 
obtained  with,  and  without,  drains.  In  cases  in 
which  sulfanilamide  was  used  in  the  wound  and 
drains  inserted,  the  postoperative  course  was  much 
as  it  had  been  before  the  use  of  the  drug — purulent 
drainage  for  three  to  six  weeks.  In  a  later  series 
of  13  cases,  in  which  sulfanilamide  powder  was 
implanted,  then  the  wound  closed  tight  without  the 
use  of  drains,  in  only  one  case  was  there  a  purulent 


December,  1941 


THE  LOCAL  USE  OF  SULFONAMIDES— Jervey 


645 


discharge,  and  the  average  healing  time  was  6}4 
days. 

Most  of  this  discussion  has  been  of  hospital 
work,  but  the  method  can  be  applied  to  office  and 
heme  use  on  a  smaller  scale.  Contused  or  contam- 
inated lacerations  can  be  equally  well  closed  with- 
out drainage  after  the  implantation  of  sulfanila- 
mide or  sulfathiazole.  On  a  surface  infection  which 
can  not  be  packed,  an  ointment  of  equal  parts  sul- 
fanilamide crystals  and  lanolin  hastens  healing  but 
not  comparably  to  the  benefit  in  closed  cases. 

Conclusions 

1 .  The  use  of  sulfonamides  on  the  peritoneum  in 
cases  of  peritonitis  or  abscess  is  of  proven  value. 

2.  Their  use  in  traumatic  surgery  will  minimize 
the  percentage  and  severity  of  infections. 

3.  Their  use  in  no  way  means  that  there  can  be 
any  let-up  in  technique  as  regards  to  debridement 
and  immobilization. 

4.  Their  presence  in  wounds  or  peritoneum  does 
not  delay  healing  or  have  any  ill  effect  on  tissue. 

5.  Toxic  effects  are  rare  from  intramuscular, 
subcutaneous  or  intraperitoneal  implantation.  Over- 
dosage is  almost  impossible,  except  intraperitoneal- 
ly  without  drainage. 

6.  Therapeutic  results  are  directly  proportionate 
to  the  local  concentration,  therefore  efficacy  is 
greatly  reduced  by  the  use  of  drains. 

Bibliography 
'.  Thompson,  Brabson  and  Walker:    The  intraabdominal 
application  of  sulfanilamide  in  acute  appendicitis.   5.  G. 
&  0.,  April. 

2.  Key:     The    use    of   sulfanilamide    and    sulfathiazole   in 
orthopedic  surgery.   J.  A.  M.  A.,  August  9th. 

3.  Campbell  and  Smith:     Fresh  compound  fractures.    /. 
A.  M.  A.  August  30th. 

4.  Livingston:    Local  sulfonamide  therapy  in  acute  mas- 
toiditis.    /.  A.  M.  A.,  September  27th. 

5.  King:    Treatment  of  open  wounds  by  the  sulfanilamide 
pack.   Brit.  Med.  Jour.,  February  ISth. 


NEW  DF.VELOPMENTS  IN  THE  DIAGNOSIS  AND 

TREATMENT  OF  BRUCELLOSIS   (UNDULANT 

FEVER) 

I  W.  M.  Simpson.  Dayton,  O.,  in  Minn.  Med.,  Sept.) 
Because  brucellosis  presents  many  symptoms  and  signs 
common  to  typhoid  fever,  malaria,  tuberculosis  and  influ- 
enza, it  is  frequently  confused  with  these  diseases.  Less 
often,  the  disease  has  been  confused  with  acute  rheumatic 
fever,  subacute  bacterial  endocarditis,  bronchitis,  pyelitis, 
appendicitis,  cholecystitis,  or  tularemia. 

The  symptoms  of  the  acute  and  the  chronic  forms  of 
brucellosis  vary  greatly.  The  diagnostic  criteria  for  the 
acute  are  usually  not  applicable  to  the  chronic  form  of  the 
disease.  There  is  little  doubt  that  chronic  ambulatory 
brucellosis  is  widely  prevalent,  is  often  confused  with  other 
diseases,  and  frequently  is  not  recognized.  Many  "neuras- 
thethenics"  and  patients  with  fever  of  unknown  cause  have 
been  found  to  be  victims  of  chronic  brucellosis.  Less  than 
10  per  cent  of  patients  with  chronic  brucellosis  have  ex- 
perienced a  previous  acute  febrile  illness,  compatible  with 
a  diagnosis  of  acute  brucellosis. 


The  only  procedure  by  which  the  diagnosis  of  brucello- 
sis may  be  established  with  certainty  is  by  the  cultivation 
and  identification  of  the  organism.  The  agglutination  test 
and  skin  test  are  of  considerable  value  in  the  diagnosis  of 
acute  brucellosis,  but  these  procedures  are  notoriously  in- 
adequate as  diagnostic  aids  in  cases  of  chronic  brucellosis. 
Both  the  agglutination  test  and  the  skin  test  will  yield  en- 
tirely negative  results  in  an  appreciable  number  of  persons 
from  whose  blood  Brucella  may  be  recovered. 

Leukopenia  occurs  in  the  majority  of  patients  with  acute 
brucellosis.  In  chronic  brucellosis,  either  leukopenia,  mod- 
erate leukocytosis  or  normal  leukocyte  levels  may  be  found. 
The  most  striking  and  constant  feature  of  the  blood  picture 
in  all  of  the  manifestations  of  brucellosis  is  an  increase  in 
percentage  and  absolute  number  of  lymphocytes  and  by  an 
unusually  high  proportion  of  immature  forms. 

It  is  now  well  established  that  brucellosis  is  caused  most 
frequently  by  the  ingestion  of  raw  milk  containing  Bru- 
cella, the  most  important  consideration  in  the  control  of 
the  disease  is  adequate,  controlled  pasteurization  of  all 
milk  and  other  dairy  products. 

It  is  hard  to  evaluate  the  effectiveness  of  any  form  of 
specific  therapy  in  a  disease  characterized  by  natural  re- 
missions by  an  extremely  variable  symptomatology.  Re- 
ported results  of  vaccine  therapy  or  serum  run  pessimism 
to  hyperenthusiasm. 

Some  have  obtained  an  apparently  satisfactory  response 
to  vaccine  therapy  with  little  thermal  reaction,  but  the 
most  prompt  and  lasting  results  have  occurred  in  those 
who  have  experienced  several  high  fever  reactions. 

Results  of  vaccine  or  brucellin  therapy — 60  per  cent 
cent  of  patients  with  brucellosis  obtain  apparently  complete 
recovery  after  a  satisfactory  course  of  either  agent.  An 
additional  25  per  cent  appear  to  obtain  some  benefit,  while 
the  remaining  IS  per  cent  are  not  improved. 

Sulfanilamide  and  other  sulfonamide  drugs  have  given 
little  benefit.  Artificial-fever  therapy  has  yielded  favorable 
results,  particularly  in  those  refractory  patients  who  have 
not  responded  to  vaccine  therapy. 


DOCTOR  WILLIAM  HUNTER 
(Roland  Hammond,  Providence,  in  R.  I.  Med.  Jl.,  Nov.) 

Dr.  William  Hunter  born  in  Scotland  in  1729,  a  relative 
of  the  famous  Sir  John  and  his  brother  William,  Hunter, 
studied  at  Edinburgh  under  the  elder  Munro,  came  to 
Rhode  Island  about  1752,  gave  at  Newport  the  first  lec- 
tures in'  anatomy  and  surgery  ever  delivered  in  the  colo- 
nies, possessed  the  largest  Medical  Library  in  New  Eng- 
land, and  died  in  his  47th  year. 

Some  books  from  his  library  are  now  preserved  in  the 
library  of  Brown  University. 

Hunter,  in  1758,  was  elected  by  the  General  Assembly  to 
the  office  of  Physician  and  Surgeon  General  to  the  Rhode 
Island  Troops.  As  a  Tory  he  was  highly  esteemed  by  the 
British  and  Colonial  Loyalists,  but  when  the  Revolutionary 
War  began  he  was  bitterly  hated  and  denounced  by  Ezra 
Stiles,  President  of  Yale  College,  and  other  eminent  pa- 
triots. The  population  of  Newport  in  1774  was  7917 
whites,  1292  blacks  and  9209  Indians. 

In  the  inventory  of  his  personal  estate  273  drugs  are 
listed  in  amounts  varying  from  a  drachm  of  cinnamon  to 
31  lb.  of  ammonia.  Many  of  these  drugs  have  long  since 
departed  from  our  pharmacies,  and  many  are  unrecogniz- 
able. 


Ei.oerly  persons  who  come  to  us  with  history  of  cold 
or  cough  and  fever,  accompanied  by  rapid  weight  loss  and 
weakness,  should  be  looked  upon  as  highly  suspicious. 
Tuberculosis  in  the  aged  is  just  as  surely  fatal,  and  fre- 
quently much  more  rapidly  so,  than  is  malignant  disease. — 
E.  M.  Norton,  Fairfield,  in  Jl.  Med.  Assn.  Ah.,  Nov, 


646 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


Insulin-Shock  Therapy* 

Otto  Billing,   M.D.,  lAsheville-Durham 

Highland  Hospital — Duke  University 


SINCE  Sakel  gave  his  first  lecture  on  Insulin- 
shock  treatment  before  a  session  of  the 
Vienna  Chamber  of  Physicians  in  1933  many 
articles  have  been  published  in  specialized  journals, 
in  periodicals  for  the  general  practitioner,  and 
many  reports,  by  far  too  detailed,  have  been  made 
to  the  laity.  In  particular,  the  articles  to  the  lay 
public  caused  very  optimistic  expectations  which 
at  times  could  but  discredit  the  treatment.  In  one 
of  such  attempts  to  publicize  the  treatment  recov- 
ery was  reported  after  a  single  shock.  However, 
reliable  statistics  prove  that  much  can  be  done  to 
improve  the  recovery  rate  of  schizophrenic  patients. 
Due  to  situations  bevond  our  control  we  are  not 
able  to  report  to  vou  the  present  condition  of  pa- 
tients whom  we  treated  in  1933  and  1934  in 
Vienna.  Such  a  report  would  be  particularly  help- 
ful since  it  would  reach  back  over  a  period  of  seven 
to  eight  years. 

Not  to  tire  you  with  figures  we  will  quote  only 
briefly  the  findings  of  a  follow-up  study  of  1039 
cases  reported  by  the  New  York  State  Department 
of  Mental  Hygiene.1.  We  selected  this  set  of  sta- 
tistics because  it  impresses  us  as  a  conservative 
one.  It  shows  that  30  days  after  termination  of  the 
treatment  65  per  cent  of  all  patients  were  either 
recovered  or  improved.  In  comparison  only  22  per 
cent  recovered  or  improved  without  treatment. 
However,  two  years  later  the  percentage  in  insulin- 
treated  cases  dropped  from  65  per  cent  to  45  per 
cent.  It  is  interesting  to  note  that  almost  all  of 
the  fully  recovered  cases  could  maintain  their  origi- 
nal gain  and  insulin  recoveries  are  three  to  four 
times  higher  than  spontaneous  recoveries.  The 
authors  of  that  publication  expected  stabilization 
of  the  results  after  two  years  and  that  no  major 
changes  would  take  place  after  that  time. 

We  might  add  that  that  follow-up  study  was 
done  on  cases  regardless  of  duration  of  disease  be- 
fore treatment.  Now  we  know  that  the  best  results 
are  usually  obtained  in  early  cases  with  a  duration 
of  less  than  six  months.  Recently,  we  treated  a 
patient  whose  illness  lasted  over  three  years,  with  a 
steady  increase  of  the  psychosis  and  without  lucid 
intervals.  After  we  started  treatment  the  patient 
began  to  improve  steadily.  We  can  certainly  draw 
the  conclusion  that  this  improvement  was  too 
closely  associated  with  the  beginning  of  treatment 
to  be  incidental.    This  case  demonstrates  that  we 


can  not  be  too  strict  in  setting  the  indications 
when  to,  and  when  not  to,  use  shock  treatment.  In 
general  we  can  expect  that  the  better  the  person- 
ality is  preserved  the  better  the  prognosis.  No 
shock  treatment  can  build  up  a  dilapidated,  emo- 
tionally and  intellectually  reduced  patient.  Before 
we  start  treatment  we  should  ascertain  that  there 
is  something  left  to  build  upon.  The  other  factors 
still  important  are  of  secondary  significance.  Of 
course,  in  most  cases  a  long  duration  will  coincide 
with  a  poor  preservation  of  the  original  personality, 
but  not  necessarily  so.  In  brief,  paranoid  schizo- 
phrenias or  catatonic  excitements  with  well  pre- 
served personality,  whose  psychoses  started  less 
than  six  months  previous  to  the  beginning  of  treat- 
ment, give  the  best  prognosis.  Catatonic  stupor  re- 
sponds better  to  convulsive-shock  treatment.  Some- 
times it  happens  that  patients  show  good  initial 
response  to  convulsive  treatment:  they  improve 
rapidly  at  first  but  soon  slip  back  again.  In  that 
case  we  recommend  continuing  with  insulin  shock. 
On  the  other  hand,  patients  may  respond  very 
slowly  to  insulin ;  in  such  cases  we  may  be  able  to 
hasten  improvement  with  a  few  convulsive  shocks. 
The  prognosis  is  less  hopeful  in  hebephrenic  cases 
and  poor  in  simple  dementia. 

Case  1. — A  24-year-old  white  woman  was  admitted  to 
the  hospital  because  of  persecutory  ideas,  ideas  of  refer- 
ence, acute  excitement  and  assaultiveness. 

This  patient  is  the  youngest  living  child.  There  was 
much  tension  between  her  father  and  mother,  because  of 
the  father's  unfaithfulness.  Many  scenes  occurred  in  the 
patient's  presence.  The  patient  resented  intensely  the 
father's  attitude.  She  married  at  the  age  of  21  an  intel- 
lectually and  socially  inferior  husband.  Dream  material 
suecested  strong  sexual  conflicts  and  dissatisfaction  with 
the  husband. 

Eleven  months  previous  to  admission  she  bore  a  son. 
The  dream  material  revealed  that  the  pregnancy  and  birth 
produced  also  strong  conflicts.  For  several  nights  after  the 
delivery,  while  still  in  the  hospital,  the  patient  was  fright- 
ened by  feeling  that  "someone''  tried  to  come  in  her  room 
through  the  window.  From  then  on  she  was  afraid  in  the 
dark  while  previously  she  was  not.  She  thought  she  would 
be  unable  to  nurse  her  baby  and  began  to  be  very  appre- 
hensive about  its  proper  feeding.  During  the  following 
months  the  patient  became  increasingly  tense.  She  devel- 
oped ideas  of  reference,  thought  that  articles  in  the  papers 
referred  to  her,  that  relatives  and  friends  acted  in  a  pecu- 
liar way  in  order  to  impress  on  her  that  she  was  "silly." 
She  began  to  tear  up  books  which  she  felt  referred  to  her; 
became  assaultive,  struck  her  husband  when  he  wanted  to 
give  her  medicine  which  she  had  been  taking  regularly. 

Insulin-shock  treatment  was  started.  On  the  fourth  day 
of  treatment  she  began  to   show  partial  insight   into  her 


•Read  in  part  to  the  North  Carolina  Neurological  and  Psychia  trie  Association  in  Morganton,  N.  C,  October  24th,  1941. 


December,  1941 


INSULIN-SHOCK  THERAPY— Sillig 


647 


condition  for  the  first  few  hours  after  termination  of  treat- 
ment. "I  feel  crazy  .  .  .  there  is  nothing  wrong  with  me 
except  I  need  someone  to  straighten  me  out  so  I  will  get 
rid  of  those  crazy  ideas  I  have."  During  the  first  week  of 
treatment  this  improvement  was  strictly  associated  with 
the  termination  of  treatment.  In  the  evenings  of  those 
days  she  was  suspicious  again,  prayed  much,  exhibited  a 
good  many  mannerisms. 

After  10  comas  the  patient  revised  spontaneously  many 
of  her  psychotic  ideas;  after  10  more  she  was  free  of  any 
psychotic  symptoms,  and  showed  complete  insight  into  her 
condition.  After  the  first  10  treatments  she  had  already 
become  interested  in  her  surroundings,  associated  with 
other  patients,  spontaneously  took  part  in  conversation, 
showed  good  emotional  response.  The  patient  was  dismiss- 
ed and  is  carrying  on  with  her  usual  work.  In  repeated 
follow-up  examinations  no  pathological  symptoms  could 
be  elicited. 

Success  in  insulin-shock  treatment  depends 
largely  on  choice  of  dosage  adequate  for  producing 
reactions  of  the  proper  duration  and  depth,  at 
appropriate  intervals  and  in  appropriate  total 
number.  To  ascertain  the  correct  shock  dosage  we 
give  before  breakfast  IS  to  25  units  of  insulin  and 
increase  gradually,  first  by  five  or  10  units,  later 
more  until  we  produce  a  coma  of  sufficient  depth. 
The  shock-dosage  is  variable  from  patient  to  pa- 
tient, frequently  even  in  the  same  individual.  In 
our  cases,  the  lowest  insulin  dosage  necessary  to 
produce  deep  coma  was  18  units,  the  highest  400 
units. 

Tn  a  typical  deep  shock  the  patients  become 
somnolent  during  the  first  hour  of  coma,  at  times 
they  are  euphoric;  start  to  perspire  and  become 
hypotonic.  During  the  second  hour  the  conscious- 
ness becomes  increasingly  clouded,  the  psychic 
functions  slowed  and  less  precise;  in  some  patients 
motor  excitement  begins  and  the  psychotic  symp- 
toms may  be  temporarily  aggravated.  During  the 
3rd  hour  the  patients  are  unconscious,  pupils  be- 
come dilated  but  react  to  light,  pulse  rate  and 
motor  restlessness  have  increased,  frequently  the 
face  is  flushed,  the  temperature  has  fallen,  often  as 
low  as  93°  or  even  lower.  During  the  fourth  hour 
an  irregular  distribution  of  tonus  appears  together 
with  generalized,  repeated  torsion  spasms.  Later 
the  pupils  become  small,  react  sluggishly  to  light, 
corneal  reflexes  are  sluggish  and  finally  absent, 
pulse  rate  has  dropped,  respiration  becomes  shal- 
low: the  temperature  has  started  to  rise  again. 

Roughly  speaking,  we  can  differentiate  three 
Stages  during  the  insulin  shock — subshock,  medium 
coma  and  deep  coma.  During  subshock  the  corti- 
cal centers  are  depressed;  we  find  clouded  con- 
sciousness, sometimes  euphoria,  aphasia,  motor 
restlessness,  increased  pulse  rate  during  the  first 
two  hours  after  administration  of  insulin  provided 
the  proper  dosage  is  used.  During  the  3rd  and  4th 
hour  we  find  evidences  of  stimulation  of  the  sub- 
cortical centers — pronounced  motor  excitement, 
fast  pulse,   flushed   face,  dilated   pupils,   primitive 


movements  such  as  athetoid,  choreiform  and  hemi- 
ballistic  movements. 

During  the  deep  coma  the  pupils  are  small  and 
react  very  slightly  or  not  at  all  to  light,  corneal 
reflexes  are  absent,  pulse  rate  is  slow  (around  60), 
there  is  marked  pallor,  respiration  is  shallow,  at 
times  of  Cheyne-Stokes  type.  This  stage  should 
not  be  reached  before  four  to  4)/2  hours  after  ad- 
ministration of  insulin  and  the  patients  should  re- 
main for  one-half  hour  in  this  stage.  We  consider 
it  essential  that  this  stage  be  reached,  as  only 
really  deep  comas  are  helpful.  The  more  super- 
ficial stages  of  insulin  shock  are  only  of  sympto- 
matic help.  This  deep  stage  seems  to  be  due  to  a 
beginning  depression  of  the  vital  centers  in  the 
medulla  oblongata.  At  this  stage  we  terminate  by 
giving  200  grams  of  sugar  in  500  c.c.  of  water  by 
nasal  tube.  A  few  minutes  after  the  administration 
of  sugar  the  shock  may  become  temporarily  deeper 
— the  administered  sugar  is  a  stimulus  for  the  pan- 
creas to' produce  its  own  insulin — but  after  5-10 
minutes  the  patient  begins  to  respond  and  should 
be  fully  awake  after  15-20  minutes,  otherwise  one 
should  give  glucose  by  vein  without  delay. 

Right  after  awakening  the  patient  is  frequently 
euphoric,  often  free  of  psychotic  symptoms,  which 
then  return  one-half  to  one  hour  after  termination ; 
with  additional  treatments  these  lucid  intervals  be- 
come longer  and  longer.  After  the  patient  has  im- 
proved we  may  find  a  very  interesting  reversal  of 
symptoms:  the  patient  no  longer  shows  any 
psychotic  symptoms  during  the  daytime,  only  dur- 
ing the  awakening  period,  and  we  term  this  phe- 
nomenon the  "reactivated  psychosis."  As  long  as 
there  are  such  symptoms,  we  have  to  continue  the 
treatment,  even  when  the  patient  appears  normal 
during  the  rest  of  the  day. 

In  general  we  give  at  least  15  deep  shocks,  the 
number  varying  with  the  great  individual  differ- 
ences. Sakel  advises  giving  several  deep  shocks 
after  all  psychotic  symptoms  have  disappeared,  so 
as  to  stabilize  the  patient's  improved  condition.  If 
we  do  not  see  any  improvement  after  35  shocks, 
we  usually  stop  the  treatment.  Rarely  do  we  give 
more  than  60  shocks. 

I  am  sorry  that  we  do  not  have  time  to  discuss 
fully  (he  possible  complications.  We  are  safe  in 
saying  that  with  care  serious  or  fatal  complications 
can  be  greatly  reduced.  During  the  first  years  of 
treatment  we  considered  spontaneous  convulsions  as 
a  serious  complication.  Today  we  think  them  help- 
ful at  times.  You  will  recall  our  mentioning  that  we 
induce  such  convulsions  purposely  to  influence  the 
course  of  treatment.  If  the  dosage  is  very  high, 
the  hypoglycemic  symptoms  appear  too  early  and 
in  irregular  sequence;  dangerous  signs  come  forth, 
and  we  can  not  safely  keep  the  patient  sufficiently 


INSULIN-SHOCK   THERAPY— Billig 


December,  1941 


long  in  the  coma.  Sudden  respiratory  or  vasomotor 
failure  may  appear.  The  most  serious  and  impor- 
tant complication  is  the  protracted  or  prolonged 
shock  from  which  the  patient  does  not  awaken  even 
after  repeated  administration  of  sugar  by  tube  or 
vein;  the  blood  sugar  has  reached  normal,  at  times 
higher  than  normal  values;  however,  the  patients 
are  restless,  do  not  respond,  temperature  is  ele- 
vated, pulse  and  respiration  are  increased.  A  few 
of  these  patients  die  of  cardiovascular  complica- 
tions. However,  in  most  of  these  cases  recovery  is 
brought  about  after  several  hours,  often  after  days; 
and  the  majority  of  such  patients  are  definitely 
improved  mentally.  A  case  will  illustrate  this  to 
you. 

Case  2. — A  19-year-old  college  student  of  a  prominent 
Alabama  family  was  admitted  to  our  hospital.  There  are 
several  outspoken  schizophrenic  psychoses  and  schizoid 
personalities  among  the  relatives.  The  patient  was  in 
extremely  unstable  surroundings  among  more  or  less 
psychotic  relatives.  The  father  in  particular  was  unstable 
drank  heavily  and  gambled  a  great  deal.  The  mother  sep- 
arated from  him  in  the  patient's  early  childhood. 

From  his  2nd  to  his  3rd  year  the  patient  was  very  un- 
stable and  had  temper  tantrums.  In  his  later  years  of 
childhood  he  became  more  quiet  and  was  not  further  con- 
spicuous; he  made  a  number  of  good  friends  and  mingled 
well.  In  school  he  was  prone  to  be  a  leader  up  to  four 
years  previous  to  admission  to  our  hospital. 

Around  that  time  he  began  to  have  difficulties  in  con- 
centrating, his  school  work  became  difficult  for  him;  he 
dropped  in  his  grades,  became  preoccupied  with  religious, 
philosophical  and  political  problems,  was  seclusive,  began 
to  hear  voices,  developed  ideas  of  reference.  During  the 
next  several  months  he  became  manneristic,  showed  object- 
less laughter  and  scattering.  He  developed  ideas  of  gran- 
deur, became  very  impulsive.  Just  before  being  started  on 
insulin-shock  treatment  he  had  written  a  letter  to  Presi- 
dent Roosevelt  addressing  him  as  "Dear  Franklin."  He 
asked  in  this  letter  that  all  gangsters  should  be  instantly 
killed  and  signed  it  "The  Leader  of  Humanity."  On  the 
ward  he  adopted  an  arrogant  attitude  typical  of  so  many 
schizophrenics. 

After  awakening  from  his  first  shock  he  was  pleasant, 
polite,  thanked  the  nurse  for  her  assistance;  however,  his 
presumptuous  behavior  returned  after  several  hours.  The 
second  shock  was  protracted,  lasting  13  hours.  After  th? 
patient  reacted  from  this  he  was  pleasant,  cooperative,  his 
superior  attitude  had  completely  disappeared  and  did  not 
return;  he  began  to  show  interest  in  his  surroundings  and 
was  far  less  introspective  and  preoccupied  and  took  great 
interest  in  the  hospital  activities.  While  the  patient  was 
extremely  resentful  previous  to  that  protracted  shock  he 
then  became  appreciative  and  showed  partial  insight. 

After  a  pause  of  10  days  the  shock  treatment  was  re- 
sumed. He  again  showed  delayed  awakening  from  his 
eleventh  shock,  was  extremely  restless,  temperature  106.4, 
pulse  198,  respiration  64.  However,  this  shock  lasted  5 
hours  less  than  the  first  prolonged  shock.  The  patient  re- 
mained drowsy  for  several  days.  After  he  recovered  from 
those  effects  his  general  conversation  appeared  orderly, 
without  scattering;  hallucinations,  objectless  laughter,  ideas 
of  grandeur  had  all  disappeared. 

We  have  mentioned  that  one  of  the  most  impor- 
tant factors  in  treatment  is  the  sufficient  depth  of 
coma.    The  other  factor  is  the  psychotherapeutic 


approach.  According  to  Orenstein  and  Schilder* 
the  shock  treatment  acts  on  the  deep  organic  struc- 
tures of  the  personality.  Based  upon  this  action  on 
the  deeper-lying  organic  layers  there  occurs  a  re- 
evaluation  of  the  personality  problems.  Frequently 
the  patient  may  notice  this  himself,  as  one  of  our 
patients  said:  "That  insulin  stuff  changes  my  per- 
sonality ...  at  first  people  looked  drawn  up  in  a 
shell,  looked  aloofly  disinterested  in  what  I  was 
doing  .  .  .  now  they  look  more  relaxed  and  less 
like-  in  a  shell."  The  patients  who  are  on  the  way 
to  recovery  are  often  very  perplexed  about  the 
value  of  their  psychotic  ideas.  In  several  cases 
they  asked  spontaneously  to  be  allowed  a  diary. 
This  is  a  very  important  stage  during  which  the 
patients  need  an  unobtrusive  and  very  cautious 
psychotherapy.  They  are  now  vulnerable  and  sus- 
ceptible to  psychic  trauma.  During  this  stage  al- 
most all  patients  form  a  strong  transference  to  the 
therapist.  Because  of  this  it  is  obvious  that  there 
should  be  only  one  psychotherapist,  preferably  the 
physician  who  gives  the  treatment.  It  is  also  ad- 
visable that  another  physician  take  over  the  han- 
dling of  the  administrative  affairs  which  otherwise 
might  give  occasion  to  cause  disturbing  tension. 
For  similar  reasons  the  shock  patient  should  not 
discuss  with  other  patients  the  symptoms  and  treat- 
ment. 

In  many  cases  deep  insulin  shock  may  not  be 
desired  for  one  reason  or  another,  as  was  pointed 
out  in  discussing  indications  for  deep  shock  in  the 
beginning.  However,  many  mental  patients  of  va- 
ried type  might  become  difficult  to  manage;  they 
become  aggressive  or  extremely  excited.  These 
conditions  require  either  intensive  hydrotherapy, 
physical  restraint,  or  high  doses  of  sedatives.  Con- 
tinuous use  of  large  doses  of  sedatives  depress  res- 
piration and  circulation,  and  the  risk  of  manifesta- 
tions of  toxic  delirium  in  the  form  of  increasing 
excitement  and  hallucinations  is  great.  In  such 
cases  insulin  in  subshock  doses  can  replace  seda- 
tive drugs  to  a  great  extent." 

Case  3. — A  55-year  old  white  woman  has  been  institu- 
tionalized for  the  last  21  years  with  the  diagnosis  schizo- 
phrenia. She  has  been  hallucinated,  untidy  and  very  irri- 
table at  times.  Several  weeks  previous  to  insulin  treatment 
she  became  increasingly  confused,  destructive  and  assaul- 
tive. While  she  was  oriented  before  this  exacerbation 
she  became  disoriented,  very  incoherent  and  distractiblc. 
She  was  started  on  subshock  doses  of  insulin  which  were 
gradually  built  up  to  60  units  twice  a  day.  With  such 
doses  she  became  somnolent,  perspired  freely  and  could  be 
aroused  only  with  great  difficulty.  After  the  first  of  those 
treatments  the  patient  became  more  accessible,  pleasant 
and  cooperative.  This  improvement  lasted  for  two  hours 
on  the  first  day.  The  next  day,  two  hours  after  adminis- 
tration of  insulin  the  patient  became  restless  and  was 
irritable.  Prior  to  treatment  reassurance  did  not  help  but 
she  responded  well  during  the  hypoglycemia:  "I  feel  so 
irritable.    I  know  I  am  going  to  kick  somebody  again.    I 


December,  1941 


INSULIN-SHOCK   THERAPY— Billig 


649 


am  afraid  it  will  be  just  like  it  was  .  .  .  sickness  is  so 
hard  to  understand."  The  cooperative  periods  became 
longer  after  each  treatment  and  soon  lasted  over  the  whole 
day.  To  stabilize  the  improvement  we  continued  for  two 
more  weeks.  After  that  time  the  patient  was  quiet  and 
pleasant,  could  resume  her  piano  lessons  and  she  was  again 
able  to  attend  movies  and  to  leave  the  hospital  for  short 
rides.  The  difficult  nursing  problem  created  by  her  un- 
cooperative behavior  was  relieved  and  the  patient  herself 
got  more  pleasure  out  of  routine  hospital  activities  and 
trips  to  town. 

This  case,  as  do  many  others,  shows  that  with 
subshock  treatment  we  can  shorten  exacerbations 
of  even  old  schizophrenic  psychoses.  Without  treat- 
ment, the  patients  deteriorate  more  and  more  dur- 
ing such  acute  episodes  and  rarely  return  to  the 
same  level  after  such  a  flare-up.  With  subshock 
doses  of  insulin  we  are  not  only  able  to  shorten 
those  exacerbations  but  we  can  also  prevent  such 
deteriorations.  In  previous  attacks  when  we  had 
not  given  those  treatments  the  patient  had  always 
lost  ground  and  never  returned  to  the  same  level. 

Another  indication  for  subshock  technique  is 
when  patients  refuse  to  take  food  and  constant 
tube-feeding  brings  the  risk  of  aspiration  pneumo- 
nia and  ulcerative  and  traumatic  lesions  of  the 
mucous  membranes  of  the  nose  and  throat.  Under 
insulin  the  appetite  is  acutely  stimulated  and  the 
psychotic  delusions  preventing  eating  may  become 
less  intense;  thus  the  feeding  problem  is  usually 
solved  after  a  few  treatments. 

Case  4. — A  white  man,  39,  with  general  paresis  showing 
a  clinical  picture  of  hypochondriasis  of  depressed  type, 
refused  to  take  food  so  it  was  necessary  to  use  gavage. 
After  the  first  subshock  he  drank  his  tube-feeding;  after 
three  days  of  this  he  began  taking  solid  food  and  continued 
doing  so  for  months. 

The  use  of  insulin  in  subshock  doses  in  the  treat- 
ment of  narcotic  withdrawal  symptoms  is  well 
known.  Sakel  used  it  before  he  started  the  deep- 
shock  treatments  in  schizophenia.  Some  of  the 
drug  addicts  underwent  such  sudden  personality 
changes  after  an  incidental  shock  that  it  caused 
him  to  work  out  the  classical  shock  treatment. 
Subshock  doses  of  insulin  make  the  withdrawal 
symptoms  far  less  intense;  therefore  it  is  possible 
to  replace  morphine  by  the  subshock  hypoglycemia, 
discontinuing  morphine  completely  and  at  once. 
This  shortens  the  period  of  withdrawal  symptoms 
and  enables  us  to  use  this  time  for  reconstructive 
psychotherapy. 

For  similar  reasons  we  use  subshock  doses  also 
in  cases  of  acute  alcoholism  as  a  preventive  of  de- 
lirium tremens,  alcoholic  pseudoepilepsy  etc.,  al- 
though symptoms  of  avitaminosis  require  the  usual 
vitamin  therapy  as  an  adjunct. 

Case  5. — A  37-year-old  white  man  was  admitted  to  our 
hospital  with  signs  of  acute  intoxication.  He  was  disori- 
ented, hallucinated,  perspired  and  showed  coarse  tremor. 
His  pulse  was  fast  and  irregular. 


The  patient  received  30  units  of  insulin  daily  for  the 
first  three  days.  Already  on  the  second  day  the  hallucina- 
tions had  disappeared,  he  became  oriented  and  the  pulse 
was  of  good  quality.  In  the  afternoon  of  the  fourth  day 
(the  day  after  insulin  was  discontinued)  the  patient  had 
two  grand-mal  convulsions  within  three  hours.  After  the 
patient  was  started  on  insulin  again  none  of  the  convul- 
sions returned  and  after  six  more  days  insulin  could  be 
permanently  discontinued. 

From  these  case  histories  we  can  see  verified  uses 
of  insulin  subshock  treatments.3  In  a  few  words, 
that  treatment  is  indicated  in  all  cases  in  which  it 
is  desired  to  quiet  the  excited  patient  or  to  make 
antagonistic  and  negativistic  patients  more  coopera- 
tive. The  technique  is  very  simple  and  does  not 
require  special  equipment  or  a  specially  trained 
personnel.  The  general  practitioner  can  give  those 
treatments  without  any  previous  experience.  The 
technique  of  this  treatment  is  as  follows: 

We  start  with  10  units  of  insulin  at  7:00  a.  m.,  omitting 
breakfast,  and  stop  three  hours  later  with  a  glass  of  sugar- 
ed water  (60-100  Gm.  sucrose)  ;  or,  better,  a  glass  of  orange 
juice  also  sugared.  We  do  this  whether  or  not  the  patient 
shows  symptoms  of  hypoglycemia.  At  each  injection  (7 
a.  m.,  2  and  7  p.  m.)  we  increase  the  dose  by  S  units  until 
a  slight  hypoglycemic  stage  is  reached — the  patient  begins 
to  perspire,  often  complains  of  being  hungry,  weak  and 
drowsy;  sometimes  there  is  diplopia.  This  stage  should 
appear  2-2Vz  hours  after  the  injection.  We  leave  the  pa- 
tients in  this  stage  for  y2-l  hour  and  stop  when  they  be- 
come increasingly  drowsy  and  the  speech  thickens.  If  the 
dose  is  sufficient  these  symptoms  appear  3  hours  after 
administration  of  insulin.  If  these  signs  appear  earlier  the 
next  dose  has  to  be  decreased.  Often  it  is  necessary  to 
give  a  higher  dose  in  the  morning  and  the  next  two  doses 
5-10  units  less.  Apparently,  the  body  does  not  utilize  all 
the  insulin  of  the  previous  treatments  of  the  same  day. 
After  the  termination  of  the  morning  dose  the  patients 
have  breakfast.  Lunch  and  supper  are  given  at  the  usual 
hours,  1:00  and  6:00  p.  m.,  and  a  light  meal  after  the  ter- 
mination of  the  last  injection  at  10  p.  m.  Should  a  patient 
go  into  coma  he  is  easily  awakened  by  sugar  (20-40  c.c. 
of  a  33  1/3%  or  50%  glucose  solution)  given  by  intra- 
venous injection. 

Syringes  and  nasal  tube  should  always  be  ready  for 
emergencies.  Muscular  twitching  may  occur,  but  it  is 
harmless.  It  can  be  easily  differentiated  from  a  true  epilep- 
tiform seizure  by  the  absence  of  sudden  unconsciousness, 
cyanosis,  pupillary  signs  etc.  The  muscular  twitching  is  no 
indication  to  terminate  the  subshock.  During  the  rest  of 
the  day  we  watch  for  drowsiness,  perspiration,  pallor, 
weakness,  restlessness,  excitement  with  or  without  hunger 
in  an  otherwise  quiet  patient.  We  give  immediately  sugar- 
ed water  to  drink  when  such  reactions  occur. 

If  the  patient's  condition  is  improving  we  stop  the  even- 
ing dose  of  insulin  to  relieve  the  need  of  close  supervision 
during  the  night  sleep;  but  we  continue  the  treatment  for 
several  days  even  after  the  desired  effect  is  reached  in  order 
to  stabilize  the  improvement. 

We  have  tried  to  show  that  insulin  shock  and 
subshock  treatment  can  be  of  great  help  in  many 
cases.  The  shock  treatment  may  appear  very  ex- 
pensive; the  immediate  costs  are  high,  but  even 
careful  statistics  as  I  have  mentioned  in  the  begin- 
rting  show  that  the  immediate  increase  of  expenses 
is  overshadowed  by  the  financial  gain  due  to  the 

{To   Page   653) 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


The  Management   of  Epidemic  Respiratory   Diseases* 

Russell  L.  Cecil,  M.D.,  New  York  City 


THE  SUBJECT  assigned  for  my  discussion 
tonight  covers  considerable  territory,  for 
we  must  assume  that  the  management  of 
acute  coryza,  epidemic  influenza  and  influenzal 
pneumonia,  but  also  streptococcal  sore  throat,  per- 
tussis, measles  and  scarlet  fever.  All  of  these  res- 
piratory diseases  were  seen  in  epidemic  form  during 
the  last  world  war,  and  most  of  them  can  be  ex- 
pected for  a  return  visit  if  we  continue  to  retain 
large  groups  of  young  men  in  barracks  for  military 
training.  Tonight,  however,  I  propose  to  devote 
most  of  my  time  to  a  discussion  of  the  prevention 
and  treatment  of  influenza  and  its  complications. 
The  management  of  pertussis,  measles  and  scarlet 
fever  is  so  much  in  the  domain  of  the  pediatrician 
that  I  should  hesitate  to  invade  the  field.  It  should 
be  noted,  however,  that  with  the  exception  of  per- 
tussis and  the  streptococcal  infections,  all  of  these 
epidemic  respiratory  infections  fall  into  the  realm 
of  the  virus-borne  diseases. 

The  nature  of  viruses  is  not  definitely  known. 
There  are  several  theories,  however,  which  should 
receive  considerable  support:  First,  that  they  are 
entirely  inanimate  incitants  ol  disease,  like  the 
virus  of  tobacco  mosaic  which  Stanley  has  shown 
to  be  a  nucleoprotein  and  obtainable  regularly  in 
crystalline  form.  Stanley's  work  is  of  the  greatest 
importance  and  bids  fair  to  throw  an  entirely  new 
light  on  the  nature  of  the  virus  problem.  Other 
viruses,  such  as  the  agent  of  yellow  fever,  may 
represent  forms  of  life  as  yet  unfamiliar  to  the 
bacteriologist,  while  the  virus  of  vaccinia  may,  as 
Rivers  expresses  it,  be  a  midget  in  the  microbial 
world  since  it  contains  protein,  fats  and  carbohy- 
drates similar  to  those  found  in  many  bacteria. 
One  thing  the  virus  diseases  have  in  common. 
None  of  them  has  been  cultivated  in  the  absence 
of  living  cells.  Therefore,  dead  or  alive,  they  may 
be  considered  as  obligate  parasites.  Most  virus 
diseases  are  followed  by  permanent  immunity,  but 
there  are  exceptions  such  as  the  common  cold  and 
herpes  simplex.  Even  herpes  zoster  may  occur 
repeatedly  in  the  same  individual. 
Acute  Coryza 
It  has  now  been  shown  by  numerous  observers 
that  the  nasal  secretions  of  persons  suffering  from 
a  fresh  cold  contain  an  ultramicroscopic  virus 
which,  when  instilled  into  the  nostrils  of  normal 
individuals,  produces  the  disease.  Dochez  and  his 
co-workers  have  succeeded  in  cultivating  this  virus 

*Part  of  a  Symposium  on   Problems  of  Civil  and  Military  Emerge: 


in  tissue  media,  and  even  after  forty  to  fifty  pas- 
sages the  virus  is  still  capable  of  transmitting  the 
disease  to  man.  Complications  of  the  common  cold, 
such  as  sinusitis,  otitis  media,  mastoiditis  and 
bronchitis  and  pneumonia  are  the  results  of  sec- 
ondary bacterial  invaders.  It  has  been  shown  that 
fresh  colds  are  more  contagious  than  colds  of  sev- 
eral days'  duration.  Colds  are  more  common  in 
winter  than  in  summer,  but  perhaps  not  so  much 
from  the  differences  in  temperature  as  from  the 
inevitable  crowding  during  the  winter  months,  espe- 
cially in  the  schools. 

Influenza 

Influenza  is  a  highly  infectious  disease  which 
occurs  most  frequently  in  epidemic  and  pandemic 
outbreaks,  during  which  it  spreads  with  great 
rapidity.  In  ordinary  times  it  is  sometimes  difficult 
to  distinguish  a  mild  case  of  influenza  from  a 
severe  coryza.  Certainly  there  are  borderline 
cases  which  are  always  difficult  to  classify. 
However,  in  times  of  great  epidemics  of  influ- 
enza the  clinical  pictures  become  quite  charac- 
teristic. The  onset  is  usually  sudden  with 
chilliness,  marked  general  malaise,  severe  headache 
and  general  muscular  aching  throughout  the  body, 
but  especially  in  the  back  and  extremities.  The 
prostration  is  quite  marked,  sometimes  extreme. 
The  temperature  rises  rapidly  to  103-4°,  or  even 
higher.  The  pulse  and  respiration  are  accelerated. 
The  patient  appears  listless  and  often  the  face, 
neck  and  upper  thorax  are  deeply  flushed.  The 
conjunctivae  are  injected  and  the  pharyngeal  mu- 
cosa is  intensely  reddened.  Shortly  after  onset  the 
sore  throat  or  rhinitis  makes  its  appearance,  though 
in  not  a  few  cases  the  local  symptom  is  a  dry 
hacking  cough.  Cases  of  influenza  have  been  re- 
ported in  which  there  were  no  respiratory  symp- 
toms, but  all  agree  that  this  is  an  extremely  rare 
phenomenon. 

Influenza,  like  the  common  cold,  has  been  proven 
to  be  a  virus-borne  disease.  For  many  years  the 
haemophilus  influenzae  was  looked  upon  as  the  spe- 
cific cause  of  the  disease,  but  in  1933,  Smith,  An- 
drews and  Laidlaw  succeeded  in  isolating  a  filtra- 
ble  virus  from  patients  with  influenza  by  inocu- 
lating ferrets  intranasally  with  filtrates  of  throat 
washings  from  early  cases.  The  infection  was 
then  transmitted  from  ferret  to  ferret  and  subse- 
quently to  mice.  Francis  has  cultivated  the  pas- 
sage virus  in  tissue  medium  and  demonstrated  the 


Duke  University  School  of  Medi< 


October  16th-18th. 


December,  1941 


MANAGEMENT  OF  EPIDEMIC  RESPIRATORY  DIS  EASES— Cecil 


appearance  of  antibodies  in  the  blood  of  persons 
convalescing  from  influenza.  It  has  also  been 
shown  by  Andrews  that  different  pandemics  of 
influenza  may  be  caused  by  immunologically  dis- 
tinct races  of  viruses. 

As  yet  we  have  no  practical  laboratory  tests  for 
the  diagnosis  of  influenza.  The  antibodies  of  course 
appear  after  the  disease  is  over  and  are  therefore 
of  no  practical  importance  from  the  standpoint  of 
diagnosis. 

The  methods  of  treatment  of  these  two  preva- 
lent and  important  infections  are  similar,  but 
perhaps  may  best  be  discussed  separately.  For 
example  we  have  not  yet  reached  the  Utopian  state 
in  which  every  victim  of  the  common  cold  would 
be  put  to  bed  and  kept  there  until  his  symptoms 
disappeared.  Such  a  drastic  therapy  would  prob- 
ably be  better  for  the  patient  and  certainly  much 
better  for  the  community  in  general.  I  know  of  no 
group  of  workers  who  are  systematically  put  to  bed 
for  acute  coryza  except  trained  nurses.  In  the  New 
York  Hospital  this  is  routine  treatment.  As  a  re- 
sult there  is  a  minimum  spread  of  colds  from  nurse 
to  nurse  and  from  nurse  to  patient  and  a  small 
incidence  of  complications  among  the  nurses  who 
have  the  colds.  So  far  as  actual  treatment  of  the 
common  cold  is  concerned  it  may  be  classified  as 
local  and  general.  Spraying  and  gargling  with 
antiseptics  is  much  advertised  by  manufacturers  of 
patent  cold  killers,  but  is  ineffectual  because  it  is 
impossible  to  free  the  mucous  membrane  completely 
of  bacteria  by  this  method.  Perhaps  the  safest  and 
best  of  all  sprays  and  gargles  is  the  hot  saline  solu- 
tion. Occasionally  colds  can  be  checked  in  the 
early  stage  by  the  local  application  of  silver  nitrate 
or  10  per  cent  argyrol.  Usually,  however,  the  cold 
has  a  good  start  before  the  application  is  made. 
The  common  cold  usually  lasts  only  three  to  four 
days,  hence  the  treatment  should  be  mainly  for  the 
symptoms  as  they  arise.  Rest  should  be  made  im- 
perative if  the  temperature  is  100°  or  over,  or  if 
the  patient  is  a  victim  of  any  chronic  systemic 
disease,  such  as  diabetes  mellitus,  nephritis,  rheu- 
matic fever,  heart  disease  or  tuberculosis.  Striking 
relief  is  offered  by  some  of  the  coal-tar  derivatives, 
such  as  the  well-known  APCC  capsule  consisting 
of  codein,  aspirin,  phenacetin  and  caffein.  In  some 
patients  colds  will  be  completely  aborted  by  the 
popular  codein  and  papaverein  capsule  consisting 
of  codein  sulfate  34  grain,  papaverein  hydrochlorid 
l/\  grain.  Three  of  these  capsules  may  be  taken  as 
often  as  every  three  hours. 

Symptomatic  relief  can  be  readily  obtained  from 
a  one  per  cent  solution  of  cocain,  but  helpful  as 
this  is,  it  should  rarely  be  used  because  of  the  ob- 
vious danger  of  addiction.  Spraying  with  a  1.5  per 
cent  solution  of  ephedrin  hydrochlorid  will  relieve 


nasal  congestion  for  several  hours;  also  the  fumes 
of  benzedrine  or  menthol  are  very  helpful  for  re- 
lieving stuffiness  in  the  nose  and  throat  and  main- 
taining adequate  drainage  from  the  sinuses. 

The  treatment  of  influenza  is  still  almost  entirely 
symptomatic,  as  no  specific  cure  has  yet  been  dis- 
covered. The  most  important  part  of  the  treatment 
is  absolute  rest  in  bed  until  convalescence  is  well 
established.  Fluids  should  be  forced,  about  4000 
c.c.  daily  during  the  febrile  stage.  The  patient 
should  be  on  a  light  diet  and  alcohol  in  the  form 
of  whisky  or  brandy  can  be  used  for  stimulation. 
The  usual  remedies  should  be  employed  for  head- 
ache, persistent  cough  and  insomnia.  A  favorite 
mixture  for  inhalation  is  equal  parts  of  menthol, 
creosote  and  chloroform. 

The  most  serious  complication  of  influenza  is 
influenzal  pneumonia.  This  occurs  in  5-15  per  cent 
of  all  influenza  patients.  The  pneumonia  may  be 
primarily  of  virus  origin,  but  nearly  always  there 
is  a  mixed  infection  with  haemophilus  influenzae 
and  one  of  the  more  common  pathogenic  cocci, 
such  as  the  pneumococcus,  streptococcus  or  staph- 
ylococcus aureus.  In  influenzal  pneumonia  the 
pneumococci  present  are  usually  of  the  higher  types. 
During  the  epidemic  of  1918,  a  good  many  of  the 
more  serious  cases  were  caused  by  hemolytic  strep- 
tococci. Influenzal  pneumonia  varies  from  an  ordi- 
nary mild  broncho-  or  lobar  pneumonia  to  an  in- 
tense and  rapidly  fatal  hemorrhagic  pneumonia  ac- 
companied by  edema  of  the  lungs.  This  fulminat- 
ing form  is  very  alarming  and  many  of  the  patients 
in  the  last  epidemic  died  within  twenty-four  hours 
of  the  onset  of  the  pneumonic  symptoms. 

The  treatment  of  influenzal  pneumonia  does  not 
differ  essentially  from  the  treatment  of  pneumonia 
in  general.  During  the  epidemic  of  1918  we  had 
only  Type  I  serum  with  which  to  combat  pneu- 
monia in  a  specific  way.  Since  then  serums  for  the 
various  types  of  pneumococci  have  been  developed, 
but  far  more  important  has  been  the  discovery  of 
the  sulfonamid  drugs  as  a  specific  agent  for  con- 
trolling pneumonia  of  nearly  all  types.  Certainly 
nearly  all  pneumococcal  and  streptococcal  pneumo- 
nias should  be  quite  amenable  to  chemotherapy, 
and  probably  the  occasional  staphylococcus  and 
Friedlander  pneumonias  would  respond  to  some 
extent  to  these  remarkable  agents.  In  our  rather 
extensive  experience  with  chemotherapeutic  agents 
at  Bellevue  Hospital,  we  have  reached  two  rather 
important  conclusions:  (1)  That  sulfadiazine  is  the 
least  objectionable  of  all  the  sulfonamids  from  the 
standpoint  of  toxicity,  yet  possesses  all  the  curative 
power  of  sulfapyridine  and  sulfathiazole.  (2)  Ac- 
cording to  the  careful  statistical  study  recently 
published  by  Plummer  and  others  from  our  Belle- 
vue service,  the  combination  of  specific  serum  with 


MANAGEMENT  OF  EPIDEMIC  RESPIRATORY  DIS  EASES— Cecil 


December,  1941 


sulfonamids  in  the  treatment  of  pneumonia  has 
proved  no  more  efficacious  than  the  sulfonamid 
alone.  Theoretically  the  combination  should  be 
more  effective,  but  practically,  sulfonamids  seem  to 
be  able  to  save  nearly  all  cases  that  can  be  saved 
by  any  form  of  treatment. 

Prophylaxis 
The  prevention  of  the  common  cold  is  still  an 
unsolved  problem,  chiefly  because  the  sanitarian 
has  no  way  of  preventing  contact  of  the  patient 
with  crowds.  Sprays  and  gargles  are  disappointing 
and  irrigations  are  apt  to  impair  the  natural  mech- 
anism of  elimination.  Bacterial  vaccines  are  of 
limited  value,  though  they  seem  to  give  some  indi- 
viduals definite  protection.  Attempts  to  immunize 
against  the  virus  of  the  common  cold  have  thus 
far  been  unsuccessful.  In  many  cases,  especially  in 
children,  the  removal  of  a  focus  of  infection  in  the 
tonsils  or  sinuses  will  cause  a  marked  reduction  in 
the  number  of  colds.  Exposure  to  chilling  and  out- 
door hardships  is  sometimes  recommended  to  in- 
crease resistance  to  colds,  though  this  is  probably 
of  limited  value.  The  same  applies  to  ultraviolet 
radiation  and  vitamins. 

With  respect  to  influenza,  isolation,  as  in  the 
case  of  the  common  cold,  is  a  preventive  measure 
of  some  value,  though  influenza  is  so  extremely 
contagious  that  in  times  of  pandemic,  isolation 
has  proved  to  be  a  rather  impractical  procedure. 

It  has  been  shown  by  several  investigators  that 
ferrets  and  mice  can  be  successfully  immunized 
against  the  experimental  disease  and  that  protec- 
tive antibodies  develop  in  the  blood  serum  of  human 
subjects  following  the  subcutaneous  injection  of  the 
influenza  virus  culture. 

Immunization  against  influenza  is  complicated 
by  the  fact  that  there  appear  to  be  more  than  one 
type  of  influenza  virus.  However,  the  so-called  in- 
fluenza virus  has  certainly  been  responsible  for  a 
certain  number  of  recent  epidemics.  As  time  goes 
on,  it  will  probably  be  shown  that  a  good  many 
epidemics  were  caused  by  a  different  virus.  The 
recovery  and  identification  of  influenza  A  virus 
from  the  throat  of  a  patient  with  influenza  can  not 
be  accomplished  in  less  than  three  weeks.  Serologi- 
cal tests  for  antibodies  are  more  quickly  carried 
out,  but  in  either  the  case  of  the  complement  fixa- 
tion test  or  the  neutralization  test,  sufficient  time 
must  elapse  between  the  onset  of  the  disease  and 
the  day  on  which  the  convalescent  serum  is  ob- 
tained for  the  production  of  additional  antibodies 
by  patients  infected  with  the  virus.  This  usually 
requires  from  ten  days  to  two  weeks. 

Recently  Horsfall  and  Lennette7  have  shown 
that  a  formalized  complex  vaccine  containing  both 


influenza  A  virus  and  canine  distemper  virus  was 
effective  in  the  immunization  of  ferrets  against 
antigenically  different  strains  of  the  influenza  A 
virus.  Such  a  combination  will  undoubtedly  be 
tried  extensively  in  vaccinating  human  beings  if 
an  extensive  epidemic  should  break  out  during  the 
present  war,  and  there  is  good  theoretical  evidence 
that  such  a  vaccine  might  prove  of  real  practical 
value  in  preventing  the  disease. 

The  most  important  problem  in  this  whole  ques- 
tion of  common  colds  and  particularly  influenza  is 
the  prevention  of  complications.  There  is  plenty 
of  evidence  to  show  that  patients  who  return  to 
their  routine  life  and  occupation  too  soon  after 
any  kind  of  a  respiratory  infection  are  more  prone 
to  complications  than  those  who  exercise  more  pa- 
tience and  wait  until  they  are  completely  recovered 
from  the  infection.  During  the  winter  and  spring 
months  the  noses  and  throats  of  most  people  con- 
tain pathogenic  bacteria  which  are  quite  capable  of 
starting  up  any  kind  of  secondary  infection  once 
the  barriers  have  been  lowered  by  an  attack  of 
coryza  or  influenza.  In  the  prevention  of  compli- 
cations we  must  again  depend  largely  on  isolation, 
that  is  the  protection  of  an  infected  individual  from 
his  family  and  friends  while  his  resistance  is  low- 
ered. We  discovered  during  the  last  World  War 
that  patients  with  influenza  could  not  be  put  into  a 
general  medical  ward  without  running  grave  risks 
of  secondary  infection,  particularly  pneumonia. 
Those  of  us  who  worked  through  the  last  epidemic 
were  convinced  after  it  was  over  that  many  lives 
could  have  been  saved  by  complete  isolation  of 
soldiers  with  influenza.  Obviously  the  isolation  of 
so  many  sick  individuals  presented  serious  practi- 
cal difficulties,  but  if  these  could  have  been  over- 
come, the  frightful  toll  of  deaths  exacted  by  the 
pandemic  of  1918  could  have  been  very  much  low- 
ered. 

One  question  which  usually  has  to  be  raised  in 
the  case  of  an  influenza  epidemic  would  be  whether 
sulfonamid  therapy  should  be  applied  as  a  prophy- 
lactic agent  during  the  course  of  clinical  influenza. 
It  is  now  pretty  well  recognized  that  the  sulfona- 
mids have  no  specific  effect  on  either  the  common 
cold  or  influenza,  and  most  practitioners  are 
strongly  opposed  to  their  use  in  these  infections, 
feeling  that  the  danger  of  toxic  reactions  which 
accompanies  the  administration  of  sulfonamids  far 
outweights  any  practical  benefit  which  they  might 
confer  on  a  patient  as  a  protection  against  com- 
plications. This  is  a  problem  which  will  require 
considerable  investigation.  For  the  time  being  it 
would  seem  that  the  sulfonamid  drugs  should  not 
be  used  at  all  during  the  course  of  coryza  or  influ- 
enza, except  perhaps  in  very  small  doses. 


December;  1941 


MANAGEMENT  OF  EPIDEMIC   RESPIRATORY   DIS EASES— Cecil 


653 


The  treatment  and  control  of  epidemic  sore 
throat,  measles  and  pertussis  are  problems  which 
we  can  not  discuss  tonight.  The  treatment  of  these 
infections  is  simple  enough,  as  long  as  serious  com- 
plications can  be  avoided.  Here,  however,  as  in  the 
case  of  influenzal  pneumonia,  the  serious  pulmonary 
complications  of  streptococcal  sore  throat,  pertussis 
and  measles  should  be  quite  amenable  to  control 
by  modern  chemotherapy. 

Finally,  therefore,  we  conclude  that  the  physi- 
cian and  the  health  officer  can  now  approach  the 
problem  of  epidemic  respiratory  infections  with  a 
considerable  degree  of  confidence  and  optimism. 
The  situation  is  far  different  from  that  which  ex- 
isted twenty-three  years  ago  during  the  pandemic 
of  1918.  The  terror  which  prevailed  then  among 
doctors  and  laymen  can  hardly  be  realized  now. 
Today,  however,  we  have  a  promising  virus  vaccine 
which  may  help  materially  in  controlling  influenza, 
as  well  as  sulfonamid  therapy,  which  should  be  of 
tremendous  aid  in  the  control  of  the  serious  com- 
plications. Thus,  fortunately,  we  have  every  reason 
to  face  the  future  with  courage 

— 33  East  61st  Street 


INSULIN-SHOCK  THERAPY— Billings 


possibility  of  an  early  discharge  of  the  patient. 
Many  years  of  hospitalization  can  be  saved  to  the 
community  and  persistent  treatment  may  reduce 
the  population  of  already  overflowing  mental  hos- 
pitals to  a  great  extent.  What  a  patient's  recovery 
means  to  the  patient  and  family  we  do  not  need  to 
mention. 

Bibliography 

1.  J.  B.  Ross,  J.  M.  Rossman,  W.  B.  Cline,  O.  J.  Schwo- 
erer,  B.  Malzberc:  The  Pharmacological  Shock  Treat- 
ment of  Schizophrenia.  Amer.  Jour,  of  Psychiatry,  97: 
1007   (March),  1941. 

2.  L.  L.  Orensteln  and  P.  Schilder:  Psychological  Con- 
siderations of  the  Insulin  Treatment  of  Schizophrenia. 
Jour,  of  Nervous  &  Mental  Diseases,  Oct.,  1938. 

3.  0.  Billig  and  D.  J.  Sum.ivan:  Insulin  Shock  and  Sub- 
shock  Treatment  in  Psychoses.  Southern  Medicine  & 
Surgery,  102:555  (Oct.),  1940. 


Anuria  after  Sulfathiazine. — A  case  is  reported  in 
Proc.  of  Staff  Meetings  of  Mayo  Clinic,  of  a  man,  33,  who 
after  taking  75  to  90  gr.  daily,  on  the  7th  day  put  out 
only  150  c.c.  of  urine,  and  there  was  11.4  mg.  of  the  drug 
to  100  c.c.  blood.  On  the  8th  day,  when  seen  by  the  doc- 
tor reporting  the  case,  there  was  complete  anuria,  and  the 
drug  concentration  in  the  blood  was  70  mg.  per  100  c.c. 
Catheters  passed  to  both  kidneys  dislodged  crystals  of 
sulfadiazine.  The  first  urine  obtained  contained  390  mg.  of 
the  druc  per  100  c.c.  urine.  For  the  24  hrs.  after  catheteri- 
zation the  output  of  urine  was  2,000  c.c. 


WHEN  YOU  GO  TO  NEW  YORK 

ATTEND  A  PERFORMANCE  of  "The  New  Opera 
Company"  reopening  by  public  demand  with  "La  Vie 
Parisienne"  at  the  44th  street  Theatre,  just  west  of  Broad- 
way. The  Opera  Company  was  launched  recently  by  a 
group  of  public-spirited  and  musically-minded  citizens 
which  is  intended  to  bring  opera  and  ballet  to  New  York 
and  visiting  audiences  for  a  modest  sum. 

GO  TO  THE  BILTMORE  THEATRE  and  see  "My 
Sister  Eileen,"  a  very  clever  comedy  concerning  the  ad- 
ventures of  two  young  sisters  who  leave  their  small  home 
town  to  make  a  place  for  themselves  in  the  Art  World  of 
New  York  City.  They  find  themselves  in  a  Greenwich 
Village  basement  apartment.  Lots  of  action  and  wit  which 
has  kept  audiences  in  riotous  laughter  for  over  two  years. 

DON'T  MISS  "Cuckoos  On  The  Hearth,"  playing  at  the 
Ambassador  Theatre,  49th  Street  West  of  Broadway.  This 
is  a  comedy  with  some  very  unexpected  twists.  There  are 
two  solutions  to  the  mystery  and  it's,  anyone's  guess  which 
is  the  right  solution.  The  medical  fraternity  is  represented 
in  the  cast  by  "Dr.  Gordon." 

CALL  AT  THE  INVENTION  EXHIBIT  at  the  estab- 
lishment of  Z.  H.  Polachek,  1236  Broadway,  corner  31st 
street.  This  landmark  in  New  York  has  been  in  existence 
for  16  years.  Many  doctors  have  secured  patents  through 
this  office.  There  is  a  wide  variety  of  inventive  exhibits 
collected  through  the  years. 

SPEND  A  FEW  HOURS  with  Mr.  Edward  T.  Hall, 
Director  of  the  Universal  School  of  Handicrafts,  on  the 
25th  floor  of  the  RKO  Building  at  1260  Sixth  Avenue  at 
50th  street.  Many  doctors  use  the  facilities  of  this  school 
in  the  work  of  occupational  therapy.  Among  some  of  the 
fields  of  creative  expression  are:  Loom  Weaving,  Sculpture, 
Block  Printing,  Painting,  Lithography  etc. 

LEARN  HOW  MUSIC  is  being  used  in  hospitals  to 
allay  fear  and  pain.  The  National  Foundation  of  Musical 
Therapy,  Studio  704  Steinway  Building,  113  West  57th 
street.  This  Foundation  has  been  established  as  a  non- 
profit organization  for  the  study  and  use  of  Musical  Ther- 
apy in  and  out  of  hospitals. 

BE  SURE  TO  RESERVE  SEATS  for  "It  Happens  On 
Ice,"  the  big  ice-travaganza  now  in  its  second  year  at 
America's  First  Ice  Theater,  THE  CENTER  THEATRE, 
Rockefeller  Center.  Over  1,000,000  people  have  enjoyed 
this  show,  one  of  the  outstanding  in  New  York  City. 
Visitors  to  Rockefeller  Center  are  now  making  the  big  ice 
show  a  must  among  the  city's  unique  attractions. 

FOR  AN  EVENING  OF  OPERA  the  visitor  to  New 
York  City  will  surely  go  to  the  Metropolitan  Opera  House 
on  Broadway  at  40th  street.  The  1941-42  season  will  fea- 
ture "The  Magic  Flute,"  a  Mozart  Opera,  "Le  Nozze  Di 
Figaro,"  "Don  Giovanni."  New  scenery  and  costumes 
have  been  designed.  A  notable  cast  has  been  selected.  Sev- 
eral guest  conductors  of  international  prominence  will  be 
introduced  this  year. 


Ix  1939-1940,  at  the  Mayo  Clinic,  stag-horn  calculi  were 
removed  from  the  kidneys  of  54  patients,  only  one  of 
whom  died. 


SYPHILIS   IN  THE  TUBERCULOUS 

(P.  Murphy  &  L.  Bromberg,  in  Amer.  Rev.  Tubcrc,  June) 
Syphilis  can  be  treated  safely  and  effectively  in  tuber- 
culous patients.  In  a  patient  suffering  from  hopelessly  ad- 
vanced tuberculosis,  latent  syphilis  may  be  disregarded. 
Syphilis  in  an  individual  with  tuberculosis  which  gives 
promise  of  being  controlled  should  be  treated.  Late  types 
of  syphilis,  notably  cardiovascular  and  cerebrospinal,  may 
be  debilitating  and  even  fatal  in  a  patient  with  advanced 
lesions  of  tuberculosis.  It  is  a  mistake,  however,  to  upset  a 
satisfactory  equilibrium  in  a  tuberculous  patient  by  dras- 
tic antisyphilitic  treatment. 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


Gout   and   the   Negro 

Abraham  Cohen,  M.D.,  Philadelphia 

From  the  Arthritis  Clinics  of  the  Philadelphia  General  Hospital  and  the  Jefferson  Medical  College  Hospital 


IN  A  REVIEW  of  the  literature,  little  mention 
is  found  of  gout  in  the  negro.  Futcher's  re- 
port1 in  1904  on  59  cases  indicates  that  three 
were  of  some  race  other  than  the  white  and  since 
his  report  came  from  cases  seen  in  Baltimore  it  is 
to  be  assumed  that  these  were  negroes. 

In  1937  Burman  reported12  a  case  of  gout  in  a 
negro.  On  another  occasion  the  author  of  this  pa- 
per reported  such  a  case:'  Since  so  few  cases  of 
this  disease  in  this  race  are  reported,  it  is  to  be 
assumed  that  the  disease  is  either  rare  in  the  black 
race  or,  as  is  the  case  in  members  of  the  white 
race,  it  is  often  misdiagnosed.  While  it  may  not 
be  so  common  in  the  colored  as  it  is  in  the  white 
race,  the  fact  remains  that  it  does  exist  and  that 
the  question  of  heredity  seems  to  be  a  factor  to  be 
considered.  A  family  history  beyond  this  genera- 
tion appears  to  be  negative  from  the  knowledge  of 
the  patients. 

Case  1. — Negro  man,  born  in  South  Carolina  in  1914, 
had  ordinary  diseases  of  childhood  and  a  family  medical 
history  irrelevant  except  that  a  younger  brother  has  gout. 

The  onset  of  present  illness  dates  back  to  when  he  was 
twelve  years  of  age.  At  this  age  he  would  awaken  during 
the  night  with  stiffness  and  swelling  in  the  right  knee. 
This  lasted  for  a  week,  was  not  accompanied  by  pain,  did 
not  confine  him  to  bed,  and  he  made  a  complete  recovery. 
A  year  later,  he  was  awakened  one  night  by  severe  pain  in 
the  right  knee  and  found  the  joint  swollen.  The  pain  and 
swelling  lasted  for  ten  days,  were  confined  to  the  knee, 
and  did  not  keep  the  patient  in  bed.  He  again  made  a 
complete  recovery.  The  patient  was  residing  in  the  coun- 
try in  South  Carolina.  The  family  was  poor  and  could 
afford  only  an  ordinary  diet.  The  patient  ate  sparingly  of 
proteins,  was  not  a  drinker  of  alcohol. 

About  two  years  later,  while  at  work  one  morning  he 
noticed  swelling  in  the  right  great  toe  and  left  ankle. 
Soon  there  were  redness,  heat  and  severe  pain.  A  few 
days  later  the  right  knee  became  involved  and  the 
patient  was  forced  to  bed  for  the  first  time.  Here  he  re- 
mained, unattended  by  a  physician  for  two  weeks.  The 
condition  remained  in  the  left  ankle,  right  great  toe  and 
right  knee,  until  convalescence.  A  good  recovery  was  made 
without  residual  signs  or  symptoms  and  no  further  diffi- 
culty was  experienced  until  6  years  later  at  the  age  of  22 
when,  while  at  work,  pain  and  swelling  developed  sud- 
denly in  the  right  metacarpo-phalangeal  joint.  This  attack 
was  very  painful  and  lasted  for  one  week.  The  following 
week  the  right  elbow  became  involved  similarly.  This  was 
followed  by  involvement  of  the  left  great  toe,  right  ankle 
and  right  knee.  All  joints  were  red,  hot,  swollen  and  ex- 
tremely painful.  Three  weeks  were  spent  in  the  hospital 
where  treatment  was  given  for  arthritis. 

There  were  ten  more  visits  to  the  hospital  and  in  this 
fever-therapy,  baking  and  massage — as  well  as  the  other 
fever  therapy,  baking  and  massage — aswell  as  the  other 
forms  of  therapy  ordinarily  prescribed  for  arthritis  were 
given  trial.  The  longest  stay  in  the  hospital  was  19  days, 
the  shortest  7  days. 


Examination:  A  negro  man,  S  ft.  9  in.  tall,  weighs  141 
lbs. ;  eyes,  nose,  throat  and  teeth  negative ;  ears  negative 
except  for  tophi;  heart,  lungs  and  abdomen  are  negative. 

A  large  tophus  is  found  at  first  right  metacarpo-phalan- 
geal joint  and  a  small  one  on  the  palmar  surface  at  the 
distal  joint  of  the  corresponding  finger. 

There  is  considerable  enlargement  of  the  right  knee, 
particularly  on  the  medial  aspect. 

Course:  For  the  past  year  this  patient  has  been  under 
the  supervision  of  the  arthritis  clinic  at  the  Philadelphia 
General  Hospital.  He  has  had  four  minor  attacks  of  gout. 
The  longest  lasted  three  days,  while  the  shortest  was  over- 
night. His  blood  uric  acid  (serum)  ranges  between  6.5  and 
9.3  mgms.  per  cent.  He  admits  indiscretions  in  his  habits 
just  prior  to  an  attack.  He  contends  that  if  he  were  not 
"so  weak"  in  his  habits  he  probably  would  have  no  at- 
tacks. He  is  invariably  relieved  by  colchicin,  gr.  1/60 
q.  4  h. 

Case  2. — Negro  boy,  aged  16  years,  born  in  South  Caro- 
lina. He  had  the  ordinary  diseases  of  childhood.  One 
other  brother  has  tophaceous  gout.  At  the  age  of  12  one 
night  he  was  suddenly  awakened  with  severe  pain  in  the 
left  heel.  In  the  morning  there  was  swelling  along  the 
Achilles  tendon  accompanied  by  pain.  The  attack  lasted 
about  two  weeks  and  was  confined  to  the  heel.  He  made  a 
good  recovery  without  residual  signs  or  symptoms. 

Two  years  later  at  the  age  of  14,  he  was  again  awakened 
in  the  night  with  pain,  swelling  and  extreme  tenderness  in 
the  left  great  toe.  This  time  the  attack  lasted  a  week  and 
was  confined  to  this  toe. 

The  third  and  final  attack  came  on  at  the  age  of  16  and 
the  right  great  toe  and  left  ankle  were  involved.  The  pa- 
tient was  confined  to  bed  for  ten  days.  There  was  swell- 
ing, redness  and  severe  pain  particularly  at  night.  At  the 
end  of  ten  days  recovery  was  complete  except  for  residual 
swelling,  but  no  pain  or  tenderness  in  the  right  great  toe. 
Examination:  A  negro  boy  16  years  of  age,  weight  118 
lbs.,  height  S  ft.  3  in.  His  blood  uric  acid  (serum)  is  6.1 
mgms.  per  cent.  X-ray  examination  of  the  left  great  toe 
shows  a  punched-out  area  at  the  left  first  metatarso- 
phalangeal joint. 

The  following  table  represents  the  genealogy  for 
three  generations  as  obtained  from  the  family 
bible: 

g.GJF.  G.G.M.  G.G.F.  G.G.M.  G.G.F.  G.G.M.  G.G.F.  G.G.M. 
W&I    W&I        W       W&I    C  C  C        W&I 


G.F.  G.M.  G.F. 

Mixed  W  &  I         Mixed  W&I  C 


G.M. 
Mixed  W  &  C  &  I 


Father 
Mixed  W&I 


Mother 
Mixed  W  &  C  &  I 


Pt.  J.A. 

W — wliite  race. 
I — indian  race. 
C — colored  race. 


Pt.  P.  A. 


December,  1941 


GOUT  AND   THE  NEGRO— Cohen 


655 


This  table  reflects  the  possibility  that  these  pa- 
tients may  have  inherited  their  gouty  diathesis 
from  the  white  race.  However,  it  may  well  be  that 
many  of  our  negro  brothers  have  the  same  mixture 
of  blood  and  therefore  it  becomes  increasingly  nec- 
essary to  be  on  the  lookout  regardless  of  color. 
Summary  and  Conclusions 

1.  Gout  is  supposedly  rare  in  the  negro  race. 

2.  Two  cases  (of  brothers)  are  herewith  report- 
ed. 

3.  The  genealogy  of  the  patients  is  presented. 

Bibliography 

1.  Futcher,  T.  B.:  The  Etiology  and  Pathology  of  Gout. 
/.  A.  M.  A.,  Vol.  xliii,  1904. 

2.  Burmax,  M.  S.:  Synovial  Fluorescence  in  a  Case  of 
Gout  with  Jaundice.  Acta  Rheumatologica,  Vol.  lx,  pp. 
10-12,  1937. 

3.  Cohen,  Abraham:  Gout  Among  Arthritics.  Pennsylva- 
nia Medical  Jour.,  Sept.,  1938. 

— 2106  Spruce  Street 


A  CRITICAL  ANALYSIS  OF  A  SERIES  OF 

APPENDECTOMIES 

iZachary    Sagal    &    Walter    Heinemann,    New    York,    in   Dig.    of 

Treat.,  Dec.) 

An  analytic  study  of  387  appendectomized  patients 
among  3,460  clinic  admissions  has  been  conducted  in  our 
private  practice  and  with  patients  at  the  New  York  Post- 
Graduate  Clinic,  the  latter  covering  a  period  of  8  years. 

Removing  the  appendix  for  the  cure  of  gastro-intestinal 
conditions,  except  acute  and  recurrent  appendicitis  has 
proved  futile.  Cases  diagnosed  as  chronic  appendicitis  con- 
stitute a  diagnostic  error  in  every  instance.  Usually  it 
means  either  insufficient  study  of  the  case  or  incorrect 
interpretation  of  the  findings.  In  many  cases  it  is  merely 
an  escape  due  to  unsatisfactory  management  of  a  case  and 
inability  to  obtain  results. 

Asymptomatic  appendices  very  often  show  the  same 
histologic  picture  as  the  presumably  diseased  ones. 

As  pathognomonic  of  so-called  chronic  appendicitis,  pain 
and  tenderness  in  the  right  lower  quadrant  of  the  abdomen 
comes  closest,  but  this  symptom  is  present  in  sundry  other 
conditions  and  in  many  appendectomized  patients — in  20 
per  cent  of  our  series.  In  every  case  in  our  series  in  which 
the  diagnosis  of  chronic  appendicitis  might  have  been  con- 
sidered, careful  study  revealed  some  other  condition  which 
we  thought  more  likely  to  be  responsible  for  the  patient's 
complaints,  and  we  treated  it  accordingly. 

Rontgenologists  generally  attach  a  good  deal  of  impor- 
tance to  tenderness  on  palpation  under  the  fluoroscope,  to 
fixation,  to  the  presence  of  fecaliths,  to  unduly  long  reten- 
tion of  barium.  Many  clinicians  and  rontgenologists  dis- 
claim the  significance  of  any  and  all  of  these  findings. 

There  is  not  much  objection  in  the  literature  or  in  our 
experience  to  surgery  for  recurrent  appendicitis.  When  a 
history  of  one  or  more  fairly  typical  attacks  of  acute  ap- 
pendicitis is  obtainable,  the  predominating  number  of  writ- 
ers on  the  subject  believe  that  the  appendix  should  be  re- 
moved. 

The  fact  that  many  appendectomized  patients  are  sub- 
sequently found  to  be  suffering  from  peptic  ulcer,  gall- 
bladder disease,  colitis,  genito-urinary  disease,  pelvic  and 
sundry  other  diseases  made  many  wonder  whether  the 
conditions  were  not  previously  overlooked,  though  present. 
We  believe  that  cases  diagnosed  chronic  appendicitis  con- 
stitute a  diagnostic  error  in  every  instance. 

A   Postcard  Request  of  the  Author  will  bring  a  Reprint. 


URINARY  INCONTINENCE  OF  FIFTEEN  YEARS' 

DURATION  IN  A  TABETIC  PATIENT  RELIVED 

BY    TRANSURETHRAL    RESECTION 

(J.  L.  Emmett,  from  Prof.  Staff  Meetings  The  Mayo  Clinic, 
Nov.  12th) 
Last  September  a  man,  66,  came  to  the  Clinic  who  for 
15  years  had  found  it  necessary  to  wear  a  rubber  urinal 
because  of  urinary  incontinence.  Three  weeks  before  his 
coming  the  dribbling  had  ceased  entirely,  and  he  had  been 
obliged  to  empty  his  bladder  t.i.d.  by  means  of  a  catheter. 
He  has  complained  of  fleeting  sharp  pains  across  his  abdo- 
men and  thorax  for  a  few  months. 

On  questioning  it  was  found  that  it  was  not  a  constant 
dripping  of  urine,  but  involuntary  urination  at  irregular 
intervals.  The  flow  of  urine  had  never  been  free,  and  the 
patient  felt  that  he  had  never  emptied  his  bladder  com- 
pletely. 

The  patient  had  had  gonorrhea  as  a  youth,  but  no  syph- 
ilitic lesion  had  been  recognized. 

B.  p.  was  176/94,  no  enlargement  of  the  prostate  gland, 
Argyll  Robertson  pupils,  a  marked  delay  in  sensation  of 
pain  over  the  lower  extremities  and  over  the  anterior  sur- 
face of  the  chest,  questionable  Romberg's  sign. 
Tests  of  the  blood  were  negative.  Spinal  fluid  negative. 
On  the  basis  of  the  neurologic  observations  and  the 
typical  "spot"  pains,  a  diagnosis  of  tabes  dorsalis  was 
made. 

Cystoscopic  examination  under  local  anesthesia  disclosed 
moderate  relaxation  of  internal  and  the  external  sphincter 
muscles.  In  the  bladder  were  trabeculae  of  large  caliber. 
No  definite  obstruction  of  the  neck  of  the  bladder  was 
apparent.  Because  of  our  experience  with  this  type  of 
condition  cystoscopy  under  anesthesia  was  done,  to  see 
whether  or  not  during  the  procedure  tissue  which  might 
be  causing  moderate  obstruction  could  be  removed  from 
the  vesical  neck,  in  some  cases  obstructing  tissue  may  not 
be  apparent  until  resection  actually  is  in  progress. 

After  intravenous  administration  of  pentothal  sodium  it 
was  found  that  the  urethra  in  the  region  of  the  penoscro- 
tal angle  could  not  be  dilated  to  admit  no.  27  French  or  a 
no.  30  French  Thompson  resectoscope.  The  cause  of  this 
narrowing  apparently  was  a  stricture  of  larger  caliber  re- 
sulting from  the  gonorrhea  in  early  life,  as  previously 
mentioned.  A  no.  24  French  Braasch-Bumpus  resectoscope 
was  passed  easily.  On  close  inspection  there  was  a  slight 
enlargement  of  all  three  lobes  of  the  prostate.  As  resection 
proceeded,  this  enlargement  became  more  apparent  and  8 
gm.  of  adenomatous  tissue  were  removed,  which  left  the 
fibers  of  the  prostatic  capsule  exposed  in  the  entire  cir- 
cumference. 

When  dismissed  from  the  Clinic  two  weeks  after  opera- 
tion he  was  voiding  a  normal  urinary  stream,  his  urinary 
control  was  perfect,  he  was  emptying  his  bladder  com- 
pletely and  was  finding  it  necessary  to  void  only  once 
during  the  night. 


PROTECT  GASTRO-INTESTINAL  MUCOSA  WHEN 
GIVING  SULFAPYRIDINE 

(S.  D.  Maiden,  Council  Bluffs,  in  //.  Iowa  Med.  Soc.,  Oct.) 

Sulfapyridine  should  be  tried  in  all  streptococcic  infec- 
tions which  do  not  promptly  respond  to  sulfanilamide, 
neoprontosil  or  sulfathiazole  therapy.  The  gastric  mucosa 
membrane  should  be  protected  when  sulfapyridine  is  used 
whenever  possible  by  solid  foods  and  ample  fluids.  Where 
such  protection  can  not  be  given,  intravenous  therapy 
should  be  resorted  to,  using  sufficient  dilution  and  admin- 
istering such  dilutions  slowly  so  as  not  to  obliterate  the 
lumen  of  the  vein. 

A  Postcard  Request  of  the  Author  will  bring  a  Reprint. 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


Effective  Therapy   in   Chronic  Alcoholism* 

Thomas  B.  Mitchell,  M.D.,  Shelby,  North  Carolina 


THIS  is  in  no  sense  an  original  paper.  It 
discusses  means  used  by  others,  and  is  pre- 
sented in  the  hope  of  bringing  to  the  atten- 
tion of  the  medical  profession  a  practical,  and  I 
believe  a  successful,  method  of  dealing  with  alco- 
holism. These  conditions  are  problems  that  the 
family  physician  is  frequently  faced  with,  and 
after  the  acute  medical  phase  or  period  of  hos- 
pitalization has  passed,  some  form  of  moral  psycho- 
logic support  is  essential  to  the  individuals'  per- 
manent cure.  "There  is  a  great  deal  more  to  the 
understanding  and  successful  treatment  of  alcohol 
addiction  than  can  be  found  either  in  drugs  or  in 
the  usual  methods  employed  in  sanatoriums  or 
other  havens  of  refuge."  Custodial  or  protective 
care  is  very  inadequate  preparation  for  that  which 
lies  ahead.  Usually  the  fundamental  alcoholic  habit 
is  left  untouched  and,  unless  some  definite  practi- 
cal moral  therapy  is  instituted,  the  patient  is  left 
defenseless  on  his  return  to  his  usual  environment. 
We  have  reference  to  the  true  alcoholic,  rather 
than  to  the  occasional  spreer  or  even  hard-drinker; 
to  that  numerous  group  in  which  there  is  an  under- 
lying disease  that  expresses  itself  in  pathological 
drinking.  The  psychology  of  this  group  is  fairly 
well  understood.  We  know  that  the  making  of  an 
alcoholic  reaches  far  back  through  adolescence  and 
childhood  to  heredity,  recent  and  remote.  "The 
frequency  of  its  occurrence  among  only  sons  or 
younger  sons  gives  us  a  key,  and  we  find  that  the 
unfortunate  combination  of  parental  spoiling  and 
dominance  makes  for  a  pattern  of  emotional  imma- 
turity that  furnishes  a  ripe  soil  for  dangerous  alco- 
holic indulgence  later  in  life." 

The  normally  controlled  user  of  alcohol  drinks 
to  exaggerate  reality,  because  he  finds  reality  en- 
joyable; and  only  on  this  plane,  where  it  acts  as  a 
social  lubricant  and  promotes  convivialty,  is  there 
any  defense  for  its  use.  In  contrast  to  this,  the 
true  alcoholic  finds  ordinary  reality  so  unpleasant, 
in  some  cases  unendurable,  that  he  must  find  a 
retreat  or  a  defense  from  it ;  and  in  alcohol  he  finds 
an  escape  from  the  responsibility  and  burden  of 
mature  emotional  life  and  its  decisions.  What  is 
not  always  realized  is  that  the  true  alcoholic  is  a 
very  sick  person,  and  of  a  disease  which  up  to  the 
present  time  our  profession  has  failed  to  solve  or 
to  cope  with. 

Some  idea  of  the  frequency  of  this  condition  and 
of  the  economic  and  social  damage  caused  by  it 
may  be  gained  if  one  recalls  the  number  of  his 


friends  and  acquaintances  whose  use  of  drink  has 
caused  grave  social  impairment  in  the  person  and 
in  the  family.  While  the  success  of  psychiatrists 
in  effecting  cures  has  been  considerable,  their  non- 
availability to  the  ordinary  individual  discourages 
hope  that  any  great  progress  can  be  had  from  them. 
Their  efforts  are  along  the  lines  of  reeducation.  In 
a  period  lasting  months  or  years  they  try  to  ac- 
complish a  gradual  maturing  process,  the  treat- 
ment successfully  terminating,  not  in  a  rebellion 
at  reality,  but  in  an  adjustment  that  makes  for 
confidence  and  a  feeling  of  justifiable  independ- 
ence. This  is  largely  accomplished  by  getting  the 
patient  to  retrace  his  life  course,  and  certain 
changes,  both  great  and  small,  are  advised  that 
make  for  the  emotional  adjustment  that  was  passed 
over  during  formative  years.  In  addition  to  the 
small  number  cured  by  these  methods,  there  has 
been  from  time  immemorial  the  occurrence  of  emo- 
tional cures  from  strong  religious  stimuli.  This 
occurs  when  a  man  makes  a  contact  with  some 
power  that  is  revered  or  feared  and  thereafter  the 
course  of  his  life  becomes  permanently  changed. 
These  recoveries  have  been  sporadic  and  possibly 
insufficient  in  number  and  impressiveness  to  make 
headway  with  the  alcoholic  problem  as  a  whole  or 
to  impress  scientific  men  that  the  cure  may  be 
simple  and  without  complicated  psychological  pro- 
cedures and  that  all  the  tools  are  at  hand. 

I  think  all  psychiatrists  and  all  other  observers 
are  certain  that  a  man  is  never  permanently  cured 
of  these  abnormal  states  until  there  is  a  personal- 
ity change  and  the  object  of  this  discussion  is  to 
relate  briefly  a  practical  and  promising  method  of 
effecting  such  a  change  in  an  individual.  The  ideas 
incorporated  in  the  following  methods  were  origi- 
nated and  applied  by  a  small  group  of  alcoholics, 
who  found  that  they  were  successful  with  them- 
selves; and  within  a  few  years  there  has  been  suffi- 
cient evidence  of  the  success  of  their  approach  to 
alcoholism  that  it  merits  the  attention  of  all  med- 
ical men.  Perhaps  some  of  you  read  in  the  March 
1st  issue  of  the  Saturday  Evening  Post  an  article 
entitled  "Alcoholics  Anonymous,"  which  gave  an 
unbiased  laymen's  review  of  the  growth  of  this 
movement  up  to  that  time.  The  central  idea  is 
that  of  a  fellowship  of  ex-alcoholic  men  and  women 
who  have  been  cured  by  the  application  of  certain 
principles  and  who  are  banded  together  for  mutual 
help.  Their  approach  to  alcoholism  is  based 
squarely  on  their  own  drinking  experience,  what 


•Presented  to  The  Thermal  Belt  (N.  C.)  Medical  Society  meeting  at  Shelby,  October  16th. 


December,  1941 


EFFECTIVE  THERAPY  IN  CHRONIC  ALCOHOLISM  —Mitchell 


657 


they  have  learned  from  medicine  and  psychiatry 
and  upon  certain  spiritual  principles  that  are  com- 
mon to  all  creeds. 

As  set  forth  in  that  article,  their  methods  are 
simple  and  have  proved  successful — as  they  con- 
stitute good  medicine,  good  psychology  and  good 
religion.  They  recommend  that  a  person  who  hon- 
estly desires  to  be  free  from  his  alcoholic  habit  do 
certain  things  that  will  lead  to  a  spiritual  experi- 
ence; and,  as  soon  as  these  steps  are  undertaken, 
it  is  further  urged  that  the  patient  begin  work 
with  other  alcoholics  as  a  means  of  perfecting  his 
own  cure.  This  is  not  entirely  from  a  sense  of 
duty,  but  rather  for  self-preservation  and  certainly 
in  the  early  stages  unless  they  spend  time  in  help- 
ing others  to  health  they  can  not  remain  sober 
themselves.  A  basis  of  understanding  and  friend- 
liness is  first  established;  and,  because  of  the  abil- 
ity of  one  alcoholic  to  gain  the  confidence  of  an- 
other, almost  impossible  of  attainment  by  an  out- 
sider, there  is  little  chance  of  that  rationalization 
and  mental  camouflage  which  all  alcoholics  indulge 
in. 

Once  the  patient  admits  he  is  powerless  to  con- 
trol his  drinking  habits  he  is  told  that  there  is  a 
remedy  for  his  condition,  and  that,  outside  of  this 
course  so  far  as  they  know,  there  is  no  hope  for 
him.  This  becomes  convincing  to  the  prospective 
patient  when  former  alcoholics  can  cite  their  own 
cases  and  prove  the  results,  and  if  he  honestly 
desires  relief,  he  is  put  in  a  rather  embarrassing 
situation  unless  he  is  willing  to  go  further.  It  is 
suggested  he  accept  and  apply  a  simple  religious 
proposal  and  very  frequently  he  accepts. 

The  first  and  essential  step  is  that  he  become 
willing  to  and  does  turn  his  life  over  to  the  care 
and  direction  of  his  Creator.  When  this  is  sin- 
cerely done,  and  the  further  suggested  steps  are 
carried  out,  he  undergoes  the  profound  mental  and 
emotional  change  common  to  religious  experience. 
Xo  effort  is  made  to  convert  him  to  any  particular 
faith  or  creed  and  no  emotionalism  or  aggressive 
evangelism  is  exhibited.  The  succeeding  recommen- 
dations are  that  he  make  a  careful  inventory  of 
himself  and  discuss  confidentially  his  findings  with 
some  competent  person  whom  he  trusts.  He  is  then 
advised  to  begin  at  once  an  honest  effort  to  adjust 
all  bad  personal  relationships  and  to  rectify  his 
life  in  so  far  as  it  is  possible  without  hurting  inno- 
cent people.  The  fellowship  endeavors  to  guide 
and  help  the  patient  in  his  efforts  and  when  this  is 
consummated  there  comes  into  the  patient's  life  a 
spiritual  experience  which  is  the  foundation  upon 
which  his  cure  is  built.  Its  permanency  depends 
only  upon  his  willingness  to  remain  spiritually 
alive  and  this  he  does  through  prayer  and  medita- 
tion to  improve  his  conscious  contact  with  God  as 
he  understands  Him,  praying  for  knowledge  of  His 
will  and  power  to  carry  it  out.    This  relationship 


is  also  maintained  by  his  willingness  to  work  with 
other  alcoholics  and  to  carry  this  message  to  them 
and  to  try  to  practice  these  principles  in  all  his 
affairs. 

This  seems  quite  like  an  impossibility  but  in 
essence  it  means  only  the  willingness  to  grow  along 
spiritual  lines  and  the  permanency  of  the  cure 
depends  on  this  attitude.  There  is  always,  in  a 
successful  case,  a  radical  change  in  attitude  and 
habits  of  thought,  sometimes  with  amazing  rapid- 
ity. His  hope  and  imagination  are  fired  by  the 
opportunity  of  fellowship  with  other  ex-alcoholics 
who  have  as  a  primary  object  the  saving  of  lives 
and  homes  of  those  who  have  suffered  as  he  has 
suffered.  The  fellowship  is  maintained  by  a  loose 
organization,  without  dues  or  officers.  A  regular 
weekly  meeting  is  held  which  each  member  attends 
whenever  it  is  possible. 

These  methods  in  no  wise  minimize  the  place  of 
the  physician  or  institutional  care.  Most  will  agree 
that  practical  psychology  needs  to  be  applied,  with 
the  further  essential  element  of  a  spiritual  experi- 
ence and  revitalization.  My  own  feeling  is  that 
there  can  be  no  real  adjustment  in  the  moral  realm 
until  there  is  an  adjustment  in  the  spiritual  realm. 
The  basic  promise  of  Scriptural  philosophy  and 
psychology  is  that  man  is  lost  and  alienated  from 
God,  the  source  of  goodness  and  truth,  and  unless 
this  fundamental  fact  is  spiritually  apprehended 
there  can  be  no  philosophy  or  psychology  that  is 
properly  oriented  or  basically  true. 

It  may  be  too  early  to  say  that  this  is  the  com- 
plete answer  to  alcoholism  and  certainly  some  phy- 
sicians will  disagree. 

At  the  present  time  there  are  approximately 
4000  members  of  this  organization,  Alcoholics 
Anonymous,  scattered  largely  over  the  middle  west 
and  eastern  seaboard.  They  hope  to  extend  their 
work  to  all  parts  of  the  country  and  to  make  their 
methods  and  answers  known  to  every  alcoholic 
who  wishes  to  recover.  They  have  prepared  a  book 
called  Alcoholics  Anonymous,  which  sets  forth 
their  methods  and  experience  with  clarity  and 
force.  Certainly  not  for  all  alcoholics  who  are  in- 
troduced to  these  methods  is  a  cure  effected,  and 
while  no  definite  statistics  are  yet  available,  ap- 
parently a  cure  is  completed,  or  the  basis  laid  for 
a  permanent  cure,  in  half  of  these  cases  with  which 
an  active  organization  has  an  opportunity  to  work. 
These  are  two  essentials  to  its  success,  a  capacity 
to  be  honest  and  a  genuine  desire  to  do  without 
beverage  alcohol.  This  work  is  in  its  infancy  but 
there  seems  every  reason  for  our  profession  to  give 
encouragement  to  methods  that  are  as  promising 
as  are  these. 

References 
Strecker,  E.  A.,  and  Chambers,  F.  T.:    Alcohol,  One 
Man's  Meat.    The  Macmillan  Co.  1939.  Alcoholics  Anony- 
mous.   Works  Publishing  Co.,  1939. 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


CASE  REPORT 


rRIMARY  TUBERCULOUS  PERICARDITIS 
G.  C.  DALE,  M.D..  Goldsboro.  N.  C. 

AXEGRO  MAN,  44  years  of  age,  was  ad- 
mitted to  the  hospital  on  November  30th, 
1938,  complaining  of  shortness  of  breath 
and  marked  weakness.  He  was  well  until  July  of 
1938,  when  he  had  what  was  diagnosed  as  an  acute 
attack  of  malaria.  He  was  sick  throughout  the 
month  of  July,  after  which  he  returned  to  work. 
Two  or  three  weeks  later  he  began  to  have  head- 
ache and  cough.  This  was  followed  by  dyspnea 
and  weakness  and  later  by  heart  consciousness  and 
general  malaise.  The  appetite  was  poor.  Bowels 
moved  regularly.  He  had  lost  twenty  pounds  in  the 
last  three  weeks.  There  had  been  no  expectoration 
with  the  cough.  Kidney  output  had  been  scant. 
His  nights  had  been  sleepless.  There  was  no  his- 
tory of  pleurisy  or  fistula;  nor  of  venereal  disease, 
acute  infections,  nor  any  other  illness. 

His  father  died  of  a  stroke  at  the  age  of  62. 
His  mother  died  young  of  unknown  cause.  His 
wife  was  living  and  well.  There  was  one  child  liv- 
ing and  well.  There  had  been  no  miscarriages.  His 
occupation  was  painter  and  farmer. 

Phvsical  Examination:  The  patient  was  in  much 
distress  because  of  dyspnea,  coughing  at  intervals. 
He  had  the  pallor  of  anemia  and  marked  tremor  of 
the  hands.  Pupils  were  normal  in  reaction.  Nose 
and  throat  were  negative.  Teeth  and  gums  were 
in  fair  condition.  Tongue  was  coated  and  tremul- 
ous. The  chest  on  inspection  gave  the  impression 
of  being  fuller  anteriorly  on  the  left  side  and  ex- 
pansion was  impaired  on  the  left.  No  rales  were 
heard  in  either  lung,  but  in  the  left,  near  the  hilum 
posteriorly,  there  was  a  small  area  over  which  defi- 
nite tubular  breathing;  could  be  heard.  There  was 
no  impairment  posteriori}'  to  percussion.  Heart 
dullness  area  was  pyriform,  enlarged  to  the  left  as 
far  as  the  anterior  axillary  line.  The  apical  im- 
pulse, however,  was  iust  inside  the  nipple  line  and 
in  the  fifth  interspace.  The  heart  sounds  were 
somewhat  faint,  although  of  fair  volume  at  the 
apex.  There  were  no  murmurs  and  no  arrhythmias. 
There  was  a  pericardial  friction  rub  near  the  ster- 
num in  the  left  fourth  interspace.  The  abdomen 
presented  moderate  tenderness  over  the  liver  on  the 
right  side,  but  the  liver  could  not  be  felt.  No  other 
masses  were  oalpable  in  the  abdomen.  Reflexes 
were  normal.  Romberg  sisn  was  negative.  There 
were  marked  tremors  of  the  hands  and  moderate 
edema  of  the  ankles.  The  blood-pressure  was  104' 
76,  pulse  104.  temperature  102.2.  A  tuberculin 
test  showed  a  2-plus  reaction.   Circulation  time  was 


as  follows:  Arm-to-tongue  with  20-per  cent  cal- 
cium gluconate  18  seconds;  arm-to-lung  with  five 
minims  each  of  ether  and  sodium  chloride,  eight 
seconds.    The  venous  pressure  was  26  millimeters. 

Laboratory  Findings:  Urine — Sp.  gr.  1022,  trace 
of  albumin,  acid,  four  to  nine  pus  cells  per  high- 
power  field,  an  occasional  r.b.c.  Blood — Wasser- 
man  negative:  white  b.c.  5.700 — poly  75,  lymph 
21,  mono.  4:  hemoglobin  S2r;  ;  r.b.c.  4,200.000. 
No  malaria  organism  was  seen. 

Sputum  examinations  did  not  show  any  tubercle 
bacilli. 

A  fluroscopic  examination  done  at  the  first  visit 
showed  a  heart  shadow  much  enlarged,  extending 
to  the  costal  margin  on  the  left  and  well  beyond 
the  spine  on  the  right.  The  pericardium  was  of 
the  pear-shaped  form  suggestive  of  pericarditis,  but 
the  outline  fibrillation  seen  in  fluid-filled  pericardia 
was  absent.  The  aorta  was  slightly  enlarged  at  the 
arch.  Nothing  of  significance  was  seen  in  either 
lung  field.  The  diagnosis  by  the  rontgenologist  at 
that  time  was  pericarditis  with  effusion,  probably 
of  tuberculous  origin. 

A  flat  plate  of  the  chest  and  heart  on  admission 
showed  no  evidence  of  tuberculosis,  past  or  pres- 
ent. Appearance  of  the  heart  was  the  same  as  on 
fluoroscopic  examination. 

An  electrocardiogram  revealed  a  rate  of  100, 
with  regular  rhythm.  There  was  slurring  of  the 
QRS  complexes,  more  marked  in  lead  1.  There 
was  moderate  left-axis  deviation.  Negative  T 
waves  were  present  in  all  leads  except  3,  where 
they  were  isoelectric.  There  was  a  tendency  to  low 
voltage.  ^ 

On  December  6th,  1938,  750  ex.  of  bloody  fluid 
was  removed  from  the  pericardial  sac.  In  the  fluid 
were  many  lymphocytes,  a  few  polymorphonuclears 
and  many  red  blood  cells.  The  sediment  was  nega- 
tive for  tubercle  bacilli.  The  patient  was  running 
an  irregular  temperature,  from  97  to  102.  He  felt 
greatly  relieved  by  the  aspiration.  A  guinea  pig 
was  not  available  and  inoculation  with  the  pericar- 
dia! fluid  was  not  done. 

Two  weeks  later.  300  c.c.  of  darker  bloodv  fluid 
were  removed.  At  this  time  the  patient's  leukocyte 
count  was  4,900,  the  pericardial  fluid  contained 
numerous  lymphocytes,  a  few  polymorphonuclears 
and  some  red  blood  cells,  and  was  negative  for 
tubercle  bacilli. 

Five  weeks  after  the  first  tapping,  300  c.c.  of 
pericardial  fluid  was  removed  which  showed  many 
leukocytes  and  red  blood  cells,  a  few  mixed  organ- 
isms, no  tubercle  bacilli.  At  this  time,  the  liver 
was  palpable:  there  was  edema  of  the  chest  wall 
and  the  legs:  dyspnea  was  marked.  Digitalis  was 
given. 


Presented  to  the  Fourth  District   (N.  C.)   Medical  Society  meeting  at  Goldsboro,  N.  C,  November  11th. 


December.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


On  January  25th,  700  c.c.  of  straw-colored  fluid 
was  removed  from  the  pericardial  sac.  The  patient 
had  lost  a  great  deal  of  weight  by  this  time,  and 
dvspnea  was  more  severe,  as  was  edema  of  the  feet. 
An  electrocardiogram  done  after  the  tapping  re- 
vealed a  low  amplitude  of  QRS  complexes,  inver- 
sion of  T  waves  in  all  leads,  and  left-axis  devia- 
tion. 

On  February  20th,  the  patient  was  readmitted 
to  the  hospital  for  pericardial  aspiration,  which 
vielded  only  some  10  c.c.  of  straw-colored  fluid. 
The  patient  had  all  evidences  of  congestive  failure 
and  two  nights  later  he  expired  suddenly. 

Permission  for  autopsy  was  given  only  for  the 
examination  of  the  heart.  The  left  chest  was  open- 
ed by  removing  a  section  of  wall  eight  cm.  wide 
from  the  second  to  the  seventh  rib.  The  pleural 
cavity  was  completely  filled  with  a  straw-colored 
fluid  and  the  lung  was  collapsed.  There  were  sev- 
eral long,  white,  fibrinous  strings  radiating  from 
the  pleura.  The  pericardium  was  covered  with  a 
thick  pink  exudate,  which  covered  both  the  inner 
and  outer  surfaces,  and  the  sac  contained  100  c.c. 
of  sero-sanguinous  fluid. 

The  pericardium  was  1  cm.  thick  and  inelastic. 
The  heart  itself  was  also  covered  with  a  thick, 
pink,  fatty-fibrinous  exudate  and  was  only  slightly 
enlarged.  The  heart  was  removed  but  was  not 
weighed.  The  tricuspid  valve  was  normal,  but  the 
mitral  presented  several  small,  firm  shot-like  no- 
dules. 

The  heart  and  a  section  of  the  pericardium  were 
sent  to  Dr.  C.  C.  Carpenter  of  Wake  Forest  for 
microscopical  study.  A  gross  clinical  diagnosis 
was  recorded  as  a  tuberculous  pericarditis. 

Microscopic  pathological  report  by  Dr.  Carpen- 
ter was  as  follows:  Sections  show  a  sero-fibrinous 
exudate  on  the  surface  of  the  myocardium.  There 
is  an  infiltration  of  mononuclear  cells  and  typical 
foreign-body  giant  cells  are  present.  Mononuclear 
cells  are  present  which  resemble  epitheloid  cells. 
Diagnosis:  Tuberculous  pericarditis. 

Discussion:  Our  medical  teachers  had  taught 
that  tuberculous  pericarditis  is  usually,  if  not  al- 
ways, secondary  to  tuberculosis  elsewhere  in  the 
body.  This  case,  both  by  the  history  and  physical 
manifestations,  seemed  to  be  one  of  the  primary 
type.  A  few  months  after  the  death  of  this  patient, 
we  had  the  opportunity  to  review  this  case  with 
Dr.  Torrey  of  Philadelphia,  and  it  was  his  opinion 
that  this  case  was  one  of  the  primary  type.  He 
stated,  too,  that  he  had  among  his  records  over  a 
period  of  many  years,  ten  or  a  dozen  cases  which 
he  felt  were  of  primary  tuberculous  pericarditis. 

This  man.  having  no  history  of  acute  infections 
or  rheumatic  disease  and  requiring  repeated  aspira- 
tions of  pericardial  fluid,  could  practically  be  ruled 


out  as  having  pericarditis  of  rheumatic  origin.  The 
leukopenia  and  the  abundance  of  lymphocytes  in 
the  pericardial  fluid  would  also  be  against  pericard- 
itis of  rheumatic  origin. 

It  is  interesting  to  attempt  to  explain  this  pa- 
tient's low  venous  pressure  when  first  seen.  Mod- 
erate decompensation  and  cardiac  dilatation  had  to 
be  considered.  The  minor  liver  engorgement  and 
the  presence  of  edema  of  the  legs,  in  the  absence  of 
renal  disease  and  any  marked  anemia,  would  seem 
to  indicate  that  the  right  side  of  the  heart  was  hold- 
ing up  fairly  well  in  comparison  with  the  left.  To 
some  extent  this  fact  might  prevent  a  high  venous 
pressure,  which  one  would  expect  in  congestive 
failure.  This  explanation  would  seem  unlikely  in 
view  of  the  knowledge  that  the  heart  was  com- 
pressed by  an  effusion  and  therefore  could  not 
undergo  dilatation.  The  most  plausible  explanation 
of  the  venous  hypopressure  seems  to  be  found  in 
peripheral  relaxation  of  the  vascular  system,  toxic 
in  origin. 

The  typical  electrocardiographic  findings  ordi- 
narily seen  in  acute  pericarditis — high  take-off  of 
the  ST  segment  in  all  leads  with  exaggerated  T 
waves — would  not  appear  in  tuberculous  pericard- 
itis. The  QT  interval  in  this  case  was  normal  or 
reduced — the  opposite  of  what  occurs  in  cardiac 
dilatation. 

The  origin  of  this  tuberculous  process  was  prob- 
ably in  the  mediastinal  lymph-nodes.  This  was  not 
demonstrated  in  our  patient. 


CORNEAL  INJURIES  AND  COMPLICATIONS 
(W.  W.  Mall,  Ponca  City,  in  //.  Okla.  Med.  Assn.,  Oct.) 

In  all  injuries  my  first  step  is  instillation  of  %%  ponto- 
caine  for  anesthesia.  In  simple  surface  erosion,  the  diagno- 
sis is  made  simple  by  the  instillation  of  fluorescein  stain, 
which  will  very  definitely  outline  the  extent  of  injury. 

Clean-cut  perforations  will  often  heal  without  interven- 
tion. In  a  gaping  wound  a  corneal  suture  may  be  neces- 
sary. Thorough  examination  should  be  made  for  a  foreign 
body  lodged  within  the  eyeball  and  if  found  it  (or  they) 
should  be  removed  in  almost  all  cases.  Cleanliness  and 
symptomatic  treatment  should  be  carefully  instituted,  be- 
ginning signs  of  complications  closely  watched  and  con- 
trolled if  possible.  In  severe  damage  to  the  eye,  where 
useful  vision  has  been  destroyed,  surgical  removal  is  indi- 
cated for  prevention  of  sympathetic  ophthalmia. 

ForeiEn  bodies  are  most  easily  found  with  a  loupe  and 
indirect  light  through  a  magnifying  glass.  A  rather  blunt 
eye  spud  should  be  used  for  removing  the  foreign  bodies. 
In  deep  seated  foreign  bodies  a  rust  stain  often  remains 
after  the  foreign  body  is  removed,  this  should  also  be  re- 
moved with  some  type  of  burr,  well  irrigated  with  boric 
acid  and  medication  instilled.  As  a  rule  a  loose  bandage 
should  be  applied  for  a  few  hours,  and  the  patient  in- 
structed to  return  to  the  office  the  following  day  if  any 
discomfort  remains  in  the  eye. 


Carcinoma  of  the  larynx  is  increasing;  82%  or  early 
intrinsic  cases  are  CURABLE.  Hoarseness  in  an  adult  calls 
for  immediate  laryngeal  examination;  it  might  be  a  carci- 
noma.— Tracewell. 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


CLINIC 


Conducted  By 
Frederick    R.    Taylor,    B.S.,    M.D.,    F.A.C.P. 


A  34-year-old  accountant  consulted  me  on  Nov. 
10th,  1931,  complaining  of  difficult  urination  and 
nervous  depression.  He  stated  that  12  years  pre- 
viously, the  day  after  coming  back  from  military 
service  in  the  First  World  War,  he  was  in  a  serious 
automobile  wreck  and  injured  his  back,  fracturing 
two  vertebrae.  On  being  shown  a  picture  of  a 
spine,  he  thought,  from  his  recollection  of  the  x-ray 
film,  that  the  transverse  processes  had  been  the 
sites  of  the  fractures.  The  injury  paralyzed  him 
from  his  waist  down  and  he  was  catheterized  for 
3^2  months.  He  did  not  lose  control  of  his  bowels, 
though  he  was  severely,  constipated.  He  was  treat- 
ed for  his  injury  by  a  competent  surgeon  in  Ashe- 
ville.  He  got  out  of  the  hospital  and  went  for  a 
year  without  further  treatment,  but  was  troubled 
greatly  by  nocturia  (6  to  10)  and  a  foul  odor  to 
his  urine,  so  consulted  an  Asheville  urologist,  who 
gave  him  bladder  irrigations  for  a  year,  weekly  at 
first,  then  monthly.  Then  he  moved  to  High  Point. 
The  Asheville  urologist  had  advised  him  to  consult 
the  Crowell  Clinic  in  Charlotte  after  leaving  Ashe- 
ville, but  he  did  not  do  this  at  once,  but  had  treat- 
ment from  a  couple  of  High  Point  physicians. 
Then  he  did  go  to  the  Crowell  Clinic  and  improved 
a  lot.  He  kept  going  back  for  treatment"  every  two 
or  three  months  until  about  a  year  before  consult- 
ing me.  Then  he  went  to  the  Veterans'  Bureau  at 
Charlotte  and  was  sent  to  Oteen  for  observation. 
At  Oteen  he  was  examined  thoroughly,  but  given 
no  advice  other  than  to  work  shorter  hours,  exer- 
cise more  etc. — things  he  could  not  readily  do.  He 
was  also  sent  to  a  surgeon  who  did  not  advise  any 
operation.  A  rontgenologist  at  Oteen  raised  the 
question  of  Pott's  disease,  but  the  final  diagnosis 
obviously  was  not  that,  as  exercise  was  advised  and 
no  mechanical  fixation  employed.  The  problem  of 
marriage  arising,  he  returned  to  the  Crowell  Clinic 
to  try  to  get  completely  cured.  A  urologist  there 
who  was  thoroughly  conversant  with  his  condition 
touched  up  his  verumontanum  with  silver  nitrate 
and  told  him  to  go  ahead  and  marry.  He  had  had 
satisfactory  erections  up  until  5  or  6  mos.  before 
consulting  me,  but  not  after  that  time.  He  had  not 
yet  married.  He  had  felt  that  for  the  past  2  or  3 
months  he  had  been  getting  less  benefit  from  his 
treatment  than  formerly.  He  then  went  to  Duke, 
where,  after  thorough  examination,  the  patient 
says  he  was  told  he  could  be  cured;  but  he  got  no 
better.  For  two  months  before  coming  to  me  he 
had  been  treated  further  with  irrigations  by  a  High 
Point  physician.  The  only  other  items  of  interest 
in  his  personal  history  were  a  tendency  to  stringy  or 


pencil-like  stools  and  rather  marked  constipation. 
His  habits  and  past  history  were  not  contributory. 
His  family  history  threw  no  light  on  his  trouble. 

Physical  examination  showed  normal  findings  in 
every  respect  except  for  the  following:  The  spin- 
ous processes  of  his  last  thoracic  and  first  lumbar 
vertebrae  were  abnormally  prominent.  This  was 
the  site  of  his  old  injury.  There  was  no  transmit- 
ted tenderness  on  jarring  his  head  with  his  neck 
held  rigid.  Abdominal  palpation  gave  a  sensation 
of  slight  thickening  of  the  bladder  wall.  He  was 
somewhat  tender  over  the  left  kidney,  but  not  over 
the  right,  posteriorly.  Examination  of  the  genitals 
was  negative.  Rectal  examination  showed  no  hem- 
orrhoids, the  prostate  was  neither  enlarged  nor  ten- 
der, but  what  was  probably  a  thickened  bladder 
wall  could  be  felt  quite  definitely  through  the  rec- 
tum. His  feet  were  not  examined.  He  said  he  had 
mild  athlete's  foot,  but  not  enough  to  bother  with. 
His  kneejerks  were  absent.  He  says  they  were 
present  up  to  the  time  of  his  injury,  but  have  been 
absent  since.  He  showed  no  Romberg  sign,  his 
coordination  was  good  and  his  gait  seemed  perfect- 
ly normal.  There  was  no  paralysis  of  his  lower 
extremities.  His  urine  showed  some  albumin  and 
was  loaded  with  pus,  but  otherwise  was  negative. 
He  had  been  taking  methenamine  and  ammonium 
chloride  prescribed  at  Duke  for  four  weeks.  He 
was  tried  on  niazo,  a  pyridium-like  dye  put  out 
by  Schering  and  Glatz,  and  seemed  to  improve  for 
a  very  short  time,  but  then  got  as  bad  as  ever. 
Increasing  the  dose  of  niazo  then  reduced  the  pus 
in  the  urine  very  markedly.  His  prostatic  fluid  was 
loaded  with  pus,  although  there  was  no  prostatic 
tenderness  or  enlargement  on  rectal  palpation.  This 
gradually  cleared  up  until  his  cystitis  did  not  both- 
er him. 

He  returned  to  me  in  April,  1934,  saying  that 
he  had  gone  back  to  Duke  and  they  had  found  his 
same  old  trouble.  He  felt  it  too  costly  in  time  to 
keep  going  to  Duke  for  treatment,  so  I  referred 
him  to  Dr.  E.  A.  Sumner,  who  treated  him  with 
satisfactory  results. 

My  next  note  on  his  case  is  dated  March  28th. 
1935.  At  this  time  he  complained  of  pain  in  his 
right  inguinal  region.  He  had  noted  no  bladder 
irritation.  He  had  been  going  to  Dr.  Sumner  about 
every  2  weeks  for  treatment,  but  this  had  come  on 
rather  suddenly  since  his  last  visit  to  Dr.  Sumner. 
His  temperature  was  98.4,  pulse  rate  88  and  res- 
piratory rate  normal.  He  had  no  nausea  and  vom- 
iting, and  no  hernia.  He  had  a  tender  area  starting 
an  inch  below  McBurney's  point  and  extending 
down  to  Poupart's  ligament.  He  said  that  his  pain 
had  begun  as  generalized  pain  and  had  later  local- 
ized in  the  area  described.  Dr.  Sumner,  called  in 
consultation,  demonstrated  that  the  maximum  ten- 


December,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


derness  was  in  the  vas  deferens  and  feared  infec- 
tion going  from  the  bladder  to  the  epididymis.  The 
urine  still  contained  pus.  Recovery  from  inguinal 
pain  was  made  in  two  days  on  Dr.  Sumner's  treat- 
ment, without  going  to  the  hospital.  He  married 
and  his  wife  has  had  a  fine  baby. 

Diagnosis:  Spinal  cord  trauma  with  ''cord  blad- 
der." Complicating  chronic  cystitis  and  acute  def- 
erentitis. 

Discussion:  At  the  time  of  his  injury,  constant 
catheterization  of  a  cord  bladder  was  the  accepted 
standard  treatment.  In  more  recent  times  the 
trend  has  been  to  keep  out  of  an  uninfected  pa- 
ralyzed bladder,  because  it  seems  practically  cer- 
tain that  continued  catheterization,  even  with  the 
most  meticulous  care  to  insure  asepsis,  will  infect 
the  bladder  and  necessitate  prolonged,  even  life- 
long treatment.  It  is  recognized  that  if  the  bladder 
be  left  alone,  while  it  will  become  greatly  distended 
and  for  a  time  there  may  be  incontinence  of  reten- 
tion, it  will  eventually  develop  its  own  automatic 
rhythmicitv.  when  freed  from  spinal  control.  In 
1919,  however,  before  this  became  recognized,  it 
would  have  been  considered  gross  negligence  not  to 
have  catheterized  him.    Medicine  marches  on! 


SURGICAL  OBSERVATIONS 


OF  THE  STATF 

DAVIS  HOSPITAL 
Statesville 


POSTGRADUATE  COURSES  IN  OBSTETRICS 
Five  postgraduate  courses  in  obstetrics,  each  of  four 
weeks'  duration,  will  be  offered  at  the  Chicago  Lying-in 
Hospital  between  January  12th  and  June  6th,  1942.  These 
arc  sponsored  by  the  Illinois  State  Department  of  Health 
and  the  Children's  Bureau  of  the  U.  S.  Department  of 
Labor.  The  features  of  the  program  consist  of  observations 
on  current  managements  of  normal  and  abnormal  states  of 
the  pregnant,  the  parturient  and  the  puerperal  patient. 
Lectures,  demonstrations,  clinics  and  other  teaching  means 
augment  the  operating-room  and  birth-room  observations. 
and  ward-round  discourses.  The  course  is  run  on  a  non- 
profit basis.  A  deposit  of  $25.00  is  required  on  registra- 
tion. SIO.OO  of  which  is  refunded  at  the  completion  of  the 
course.  All  the  members  of  the  department  participate  in 
giving  Ihe  courses.  Additional  information  and  application 
blanks  may  be  obtained  by  request  from 

POSTGRADUATE    COURSE,    DEPARTMENT    OF    OBSTETRICS    AND 
BSNECOLOGY,   S848   DREXEL  AVENUE,   CHICAGO. 


UROLOGY  AWARD:  The  American  Urological  Asso- 
ciation offers  an  annual  award  not  to  exceed  $500.00  for  an 
Essay  (or  essays)  on  the  result  of  some  specific  Clinical 
or  Laboratory  Research  in  Urology.  The  amount  of  the 
prize  is  based  on  the  merits  of  the  work  presented;  if  the 
Committee  on  Scientific  Research  deem  none  of  the  offer- 
ings worthy,  no  award  will  be  made.  Competitors  shall 
be  limited  to  residents  in  urology  in  recognized  hospitals 
and  to  urologists  who  have  been  in  such  specific  practice 
for  not  more  than  five  years. 

Essays  must  be  in  the  hands  of  the  Secretary,  Dr.  Clyde 
L.  Denting,  7S9  Howard  Avenue,  New  Haven,  Conn.,  on 
or  before  April  1st.  1942. 


THE  USE  OF  SULFATHIAZOLE  IN 
SUPPURATIVE  APPENDICITIS 

For  years  we  have  had  almost  no  deaths  even 
in  the  worse  suppurative  cases  of  appendicitis.  We 
attribute  this  to  the  fact  that,  in  addition  to  the 
surgical  procedure  and  the  earliest  possible  opera- 
tion, we  have  used  x-ray  treatment  over  the  in- 
volved area  immediately  after  operations  and  some- 
times on  each  of  three  successive  days  after  opera- 
tion, with  the  idea  of  preventing  the  growth  and 
development  of  gas-bacillus  infection.  In  addition, 
we  have  given  combined  tetanus  and  gas-bacillus 
antitoxin  in  these  cases. 

Now,  in  addition  to  these  two  measures,  we 
often  use  sulfanilamide  in  the  suppurative  areas 
before  the  abdomen  is  closed  and  as  soon  as  possi- 
ble give  sulfathiazole  by  mouth. 

It  is  likely  that  sulfanilamide  is  the  best  drug  to 
use  for  local  application  in  suppurative  conditions, 
or  where  there  is  severe  infection,  and  that  sul- 
fathiazole is  the  most  satisfactory  drug  to  use 
orally. 

With  the  rapid  development  of  the  sulfonamides 
we  hope  that  we  will  soon  have  a  drug  that  may  be 
administered  freely  intravenously  without  causing 
any  unfavorable  reaction  and,  at  the  same  time,  a 
drug  which  will  be  more  powerful  than  the  present 
sulfonamides  in  destroying  pathogenic  organisms  in 
the  body.  An  entirely  new  field  has  been  opened 
up  in  the  past  few  years  and  it  is  our  hope  that 
this  will  rapidly  develop  to  the  point  where  almost 
any  specific  infection  may  be  rapidly  and  easily 
destroyed  by  the  use  of  these  drugs. 

Another  important  thing  that  must  never  be  for- 
gotten is  the  fact  that  the  patient  must  have  plenty 
of  fluids  but,  at  the  same  time,  we  must  remember 
that  the  patient  must  have  blood  and  where  large 
amounts  of  fluids  are  given  intravenously  the  fact 
that  many  of  these  patients  should  have  repeated 
blood  transfusions  also.  Repeated  transfusions  of 
blood  are  powerful  factors  in  the  saving  of  lives  in 
desperately-ill  patients. 

The  most  meticulous  care  and  attention  to  the 
minutest  detail  of  the  treatment,  from  the  very 
beginning  until  the  patient  is  well,  and  eternal  vig- 
ilance are  required  in  reducing  and  maintaining  the 
mortality  in  surgery  to  the  minimum. 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


THE  IMPORTANCE  OF  THE  PRE-  AND 
POST-OPERATIVE  CARE  OF  PATIENTS 

In  the  public  mind,  the  performance  of  an 
operation  is  practically  the  whole  problem  in  sur- 
gery; but  as  every  real  surgeon  knows  the  care 
before  and  after  operation  is  in  many  cases  just 
as  important,  in  some  even  more  so. 

An  accurate  diagnosis,  proper  preoperative  care, 
the  correct  operation,  and  proper  care  throughout 
convalescence  reduces  the  mortality  in  surgery  to 
a  minimum  and  gives  the  highest  percentage  of 
good  results. 

The  best  of  judgment  is  essential.  No  matter 
how  skillful  an  operator  may  be,  unless  he  has 
good  judgment  the  mortality  rate  will  be  higher 
and  the  end-results  poorer.  The  fact  that  a  patient 
survives  an  operation  is  no  criterion  of  a  good  sur- 
geon. It  is  the  good  result  that  counts.  The  object 
of  any  therapy  is  to  restore  the  patient  to  as  near 
perfect  health  as  possible  and  unless  we  do  our 
utmost  to  accomplish  this  the  main  idea  in  surgerv 
is  lost. 

Even  with  the  best  of  treatment  the  results  some- 
times are  disappointing,  yet  constant  attention  to 
details  in  everything  that  has  to  do  with  the  pa- 
tient's welfare,  from  the  time  the  patient  enters 
the  hospital  until  he  is  entirely  well  and  strong 
again,  is  of  vital  importance  to  that  patient. 

Everyone  knows  the  patient  must  have  plenty  of 
fluids  and  for  this  purpose  we  usually  give  glucose 
intravenously  in  sufficient  amounts  until  the  pa- 
tient can  take  enough  fluid  by  mouth.  Meantime 
the  patient  may  require  a  lot  of  other  things. 
Blood  transfusions  are  often  indicated  even  when 
the  blood  count  is  fairly  normal,  and  there  is  no 
question  but  that  they  are  often  life-saving,  even 
in  cases  where  there  is  no  particular  anemia. 

Proper  diet,  proper  elimination  and  extra  vita- 
mines,  when  necessary,  all  have  an  important  bear- 
ing on  a  patient's  welfare  and  progress.  A  cheer- 
ful, optimistic  patient  with  the  determination  to 
get  well  will  often  recover,  where  a  fretful,  pessi- 
mistic patient  may  succumb.  Much  can  be  done 
to  assist  a  patient  in  maintaining  the  proper  frame 
of  mind. 

Faith  in  the  doctor,  in  the  nurses  and  in  the  in- 
stitution is  a  powerful  factor  in  a  patient's  recov- 
ery. A  sympathetic  understanding  of  a  patient  is 
essential.  Patients  are  quick  to  sense  the  doctor's 
interest  and  sincerity.  When  a  doctor  is  doing  his 
best  for  his  patients  and  has  the  patients'  confi- 
dence, respect  and  cooperation,  we  have  a  situation 
which  will  bring  most  through  their  serious  illness. 

These  are  just  a  few  of  the  multitude  of  things 
that  have  to  do  with  a  patient's  recovery  and  the 
doctor  who  keeps  these  things  in  mind,  maintains 
the  highest  principles  and  observes  the  best  tradi- 


tions of  our  profession,  finds  a  joy  in  his  work  and 
a  satisfaction  not  to  be  described  in  words. 

THE  IMPORTANCE  OF  TREATING  ANEMIA 
BEFORE  AND  AFTER  OPERATION 

Many  patients  who  come  in  for  surgical  treat- 
ment have  an  anemia  which,  while  it  is  not  partic- 
ularly bad — 3,500.000  red  cells,  with  a  hemoglobin 
of  72  per  cent  or  so — may  profoundly  influence 
recovery.  As  a  sort  of  rough-and-ready  rule,  it 
may  be  said  that  a  patient  with  a  hemoglobin  of 
72  per  cent  has  72  per  cent  of  the  recuperative 
powers  of  the  individual  who  has  a  normal  count 
and  hemoglobin.  Naturally  a  person  with  a  low- 
ered hemoglobin  and  red  cell  count  would  be  at  a 
disadvantage  when  the  body  is  placed  in  an  un- 
usual strain,  especially  when  this  occurs  suddenly 
as  in  the  case  of  acute  illness  requiring  immediate 
surgery. 

When  an  individual's  blood  is  below  normal,  it 
is  just  like  an  army  who  is  inferior  in  numbers 
and  equipment  to  an  opposing  army.  If  there  is 
not  time  to  build  up  the  patient's  blood  before 
operation,  it  is  important  to  give  one  or  two  blood 
transfusions  after  operation — until  the  anemia  is 
overcome.  Where  there  is  plenty  of  time  before 
operation  and  the  anemia  is  not  very  marked,  iron, 
liver  extract  and  a  rich  diet  will  usually  correct 
the  condition  promptly. 

Careful  attention  to  the  study  of  the  patient 
generally  and  not  overlooking  the  blood  picture 
should  be  an  important  part  in  the  examination  of 
every  patient  and  especially  before  surgery. 

THE  INCIDENCE  OF  UNDULANT  FEVER 

We  continue  to  be  impressed  with  the  number 
of  patients  who  have  vague  and  indefinite  symp- 
toms, aches,  pains,  occasional  slight  fever,  who 
turn  out  to  have  undulant  fever.  Many  cases  of 
chronic  ill-health,  with  a  multitude  and  variety  of 
vague  symptoms,  will,  on  careful  study,  reveal  the 
subclinical  type  of  undulant  fever. 

We  can  not  depend  upon  the  agglutination  test 
or  the  intradermal  test.  A  careful  study  of  these 
patients'  history,  and  symptoms,  investigation  of 
the  origin  of  the  trouble,  and  determining  if  possi- 
ble the  presence  of  undulant  fever  in  a  herd  of 
cattle  from  which  the  milk  and  butter  used  was 
obtained,  will  often  be  of  great  help. 

All  milk  for  human  consumption  should  be  pas- 
teurized. From  this  pasteurized  milk,  by  means  of 
a  cream  separator,  the  cream  may  be  obtained  for 
use  in  making  butter.  Butter  made  in  this  sway 
would  be  safe  to  use,  also  buttermilk  made  from 
the  skimmed  milk;  and  pasteurized  whole  milk 
made  into  lactic-acid  buttermilk. 

The  treatment  of  undulant  fever  is  not  easy. 
Those  who  are  able  to  stand  fever-therapy  are  for- 


December.  1941 


SOUTHERX  MEDICINE  &  SURGERY 


663 


tunate.  This  is  perhaps  the  best  and  can  be  used 
in  conjunction  with  vaccine.  In  those  who  can  not 
stand  this  form  of  treatment,  the  immunization  of 
donors  and  blood  transfusions  from  these  are  ex- 
cellent. It  is  necessary,  however,  that  the  donors 
be  given  vaccine  until  the  blood  reaches  a  high 
titer  and  then  transfusions  from  these  donors  will 
be  of  great  help.  In  any  event,  it  is  necessary  that 
the  treatment  be  kept  up  continuously  sometimes 
for  weeks  or  even  months  before  relief  is  obtained. 

DIAGNOSIS  OF  ENLARGEMENT  OF  THE 
THYROID  GLAND 

The  diagnosis  of  enlargement  of  the  thyroid 
gland  is  not  always  easy.  A  goiter  may  be  for  the 
greater  part  substernal.  Even  the  smallest  adeno- 
matous growths  may  project  downward  from  the 
lower  pole  of  the  thyroid  gland  and  not  be  readily 
palpable  except  when  a  very  careful  examination 
of  the  neck  is  made. 

First  observe  the  patient  carefully.  A  thin  pa- 
tient's enlarged  thyroid  usually  shows  up,  but  even 
then,  if  the  enlargement  projects  downward  or 
backward,  or  both,  inspection  may  reveal  nothing 
diagnostic  and  palpation  is  more  difficult. 

In  all  cases  it  is  well  to  have  the  patient  swallow 
several  times,  each  time  palpating  the  right  or  left 
side,  or  both  together.  During  the  process  of  swal- 
lowing the  thyroid  gland  comes  upward  and  then 
drops  down  again,  and  it  is  during  this  time  that 
one  can  often  feel  an  adenomatous  growth  which 
would  ordinarily  escape  attention. 

I  have  often  been  surprised  at  the  size  of  a  re- 
moved thyroid  mass  which  had  felt  only  slightly 
enlarged  to  the  examining  fingers.  On  elevating  the 
thyroid  gland  during  the  process  of  thyroidectomy 
a  downward  or  backward  projection,  particularly  a 
retrotracheal  lobe,  made  a  surprisingly  large  mass 
which  was  not  suspected  before  operation.  In  all 
cases,  in  which  a  substernal  thyroid  suspected, 
a  careful  x-ray  examination  should  be  made  in  or- 
der to  get  an  accurate  diagnosis.  It  is  not  a  bad 
idea  to  examine  a  patient  at  different  times  over  a 
period  of  a  week,  if  there  is  some  doubt  as  to 
whether  or  not  there  is  an  adenomatous  growth. 

In  all  cases  of  suspected  enlargement  of  the  thy- 
roid a  basal  metabolism  test  should  be  done, 
preferably  two  or  three  in  succession — each  day  for 
three  days  usually  suffices. 

Even  with  enlargement  of  the  thyroid  gland 
there  may  be  no  increased  basal  rate  ,and  con- 
versely, we  sometimes  find  an  increased  basal  rate 
with  very  little  enlargement. 

Every  suspected  case  of  disease  of  the  thyroid 
gland  should  receive  a  thorough  examination.  Anv 
operation  found  necessary  should  be  done  only  by 
those  well  experienced  in  thyroid  surgery. 


DEPARTMENTS 


INSURANCE  MEDICINE 

H.  F.  Starr,  M.D.,  Editor,  Greensboro,  N.  C. 


DYSPNEA 

Dyspnea  is  an  extremely  important  symptom 
which  should  receive  careful  attention  in  any  ex- 
amination. When  we  consider  its  implications  and 
the  case  with  which  a  history  can  be  elicited  or  its 
presence  demonstrated,  it  is  surprising  that  it  so 
often  receives  but  little  attention  in  the  routine 
examination  for  life  insurance.  Its  value  and  ac- 
curacy as  a  symptom  compare  favorably  with  many 
tests  requiring  considerable  time,  labor  and  special 
equipment. 

The  demand  for  pulmonary  ventilation  is  sub- 
ject to  sudden  change  which  is  met  by  variation 
in  the  depth  of  respiration  and  if  necessary  an 
alteration  in  the  rate.  The  reversal  of  inspiration 
into  expiration  is  brought  about  by  the  Hering- 
Breuer  reflex.  With  inspiration  the  alveolar  atmos- 
pheric tension  increases  to  a  point  where  the  re- 
flex turns  from  that  of  inspiration  to  expiration. 
The  afferent  impulse  is  through  the  vagus,  the  ef- 
ferent by  way  of  the  phrenic  and  spinal  nerves. 
The  points  at  which  the  reflex  becomes  reversed  is 
variable  with  different  conditions,  rendering  the 
mechanism  flexible.  The  respiratory  center  not 
only  initiates  the  respiratory  rhythm  but  controls 
the  points  or  threshold  of  the  reflex.  With  an  in- 
crease in  the  hydrogen-ion  concentration  or  acidity 
of  the  respiratory  center,  the  points  of  the  Hering- 
Breuer  reflex  become  farther  apart  and  as  a  con- 
sequence respirations  become  deeper  and  the  rate 
increases,  while  if  the  hydrogen-ion  concentration 
decreases  or  if  the  center  becomes  more  alkaline, 
the  points  approximate  and  respirations  become 
shallower  and  slower. 

The  gross  hydrogen-ion  equilibrium  is  maintain- 
ed chiefly  by  the  kidnevs,  but  the  finer  variations 
are  controlled  by  the  lungs  through  their  elimina- 
tion or  retention  of  carbon  dioxide.  The  kidneys' 
role  may  be  compared  to  that  of  the  coarse  ad- 
justment on  the  microscope,  while  that  of  the  lungs 
corresponds  to  the  fine  adjustment.  Carbon  dioxide 
is  a  weak  acid,  soluble  and  readily  diffusable,  serv- 
ing admirably  in  making  the  rapid  and  delicate 
adjustments  here  required.  With  an  increase  of 
hydogen-ions,  the  respiratory  center,  through  its 
control  of  the  Hcring-Breuer  reflex,  increases  pul- 
monary ventilation  which  augments  the  elimination 
of  carbon  dioxide,  thereby  reducing  the  hydrogen- 
ion  concentration  of  the  blood.  When  the  hydro- 
gen-ion concentration  is  reduced,  the  opposite  oc- 
curs and  pulmonary  ventilation  is  reduced. 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


Oxygen  tension  also  plays  an  important  role.  If 
the  supply  of  oxygen  to  the  respiratory  center  is 
inadequate  the  center  becomes  more  sensitive  to 
hydrogen-ion  concentration. 

Thus,  dyspnea  may  result  from  either  increased 
acidity  or  decreased  oxygen  pressure  in  the  respira- 
tory center.  Also,  any  condition  in  the  lung,  such 
as  pulmonary  engorgement,  emphysema  or  fibrosis 
which  will  exaggerate  the  excitability  of  the  Her- 
ing-Breuer reflex  will  play  an  important  part  in 
the  production  of  dyspnea. 

With  this  brief  and  much  simplified  descrip- 
tion of  the  mechanism  of  respiratory  control  it  is 
obvious  that  the  cause  of  dsypnea  may  be  either 
acidosis;  want  of  oxygen;  lesions  near  the  respira- 
tory center;  increased  sensitivity  of  the  Hering- 
Breuer  reflex  whether  due  to  pulmonary  congestion, 
emphysema  or  fibrosis;  interference  with  the  action 
of  the  respiratory  muscles;  or  neuroses. 

Dyspnea  may  be  physiologic.  A  young  normal 
athlete  in  excellent  training  can  become  short  of 
breath.  Dyspnea  is  not  abnormal  unless  it  is  more 
readily  produced  than  in  the  average  individual, 
considering  age,  occupation  and  living  habits.  It  is 
not  always  easy  to  draw  a  line  separating  normal 
breathlessness  from  the  abnormal. 

Metabolic  disturbances  causing  dyspnea  by  acid- 
osis may  be  due  to  diabetes,  nephritis  or  advanced 
prostatism.  In  hyperthyroidism  there  is  an  excess 
of  carbon  dioxide  together  with  altered  sympathetic 
action.  In  insulin  shock  low-blood-pressure  and 
possibly  its  effect  upon  the  carotid  sinus  produces 
rapid,  shallow  breathing. 

A  variety  of  pulmonary  conditions  may  ptoduce 
dyspnea.  Laryngeal  or  bronchial  obstruction  gives 
rise  to  carbon-dioxide  retention  and  oxygen  want. 
Emphysema  and  pneumoconiosis  produce  loss  of 
elasticity  of  the  pulmonary  tissues  and  increase 
the  sensitivity  of  the  Hering-Breuer  reflex.  In 
lobar  pneumonia  or  massive  collapse  there  is  pul- 
monary congestion  and  sensitivitv  of  the  Hering- 
Breuer  reflex  and  in  bronchopneumonia  there  is  in 
addition  carbon-dioxide  retention  and  oxygen  want. 
The  acute  conditions  are  not  encountered  in  the 
examination  of  applicants  for  life  insurance  except 
in  the  history. 

Aside  from  dyspnea  due  to  physiologic  causes  or 
acute  infections,  circulatory  disease  is  by  far  the 
most  common  cause.  Breathlessness  is  the  first 
symptom  of  cardiac  disease  in  the  majority  of 
cases.  Dyspnea  in  circulatory  failure  is  a  compen- 
satory reaction,  complex  in  origin,  based  partly 
upon  central  anoxemia  and  carbon-dioxide  reten- 
tion. When  the  myocardial  reserve  is  reduced 
dyspnea  on  exertion  is  due  to  failure  of  the  heart 
to  deliver  the  required  amount  of  oxygen  to  the 
respiratory  center.  When  the  left  ventricle  fails  to 


maintain  the  normal  output  of  blood,  there  is  an 
accumulation  of  blood  in  the  ventricle,  leading 
eventually  to  its  dilatation  and  increased  pressure 
in  the  pulmonary  circuit.  In  the  early  stages,  the 
right  ventricle  continues  to  discharge  a  normal 
supply  of  blood  to  the  lungs,  thereby  increasing 
the  engorgement.  With  slowing  of  both  the  sys- 
temic and  pulmonary  circulation  a  reduction  in 
vital  capacity  and  an  increase  in  anoxemia  results. 

Simple  changes  in  posture  alter  the  load  requir- 
ed of  the  left  ventricle  and  increase  or  decrease 
the  venous  pressure  and  the  return  of  blood  to 
the  heart.  The  total  circulating  blood  volume  in- 
creases during  sleep  and  pulmonary  engorgement 
is  favored,  giving  rise  to  nocturnal  attacks  of 
dyspnea,  so-called  cardiac  asthma.  These  attacks 
must  be  distinguished  from  bronchial  asthma.  This 
may  be  difficult  when  symptoms  appear  in  patients 
of  middle  age  and  beyond.  Here  the  heart  should  be 
considered  at  fault  until  proved  otherwise.  Cardiac 
asthma  is  usually  preceded  by  gradually  increasing 
dyspnea  on  exertion  of  rather  recent  occurrence, 
while  dyspnea  due  to  chronic  pulmonary  disease 
will  have  been  present  for  years.  Differentiation 
may  be  clouded  by  the  fact  that  in  the  asthmatic 
patient  of  middle  age  or  beyond  asthmatic  breath- 
ing may  become  continuous,  worse  at  night,  and 
tolerance  to  effort  may  decrease  as  emphysema, 
bronchiectasis  or  pulmonary  fibrosis  develops.  In 
such  a  case  it  is  difficult  to  say  whether  the  heart 
is  at  fault  or  just  when  myocardial  failure  begins. 
Inability  to  perform  in  comfort  exertion  which 
formerly  caused  no  discomfort  is  very  suggestive 
of  cardiac  disease.  Both  pulmonary  and  cardiac 
disease  may  be  present,  each  contributing  to  the 
production  of  dyspnea. 

The  obese  are  generally  short  of  breath.  If 
there  is  an  increase  in  dyspnea  in  a  person  long 
obese,  without  recent  gain  in  weight,  cardiac  dis- 
ease should  be  suspected  until  ruled  out  by  care- 
ful investigation.  Obesity  invariably  adds  to  the 
work  of  the  heart. 

Nervous  exhaustion  may  give  rise  to  the  com- 
plaint of  shortness  of  breath.  These  patients 
usually  describe  the  sensation  as  inability  to  take 
a  deep  breath,  a  feeling  that  the  lungs  do  not 
completely  fill  during  inspiration,  or  as  a  heavy 
sensation  in  the  chest.  There  may  be  periodic  sigh- 
ing. Attacks  are  precipitated  by  nervous  or  emo- 
tional strain  rather  than  by  physical  exertion, 
which  is  an  important  point  to  consider  in  differ- 
entiating between  dyspnea  due  to  nervous  exhaus- 
tion and  dyspnea  due  to  organic  disease. 

The  majority  of  applicants  for  life  insurance  are 
in  good  health  and  it  is  rare  that  one  in  advanced 
stage  of  chronic  disease  presents  himself  for  ex- 
amination.   Signs  and  symptoms  are  not  as  a  rule 


December,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


definite  and  pronounced  as  with  the  patient  whose 
disease  has  become  established.  As  with  other 
signs  and  symptoms,  the  examiner  should  not  ex- 
pect to  find  dyspnea  as  pronounced  in  the  appli- 
cant for  insurance  as  in  the  average  patient.  It  is 
not  apt  to  force  itself  upon  the  attention  of  the 
examiner.  It  must  be  sought  out.  The  chief  object 
of  the  examination  for  life  insurance  is  largely  to 
discover  disease  in  its  incipiency. 


UROLOGY 

Raymond  Thompson,  M.D.,  Editor,  Charlotte,  N.  C. 


PROGNOSIS  IX  BILATERAL  RENAL 
TUBERCULOSIS 

Recent  statistics  reveal  that  the  incidence  of 
tuberculosis  in  man  is  much  less  now  than  former- 
ly.1 Henderson  states  that  tuberculosis  of  the  bones 
and  joints  has  decreased  to  such  an  extent  that 
some  medical  schools  find  it  difficult  to  obtain  suf- 
ficient number  of  patients  who  have  such  lesions 
for  purposes  of  instruction.  Urologists  agree  that 
the  incidence  of  renal  tuberculosis  has  decreased 
considerably  in  the  past  two  decades.  The  degree 
of  involvement  of  the  kidney  and  bladder  is  less 
than  in  former  vears  and  the  clinical  evidence  of 
its  existence  is  often  more  obscure.  This  is  the 
result  of  elimination  of  etiologic  factors  and  of 
increased  resistance  to  tuberculous  infection. 

Bilateral  renal  tuberculosis  is  reported  more  fre- 
quently in  recent  years.  From  1910-1934  approxi- 
mately 2,200  cases  were  observed  at  the  Mayo 
Clinic  in  which  a  diagnosis  of  renal  tuberculosis 
was  made.  Clinical  evidence  of  bilateral  involve- 
ment was  present  in  291  cases  (13  per  cent). 

Definition. — There  is  a  decided  difference  among 
urologists  as  to  the  type  and  degree  of  evidence  of 
disease  deemed  necessary  to  establish  such  a  diag- 
nosis. Radicals  state  that  renal  tuberculosis  at  the 
time  of  onset  is  bilateral  in  all  cases.  There  is  in- 
sufficient pathologic  evidence  available  to  substan- 
tiate such  a  statement  and  much  clinical  evidence 
to  disprove  it.  If  the  urine  obtained  on  catheteri- 
zation from  the  least-affected  kidney  does  not  con- 
tain pus  cells,  is  negative  on  stain  for  the  tubercle 
bacillus,  and  inoculation  of  the  guinea  pigs  gives 
negative  results,  the  kidney  may  be  accepted  as 
normal  and  removal  of  the  diseased  kidney  is  per- 
missible. The  best  prognosis  is  offered  after  ne- 
phrectomy. The  mortality  for  5  years  after  opera- 
tion was  20  per  cent  and  for  10  years  after  opera- 
tion 34  per  cent.  Bilateral  renal  tuberculosis  would 
be  very  improbable  in  most  of  the  cases  of  this 
group. 

The  controversy  starts  concerning  the  next 
group  of  cases.    In  a  series  of  proved  tuberculosis 

1.  Al.st.  Braasch,  W.  F„  &  Sutton,  E.  B.:  Prognosis  in  bilat- 
eral  renal   tuberculosis.   /.    Urol.,  46:567   (Oct.),   1941. 


in  one  kidney  and  no  microscopic  evidence  of  in- 
fection in  the  urine  from  the  good  kidney  observed 
at  the  clinic,  guinea  pigs  were  inoculated  with  the 
apparently  negative  urine.  In  many  cases  the  re- 
actions were  positive.  From  the  follow-up  exam- 
ination we  concluded  that  the  positive  report  was 
due  to  technical  factors.  In  another  group  of  cases 
three  or  more  pus  cells  per  high-power  field  were 
found  in  the  urine  from  the  good  kidney.  If  the 
presence  of  mycobacterium  tuberculosis  was  also 
demonstrated  the  mortality  for  six  years  after  in- 
creased to  60  per  cent.  A  third  of  the  patients 
who  had  definite  evidence  of  bilateral  disease  at 
the  time  of  operation  lived  five  years  or  longer. 
Among  this  group  were  patients  who  apparently 
recovered  from  the  infection.  Three  inferences  are 
possible:  (1)  the  kidney  may  occasionally  recover 
from  tuberculous  infection;  (2)  positive  evidence 
of  the  disease  in  the  good  kidney  as  determined  by 
inoculation  of  urine  into  guinea  pig  is  inaccurate 
and  misleading;  (3)  there  is  a  definite  group  of 
patients  who  live  fairly  comfortably  with  chronic 
tuberculosis.  The  apparent  recovery  is  explained 
by  the  last  two  inferences. 

Indications  for  operations:  Unless  there  is  de- 
cided difference  in  the  extent  of  the  disease  in  the 
two  kidneys  surgical  intervention  is  rarely  indi- 
cated. It  is  unreasonable  to  remove  one  kidney 
when  the  extent  of  the  disease  is  equal  in  both 
kidneys.  The  presence  of  tuberculosis  in  the  other 
tissues  of  the  body,  even  if  active,  does  not  neces- 
sarily interfere  with  nephrectomy.  Active  pulmo- 
nary complications  would  contraindicate  operation 
if  both  kidneys  were  involved.  In  most  cases  of 
bilateral  renal  tuberculosis  there  is  not  a  great 
difference  in  the  degree  and  extent  of  the  disease 
in  the  two  kidneys  and  other  complications  make 
surgical  treatment  impossible. 

Sex  and  age:  Only  39  patients  (10  per  cent) 
were  females.  Of  the  204  patients,  58.8  per  cent 
who  had  bilateral  renal  involvement  were  in  the 
fourth  and  fifth  decades  of  life.  The  youngest  was 
28  months,  and  the  oldest  63  years. 

Symptoms  and  laboratory  data:  The  symptoms 
did  not  differ  much  from  those  of  unilateral  tuber- 
culosis, except  that  they  were  more  severe.  A  pe- 
riod of  dysuria  and  frequent  micturition  many 
years  ago,  with  recovery.  This  is  the  period  of 
infection  and  occlusion  of  one  kidney,  with  recent 
infection  of  the  other  kidney.  Rbntgenographic 
studies  revealed  areas  of  renal  calcification.  Cys- 
toscopy examination  reveals  more  involvement  of 
the  bladder,  with  deformity  and  ulceration,  than 
in  unilateral  renal  tuberculosis. 

Complications:  Renal  tuberculosis  is  a  local 
manifestation  of  a  constitutional  disease. 


SOUTHERN  HfEDICINE  &  SURGERY 


December,  1941 


Renal  function:  A  slight  reduction  in  f miction 
usually  is  noted  in  the  early  stages  of  unilateral 
renal  tuberculosis.  In  spite  of  apparently  advanced 
involvement  of  both  kidneys,  the  combined  renal 
function  often  is  normal  or  reduced  only  slightly. 

Hypertension:  The  incidence  of  hypertension 
associated  with  unilateral  renal  tuberculosis  is  less 
than  that  observed  among  average  persons. 

Prognosis:  The  subsequent  clinical  course  was 
traced  in  167  of  204  cases.  Most  of  the  patients 
traced  died,  directly  or  indirectly,  of  some  form  of 
tuberculosis;  58.1  per  cent  lived  5  years  or  more; 
26.3  per  cent  were  living  IS  years  after.  The  gen- 
eral condition  of  most  of  the  patients  living  10  to 
IS  years  after  examination  was  better  than  expect- 
ed. The  prognosis  in  cases  of  bilateral  renal  infec- 
tion of  equal  degree  is  distinctly  worse  than  in 
cases  in  which  infection  is  predominant  in  one  kid- 
ney. Sixty-three  patients  (66.6  per  cent)  died 
within  two  years,  only  seven  lived  five  years  or 
more. 

In  reviewing  the  cases  in  which  there  seemed  to 
be  more  resistance  to  the  disease,  it  is  difficult  to 
find  any  conspicuous  feature  that  is  common  to  all. 
The  care  of  the  patient  after  leaving  the  clinic  at 
best  was  inadequate.  With  supervised  rest,  good 
diet,  and  heliotherapy,  the  survival  rate  among 
these  patients  would  increase. 

Summary  and  conclusions:  Our  previous  con- 
cepts concerning  life  expectancy  in  cases  of  non- 
surgical renal  tuberculosis  demand  radical  revision. 
Unless  the  indications  for  nephrectomy  are  quite 
definite  iu  a  case  of  bilateral  disease,  it  would  be 
well  to  give  Nature  a  chance. 


SURGERY 

Geo.   H.  Bunch,  M.  D.,  Editor,  Columbia,  S.  C. 


THE  TREATMENT  OF  CANCER  OF  THE  LIP 

Because  of  the  spread  of  education  on  the  sub- 
ject, many  persons  now  have  suspicious  lesions  of 
the  lip  treated  early.  Most  cases  go  directly  to  the 
dermatologist  or  to  the  radiologist  and  are  seen  by 
the  surgeon  only  as  he  is  called  in  consultation.  In 
an  attempt  to  determine  the  indication  for  radia- 
tion as  compared  to  that  for  surgery,  or  for  the 
combination  of  radiation  and  surgery,  in  the  treat- 
ment of  cancer  of  the  lip,  members  of  the  staff 
have  recently  reported  a  detailed  study  of  375 
consecutive  cases  treated  in  the  Memorial  Hospi- 
tal, during  the  7-year  period  from  1928  to  1934, 
with  the  surprisingly  high  net  S-year  cure  rate  of 
70  per  cent. 

Radiation  alone  is  used  in  primary  superficial 
lesions  whether  large  or  small,  because  of  better 
cosmetic  effect.  Deeply  infiltrating  and  eroding 
primary  lesions — over  one-third  of  the  total  group 


— are  treated  by  wide  surgical  excision  with  plastic 
closure.  There  should  always  be  a  safe  margin  of 
normal  tissue  even  at  the  risk  of  the  ultimate  cos- 
metic effect  being  not  so  good.  Bulky  tumors  that 
are  not  infiltrating  mav  continue  for  two  or  three 
years  without  glandular  metastases.  The  tendency 
to  metastasize  varies  greatly  and  is  of  greater  prog- 
nostic value  than  is  the  size  of  the  growth. 

The  treatment  of  metastatic  lesions  is  a  great 
problem.  In  the  absence  of  palpable  cervical 
metastases,  after  the  primary  lesion  has  been  erad- 
icated, there  should  be  neither  prophylactic  radia- 
tion nor  block  dissection  of  the  neck.  In  cases 
without  demonstrable  metastases  in  which  the  pri- 
mary lesion  has  been  cured  only  8  per  cent  have 
developed  metastases  within  an  observation  period 
of  five  years.  Aspiration  biopsy  provides  tissue  for 
histologic  examination  without  surgical  excision. 

The  choice  of  treatment  for  clinically  demon- 
strable cervical  metastases  should  be  determined 
by  the  indications  in  the  individual  case.  Radia- 
tion alone  should  be  used  in  the  aged,  in  the  poor- 
risk  patient  and  in  the  patient  with  lesions  too  dis- 
seminated or  too  far  advanced  for  surgical  removal. 
It  may  be  administered  without  particular  risk  at 
the  same  time  and  in  conjunction  with  irradiation 
of  the  primary  lesion.  In  the  treatment  of  cancer 
the  term  inoperable  is  not  synonymous  with  incur- 
able. It  should  be  known  by  all  doctors  that  "prov- 
ed clinical  metastatic  nodes  can  be  cured  by  ra- 
diation alone."  Eleven  patients  with  histologically 
proved  cervical  metastases  have  survived  for  five 
years.  Of  35  microscopically  proved  cases  having 
block  dissection  of  the  neck  there  have  been  13 
S-year  survivals  without  recurrence.  In  the  final 
analysis  the  selection  of  radiation  or  surgery  is  op- 
tional. 

Cancer  of  the  lower  lip,  in  which  irritation  is  a 
striking  etiological  factor,  is  much  less  malignant 
than  is  the  spontaneous  cancer  of  the  upper  lip. 
Early  lesions  of  the  lower  lip  up  to  1.5  cm.  in 
diameter  may  be  cured  in  practically  all  cases  if 
the  patient  is  properly  treated  and  regularly  ob- 
served for  recurrences,  and  in  lesions  over  3  cm. 
there  is  a  cure  rate  of  55  per  cent.  In  all  lesions 
which  have  had  no  metastases  at  any  time  the 
cure  rate  is  95  per  cent.  Of  17  patients  with  pri- 
mary cancer  of  the  upper  lip  only  7  survived  for 
five  years. 

Although  the  authors  do  not  comment  upon  it, 
the  Memorial  Hospital  study  shows  a  definite 
trend  toward  irradiation  as  compared  to  block  dis- 
section in  the  treatment  of  cervical  metastases  from 
lip  cancer.  This  conforms  to  the  practice  over  the 
nation  generally.  Certainly,  block  dissection  of  the 
neck  for  any  cause  is  now  seldom  done. 

Reference — Annals  of  Surgery,  Sept.,   1941. 


December,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


667 


DENTISTRY 

J.   H.   Guion,   D.  D.  S.,   Editor,   Charlotte,   N.    C. 


TOOTH  DECAY 
A  tooth  for  each  pregnancy  is  an  old  saying. 
However,  pregnancy  can  be  so  managed  as  to  in- 
troduce a  new  dictum — "Healthy  teeth  through  all 
pregnancies."  In  dental  disease  during  pregnancy, 
the  most  important  etiologic  factors  are  improper 
diet,  certain  disease  conditions  and  endocrinologic 
imbalance.  There  is  no  other  time  when  the  diet 
should  be  so  well  chosen  as  in  pregnancy.  One 
should  not  assume  that  the  patient  eats  sensibly 
just  because  she  appears  strong.  Adair  states  that 
a  pregnant  woman  requires  a  diet  so  varied  that 
she  will  receive  in  the  necessary  amounts  proteins, 
fats,  carbohydrates,  vitamins,  iron,  calcium  and 
phosphorus.  The  diet  should  be  sufficient  to  build 
her  body  tissues  to  full  strength  and  without  stor- 
age of  excess  fat.  The  minimum  protein  require- 
ment must  be  maintained.  Minerals,  the  chief 
building  material  for  bones  and  teeth  are,  with 
meat,  an  important  source  of  iron,  to  supply  hemo- 
globin. Foods  of  high  mineral  content  are  there- 
fore desirable  and  are  probably  the  best  means  of 
administering  inorganic  salts.  These  are  found  in 
milk,  certain  vegetables  and  fruits.  The  best  cal- 
cium-containing food  is  milk  and  skimmed  milk 
products,  but  calcium  is  obtainable  also  from  beans, 
cauliflower,  dandelion  greens,  green  figs  and  oranges. 
Iron  is  obtained  from  beef  liver,  oysters  and  spin- 
ach, less  readily  from  eggs,  potatoes,  codfish,  her- 
ring, tomatoes,  peas,  lettuce,  dates,  prunes  and 
strawberries.  The  vitamins  are  found  in  milk  and 
its  products,  meats,  eggs,  whole  wheat,  cereals,  veg- 
etables, fruits  and  codliver  oil.  With  such  a  wide 
distribution  of  food  elements  meals  can  be  appetiz- 
ing as  well  as  wholesome.  Cutting  down  on  sugars 
and  fats  during  pregnancy  is  a  sensible  precaution 
as  long  as  enough  carbohydrate  and  fat  are  left  in 
the  diet  to  furnish  necessary  energy.  Bulk  to  com- 
bat constipation,  except  in  spastic  constipation,  as 
well  as  to  supply  needed  food,  is  best  obtained 
from  vegetables  and  fruits.  Desserts  should  be  of 
fruits,  not  pastry.  Coffee,  tea,  alcohol  and  smoking 
are  all  undesirable  during  pregnancy.  In  a  study 
of  three  groups  of  pregnant  women  as  regards  diet 
and  teeth:  In  the  first  group  the  diet  contained 
plenty  of  milk,  raw  fruits  and  vegetables  and 
cooked  vegetables;  in  the  second  group,  there 
were  little,  if  any,  fruit,  vegetables  and  milk  in  the 
diet;  in  the  third  group,  the  diet  contained  plenty 
of  cooked  vegetables. 

In  the  first  group,  the  condition  of  the  teeth  and 
gums  was  usually  excellent;  in  the  second  it  was 
very  poor,  there  being  many  carious  teeth  and 
swollen,  bleeding  gums;  in  the  third,  the  teeth  and 


gums  were  in  very  poor  condition.  When  these  pa- 
tients were  interrogated  it  was  learned  that  the 
vegetables  were  cooked  three-quarters  of  an  hour  to 
an  hour  and  a  half.  Cooking  vegetables  for  that 
length  of  time  destroys  many  vitamins  and  dis- 
solves the  minerals  into  the  water,  which  is  subse- 
quently discarded.  Hence,  it  is  good  practice  to 
instruct  all  pregnant  women  to  make  sure  that 
vegetables  are  not  overcooked  and  to  eat  plenty  of 
raw  vegetables  and  fruit  daily,  and  in  addition  to 
eat  liver  at  least  once  a  week  for  its  iron  content 
in  order  to  combat  the  anemia  prevalent  during 
normal  pregnancy,  and  to  eat  fish  and  seafoods  for 
their  iodine  content  twice  a  week,  and  two  pints  of 
milk  and  to  take  two  capsules  of  dicalcium  phos- 
phate with  viosterol  daily. 

The  lactating  period  is  not  infrequently  given 
less  attention  than  the  prenatal  period.  The  need 
for  plenty  of  vegetables  and  fruits,  vitamins  and 
minerals  during  pregnancy  is  often  last  sight  of 
during  lactation. 

It  is  generally  conceded  that  breast-feeding  is 
superior  to  artificial  feeding.  Therefore,  if  the  diet 
is  important  prenatally,  it  is  just  as  important  dur- 
ing the  lactating  period,  for  general  health  and  for 
dental  prophylaxis. 

Dental  caries  is  a  destructive  process  affecting 
the  hard  tissues  of  the  teeth.  It  is  practically  uni- 
versal and  constitutes  the  most  prevalent  disease 
known.  It  is  a  disease  and  is  to  be  regarded  as 
such  and  not  just  a  hole  in  the  tooth.  It  is  prob- 
ably the  only  disease  of  the  body  that  does  not 
have  a  tendency  toward  recovery.  A  cavity  does 
not  become  smaller  and  smaller  to  finally  dis- 
appear; on  the  contrary  it  gets  larger  and  the  only 
remedy  is  to  remove  the  decay  and  fill  it  with  some 
foreign  materials. 

Caries  is  notably  a  disease  of  childhood,  95  per 
cent  being  found  to  be  afflicted  with  the  disease. 
Children  in  the  tenth  and  twelfth  year  average 
seven  cavities  each. 

The  period  of  childhood  is  thus  that  of  greatest 
susceptibility.  It  is  the  period  of  rapid  growth  of 
the  body  at  which  time  calcium  and  phosphorus  go 
into  building  long  bones,  not  much  being  left  for 
calcification  of  the  teeth  unless  the  excessive  de- 
mand is  recognized  and  supplied. 

There  are  two  main  theories  today  as  to  the 
cause  of  caries.  One  believes  in  the  theory  of  bac- 
lerial  plaque  and  the  other  believes  that  all  pre- 
ventative dentistry  is  by  diet.  The  theory  of  the 
bacterial  plaque  is  that  the  plaques  are  nuclei  of 
decay  which  develop  from  without  inward. 

The  fermentation  of  carbohydrates  by  bacteria 
results  in  free  lactic  acid,  which  decomposes  the 
mucin  of  the  saliva  and  precipitates  adhesive  mucic 
acid.  The  mucic  acid  envelops  the  colony  of  micro- 


668 


SOUTHERX  MEDICINE  &  SURGERY 


December,  1941 


organisms  and  the  carbohydrate  food  debris,  ce- 
menting them  to  the  tooth  surface.  This  mass  of 
bacteria  and  food  debris  adhering  to  the  surface 
of  the  tooth  is  the  bacterial  plaque,  and  under  its 
protective  covering  the  lactic  acid  action  is  inten- 
sified and  caries  goes  on  undisturbed.  The  plaque 
may  thus  be  regarded  as  the  initial  cause  of  dental 
caries,  and  as  the  essential  factor  in  its  localiza- 
tion. 

The  logical  deduction  would  seem  to  be  then 
that  the  prevention  of  dental  caries  lies  chiefly  in 
those  measures  which  will  prevent  the  formation 
of  the  bacterial  plaque  or  effect  its  removal  before 
disintegration  of  the  enamel.  The  principles  of 
prevention  of  dental  decay  have  been  based  on  this 
deduction,  with  the  result  that  extreme  cleanliness 
of  the  tooth  surfaces  has  greatly  reduced  the  inci- 
dence of  caries,  but  the  problems  of  immunity  and 
susceptibility  are  still  unsolved. 

Every  dental  practitioner  knows  from  clinical 
experience  of  seemingly  clean  mouths  which  are 
ravaged  by  dental  caries;  and  of  unclean  mouths, 
with  teeth  covered  with  plaques  and  fermenting 
carbohydrates  showing  a  high  degree  of  immunity. 

The  most  recent  researches  into  the  problems  of 
immunity  and  susceptibility  point  to  the  diet  as 
the  great  controlling  factor.  A  comparison  with 
the  refined  and  unnatural  dietaries  of  modern  civ- 
ilized nations,  in  each  instance  highly  susceptible 
to  dental  caries,  probably  offers  the  solution  to  the 
problem. 

Diet  and  absorption  together  play  an  important 
part  in  susceptibility  to  caries.  All  the  necessities 
for  building  body  structure  must  be  gotten  from 
the  food  taken  into  the  body.  In  countries  where 
people  live  in  the  open  and  live  on  natural  diet, 
their  mouths  show  little  caries.  Therefore  proper 
diet  and  assimilation  is  the  answer  to  dental  im- 
munity or  non-susceptibility  to  caries  that  may  be 
obtained  by  the  body  to  a  certain  extent. 


TUBERCULOSIS 

J.  Donnelly,  M.  D.,  Editor,  Charlotte,  N.  C. 


PENETRATION  OF  PHENOL  IN  TOOTH 

STRUCTURE 

(B.  O.  A.  Thomas,  New  York,  in  II.  Dental  Research,  Oct.) 

Phenol  does  penetrate  tooth  structure,  and  is  not  self- 
limiting  as  a  result  of  its  action  on  organic  matter.  The 
degree  of  penetration  depends  on  several  factors.  Histolo- 
gic evidence  shows  that  there  are  inflammatory  reactions 
in  the  dental  pulp  under  phenolized  cavities  even  though 
there  are  no  subjective  symptoms.  However,  such  evidence 
is  not  sufficient  to  warrant  the  condemnation  of  this  drug 
for  cavity  sterilization. 

In  vitro  experiments  showed  the  penetration  from  the 
pulp  canal  through  the  dentin  and  cementum  to  the  sur- 
face. In  vivo  tests  illustrate  that  phenol  will  penetrate 
from  the  base  of  a  cavity  to  the  pulp,  following  the  curva- 
ture of  the  dentinal  tubules. 


PRIMARY  MALIGNANT  TUMORS  OF  THE 
LUNG 

Carcinoma  of  the  lung  was  considered  a  few 
years  ago  as  somewhat  of  a  rarity.  Recent  statis- 
tics gives  the  incidence  as  from  10  to  IS  per  cent 
of  all  carcinomas.  Unfortunately  there  still  re- 
mains in  the  minds  of  numbers  of  the  laity,  and  of 
a  good  many  physicians,  the  idea  that  cough, 
hemoptysis  and  dyspnea  are  always  due  to  tuber- 
culosis. 

In  the  November  issue  of  Diseases  of  the  Chest 
Konterwitz  states  that  neoplasms  of  the  lung  may 
occur  at  any  age,  but  are  most  frequent  between 
the  ages  of  40  and  60  years,  and  more  frequent  in 
the  male  than  in  the  female  by  a  ratio  of  5  to  1, 
for  which  disparity  between  the  two  sexes  no  sat- 
isfactory explanation  has  been  found.  No  relation- 
ship is  found  between  occupation — not  even  silica 
work — and  lung  carcinoma.  The  tumor  may 
originate  in  the  parenchyma,  but  the  origin  was  in 
a  bronchus  in  41  cases,  and  almost  all  broncho- 
genic tumors  are  of  epithelial  origin. 

A  matter  of  prime  importance  is  differentiating 
between  malignant  conditions  of  the  lung  and  tu- 
berculosis. The  malignant  tumor  may  occur  as  a 
single  large  mass  originating  in  the  root  of  the 
lung,  or  there  may  be  a  number  of  nodules  of  va- 
rious sizes  throughout  both  lungs.  The  lungs  may 
contain  numerous  small  nodules  resembling  those 
of  miliary  tuberculosis.  Malignant  disease  of  the 
lungs  often  occurs  as  a  general  infiltration  of  large 
areas  of  lung  tissue,  resembling  an  extensive  tuber- 
culous infiltration.  Soft  cancerous  areas  in  the  lung 
may  break  down,  and,  discharging  into  a  bronchus, 
form  a  cavity,  which,  secondarily  infected,  simu- 
lates a  putrid  pulmonary  abscess.  Pleural  effusions, 
not  uncommon,  tend  to  recur  after  aspiration,  and 
are  often  hemorrhagic.  A  hemorrhagic  effusion, 
however,  is  always  suggestive  of  cancer,  but  a  clear 
effusion  does  not  eliminate  that  condition.  In  662 
autopsies  at  Phipps  Institute  there  was  no  case  in 
which  lung  cancer  and  tuberculosis  occurred  to- 
gether. 

The  author  lists  the  symptoms  as  cough,  expec- 
toration and  hemoptysis,  all  due  to  bronchial  irri- 
tation. The  size,  location  and  type  of  the  new 
growth,  with  or  without  secondary  pyogenic  infec- 
tion, are  the  causes  of  the  clinical  symptoms  of 
lung  tumors.  Blood  in  the  sputum,  or  small  hemop- 
tyses  in  a  person  over  40  years  of  age,  whose  spu- 
tum is  persistently  negative  for  tubercle  bacilli 
should  arouse  suspicion  of  primary  cancer  of 
the  lung.  Pain  in  the  chest  is  early  and  often  se- 
vere, and  may  radiate  from  the  chest  to  the  arm. 


December,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


This  pain  may  indicate  involvement  of  the  pleura, 
but  may  be  a  symptom  of  pressure.  Mediastinal 
tumors  may  cause  pain  similar  to  that  of  thoracic 
aneurism.  Dyspnea  is  frequent,  particularly  if 
there  is  a  pleural  effusion. 

The  constitutional  symptoms  are  those  of  can- 
cerous growths  in  any  part  of  the  body.  Progres- 
sion may  be  rapid  or  slow,  the  duration  ranging 
from  4  months  to  3  years,  the  acuteness  depending 
on  the  rate  of  atelectasis  caused  by  pressure  of  the 
mass.  The  author  states  that  in  nearly  all  cases 
there  is  an  irregular  type  of  fever  which  may  sub- 
side and  then  recur,  due  to  the  development  and 
recrudescence  of  a  non-specific  type  of  pneumonia. 
The  most  common  pressure  sign  is  the  occurrence 
of  dilated  veins  over  the  upper  part  of  the  chest, 
caused  by  pressure  on  the  superior  vena  cava  or 
one  of  its  tributaries. 

If  the  tumor  arises  in  a  large  bronchus,  atelec- 
tasis of  part  or  of  a  whole  lobe  may  result,  with 
dullness  and  flatness  over  the  diseased  area  and 
diminished  or  absent  breath  sounds.  Involvement 
of  the  pulmonary  tissue  causes  bronchovesicular  or 
bronchial  breathing.  Frequently  the  growth  be- 
comes necrotic,  in  which  case  the  physical  findings 
suggest  pulmonary  abscess.  Often  this  condition 
causes  a  diagnosis  of  pneumonia.  The  author  says 
that  persistent  findings  such  as  these,  with  the  con- 
tinuance of  the  fever,  demands  bronchoscopy, 
which  will  usually  give  a  positive  diagnosis.  In 
cases  with  practically  no  physical  signs  the  author 
advises  injection  of  lipiodol  followed  by  x-rav  films. 
Effusion  indicates  looking  for  tumor  cells.  Films 
of  the  chest  are  always  necessary  in  cases  of  sus- 
pected lung  cancer,  but  a  diagnosis  can  only  be 
made  by  combining  the  x-ray  and  physical  findings. 
Widespread  use  of  the  x-rays  and  the  bronchoscope 
has  made  easier  the  diagnosis  of  primary  carcinoma 
of  the  lung.  The  information  obtained  by  broncho- 
scopic  examination  as  to  the  size  of  the  growth 
and  the  type,  and  as  to  whether  or  not  there  is  a 
complicating  infection,  is  of  great  value  in  pre- 
operative and  postoperative  treatment. 

Primary  cancer  of  the  lung  must  be  differentiat- 
ed from  pleural  effusion,  Hodgkin's  disease  and 
lymphosarcoma,  pulmonary  tuberculosis  (in  per- 
sons over  40  years  of  age),  and  chronic  inflamma- 
tory conditions  of  the  lung.  A  hemorrhagic  effu- 
sion although  not  positive  evidence  of  malignancy, 
is  suggestive.  The  presence  of  enlarged  lymph 
glands  elsewhere  in  the  body  which  may  be  re- 
moved for  laboratory  examination  will  serve  to 
differentiate  in  Hodgkin's  disease.  Persistent  ab- 
sence of  tubercle  bacilli  from  the  sputum  indicates 
bronchoscopy  if  there  is  a  suspicion  of  carcinoma. 
Chronic  inflammatory  conditions  of  the  lung  are 
distinguished  by  long  duration  and  the  absence  of 

severe  constitutional  symptoms. 


GENERAL  PRACTICE 

James    L.    Hamner,    M.D.,    Editor,    Mannboro,    Va. 


THE  CHOICE  OF  ANTACIDS   FOR  TREAT- 
ING PEPTIC  ULCER 

Certain  individuals  develop  peptic  ulcer  and 
even  though  the  ulcer  heals,  recurrence  in  these 
susceptible  persons  is  likely.'  The  first  attack  and 
the  early  recurrences  are  easily  controlled  by  die- 
tary measures,  rest,  sedatives,  antispasmodics.  If 
the  patient  is  taught  permanently  to  live  within 
his  physical,  mental  and  digestive  capacities  and  if 
he  will  give  up  smoking,  eat  six  times  a  day  and 
solve  or  resign  himself  to  his  financial,  sexual  and 
emotional  status  he  may  never  have  a  recurrence. 

In  the  uncooperative  or  neglected-ulcer  patient 
alkalis  find  their  greatest  use.  When  all  other 
methods  fail  constant  neutralization  of  the  gastric 
contents  24  hours  a  day  results  in  freedom  from 
pain  in  one  day  and  ulcer  healing  in  four  weeks. 

An  ideal  antacid  would  be  tasteless  and  cheap. 
A  small  amount  would  neutralize  considerable  acid. 
It  would  be  neither  constipating  nor  laxative,  in- 
soluble so  as  not  to  leave  the  stomach  quickly, 
have  a  prolonged  action  and  not  produce  a  sec- 
ondary rise  of  acid.  Its  cation  should  be  unabsorb- 
able.  Carbon  dioxide  gas  should  not  evolve  after  it 
reacts  with  hydrochloric  acid. 
Antacids  commonly  employed  for  treating  peptic 
ulcer: 

Sodium  bicarbonate  should  not  be  used  for 
treating  peptic  ulcer. 

Magnesium  oxide  is  the  most  powerful  antacid. 
It  can  well  be  supplanted  with  magnesium  trisili- 
cate. 

Magnesium  carbonate  is  also  laxative  and  causes 
a  secondary  acid  rise.   Its  use  can  be  discontinued. 

Calcium  carbonate  is  a  good  antacid  and  were  it 
not  for  its  constipating  action  and  for  its  release  of 
carbon  dioxide  in  the  stomach,  it  would  approach 
the  ideal  in  antacid  therapy. 

Sodium  and  potassium  citrates  valueless  in  treat- 
ing peptic  ulcer. 

The  tribasic  phosphates  of  calcium  and  magne- 
sium could  well  be  abandoned. 

Bismuth  salts  also  have  little  neutralizing  value 
and  are  constipating. 

Aluminum  hydroxide  gel's  absorptive  power  is 
nil,  because  on  interaction  with  hydrochloric  acid 
it  is  changed  to  soluble  aluminum  chloride.  If  used 
in  sufficiently  large  amounts  to  obtain  intragastric 
neutrality,  constipation  results  and  fecal  impaction 
is  not  uncommon.  They  are  too  expensive  for  con- 
stant and  routine  use. 

Magnesium  trisilicate,  recently  introduced  for 
treating  peptic  ulcer,  a  tasteless  powder  and  very 
inexpensive,  was  recently  accepted  for  inclusion  in 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


New  and  Non-Official  Remedies.  It  is  insoluble  in 
water,  has  a  prolonged  antacid  action,  and  a  good 
neutralizing  action.  Since  magnesium  is  nonabsorb- 
able, alkalosis  can  not  result.  In  susceptible  indi- 
viduals it  may  cause  an  increase  in  frequency  of 
bowel  movements. 

Severe  cases  of  ulcer  should  be  in  hospital,  have 
milk  and  antacid  hourly,  night  and  day.  Cream  is 
poorly  tolerated.  After  a  few  days,  pudding  and 
purees  are  added  and  the  number  of  feedings  slowly 
decreased.  After  4  weeks  in  hospital  and  2  to  4 
weeks  of  home  convalescence,  the  patient  is  on  a 
fairly  complete  diet.  He  or  she  must  permanently 
eschew  spices,  condiments,  excess  roughages,  alco- 
hol and  tobacco,  and  take  a  glass  of  milk  between 
meals  and  at  bed  time. 

In  milder  cases  in  which  antacid  treatment  is  in- 
dicated the  patient  takes  a  dram  of  the  selected 
antacid,  usually  magnesium  trisilicate.  The  liquid 
medication  is  a  mixture  containing  one  half  grain 
of  soluble  phenobarbital  and  ten  minims  of  tinc- 
ture of  belladonna  to  the  dose.  If  the  patient  has 
night  pain  he  is  instructed  to  set  his  alarm  clock 
for  an  hour  before  pain  is  anticipated  and  to  drink 
a  glass  of  milk  with  a  dram  of  powder  at  that 
time. 


1.   Editorial  in  Digest  of  Treatment,  October,    1940. 

SUDDEN  DEATH 

Called  to  see  a  person  who  has  died  suddenly, 
one  needs  to  be  well-informed  as  to  the  probabili- 
ties as  to  cause.   Here1  they  are. 

Probably  the  most  common  cause  of  sudden 
death  in  young  adults  is  a  ruptured  aneurysm  at 
the  point  of  origin  of  the  cerebral  arteries  in  the 
Circle  of  Willis. 

In  apparently  healthly  males,  probably  the  most 
likely  cause  of  immediate  death  lies  in  the  coronary 
system — either  acute  or  chronic  coronary  artery 
occlusion.  In  elderly  patients  so  prone  to  be  found 
dead  in  bed,  the  cause  is  often  hemorrhage  arte- 
rial, intracraniallv  or  in  other  body  cavities. 

Status  lymphaticus  has  no  pathological  basis  as 
a  cause  of  sudden  death. 

The  heart,  especially  the  myocardium,  must  be 
suspected  as  a  seat  of  "infectious  myocarditis"  in 
infection  in  the  young  and  the  very  old;  from  such 
cause  patients  in  these  extremes  of  age  are  partic- 
ularly liable  to  succumb  suddenly  in  fulminating 
acute  infections. 

Possibly  the  ultimate  cause  of  all  cases  of  sud- 
den death  may  be  ascribed  as  ventricular  fibrilla- 
tion. 

Important  to  remember  is  that  foul  play  is  al- 
ways a  possibility,  and  that  poisoning  or  trauma 
must  be  excluded  before  considering  a  more  natural 


reason.  In  considering  sudden  heart  standstill  from 
coronary  occlusion,  remember  that  coronary  em- 
bolism is  a  rare  finding,  occurring  presumably  from 
bacterial  endocarditis,  if  at  all.  Instant  death  from 
hemorrhage  is  probably  always  due  to  the  rupture 
of  an  aneurysm  in  either  the  thoracic  aorta,  the 
cranial  cavity,  or  the  abdominal  cavity — in  that 
order.  Aneurysm  of  the  aorta  is  usually,  though 
not  always,  syphilitic,  and  frequently  ruptures  into 
the  pericardial  cavity  producing  cardiac  tamponade. 
Sometimes  it  may  be  detected  by  careful  blood 
pressure  readings  and  examination  of  the  heart 
sounds.  A  probability  of  being  correct  is  not  more 
than  35  per  cent,  and  often  the  pathologist,  after 
he  has  had  hours  of  time  and  study  of  organs,  re- 
moved and  in  situ,  can  not  for  certain  put  his 
stamp  of  disapproval  upon  the  organ  or  organs 
responsible  for  sudden  death. 

ADVANCES  IN  TREATMENT  OF  PERIPHE- 
RAL VASCULAR  DISEASE 

Here  are  some  pickups  from  an  article1  recently 
read. 

Raynaud's  disease — may  be  due  to  chronic  ar- 
senic intoxication,  and  favorable  results  have  fol- 
lowed the  use  of  sodium  thiosulfate  intravenously, 
0.5  gm.  twice  weekly  for  1-20  weeks. 

Arterial  embolism — Diffuse  regional  arterial 
spasm  must  be  broken.  Papaverine  hydrochloride 
intravenously  or  intraarterially  is  helpful  as  an  an- 
tispasmodic, ^2  gr.  every  hour  or  so. 

Thromboangiitis  obliterans — Stop  smoking.  Ty- 
phoid vaccine  intravenously  very  effective  in  pro- 
ducing vasodilatation  in  the  extremities.  Eat  no 
foods  rich  in  phospholipins.  Sodium  miodide  thio- 
sulfate in  3.3  gm.  doses  intravenously  every  other 
day  for  3-6  weeks. 

Arteriosclerosis — Reduce  the  level  of  blood  fat 
by  taking  a  diet  free  from  eggs,  milk  products  and 
fat  meat.  Mechanical  devices  for  peripheral  vas- 
cular diseases  are  valuable  and  include  the  Saun- 
ders bed,  intermittent  arterial  compression,  inter- 
mittent suction  and  pressure. 


1.   E.  V.  Alle 


Jour.  A.  M.  A. 


INTERNAL  MEDICINE 

George   R.   Wilkinson,   M.  D.,   Editor,    Greenville,   S.    C. 


I.  J.  L.  Wade,  Parkersburg,  in  W.   Va.  Med.  31.,  Nov.) 


IS  THE  8-HOUR  DAY  PHYSIOLOGICAL? 

Agitation  for  shorter  hours  and  more  wages  has 
held  forth  with  little  opposition,  since  the  turn  of 
the  century.  Now,  the  eight-hour  day  and  five-day 
week  has  become  common  practice  in  industry. 
With  the  shortening  of  the  day  have  come  the  sec- 
ond and  the  third  shifts;  so  today  industry  rolls 
merrily  along,  at  a  pace  of  24  hours  with  three 
different  groups  of  people.    This  limitation  of  the 


December,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


671 


working  hours  has  produced  problems  in  several 
fields. 

First,  the  amount  of  leisure  time  has  increased. 
Just  how  to  spend  this  time  profitably  constitutes 
no  mean  problem.  In  the  old  days,  when  a  person 
worked  10  to  12  hours,  six  days  a  week,  the  amuse- 
ment problem  was  present,  but  with  one  whole  day 
off  and  two  to  three  hours  lapped  off  each  day,  the 
less  facultative  group  to  whom  such  practices  ap- 
ply find  their  increased  pay  inadequate  to  pay  for 
amusements.  For  this  group  to  develop  to  the 
point  where  they  can  entertain  themselves  will  re- 
quire considerable  time  and  much  education. 

For  women  the  change  is  not  so  severe  as  for 
men;  since  women  can  find  in  their  homes  many 
things  to  do  that  they  ordinarily  would  be  doing 
were  they  not  working  on  the  outside.  The  men, 
on  the  other  hand,  are  not  so  easily  occupied. 
Where  the  families  live  in  company-owned  villages, 
apartments  or  small  town  houses,  diversion  is  dif- 
ficult. Where  they  commute  from  rural  sections, 
many  of  the  cotton-mill  people  actually  find  time 
enough  away  from  their  work  to  raise  and  produce 
supplies  for  the  family.  Of  course,  the  idle  time 
theoretically  is  a  godsend;  but,  in  practice,  unless 
the  man  can  be  occupied  with  suitable  labor  or 
other  time-consuming  activities,  the  additional 
spare  time  will  afford  them  an  opportunity  not  only 
for  wasteful  living,  but  also  for  unhygienic,  un- 
physiological  and  perhaps  even  degenerative  pur- 
suits. The  solution  for  this  difficulty  may  be  found 
in  night  schools  for  art,  music,  manual  arts,  gar- 
dening, athletics  and  other  avocations. 

Second,  the  next  great  difficulty  with  the  eight- 
hour  shift  may  lie  in  the  fact  that  it  is  unphysiol- 
ogical  for  a  person  to  work  eight  hours  straight 
without  relaxation,  rest  or  suitable  food.  With  the 
cost  of  labor  increased  by  the  short  hours,  indus- 
try finds  it  necessary  for  the  machinery  to  be  kept 
going  continuously,  through  the  period,  without  in- 
terruption. It  is  customary  not  to  allow  any  time 
for  the  physiological  functions  of  the  body.  It  is 
well  known  that  a  person  can  not  work  eight  hours 
straight  without  inducing  sufficient  fatigue  and 
hunger  to  cripple  the  precision  of  his  labors. 

Third,  the  shifts  work  a  physiological  hardship, 
particularly  on  the  last  night  group.  Those  that  go 
to  work  at  11  at  night  and  work  until  7  in  the 
morning  do  so  from  Monday  through  Friday.  Dur- 
ing this  time  the  worker's  family  keeps  regular 
hours.  The  children  are  off  to  school  in  the  morn- 
ing, they  must  be  fed  when  they  return  and  the 
housewife  is  forced,  not  only  to  prepare  meals  suit- 
able for  herself  and  the  children,  but  also  to  feed 
the  breadwinner.  Those  on  the  so-called  "grave- 
yard" shift  usually  eat  breakfast  with  the  family 
and  get  to  bed  by  8  o'clock.    Then  they  get  up 


about  4  in  the  afternoon,  eat  supper  about  6,  and 
a  light  lunch  at  10.  Very  few  carry  with  them  to 
their  work  any  lunch.  After  they  have  been  work- 
ing for  several  hours  they  get  a  sandwich  and  a 
soft  drink.  Here  the  normal  physiological  process 
is  reversed.  Ordinarily  a  person  works  in  the  day- 
time and  if  he  is  not  too  fatigued  plays  in  the  late 
afternoon  and  in  the  evening.  For  the  graveyard 
shift,  play  follows  rest,  and  the  worker  goes  to  his 
toil  having  had  his  usual  amount  of  play,  when  he 
is  most  rested  and  has  left  for  industry  the  next 
eight-hour  period.  Then  come  Saturday  and  Sun- 
day. The  worker  reverts  to  the  normal  hours  of 
his  family.  This  change  from  night  shift  to  the 
usual  customary  family  hours  is  too  sudden.  By 
the  time  one  gets  accustomed  to  the  night  work  he 
has  day  hours,  and  vice  versa.  The  physiological 
effect  this  may  have  on  the  night  worker  is  difficult 
to  assay.  One  factor  may  be  pointed  out  that  is 
easy  to  see.  This  pertains  to  the  rhythmical  rise 
and  fall  of  the  body  temperature.  Ordinarily,  the 
body  temperature  reaches  its  lowest  ebb  at  the  end 
of  the  night's  rest,  when  the  body  is  in  what 
might  be  called  the  basal  state.  During  the  day 
the  temperature  rises  and  reaches  maximum  about 
nightfall.  On  the  night  shift  there  is  no  opportu- 
nity afforded  to  establish  a  definite  temperature 
rhythm,  since  the  body  is  hardly  facultative  enough 
to  make  a  change  of  this  sort  twice  within  the  com- 
pass of  a  week. 

During  the  present  emergency  many  workers 
have  been  called  back  to  industry  who  would,  in 
ordinary  circumstances,  not  be  employed.  The 
large  bulk  of  these  people  are  put  on  the  night 
shift,  since  the  regular  workers  avoid  the  night 
shift  and,  by  virtue  of  their  length  of  service,  are 
afforded  the  opportunity  to  choose  their  shift.  So, 
in  the  night  group  one  finds  to  begin  with  those 
less  fit  economically  and  perhaps  less  fit  physically. 
It  is  no  small  wonder  that  the  casualty  companies 
are  complaining  about  the  increase  in  the  accident 
rate.  Perhaps  some  of  the  reasons  for  the  sharp 
rise  in  insurance  outlay  may  be  accounted  for  by 
some  of  these  considerations. 


HYPOTENSION   IN   BORDERLINE   DEFICIENCIES 
(J.  M.  Hughes,  in  Bull.  Greenville  (S.  C.)   Co.  Med.  Soc.,  Nov.) 

In  hot  weather  one  consumes  large  amounts  of  water 
without  sufficient  mineral  intake  to  make  up  what  he  is 
losing  through  excessive  perspiration.  Indicated  are  min- 
eral salts  by  mouth,  and  liver  extract  and  thiamin-chloride 
hypodermically  in  alternate  doses. 

Liver  extract  was  given  in  all  these  cases  having  hemo- 
globin of  68  per  cent  or  less;  to  our  surprise  in  2  of  the 
liver  extracts  out  of  the  6  we  used  we  found  some  factor, 
other  than  blood  building  property,  that  hastened  the  re- 
turn to  a  normal  level. 

In  the  second  group  anemia  was  found  along  with  the 
hypotension  and  relieved  by  iron  by  mouth  and  liver  ex- 
tract, S  u.,  every  third  day. 


672 


SOUTHERN  MEDICIXE  &  SURGERY 


December,  1941 


In  the  third  (vitamin-deficiency)  group  there  are  many 
who  eventually  fall  into  the  hands  of  quacks. 

Those  that  don't  take  sufficient  amounts  of  vitamins  in 
their  diet  and  those  who,  through  digestive  disturbances  or 
the  use  of  large  amounts  of  laxatives,  especially  mineral 
oil,  are  prevented  from  absorbing  the  vitamins.  Any  one 
of  a  number  of  excellent  preparations  hypodermically  will 
turn  the  trick,  or  large  amounts  of  concentrated  vitamins 
by  mouth.    The  first  procedure  is  best. 

Hypotension  when  found  without  an  obvious  cause  may 
mean  deficiency  of  minerals  or  of  vitamins  or  of  a  hypo- 
chromic anemia  of  unknown  origin. 

There  is  available  in  at  least  two  commercial  liver  ex- 
tracts a  substance,  other  than  the  blood-building  factor, 
that  helps  raise  a  low  blood  pressure. 

A  large  number  of  patients  that  are  now  lost  to  the 
patent-medicine  class  and  the  chiropractor,  through  being 
classed  as  neurotics,  could  be  and  should  be  studied  for 
possible  borderline  deficiencies. 


OPHTHALMOLOGY 

Herbert  C.  Neblett,  M.  D.,  Editor,  Charlotte,  N.  C. 


MASSIVE  INFLAMMATORY  EDEMA  OF 
THE  CONJUNCTIVA 

This  condition  arises  as  the  result  of  various 
infections  of  the  external  tissues  of  the  eyeball,  of 
the  lids,  the  structures  adjacent  thereto,  and  fol- 
lowing trauma  to  these  tissues  from  any  cause.  This 
is  not  to  be  confused  with  non-inflammatory  edema 
the  result  of  systemic  disease. 

This  type  of  edema,  of  itself,  presages  no  serious 
import  but  in  the  massive  type  presents  a  rather 
awesome  appearance.  The  conjunctiva  is  seen  to 
roll  out  between  the  lids,  principally  from  the 
lower  cul-de-sac,  from  canthus  to  canthus,  and 
often  equals  the  diameter  of  a  16-gauge  gun  car- 
tridge. It  is  boggy  in  consistency,  and  pink  in 
color  in  the  early  stages  becoming  purplish  and 
more  indurated  after  a  few  days  from  exposure  and 
disturbance  of  circulation.  It  is  somewhat  more 
sensitive  to  touch  than  the  normal  conjunctiva.  It 
can  be  reduced  after  a  few  moments'  pressure  with 
the  balls  of  the  fingers  but  will  promptly  regain  its 
original  status  upon  release  of  pressure.  In  some 
cases  it  is  rather  persistent  and  when  extremely 
large  should  be  protected  from  exposure  by  a  firm 
occlusion  dressing  after  reduction  beneath  the  lids 
and  the  lids  approximated  over  it  and  either  held 
tightlv  closed  with  adhesive  strips  or  by  suturing 
the  upper  and  lower  lids  together.  This  usually 
results  in  prompt  return  to  normal  along  with  sub- 
sidence of  the  causative  factor.  If  not  reduced  in 
the  earlv  stage  the  edema  progresses  rapidly.  Oc- 
casionally small  multiple  punctures  of  the  ede- 
matous mass  become  necessary  to  lessen  its  prog- 
ress. Ice  water  compresses  are  of  some  benefit 
with  topical  applications  of  adrenalin  chloride  to 
the  edematous  mass. 

A  discussion  of  the  condition  is  presented  mainly 
because  of  the  fact  that  the  writer  has  noticed  the 


frequency  with  which  it  occurs  in  the  Negro  race 
as  compared  to  the  white  race  under  similar  causa- 
tive agents.  No  definite  explanation  can  be  given 
for  the  frequency  of  its  occurrence  in  the  one  as 
compared  to  the  other  save  on  the  basis  of  the 
writer's  viewpoint  that  the  normal  lid  structures 
of  the  Negro  appear  more  flaccid,  particularly  the 
conjunctiva,  and  the  retro-tarsal  folds  more  full 
than  in  the  white  man,  which  would  cause  these 
structures  to  more  easily  lend  themselves  to  edema. 


RHINO-OTO-LARYNGOLOGY 

Clay  W.  Evatt,  M.  D.,  Editor,  Charleston,  S.  C. 


NOSE  BLEED 

In  the  treatment  of  nosebleed  one  must  first  at- 
tempt to  locate  the  bleeding  point.  There  are  four 
areas  corresponding  to  the  four  types. 

First — Kesselbach's  area,  the  vascular  area,  on 
the  anterior  part  of  the  septum.  Bleeding  here  is 
from  capillary  fragility,  more  frequently  occurring 
in  the  juvenile  and  the  plethoric. 

Second — The  divisions  of  the  internal  branch  of 
the  sphenopalatine  on  the  middle  part  of  the  sep- 
tum above  and  posterior  to  first-mentioned  area. 
Bleeding  here  is  due  to  fragility  of  the  arterioles 
accompanied  by  arteriosclerosis.  This  is  the  epis- 
taxis  of  the  fifties  accompanied  by  hypertension 
and  favored  by  the  abuse  of  alcohol  and  tob.icco, 
syphilis,  and  the  high-pressure  type  of  living  at 
this  age  when  the  pace  should  not  be  pressed  to 
the  breaking  point  but  rather  a  slackening  up  of 
exertion  should  be  begun. 

Third — The  branches  of  the  sphenopalatine  may 
bleeding  following  a  surgical  or  electrosurgical  pro- 
cedure. 

Fourth — The  entire  mucosa  may  give  rise  to  a 
diffuse  bleeding  as  in  the  general  hemorrhage  of  the 
hemophiliac. 

These  four  areas  are  listed  in  the  order  of  their 
increasing  gravity. 

1 .  The  first  or  juvenile  type  is  benign  but  annoy- 
ing. It  comes  on  more  frequently  during  the  day, 
from  a  slight  wound  or  effort  in  coughing  or  more 
often  from  no  discernible  cause  whatever.  The 
bleeding  is  anterior  and  seen  without  the  specu- 
lum. It  may  be  controlled  by  the  use  of  styptics, 
astringents,  or  coagulating  sera  in  the  form  of  so- 
lutions, powders,  or  crayons  applied  to  the  bleeding 
points.  Cold  compresses  applied  at  intervals  to  the 
face  promote  clotting.  Simply  pressing  the  alae 
nasae  between  finger  and  thumb  is  frequently  all 
that  is  necessary. 

2.  Epistaxis  of  the  fifties  is  serious  and  may  be- 
come grave.  The  bleeding  point  is  usually  hidden 
but  may  be  located  above  and  behind  Kesselbach's 
area.   Rarely  the  bleeding  may  be  anterior  in  which 


December.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


cases  it  is  from  a  branch  of  the  nasopalatine.  This 
nosebleed  usually  comes  on  late  at  night  during 
the  period  of  relaxation  of  the  sympathetic  tonus. 
The  flow  is  often  abundant  and  may  persist  for 
several  hours,  then  the  clot  fills  the  fossae  and  the 
bleeding  seems  to  stop;  but  serum  exudes  in  front 
and  a  fine  thread  of  blood  forms  behind.  The 
bleeding  exhausts  itself  and  in  a  few  days  reap- 
pears. This  hemorrhagic  crisis  lasts  sometimes 
eight  to  ten  days  then  stops.  Sometimes  it  returns 
in  a  few  years,  sometimes  never.  The  immediate 
or  emergency  treatment  is  packing.  Salt  pork  may 
do  the  trick.  Vaselinized  one-fourth  or  one-half 
inch  gauze  is  good.  Frequently  packing  from  the 
front  will  be  sufficient,  but  in  some  instances  post- 
nasal plug  combined  with  packing  anteriorly  is  nec- 
essary. The  packing  should  be  left  in  place  one  to 
three  days.  A  cool  room  and  quiet  surroundings 
are  helpful.  Relaxation  of  the  patient  is  essential. 
Plenty  of  morphine  until  the  hemorrhage  is  check- 
ed followed  by  barbiturate  sedation  for  several 
days  with  reassurance  and  psychotherapy  is  fun- 
damental. The  patient  and  physician  must  be 
calm.   Transfusions  may  cause  recurrence. 

Preventive  or  later  treatment  is  to  sclerose  the 
vascular  area  along  the  septal  artery  or  about  any 
points  that  seem  to  have  been  bleeding. 

3.  Surgical  epistaxis  may  be  grave  or  even  fatal. 
The  bleeding  may  be  on  the  inner  side  back  up 
and  high  on  the  septum  or  on  the  external  posterior 
part  of  the  fossa. 

It  rarely  appears  during  the  operation  but  is 
more  likely  some  hours  later  after  the  anesthetic 
and  adrenaline  effects  have  worn  off.  It  may  ap- 
pear eight  or  ten  days  postoperative  when  an  escar 
comes  off.  This  hemorrhage  is  mostly  posterior 
therefore  lots  of  blood  may  be  vomited. 

Treatment  is  packing  even  at  the  risk  of  otitis. 
In  severe  cases,  there  are  the  waxy  skin,  purple 
lips,  cold  extremities,  rapid  weak  pulse  and  res- 
piration— all  the  symptoms  of  shock.  Small  re- 
peated transfusions  may  be  helpful.  If  the  carotid 
is  tied  it  must  be  remembered  that  within  twenty- 
four  hours  anastomosis  renders  this  ineffective. 
Therefore  the  bleeding  point  must  be  packed  off 
or  tied  off  if  possible. 

4.  Epistaxis  of  all  the  mucosae — epistaxis  of  the 
hemophilics —  is  the  gravest  nosebleed.  There  are 
sooner  or  later,  all  fatal. 

1.  Bleeding  of  the  hemogenic  type  comes  on 
spontaneously  and  in  characterized  by  a  prolonged 
bleeding  time.  Coagulation  is  of  poor  quality.  The 
blood  is  deficient  in  color,  watery  with  reddish 
threads  and  the  clot  is  blackish,  soft  and  weak. 
The  cause  is  unknown.  It  usually  affects  women,  is 
not  hereditary,  and   the  liver  and  splenic  factors 


are  considered  at  fault.  In  this  type  vitamin  K 
may  prove  of  value.  The  bleeding  is  not  very 
abundant,  lasts  twelve  to  twenty-four  hours,  and 
recurs  every  few  weeks  or  months.  Purpura  may 
be  present  and  petechiae  must  be  searched  for  on 
the  turbinates  and  posterior  choanae  as  the  recog- 
nition of  purpura  is  important. 

2.  Traumatic  expistaxis  of  hemophilia — True 
hemophilia  is  characterized  by  a  prolongation  of 
coagulation  time,  indeed  the  process  is  never  com- 
plete. The  trouble  is  hereditary — affecting  the 
males  and  transmitted  by  the  females.  The  bleed- 
ing is  not  spontaneous  but  the  wound  is  often 
minimal.  The  prognosis  is  grave  and  sooner  or 
later  the  patient  succumbs  to  a  more  severe  crisis. 

3.  Mixed  type  hemophilic-hemogenic — A  grave 
type,  often  fatal.  Treatment  is  tampons  saturated 
with  horse  serum,  snake  venom,  or  other  coagulant 
sera.  Human  serum  may  be  used  by  injecting  20 
c.c.  of  blood  under  the  skin  of  the  abdomen.  Mul- 
tiple transfusions  help.  All  results  are  transient. 
Thev  rarely  reach  maturity. 

Fresh  beef  liver  vitamins  C  and  K,  various  sera, 
splenic  radiotherapy  and  transfusions  are  the 
straws  at  which  we  grasp. 


DERMATOLOGY 

J.  Lamar  Calloway,  M.D.,  Editor,  Durham,  N.  C. 


DERMATITIS  HERPETIFORMIS 
Dermatitis  herpetiformis  is  one  of  the  most 
difficult  therapeutic  problems  with  which  the  derm- 
atologist has  to  cope.  For  matters  of  prognosis  and 
treatment,  pemphigus,  erythema  multiforme,  drug 
eruptions,  and  the  various  "id"s,  should  be  elimi- 
nated. The  diagnosis  as  a  rule  can  be  established 
when  all  or  most  of  the  following  postulates  are 
fulfilled. 

1.  Grouped  vesiculo-bullous  eruption  involving 
the  body  in  a  symmetrical  distribution,  avoid- 
ing the  mucous  membranes  as  a  rule. 

2.  Intense  pruritus. 

3.  Pigmentation. 

4.  Flare-up  following  ingestion  of  iodides  or  bro- 
mides. 

5.  Positive  patch  test  to  50  per  cent  potassium 
iodide. 

6.  Chronic  course  with  exacerbations  and  remis- 
sions. 

Many  theories  have  been  advanced  as  to  the 
etiologic  factor  responsible  for  dermatitis  herpeti- 
formis and  they  may  be  divided  into  five  main 
classes;  amely.  infectious,  toxic,  virus  (neurotro- 
phic), endocrine  and  bacterial  allergy    (Callaway 


674 


SOUTHERX  MEDICINE  &  SURGERY 


December,  1941 


and  Sternberg).    No  single  theory  will  completely 
explain  all  cases. 

Many  forms  of  therapy,  including  arsenic,  chro- 
minium  sulfate,  germanin,  fever  therapy,  intra- 
venous sodium  thiosulfate  etc.,  have  been  used  in 
conjunction  with  local  therapy  with  varying  re- 
sults. The  following  is  a  treatment  regimen  which 
we  have  found  helpful: 

1.  No  medications  containing  iodide  or  bromide 
should  be  used. 

2.  Iodized  table  salt  should  be  avoided. 

3.  Careful  removal  of  all  foci  of  infection.  This 
requires  careful  x-ray  study  of  lungs,  sinuses 
and  teeth,  and  careful  examination  of  the 
naso-pharvnx,  urological  and  gynecological 
systems. 

4.  Culture  of  infected  foci  with  preparations  of 
autogenous  vaccine  and  bacterial  desensitiza- 
tion. 

5.  Local  antipruritic  lotion  such  as  calamine  lo- 
tion with  1  per  cent  phenol  may  be  used  to 
allay  the  itching. 

6.  Starch  baths,  sulfur  baths  etc.  may  be  used 
in  conjunction  with  local  antipruritics. 

7.  The  various  sulfonamids,  carefully  controlled 
administration  of  arsenic,  and  other  special 
forms  of  treatment  should  be  used  only  in 
the  hands  of  experienced  physicians. 

Administration  of  vaccines  deserves  some  atten- 
tion and  the  technique  used  is  outlined  below.  The 
patient  is  tested  for  sensitivity  to  the  various  or- 
ganisms by  injecting  0.1  c.c.  of  the  saline  suspen- 
sion intracutaneously.  If  either  an  immediate  wheal 
appears  or  a  delayed  tuberculin-like  reaction  after 
24  hours,  the  patient  is  considered  to  be  sensitive. 
The  organisms  to  which  the  patient  reacts  are  then 
mixed  together  and  diluted  1:10,  1:100,  1:1000, 
and  in  certain  cases  1:10,000. 

The  administration  of  the  vaccine  is  begun  with 
the  highest  dilution,  the  patient  receiving  0.1  c.c. 
subcutaneously  at  the  first  injection.  This  is  fol- 
lowed by  0.2  c.c.  48  hours  later,  and  the  dosage  is 
increased  0.1  c.c.  every  48  hours  until  1  c.c.  dosage 
has  been  reached.  Then  the  next  most  concentrated 
dilution  is  begun  at  0.1  c.c.  and  is  administered  as 
outlined  above. 

If  at  any  time  the  patient  shows  any  increase  in 
temperature  or  marked  erythema  at  the  site  of  in- 
jection, the  vaccine  should  either  be  diluted  or  the 
dosage  in  the  same  dilution  significantly  lowered, 
and  the  vaccine  begun  again  observing  the  same 
precautions  as  before. 


minutes.  Usually  there  are  no  ill  after  effects.  Tolerance 
and  cumulative  effects  are  minimal.  Although  not  com- 
mon, habituation  may  develop,  and  may  result  in  symp- 
toms similar  to  those  of  chronic  alcoholism. 


CARDIOLOGY 

C.  M.  Gilmore,  M.D.,  Editor,  Greensboro,  N.  C. 


Chloral  hydrate  risk  has  been  overrated  (C.  F.  Ober- 
mann,  in  Jl.  Iowa  Med.  Soc,  Oct.)  ;  it  remains  one  of  the 
most  reliable  of  sedative  agents.  It  is  administered  by 
mouth  or  rectum  in  amounts  up  to  45  grains,  IS  grains 
being   the   average   adult   dose.    It   acts   within   15   to   20 


EXPERIMENTAL  SURGERY  IN  CORONARY 
ARTERY  DISEASE 

The  work  of  Claude  Beck  and  his  coworkers  in 
Cleveland,  in  the  past  few  years,  as  reported1  re- 
cently, has  made  two  major  contributions  in  the 
field  of  heart  disease.  One  is  in  new  concepts  of 
the  coronary  circulation;  and  the  other  is  hope  in 
the  future  of  heart  surgery. 

Work  on  the  dog  has  shown  that  local  ischemia 
of  the  heart  muscle  is  far  more  dangerous  than 
marked  reduction  of  the  total  coronary  flow.  If  the 
coronary  artery  be  pinched  off  almost  completely 
at  its  origin,  this  is  far  better  tolerated  than  the 
ligation  of  a  few  peripheral  arteries,  where  a  local 
ischemic  area  becomes  a  trigger  mechanism  to  set 
off  ventricular  fibrillation.  Obviously  then,  the  pro- 
duction of  communicating  arterioles  among  the 
various  coronary  artery  branches  should  be  of  great 
benefit  in  an  occlusion,  by  distributing  over  the 
entire  myocardium  the  shock  of  a  sudden  local 
ischemia.  This  verifies  the  clinical  impression  that 
a  coronary  occlusion  is  less  likely  to  be  fatal  in  a 
patient  who  has  previously  had  anginal  syndrome, 
and  whose  coronary  sclerosis  has  forced  the  pro- 
duction of  collateral  circulation. 

In  the  first  article  the  authors  report  on  the  ef- 
fect of  abrading  or  scraping  off  the  epicardium  in 
dogs.  It  is  believed  that  the  epicardium  presents  a 
barrier  to  intercoronary  communications.  The 
heart  was  first  abraded  to  remove  the  epicardium. 
and  two  weeks  later,  the  descending  ramus  of  the 
left  coronary  artery  was  ligated.  A  series  of  con- 
trol dogs  had  the  ligation  without  the  abrasion.  By 
postmortem  injection  of  the  coronary  arteries,  it 
was  shown  that  abrasion  was  effective  in  producing 
intercommunication.  In  treated  dogs  the  infarct 
was  smaller,  or  was  prevented  altogether.  In  some 
of  the  dogs  infarcts  developed  which  certainly 
would  have  been  fatal  in  normal  dogs,  but  their 
lives  were  saved  by  the  coronary  intercommunica- 
tions. 

An  incidental  finding  on  surviving  untreated 
dogs  was  that  coronary  occlusion  in  itself  is  an 
effective  stimulus  to  the  development  of  intercoro- 
nary channels. 

Beck,  in  his  article,  discusses  the  accomplish- 
ments of  his  experiments   on   dogs   and   humans. 

1.  The  Effect  of  Abrasion  of  the  Surface  of  the  Heart  upon 
Interconary  Communications."  by  Stanton.  Schildt  and  Reck: 
"Coronary  Operation,"  by  Beck;  both  in  The  American  Hezrt 
Journal,  October,  1941. 


December.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


675 


Apparently  there  are  three  means  by  which  sur- 
gery can  help  the  human  heart  suffering  from  coro- 
nary sclerosis.  One  is  by  means  of  abrading  the 
epicardium.  Another  is  by  causing  inflammation 
of  the  heart  surface  by  the  introduction  of  an  ele- 
ment, such  as  dried  bone,  into  the  pericardial  sac, 
and  thus  producing  arterial  intercommunications 
via  granulation  tissue.  The  third  method  is  by  the 
introduction  of  an  outside  blood  supply,  either  by 
the  internal  mammary  artery,  the  triangularis 
sterni,  or  any  other  tissue — the  specific  tissue  used 
making  no  difference.  Beck  cites  the  marked  im- 
provement in  the  human  patients  operated  on  as 
proof  of  the  effectiveness  of  surgery.  He  empha- 
sizes, however,  that  this  work  is  still  in  the  early 
expreimental  stage,  and  much  more  work  will 
have  to  be  done  before  operations  on  the  heart  be- 
come practicable  as  a  general  therapeutic  proce- 
dure. 


GENERAL  PRACTICE 

Walter  J.  Lackey,  M.D.  Editor,  Fallston,  N.  C. 


THE  CHOICE  OF  ANESTHETICS 

The  conflicting  claims  of  advocates  of  various 
anesthetic  agents  confuse  many  of  us.  Here  is  the 
gist  of  an  article1  which  sets  forth  the  indications 
for  different  drugs  of  this  class  in  an  apparently 
fair  way. 

Ether  is  the  most  reliable  anesthetic  agent  for 
relaxation.  When  other  agents  fail  to  relax,  ether 
is  drafted  into  service.  Since  its  early  introduction 
in  anesthesia,  ether  has  never  failed  in  being  util- 
ized for  overcoming  the  shortcomings  of  other 
methods.  Ether  still  occupies  the  position  of  the 
most  extensively  used  agent  in  spite  of  its  great 
handicaps.  However,  the  contraindications  for  the 
use  of  ether  are  many  and  should  be  observed. 
These  are  iiammability,  idiosyncrasy,  respiratory 
disturbances,  renal  diseases,  atheromatous  vessels, 
and  old  age. 

Chloroform  is  an  excellent  anesthetic  for  relaxa- 
tion, especially  in  obstetrics;  contraindications  are 
anemic  patients,  status  lymphaticus,  prolonged 
operations,  diabetes,  diseases  of  the  heart,  liver  and 
kidneys. 

Vinethene  is  of  greatest  value  when  rapid,  easy 
induction  and  prompt  recovery  with  a  minimum  of 
postanesthetic  effects  are  especially  to  be  desired. 
Administered  by  the  open-drop  method,  it  is  espe- 
cially useful  to  produce  light  anesthesia  when  un- 
consciousness and  freedom  from  pain  are  more 
important  considerations  than  muscular  relaxation. 
Vinethene  may  also  be  used  with  oxygen  to  supple- 

1.  G.  J.  Thomas,  Pittsburgh,  in  W.  Va.  Med.  Jl.,  Oct. 


ment  the  gases,  especially  nitrous  oxide  and  ethyl- 
ene. The  explosive  and  fire  hazards  of  vinethene 
are  just  those  of  ether,  ethylene,  cyclopropane, 
ethyl  chloride.  Due  to  its  high  volatility,  vinethene 
must  be  added  continuously  to  the  mask  during 
induction  and  maintenance,  when  using  the  open- 
drop  method;  the  tip  of  the  dropper  must  be  kept 
only  one  inch  from  the  mask.  Any  mask  suitable 
for  open  drop  anesthesia  may  be  used,  covered 
either  with  stockinet  or  with  eight  to  10  layers  of 
coarse  gauze.  Protect  the  face  with  cold  cream. 
Usually  the  patient  loses  consciousness  within  one 
minute.  For  a  few  seconds,  allow  the  mask  to  fit 
loosely  and  administer  vinethene  slowly.  Then 
gradually  increase  to  a  rate  of  from  40  to  60  drops 
per  minute.  Changes  in  depth  of  anesthesia  occur 
rapidly  and  skill  is  necessary  to  maintain  an  even 
level  of  anesthesia.  The  signs  of  vinethene  anes- 
thesia differ  from  those  of  ether  anesthesia  and 
experience  in  the  use  of  vinethene  is  required  in 
order  to  obtain  optimal  results.  In  the  third  stage, 
respiration  becomes  regular,  quiet,  and  increased 
in  volume,  the  eyeball  is  fixed,  and  the  pupil  may 
dilate  as  in  deep  ethyl  ether  anesthesia.  Full  re- 
covery from  deep  vinethene  anesthesia  usually  oc- 
curs in  a  few  minutes.  When  intercostal  activity 
has  been  abolished,  the  patient  is  in  the  fourth 
plane  of  surgical  anesthesia.  This  plane  of  anesthe- 
sia should  be  avoided.  Should  respiratory  arrest 
occur,  remove  the  mask,  be  sure  of  a  patent  air- 
way, immediately  institute  artificial  respiration  and 
administer  oxygen.  Response  and  recovery  are 
usually  quite  prompt.  When  using  vinethene  in  a 
machine,  it  should  be  vaporized  with  oxygen.  It 
may  be  administered  simultaneously  with  nitrous 
oxide  or  ethylene  in  order  to  obtain  greater  muscu- 
lar relaxation.  When  using  vinethene  with  ethylene 
or  nitrous  oxide,  at  all  times  allow  a  supply  of 
oxygen  sufficient  for  good  color.  If  respiratory  ar- 
rest occurs  with  vinethene,  cardiac  arrest  will  fol- 
low in  two  and  one-half  to  three  minutes.  With 
ethyl  chloride,  cardiac  arrest  follows  respiratory 
arrest  immediately.  Vinethene  should  not  be  used 
in  the  presence  of  cautery  or  flame,  it  is  contra- 
indicated  in  diseases  of  the  liver,  cardiovascular 
system,  renal  insufficiency  and  for  old  patients. 
Cyanosis  should  never  be  tolerated. 

Ethyl  chloride  is  a  fair  agent  for  procedures  re- 
quiring not  longer  than  five  minutes,  excellent  for 
induction  in  ether  anesthesia.  Contraindications 
are  the  same  as  those  for  chloroform.  It  should  not 
be  used  where  muscular  relaxation  is  necessary. 

Nitrous  oxide  is  the  most  popular  of  the  gas- 
anesthetic  agents.  Tt.  as  well  as  oxygen,  is  non- 
inflammablp.  but  will  support  combustion.  It 
should  not  be  used  where  relaxation  is  necessary, 
in  advanced  tuberculosis,  valvular  heart  disease  or 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


where  there  is  obstruction  to  the  air  passage.  Pa- 
tients that  are  muscular,  athletic,  alcoholic,  and 
with  high  metabolic  activities  take  it  poorly. 

Ethylene  gives  better  relaxation  than  nitrous 
oxide  but  not  as  good  as  certain  other  agents.  Oxy- 
gen can  be  doubled  with  ethylene.  Ethylene  is 
contraindicated  when  flame  or  cautery  is  to  be 
used. 

Cyclopropane  is  suitable  for  chest  surgery  be- 
cause of  high  oxygen  concentration.  When  helium 
is  not  added  to  the  mixture,  is  highly  explosive.  It 
is  contraindicated  in  cardiac  diseases.  Epinephrine 
should  not  be  used  during  cyclopropane  anesthesia, 
as  its  use  may  lead  to  ventricular  fibrillation. 

Intubation  anesthesia.  Once  intubation  has  been 
performed,  the  margin  of  safety  to  the  patient  is 
greatly  increased,  provides  an  immediate  and  ef- 
fective means  of  artificial  respiration. 

Rectal  ether  has  its  place  in  surgery,  especially 
in  obstetrics. 

Barbiturates  and  avertin  by  rectum  are  useful  to 
avert  the  psychic  shock  that  patients  may  experi- 
ence when  being  transported  from  their  bed  to  the 
operating  table.  Massive  dosage  of  these  drugs 
administered  at  one  time  frequently  prove  fatal. 
Of  the  barbiturates  pentothal  sodium  is  superior. 
Preliminary  medication  is  essential  for  all  anes- 
thetics, especially  with  the  intravenous  barbitu- 
rates. Opiates  and  atropine  relax  and  prevent  the 
formation  of  mucus. 

The  dose,  bv  intermittent  technic,  must  be  ad- 
justed for  each  patient.  Venipuncture  is  performed 
after  the  skin  has  been  surgically  prepared.  Three 
c.c.  of  4  per  cent  solution  is  injected  through  a 
period  of  10  seconds,  stop  to  permit  complete  ef- 
fect to  appear — 10  seconds.  Pause  following  the 
injection  of  each  two  or  three  c.c.  of'the  drug.  If 
relaxation  is  not  sufficient,  an  additional  two  or 
three  c.c.  can  be  injected  at  the  same  rate  as  in  the 
beginning.   The  air  passage  must  be  patent. 

If  respirations  are  e-  tremely  depressed,  oxygen 
or  a  mixture  of  oxygen-carbon-dioxide  may  be  ad- 
ministered by  means  of  nasal  adaptors  or  catheters. 

Accumulated  effect  may  manifest  itself  very 
suddenlv.  Evidence  of  recovery  is  an  indication 
for  additional  one  to  two.  Not  to  be  employed 
when  there  is  any  mechanical  interference  with  the 
respiratorv  function,  severe  myocarditis  or  disease 
of  the  liver  or  kidneys. 

Local  and  block  anesthesias  have  a  definite  place 
in  surgery.  The  contraindications  are  patient's 
idiosyncrasy  to  epinephrine,  novocaine,  cocaine,  or 
their  derivatives. 

Spinal  anesthesia  is  a  valuable  adjunct  in  sur- 
gery.   It  is  being  used  with  satisfaction  in  opera- 


tions involving  the  chest  and  regions  below  the 
diaphragm.  Contraindications  are  extensive  car- 
diovascular disease,  brain  tumor,  syphilis  and 
shock. 


RADIOLOGY 

Hii.mar  Schmidt,  M.D.,  Editor,  Petersburg,  Va. 


SUBACROMIAL  BURSITIS 

The  patient  complains  of  a  painful  shoulder. 
The  history  is  rather  vague.  He  thinks  he  may 
have  injured  it.  If  so,  the  injury  was  slight,  such 
as  we  all  suffer  and  forget  immediately.  Only  in 
this  case,  the  pain  develops  and  persists.  There  is 
no  swelling  or  redness  and  no  outward  visible  evi- 
dence. Even  pressure  may  show  no  tenderness,  and 
pain  may  only  arise  from  motion  of  a  certain  pat- 
tern. 

When  rontgenograms  are  taken,  a  calcareous  de- 
posit typical  of  subacromial  bursitis  may  be  ob- 
served in  the  region  of  the  bursa  near  the  greater 
tuberosity.  It  is  frequently  necessary  that  the  arm 
be  rotated  to  bring  this  deposit  into  view  on  the 
film.  The  deposit  may  be  a  single  mass  or  multiple 
small  masses. 

Until  recently  no  method  of  treatment  has  prov- 
ed satisfactory.  Drugs  to  ease  pain  do  not  reach  the 
cause.  Liniments,  to  use  an  old  textbook  phrase, 
are  mentioned  only  to  be  condemned.  Heat  in  the 
form  of  various  physical  therapeutic  measures  has 
helped,  but  it  is  tedious  as  well  as  uncertain.  Sur- 
gery has  been  used  as  a  last  resort. 

Now  x-ray  treatment  is  being  used  because  the 
rays  are  able  to  penetrate  the  deep  tissues,  and 
because  they  have  definite  effects  on  these  calcium 
deposits.  These  results  are  carefully  discussed  and 
evaluated  in  two  articles1  :  in  Radiology. 

Whereas  the  average  period  of  disability  for 
physical  therapy  was  SO  days,  these  authors  find  a 
disability  of  only  10  days  under  x-ray  treatment. 

Here  as  in  all  other  therapy,  careful  selection  of 
cases  is  needed.  In  the  acute  cases  with  early  cal- 
cification, or  even  before  calcification  can  be 
shown,  response  is  reasonably  prompt  and  satisfac- 
tory. In  the  chronic  cases  in  which  fibrotic  changes 
have  taken  place  improvement  is  prone  to  be  slow 
and  limited. 


i',: 


1.  Baird,    L.    W. :    Roentgen    Irradiation    of    Calcareous    deposits 
out  the  shoulder.     Ridiology,  Sept. 

2.  Klein,   I.,  and   Klemes.   1.    S.:     Treatment  of   Peritendinitis 
l  the  shoulder  joint.     Radiology.  Sept. 


INTESTINAL  INFESTATIONS 

I  II.    M.    Davison,    el   -!.'.   Atlanta,   in  Jl.   S.    C.   ilcd.   Assn.,   Nov.) 

It  seems  probable  that  a  fair  percentage  of  our  local 
population  is  suffering  from  some  form  of  intestinal  infes- 
tation. 

It  seems  wise  to  suspect  intestinal  parasites  as  a  possible 
cause  of  symptoms  not  otherwise  explained. 


December,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


677 


In  suspected  cases,  diagnosis  seems  best  obtained  by  ex- 
amining one  or  more  stools  voided  in  the  usual  manner 
and  at  least  six  stools  voided  in  the  office  following  a 
saline  laxative. 


THERAPEUTICS 

J.  F.  Nash,  M.  D.,  Editor,  Saint  Pauls,  N.  C. 


DIAGNOSIS  AND  TREATMENT  OF  VESICU- 
LAR ERUPTIONS  OF  THE  HANDS 
AND  FEET 
Every  general  doctor  is  consulted  about  vesicu- 
lar eruptions  on  the  hands  and  feet.    Here  is  pre- 
sented in  abstract  an  article1  from  which  profit  may 
be  derived. 

Common  dermatoses  are  presented  all  too  rarely 
for  dermatological  discussion.  The  simplest  type 
of  cutaneous  reaction  consists  of  erythema,  edema, 
vesiculation,  oozing  and  crusting  of  the  eczema- 
dermatitis  venenata  syndrome.  The  eruption  appears 
on  the  dorsum  of  the  fingers  and  hand  in  the  form 
of  closelv  studded  vesicles,  usually  extending  from 
the  finger  nails  to  a  line  on  the  wrist.  The  palms 
are  usually  involved  only  after  the  disorder  has 
become  subacute  or  chronic.  The  reaction  is  due 
to  the  existence  of  epidermal  allergy,  which  can  be 
demonstrated  by  the  positive  patch  test.  The  con- 
dition is  often  occupational  or  industrial. 

Epidermal  allergy  is  also  present  in  the  eczema- 
tous  variety  of  fungous  infection. 

Vesicular  dermatomvcosis  of  the  soles  is  not 
unusual,  especially  during  the  summer.  Examina- 
tion of  an  untreated  vesicle  reveals  a  large  number 
of  hvphae  in  its  roof. 

Conditions  which  must  be  considered  from  the 
standpoint  of  differential  diagnosis  of  vesicular 
ioderma  are  the  two  varieties  of  dermatitis  repens, 
the  acrodermatitis  continua  and  the  infectious 
types,  respectively,  and  vesiculo-bullous  second- 
degree    burn. 

Bv  far  the  greater  number  of  vesicular  eruptions 
of  the  hands  and  feet  may  be  included  in  the  group 
referred  to  as  idiopathic  dyshidrosis,  pompholyx, 
recalcitrant  eruptions  of  the  palms  and  soles,  bac- 
terids, pustular  psoriasis,  relapsing  phlyctenular 
dermatitis  of  the  extremities,  toxic  dermatitis  and 
perhaps  have  been  given  even  other  names. 

The  only  vesicular  eruptions  the  author  has  seen 
which  convinced  him  that  bacteria  were  causative 
have  been  those  of  infectious  eczema,  where  their 
products  reach  the  skin  from  the  outside. 

Vesicular  fungous  infection  of  the  hands  is  al- 
most unknown.  Funerous  infection  of  the  feet  oc- 
curs in  30  per  cent  of  patients  with  vesicular  erup- 
tions in  a  clientele,  comparable  to  that  seen  in  pri- 
vate practice  in  the  North.    In  private  practice  in 

1.  S.   W.   Becker,   Chicago,   in   Neb.  Med.  Jl.,    Dec. 


the  warmer  South  and  in  dispensary  practice  in  the 
North  where  a  higher  percentage  of  organic  derma- 
toses is  seen,  the  incidence  of  true  fungous  infection 
is  higher.  Non-fungous  vesicular  dermatoses  may 
mimic  the  picture  of  true  fungous  infection  so 
closely  that  clinical  differentiation  is  impossible. 

Never  make  a  diagnosis  of  fungous  infection 
without  finding  the  fungous  hyphae  in  potassium 
hydroxide  preparations  or  on  culture.  Never  make 
a  diagnosis  of  vesicular  dermatomycid  of  the  hands 
unless  the  fungous  infection  of  the  feet  is  of  the 
vesicular  variety,  signifying  epidermal  allergy. 

After  any  acute  irritation  has  been  relieved  by 
potassium  permanganate  wet  dressings  and  sooth- 
ing ointments,  the  entire  area  is  painted  with  ben- 
zol containing  two  per  cent  of  iodine,  which  is 
allowed  to  dry  and  the  feet  well  powdered  with  a 
dusting  powder  composed  of  equal  parts  of  tannic 
acid,  boric  acid  and  zinc  oxide.  On  the  following 
day  a  salicylic  acid-sulfur  ointment  is  applied 
morning  and  night.  The  initial  percentages  are  two 
of  salicylic  acid  and  three  of  sulfur,  which  are 
gradually  increased  if  tolerated  up  to  five  and  six, 
respectively. 

If  fungi  are  not  found  in  vesicles  of  the  hands 
or  feet,  treat  the  patient  according  to  the  princi- 
ples of  therapy  for  functional  disease  including 
rest,  ultraviolet  irradiations  and  sedation  in  addi- 
tion. After  any  acute  irritation  has  been  relieved 
by  potassium  permanganate  wet  dressings  and 
soothing  ointments,  White's  crude  coal-tar  oint- 
ment, S  per  cent,  is  the  most  efficacious  treatment 
for  restoring  normal  keratinization  cycle. 

SYMPTOMLESS  PERIOD  OF  BRONCHIAL 
FOREIGN  BODIES 

We  grow  lots  of  peanuts  in  this  section  and 
have  our  share  of  cases  in  which  they  get  into  a 
bronchus.  For  that  reason,  and  because  it1  is  one 
of  the  rare,  rare,  articles  which  advises  that  the 
family  doctor  be  consulted,  this  F.  D.  abstracts  it. 

Soon  after  the  aspiration  of  a  potentially  lethal 
foreign  body,  there  nearly  always  ensues  a  symp- 
tomless period,  during  which  the  significance  of  an 
occasional  wheeze  or  cough  may  be  overlooked. 
More  often  than  not  the  family  doctor  is  not  con- 
sulted during  this  period,  but  it  is  not  unusual  to 
hear  that  a  physician  acquaintance,  whose  special 
field  of  endeavor  is  far  removed  from  consideration 
of  chest  complaints,  has  been  quizzed  casually  on 
the  street.  Thus  he  is  made  to  share  some  respon- 
sibility with  no  opportunity  of  conducting  an  ex- 
amination or  even  obtaining  an  adequate  history. 

A  peanut  is  one  of  the  most  dangerous  and  un- 
fortunately common  bronchial  foreign  bodies.  Why 
is  a  child  without  molar  teeth  given  peanuts? 

1.  Paul  Eailey,  Portland,  in  Northwest  Med.,  Oct,         " 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


Contrary  to  lay  opinion,  less  than  3  per  cent  of 
bronchial  foreign  bodies  are  coughed  out  again. 
Neither  do  the  peanuts  disintegrate  or  "digest"  in 
the  lung.  Peanut  kernels  are  usually  angular  and 
during  the  symptomless  interval  after  aspiration 
the  air  passes  by  during  respiration.  During  this 
period  the  examiner  may  hear  one  or  two  nondiag- 
nostic rales  at  the  lung  base. 

The  all  important  and  usually  the  only  sign  at 
this  state  is  elicitation  of  an  asthmatoid  wheeze  at 
the  end  of  forced  expiration.  This  wheeze  is  heard 
with  either  the  ear  or  the  stethoscope  bell  at  the 
open  mouth.  It  is  clearest  after  secretion  is  ex- 
pelled by  coughing.  The  mechanism  of  production 
is  probably  the  passage  of  air  by  the  foreign  body 
as  it  narrows  the  bronchial  lumen.  Presence  of  this 
wheeze  always  suggests  bronchial  foreign  body  and, 
if  reported  by  the  parents  at  the  curb-stone  consul- 
tation, dictates  a  policy  of  viewing  with  alarm. 
Advice  to  hasten  to  their  family  doctor  for  imme- 
diate examination  and  continued  observation  should 
be  given. 

If  a  peanut  kernel  is  present,  it  will  make  its 
presence  known  in  no  small  way  and  probably 
soon.  Nuts  are  extremely  irritant  to  the  bronchial 
mucosa  and  they  rapidly  induce  annular  mucosal 
swelling.  Soon  the  airway  is  obstructed,  at  first 
during  expiration  only. 

SURGERY  OF  THE  OLD 

We  tend  to  neglect  having  our  old  patients  oper- 
ated on  except  in  emergencies.  The  article1  of 
which  abstract  follows  presents  the  subject  in  a 
way  to  be  helpful  to  the  family  doctor. 

A  dissipated  man  of  35  years  is  a  much  greater 
surgical  risk  than  the  well-preserved  patriarch  of 
80.  A  redistribution  of  physicians  will  be  necessary 
when  more  of  our  elderly  patients  settle  in  the 
South.  The  chance  of  dying  of  cancer  in  one  in 
nine  for  white  males  and  one  in  seven  for  white 
females. 

The  visit  to  older  patients  should  never  be  hur- 
ried; rather  it  should  be  casual  as  though  he  were 
being  honored.  It  is  well  to  discuss  events  of  com- 
mon interest;  an  evening  at  dinner  in  the  home 
will  give  the  patient  something  to  anticipate. 

Upon  admission  to  the  hospital  the  personnel 
should  be  instructed  not  to  alter  the  patient's  usual 
routine  except  for  real  reason.  The  surgeon  should 
explain  to  these  patients  the  results  of  the  exam- 
inations and  what  is  to  be  done  at  operation.  Bed 
rest  and  abrupt  curtailment  of  previous  habits 
usually  do  more  harm  than  good.  Probably  because 
of  the  feeling  that  most  of  his  life  lies  behind  him, 
the  older  patient  has  fewer  worries  than  the  active 
younger  man  and  accepts    operation    with    more 

1.  E.  L.  Strohl,  Chicago,  in  ///.  Med.  II.,  Nov. 


tranquillity  when  in  the  proper  frame  of  mind. 

The  criteria  for  surgery  in  these  aged  people 
are: 

1.  Is  surgery  essential  to  save  the  patient's  life? 

2.  Will  operation  remove  the  physical  disability 
and  restore  the  patient  to  his  more  or  less  normal 
status? 

3.  Will  it  effect  a  cure  of  a  malignant  disease? 

An  estimate  should  be  made  of  the  cardiac  re- 
serve. A  good  rule  of  thumb  for  such  patients  is 
whether  or  not  they  can  walk  with  ease  around  the 
block.  Many  of  these  patients  have  chronic  bron- 
chitis and  bronchiectasis  which  militate  against 
surgical  procedures. 

Complications  following  cholecystitis  in  the  aged 
are  very  poorly  tolerated,  and  postponing  surgery 
because  of  age  alone  is  to  be  condemned. 

Many  of  these  patients  have  a  low-grade  pros- 
tatic obstruction  which  will  become  an  immediate 
postoperative  problem.  A  long-standing  nephritis 
may  be  revealed  in  the  preoperative  studies  and 
measures  directed  to  the  correction  of  this  condi- 
tion. 

A  routine  blood  chemistry  examination  should 
be  made,  and  the  blood  placed  in  as  nearly  normal 
status  as  possible  by  fluids  by  vein,  blood  trans- 
fusions, vitamin  therapy  and  adequate  diet.  Pre- 
operative medication  should  be  minimal,  opiates 
used  sparingly. 

For  this  "group  of  patients  we  prefer  regional 
block  supplemented  by  an  inhalation  gas  for  anes- 
thesia. If  the  hemoglobin  is  less  than  50%  spinal 
anesthesia  should  not  be  used. 

Because  old  people  react  adversely  to  long-con- 
tinued annoyances  it  is  better  to  avoid  multiple- 
stage  operations. 

Measures  should  be  taken  to  prevent  shock, 
therefore,  by  administering  fluids  by  vein,  and 
blood  transfusions.  Suprarenal  cortical  extract 
given  to  elderly  patients  before  and  after  operation 
will  aid  in  preventing  shock  and  help  buffer  the 
strain  on  the  vital  organs.  The  blood  should  be 
given  slowly. 

Immediately  after  operation  the  patient  should 
be  given  oxygen  for  100  minutes  and  should  have 
hyperventilation  with  a  carbon  dioxide-oxygen 
mixture  every  hour  for  the  first  24  hours.  At  no 
time  is  pitressin  to  be  given  because  it  produces 
coronary  spasm. 

Patients  having  diseased  hearts  must  be  given 
fluids  slowly,  in  small  volume,  preferably  in  iso- 
tonic solution.  The  danger  of  excess  fluid  far  out- 
weighs that  of  inadequacy  for  a  period  of  two  or 
three  days  after  operation. 

As  soon  as  the  danger  of  secondary  shock  is 
past,  these  patients  should  be  encouraged  to  move 
about  freely  in  bed,  to  sit  up  in  bed,  and  to  be  up 


December,  1941 


SOUTHERN  MEDICINE  &■  SURGERY 


679 


in  a  chair  on  the  2nd,  3rd,  or  4th  day.  A  Balkan 
frame  and  a  trapeze  attached  over  the  bed  allows 
more  freedom  of  motion  of  the  extremities. 

Members  of  the  family  should  call  upon  the 
aged  patient  early.  The  danger  of  excitement  is 
minimal  and  is  offset  by  the  optimism  created. 

This  Chicago  doctor's  conviction  that  there  will 
come  a  time  when  all  old  folks  will  live  in  the 
South  is  awakening.  It's  a  new  idea  to  this  com- 
mentator: but  a  verv  welcome  one,  to  whatever 
degree  it  may  turn  out  to  be  accurate  prophecy. 

The  article  shows  an  intimate  and  considerate 
acquaintance  with  the  problems  of  declining  health 
incident  to  advance  in  vears. 


HOSPITALS 

R.  B.  Davis,  M.D.,  Editor,  Greensboro,  N.  C. 


DOX'T  LET  THE  PUBLIC  DECEIVE  YOU 

It  is  common  knowledge  that  people  frequently 
sav  what  they  don't  mean  and  mean  what  they 
don't  say.  This  seems  especially  true  of  an  upset 
and  disturbed  public  such  as  the  hospital  folks 
usually  come  in  contact  with.  The  more  disturbed 
the  mind,  the  more  unreliable  the  tongue.  Trus- 
tees, Directors  and  Staff  alike  must  recognize  this 
fact  if  their  institution  is  to  keep  pace  with  the 
times. 

In  my  twenty-six  years  of  practice  I  have  never 
had  the  relatives  of  an  injured  or  sick  individual 
to  request  that  the  patient  be  given  next  to  the 
best  or  third  from  the  best  treatment  possible:  but 
rather,  they  demand  that  the  patient  have  "the 
best"  of  medical  and  nursing  service.  In  the  well 
operated  institution  this  is  what  they  should  and 
do  get. 

It  is  obvious  that,  for  best  treatment,  best  equip- 
ment in  personnel  and  materiel  is  required.  Neither 
of  these  can  be  had  without  a  high  expenditure  to 
someone.  It  is  just  that  the  people  who  receive 
the  benefits  of  such  expenditure  pay  for  them.  It 
fis  the  sick  man  who  receives  the  benefits  of  the 
services  of  a  well  trained  medical  man  and  of  a 
well  equipped  hospital.  This  being  the  case, 
"chickens  will  come  home  to  roost-'  and  he  must 
pay  the  bill:  unless,  however,  he  is  clever  enough 
to  get  someone  else  to  pay  it  for  him  or  is  far- 
sighted  em mgh  to  carry  sickness  insurance.  This 
simply  means  he  gets  a  group  of  well  people  to 
help  pay  his  bill  and  when  he  is  well  again  he,  in 
his  turn,  contributes  to  meet  the  expenses  of  some 
other  person's  illness. 

One  can  not  blame  the  sick  individual  for 
wanting  the  best  that  medical  science  can  give. 
One  can  not  blame  the  sick  individual  if  he  de- 
mands that  the  hospital  be  equipped  so  that  the 
I  well  trained  physician  may  have  all  the  facilities 


necessary  to  render  the  best  treatment.  Converse- 
ly, one  should  not  blame  the  hospital  and  the 
physician  for  demanding,  in  return,  a  fair  remu- 
neration. This  remuneration  is,  of  necessity,  higher 
than  many  other  services  rendered  because  of  the 
terrific  cost  attached,  both  for  educational  prep- 
arations for  rendering  the  service  and  the  necessary 
newer  expensive  instruments  purchased  by  the  hos- 
pital. This  fact  must  be  put  over  to  the  public  by 
word  of  mouth,  through  the  press,  and  over  the 
radio.  Once  it  is  done,  there  will  be  considerably 
less  fault-finding  with  charges  made  by  hospitals 
and  physicians.  Every  institution  should  welcome 
criticism;  but,  be  it  remembered,  criticism  is  hon- 
est, intelligent  evaluation,  not,  as  most  seem  to 
assume,  abuse  born  of  ignorance  and  saturated  with 
selfishness.  The  only  practicable  remedy  is  an 
educational  campaign  to  convince  the  public  that 
they  only  pay  for  what  they  demand.  This  is  a 
free  country  today,  thank  God,  and  I  hope  it  will 
be  tomorrow.  Patients  are  entitled  to  have  what 
they  want,  if  in  having  it,  the  rights  of  their  neigh- 
bors are  not  infringed  upon;  but  it  is  equally  a 
democratic  spirit  that  once  the  individual  has  what 
he  wants,  he  must  remunerate  someone  for  it. 

I  was  interested  a  few  years  ago  in  a  discussion 
of  advertising  at  a  meeting  of  the  American  Hos- 
pital Association.  Some  hospital  authorities  present 
said  that  three  per  cent  of  the  gross  income  of  the 
institution  was  not  too  much  to  spend  for  the  pur- 
pose of  enlightening  the  public.  It  is  the  writer's 
opinion  that  five  per  cent  is  not  too  much.  The 
average  hospital  has  lighted  its  candle  and  put  it 
under  a  bushel  and  so  it  has  limited  its  own  use- 
fulness. Next  to  the  church,  the  hospital  should 
be  enterprise  number  one  in  any  community.  Let 
us  strive  to  put  the  hospital  in  that  position  and 
exert  sufficient  effort  to  hold  it  there. 

.  The  title  of  this  paper  and  its  text  may  be  boiled 
down  in  a  summary:  The  public  does  not  want 
poorly  trained  doctors  or  poorly  equipped  hospi- 
tals, but  they  would  lead  you  to  believe  that  they 
are  not  willing  to  pay  for  the  services  of  well 
trained  physicians  and  well  equipped  hospitals.  If 
they  knew  the  exact  cost  of  every  service  rendered, 
prior  to  its  being  rendered,  they  would  still  demand 
it  and  be  willing  to  pay;  but  we  have  denied  them 
the  educational  advantage  necessary  for  them  to 
know  what  a  fair  hospital  fee  is.  It  is  our  fault 
that  this  has  been  allowed  to  go  on  so  many  years. 
It  should  not  be  classified  as  egotistical  or  uneth- 
ical for  the  physician  and  the  hospital  to  seek  to 
put  before  the  public  favorable,  enlightening  and 
fair  information  on  the  costs  of  good  medical  and 
hospital  services,  so  that  all  the  people  may  see 
that  such  services  can  not  be  rendered  unless  for 
adequate  compensation. 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


HUMAN  BEHAVIOUR 

James   K.   Hall,  M.  D.,   Editor,   Richmond,   Va. 

A  MEDICAL  ITINERARY 

I  reached  St.  Louis  on  the  day  before  the  annual 
meeting  of  the  Southern  Medical  Association. 
Physicians  from  North  Carolina  had  a  large  part 
in  the  meeting.  Dr.  Paul  H.  Ringer,  of  Asheville, 
occupied  the  presidential  chair,  and  Dr.  Hamilton 
W.  McKay,  of  Charlotte,  made  the  report  of  the 
Council.  The  assemblage  was  large,  and  the  pro- 
gram was  comprehensive  and  excellent.  The  com- 
mercial exhibits  were  varied,  informative,  and  so 
influential,  I  surmise,  that  passage  into  and  out  of 
the  great  Municipal  Auditorium  was  made  through 
side  and  rear  doors,  necessitating,  by  the  members, 
serpentine  and  sinuous  approach  to  the  meeting- 
halls  through  the  myriad  exhibits.  Most  of  us 
doubtless  learn  more  easily  and  quickly  by  visual 
information.  The  commercial  exhibits  are  educa- 
tive. No  physician  can  successfully  practice  med- 
icine without  making  use  of  chemicals,  mechanisms 
and  other  material  aids.  But  there  is  no  doubt 
that  the  commercial  exhibits,  located  as  nearly  as 
possible  within  the  meeting-halls,  distract  many 
members  and  hold  them  from  attendance  upon  the 
sessions.  No  medical  society  should  allow  any 
number  of  exhibitors  to  exert  a  distracting  influ- 
ence, or  to  develop  the  notion  that  the  society 
can  not  finance  its  own  affairs. 

At  the  meeting  in  Richmond  last  May  of  the 
American  Psychiatric  Association,  I  found  it  im- 
possible, on  the  first  day,  to  pass  from  Main  Street 
to  the  large  auditorium  of  the  Jefferson  Hotel,  for 
the  simple  reason  that  the  door  of  the  auditorium 
was  locked.  The  exhibitors  had  caused  the  door  to 
be  locked,  so  I  was  told.  The  pathway  to  and 
from  the  auditorium  was  walled  on  either  side  by 
exhibits. 

On  the  last  afternoon  of  the  Southern's  session, 
I  journeyed  by  bus,  more  than  a  hundred  miles, 
west  of  St.  Louis,  to  Fulton,  and  there  I  spent  a 
busy  and  a  pleasant  day  with  Dr.  J.  R.  Busch,  the 
superintendent,  in  visiting  the  State  Hospital.  The 
institution,  opened  more  than  a  century  ago,  was 
the  first  hospital  for  the  mentally  sick  west  of  the 
Mississippi.  The  grounds  are  spacious,  the  build- 
ings substantial,  and  I  was  impressed  by  the  quiet- 
ness and  the  home-like  atmosphere  of  the  Hospital. 
I  heard  there  what  I  heard  at  all  other  state  hos- 
pitals I  visited:  of  the  too  small  medical  and  nurs- 
ing staffs,  of  the  withdrawal  of  many  of  the  per- 
sonnel into  the  defense  service,  and  of  the  want  of 
money  with  which  to  do  many  needed  things. 

In  journeying  from  the  city  to  the  State  Hos- 
pital I  passed  near  the  last  home  and  the  first 
burial-place  of  Daniel  Boone.    Not  far  away,  at 


Florida,  Missouri,  Mark  Twain  was  born;  and 
some  miles  farther  on  General  Pershing's  birth  has 
lent  prestige  to  a  village. 

My  visit  to  Fulton  was  followed  on  the  next 
day  by  a  call  at  the  City  Sanitarium.  The  institu- 
tion does  the  work  of  a  state  hospital  for  the  City 
of  St.  Louis,  and  I  feel  that  the  work  is  well  done. 
In  the  office  of  the  Superintendent  my  attention 
was  instantly  caught  and  held  by  the  bust — two  of 
them — of  a  distinguished-looking  man.  I  was  told 
that  a  mentally  sick  man,  many  years  a  patient, 
carved  one  of  the  busts  from  a  block  of  mahogany 
and  the  other  from  a  block  of  walnut.  Though  the 
patient  had  been  a  diemaker,  he  had  never  before 
attempted  to  carve  out  a  human  head.  He  had 
never  seen  the  former  Superintendent  but,  by  the 
use  of  photographs,  the  carver  had  evoked  from 
the  two  blocks  of  wood  a  perfect  likeness  of  the 
dead  physician.  When  the  sculptor  came,  at  my 
request,  to  talk  to  me  about  his  work,  he  had  little 
to  say,  except  that  he  could  not  understand  how  he 
was  able  to  do  it.  In  the  State  Hospital  at  Mor- 
ganton  there  should  be  such  a  representation  of 
Dr.  Patrick  Livingston  Murphy,  and  at  Dix  Hill 
at  Raleigh  such  a  likeness  of  Dr.  Albert  Anderson. 
The  artist-patient  remarked,  in  response  to  my 
question,  that  if  he  had  the  proper  photographic 
views  of  their  faces  he  would  do  his  best  to  carve 
for  me  a  bust  of  each  of  them.  Dr.  Frank  M.  Gro- 
gan  and  Dr.  Louis  H.  Kohler,  as  Superintendent 
and  as  Assistant,  direct  the  work  of  the  City  Sani- 
tarium. 

I  could  have  spent  the  entire  day  in  the  hospital 
pleasantly  and  profitably,  but  Dr.  E.  F.  Hoctor,  the 
Superintendent  of  the  State  Hospital,  had  invited 
me  to  visit  him;  and  Dr.  Norbert  J.  Publis,  resi- 
dent physician  of  the  Sanitarium,  afforded  me  com- 
fortable transportation  and  delightful  companion- 
ship for  almost  a  hundred  miles  down  into  Mis- 
souri's Ozarks.  I  could  not  imagine  what  the  enor- 
mous mounds  of  earth-looking  material  were.  Dr. 
Busch  informed  me  that  we  were  passing  through 
a  lead-mining  region,  and  that  the  great  mounds 
represented  waste  from  the  mines.  Dr.  Hoctor, 
Superintendent  of  the  State  Hospital  at  Farming- 
ton,  is  a  ruddy,  boyish-looking,  energetic,  delight- 
ful bachelor,  but  he  told  me  that  he  was  old  enough 
to  have  participated  in  the  first  World  War.  His 
institution,  like  that  at  Fulton,  is  near  a  small 
town,  and  each  has  extensive  grounds  and  that 
serenity  that  goes  with  such  a  location.  Dr.  Hoc- 
tor  spoke  of  his  institution  as  being  a  group  of 
cottages.  I  found  out  that  he  meant  that  few  of 
the  buildings  have  more  than  forty  patients  each, 
and  some  buildings  even  fewer.  Neither  buildings 
nor  patients  are  crowded.  The  institution  consti- 
tutes a  sort  of    psychiatric    village.    Dr.    Hoctor 


December,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


seemed  to  take  Dr.  Publis  and  me  throughout  the 
entire  Hospital.  Yet  I  saw  no  wild  behaviour,  I 
heard  no  outcries,  and  I  saw  no  barred  windows. 
When  I  remarked  about  the  invisibility  of  the 
stays  and  restraints,  Dr.  Hoctor  thought  dusk  was 
interfering  with  my  vision.  He  laughingly  remark- 
ed that  occasionally  a  patient  eloped;  but  that 
sometimes  there  was  penitential  return  and  a  re- 
quest for  readmission. 

The  night  was  far-spent  when  we  set  forth  on 
our  return  from  Dr.  Hoctor 's  hospitable  hospital 
home  to  St.  Louis.  Dr.  Publis,  young,  vital,  op- 
timistic, buoyant,  was  wondering  whether  to  de- 
vote his  professional  life  to  psychiatry  or  to  so- 
called  internal  medicine.  I  was  thinking  of  him, 
too.  his  youth;  of  the  vast,  fertile,  slightly-pop- 
ulated mid-West,  and  of  its  youth,  too,  and  of  its 
possibilities.  I  found  myself  wondering  if  the  lead 
being  mined  in  southern  Missouri  would  have  to 
be  shot  into  the  vigorous  bodies  of  young  Euro 
peans  and  Asiatics,  could  they  be  settled  in  a 
country  so  fertile  and  so  responsive  to  cultivation 
as  our  great  mid-West  and  West.  Men  pick  up 
their  guns  and  begin  to  fight  each  other,  perhaps, 
when  their  gastrointestinal  tubes  are  empty,  and 
when  they  step  on  each  others'  toes  because  they 
are  crowded. 

As  we  looked  upon  the  distant  glow  of  the  City's 
night-sky,  I  recalled  that  Mark  Twain  and  Tom 
Sawyer  and  Huck  Finn  and  the  Negro,  Jim,  were 
born  in  that  region,  and  that  they  have  becoms 
numbered  amongst  the  world's  immortals.  And  I 
remembered  that  Colonel  Robert  E.  Lee  was  as- 
signed, about  a  hundred  years  ago,  to  St.  Louis,  to 
fix  the  banks  of  the  Mississippi;  that  Dr.  William 
Beaumont  there  made  some  of  his  observations  on 
the  gastric  activity  of  Alexis  St.  Martin.  I  recalled 
having  once  visited,  just  across  the  Mississippi,  the 
cabin  on  the  plantation  of  his  father-in-law  occu- 
pied by  the  General  Grant  to-be,  following  his 
forced  resignation  from  the  United  States  Army 
because  of  drunkenness.  The  Civil  War  reclaimed 
him  and  pedestalized  him.  And  I  visited,  too,  the 
old  three-story  brick  house,  in  a  no-longer-desira- 
ble neighborhood,  in  which  Eugene  Field  was  born. 
I  think  I  should  have  preferred  his  life — poverty, 
tuberculosis,  alcoholism,  and  even  too-early 
death — rather  than  the  life  of  any  of  the  dignita- 
ries I  have  named.  Eugene  Field  was  enabled  to 
give  us  Little  Boy  Blue;  Wynken,  Blinken  and 
Nod;  and  When  Millie  Wet  the  Bed,  and  Seein' 
Things  because  he  remained  always  a  child  for 
children.  He  must  have  been  writing  with  autobio- 
graphic, alcoholic  fidelity  in  Thr  Snakes  that 
Rowdy  Saw,  and  in  Thr  Clink  of  the  Ice. 

Abraham  Lincoln,  on  Grant's  Illinois  side  of  the 
River,   would   have   brooded    in   melancholy,  even 


though  his  wife  had  not  been  psychopathic,  for  he 
was,  also.  He  and  Mark  Twain  failed  to  cheer 
themselves  in  establishing  themselves  as  immortal 
jesters. 

The  journey  has  barely  begun.    Shall  there  be 
other  chapters? 


HISTORIC  MEDICINE 


THE  ROYAL  COLLEGE  OF  PHYSICIANS  OF 
LONDON  AND  ITS  RECENT  BOMBING 

(A.  P.  Cawadias,  in  Proceedings  of  the  Royal  Society  of 
Medicine,  October) 

One  night  in  November,  1940,  a  high  explosive 
bomb  fell  through  a  skylight  in  the  library  of  the 
Royal  College  of  Physicians.  The  College  had 
already  been  damaged  in  October,  but  the  Novem- 
ber hit  was  the  more  destructive.  Half  the  library 
was  open  to  the  sky,  the  floor  at  the  point  of 
penetration  was  found  to  be  sagging;  the  blast 
blew  the  glass  from  the  bookcases,  and  hundreds 
of  books  were  scattered.  Fortunately  precautions 
had  been  already  taken  for  the  most  valuable 
books.  Among  the  remainder  there  was  surprising- 
ly little  damage. 

With  the  assistance  of  the  Royal  Society  of 
Medicine's  staff  the  staff  of  the  College  were  able 
to  remove  the  volumes,  which  were  sent  to  the 
Secretary's  house  to  be  stored.  They  were  removed 
just  in  time  to  save  them  from  damage  by  heavy 
rain. 

The  books  were  saved,  and  some  of  them  are 
those  that  survived  also  the  Great  Fire  of  1666. 

College  in  Roman  law  means  corporation,  and 
the  object  for  which  colleges  or  corporations  of 
physicians  were  formed  in  the  early  Middle  Ages 
was  the  regulation  and  administration  of  medical 
practice.  The  College  of  Physicians  of  Rome  in 
the  very  early  Middle  Ages  was  composed  of  a 
dozen  doctors,  all  of  genuine  Roman  family  and 
education,  who  exercised  a  kind  of  surveillance 
over  all  who  professed  the  art  of  curing — physi- 
cians, barbers,  surgeons,  apothecaries.  Any  who 
wished  to  practice  these  crafts  had  to  submit  to  an 
examination  before  the  College,  and  had  also  to 
show  that  they  were  not  afflicted  by  any  infirmity 
of  a  nature  to  render  them  ridiculous  or  objection- 
able and  that  they  had  never  committed  a  volun- 
tary homicide.  Vacancies  among  the  members  were 
filled  by  co-option  among  the  other  Roman  physi- 
cians. 

In  place  of  the  Roman  colleges  the  Germanic 
peoples  had  guilds.  There  was  a  powerful  guild  in 
the  13th  century  of  all  Florentine  physicians  and 
apothecaries  which  had  a  monopoly  of  healing 
practice.  The  powers  of  the  guild  were  vested  in 
four  consuls  who  constituted  the  examining  as  well 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


as  the  general  governing  and  organizing  body  of 
medical  practice.  It  is  believed  that  the  consuls 
were  elected  by  the  vote  of  all  the  guild  members. 

The  example  of  Italy  was  followed  by  other  na- 
tions, a  college  of  physicians  arose  in  every  leading 
town. 

Other  corporations  of  teacher  physicians  and 
students,  the  Faculties,  were  founded  with  the  ob- 
ject of  teaching  and  conferring  academic  degrees. 
Clashes  between  Colleges  of  Physicians  and  Fac- 
ulties resulted  in  the  suppression  of  colleges  on  the 
Continent  towards  the  end  of  the  18th  century.  In 
Paris  there  has  never  been  a  college  of  physicians, 
because  the  Faculty  of  Medicine  developed  from 
early  times  as  a  very  powerful  body.  A  college  of 
surgeons  developed  later  and  had  violent  struggles 
with  the  Faculty  until  at  last  it  was  suppressed  and 
absorbed  by  its  opponent. 

The  College  of  Physicians  of  London  (the 
"Royal"  was  affixed  later)  was  founded  in  1518 
by  Henry  VIII  at  the  plea  of  his  physician,  Thom- 
as Linacre.  The  Fellows  of  the  College  filled  va- 
cancies in  their  ranks  by  selecting  from  other 
members  of  the  corporation,  later  called  licentiates. 
In  1555,  the  College  of  London  refused  to  license 
for  practice  two  Oxford  graduates,  Simon  Ludford 
and  David  Laughton,  on  the  grounds  of  inadequate 
knowledge  and  advised  the  University  of  Oxford 
to  be  more  careful  in  the  instruction  of  future 
physicians.  After  discussion  with  the  College  that 
University  adopted  a  more  complete  course  of 
medical  studies,  and  one  of  the  refused  candidates, 
the  ex-Franciscan  friar,  Simon  Ludford,  underwent 
the  better  instruction,  obtained  his  license  and  was 
even  admitted  to  the  Fellowship. 

These  first  organizers  of  British  medicine  under- 
stood that  medicine  is  not  only  a  natural  but  also 
a  cultural  science.  In  1559  John  Geynes,  M.D.,  of 
Oxford,  had  to  retract  his  expressed  opinion  against 
the  infallibility  of  Galen  before  being  admitted  to 
the  Fellowship. 

Anatomy  lectures  started  in  the  College  about 
1565;  the  Lumleian  lecture  was  founded  in  1581. 
Examinations  for  diplomas  to  practice,  obligatory 
even  for  university  graduates,  were  more  severe 
than  were  those  of  the  universities.  Restricted 
licences  were  granted  in  certain  cases,  as  for  in- 
stance to  John  Banister,  a  physician  of  great  re- 
pute in  Nottingham,  who  gave  only  incomplete 
satisfaction  and,  notwithstanding  the  warm  recom- 
mendation of  Queen  Elizabeth,  was  allowed  to 
practice  in  London  only  on  condition  that  he  call 
in  consultation  for  difficult  cases  a  Fellow  of  the 
College.  To  Thomas  Fludd,  a  Cambridge  M.D. 
who  also  failed  to  satisfy  the  examiners  as  to  his 
knowledge  but  impressed  them  by  his  moral  quali- 
ties, license  to  practice  was  given  but  on  condition 


that  he  should  improve  his  knowledge  by  certain 
specified  readings  from  Galen. 

The  medico-political  functions  of  the  College 
consisted  in  advising  the  government,  the  universi- 
ties, various  corporations  and  the  general  public 
on  the  medical  aspects  of  education,  medical  or- 
ganization and  public  health.  Queen  Elizabeth 
commanded  the  Fellows  to  select  a  member  of 
their  society  to  replace  Dr.  Henry  Atkins,  who 
after  being  appointed  physician  to  the  naval  expe- 
dition to  Spain  had  to  be  put  ashore  because  of 
seasickness. 

In  1614  the  Fellows  moved  their  seat  to  the 
more  spacious  Amen  Corner  premises  (at  the  end 
of  Paternoster  Row),  which  they  leased  from  the 
Dean  and  Chapter  of  St.  Paul's.  A  botanical  gar- 
den was  added,  an  anatomical  theatre  was  built 
where  Harvey  taught,  and  the  museum  for  housing 
the  library  was  erected  at  the  expense  of  Harvey. 

The  great  name  of  Sydenham  is  missing  from 
the  roll  because  the  minor  academic  degree  which 
was  all  that  he  had  for  a  long  time,  entitled  Syden- 
ham to  acceptance  only  as  a  Licentiate.  Later  the 
creation  of  honorary  Fellows  (1664)  enabled  the 
College  to  include  in  its  Fellowship  many  physi- 
cians of  good  standing  who  possessed  the  requisite 
University  degree,  but  because  of  their  age  or  po- 
sition were  unwilling  to  undergo  the  regular  exam- 
inations imposed  by  the  College.  On  the  basis  of 
this  by-law  Sir  Thomas  Browne,  the  author  of 
Religio  Medici,  was  made  a  Fellow.  The  only  pres- 
sure exerted  by  governmental  powers  was  the  ex- 
clusion from  the  College  of  Roman  Catholics,  Pres- 
byterians and  Nonconformists,  and  to  this  effect 
the  by-law  allowing  Fellowship  exclusively  to  grad- 
uates of  Oxford  and  Cambridge  was  enacted.  The 
Goulstonian  lecture  was  founded  in  1639. 

During  the  Civil  War  even  the  building  of  the 
College  was  condemned  by  Parliament  as  Church 
property  to  be  sold  by  public  auction.  Dr.  Bald- 
win Harney,  a  Fellow,  bought  and  returned  it  to 
the  College.  The  Great  Fire  of  1666  began  on  a 
Saturday,  September  1st,  but  involved  the  College 
only  on  the  following  Wednesday.  In  that  inter- 
val Dr.  Merrett,  the  Harveian  librarian,  succeeded 
in  removing  to  a  place  of  safety  many  College 
valuables,  including  some  140  important  books, 
sole  remnants  of  the  Linacre,  Gilbert,  Harvey  and 
Holbosh  collections.  After  the  Fire  until  new 
premises  in  Warwick  Lane  were  built,  the  College 
met  mostly  at  the  house  of  Sir  John  Langham. 

The  Warwick  Lane  period  of  the  College  history 
corresponds  roughly  to  the  18th  century.  The 
premises  were  constructed  especially  for  that  pur- 
pose under  the  supervision  of  Sir  Christopher 
Wren.  It  was  a  magnificent  building  worthy  of  the 
century   and   of   the   elegant   "gold-headed   cane" 


December.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


Fellows  it  housed.  It  occupied  the  four  sides  of  a 
quadrangle  enclosing  a  spacious  paved  court.  Its 
entrance  was  through  a  wide  gateway  closed  with 
massive  iron  gates  under  a  semicircular  arch  over 
which  was  a  lecture  theater  and  a  dome  which 
Garth  compared  to  a  golden  pill.  The  theater,, 
erected  at  the  expense  of  Sir  John  Cutler,  was  "a 
model  of  acoustical  and  optical  architecture."  The 
public  rooms  were  spacious  and  handsome.  The 
library  consisted  of  two  communicating  rooms  with 
galleries  running  around  them.  It  was  rapidly  en- 
riched by  gifts.  The  greatest  of  these  was  the 
magnificent  collection  given  by  the  Marquess  of 
Dorchester,  more  than  3,200  volumes  of  physics, 
mathematics,  civil  law  and  philology.  Next  came 
books  bought  with  money  left  for  that  purpose  by 
Dr.  Richard  Hale  and  other  gifts  of  Fellows,  in- 
cluding those  of  Dr.  Crow  (Greek  and  Latin 
books).  Dr.  Thomas  Gisborne  and  Dr.  Baillie. 

As  the  religious  ban  had  been  lifted  the  College 
justified  its  exclusion  of  all  who  were  not  gradu- 
ates of  the  old  universities  by  the  laxity  found  in 
various  foreign  and  even  Scottish  universities  in 
the  giving  of  degrees.  The  M.D.  of  Rheims,  for 
example,  could  be  obtained  without  residence  on 
the  basis  of  a  thesis  whose  authority  was  not  al- 
ways scrupulously  investigated,  and  for  the  mod- 
est fee  of  four  guineas.  However,  Scottish  and  for- 
eign graduates  could  be  incorporated  into  the  Col- 
lege of  London  only  after  a  very  severe  examina- 
tion, which  put  them  on  the  same  intellectual  level 
as  their  Oxford  and  Cambridge  colleagues. 

Although  the  College  was  dwindling  as  central 
organizer  and  administrative  body  in  medical  mat- 
ters, redeeming  features  were  the  courtesy  and 
urbanity  of  its  Fellows,  the  gentlemen  of  the  gold- 
headed  cane.  Sir  William  Browne,  President  of 
the  College,  when  the  Licentiates,  encouraged  by 
John  Fothergill  among  others,  forced  entry  to  the 
comitia,  was  the  first  to  propose,  although  unsuc- 
cessfully, that  Fothergill  should  be  admitted  to  the 
Fellowship.  The  futile  and  petty  obstruction 
against  the  Society  of  Apothecaries  was  ridiculed 
by  a  distinguished  Fellow,  Samuel  Garth,  who 
characterized  the  College  of  this  period  in  this 
couplet: 

"Mean  faction  reigns  where  knowledge  should  preside 
Feuds  are  increased  and  learning  laid  aside." 
Lettsom,1  an  opponent  of  the  College,  was  often 
invited  to  its  dinners. 

The  parting  of  the  ways  was  at  hand.  The  Col- 
lege had  either  to  disappear,  abandoning  its  func- 
tions to  other  institutions,  or  it  could  maintain  its 

Jndi«    rPrhm™„'Hn,  Tr"  made  rcl,u,?"'°?  "id   fortune  in  the  West 
indies    removed  to  London,  and  of  whom  this  was  written: 
1.   John    Lettsom     purges,    bleeds   and    sweats    'cm; 
Then  if  they  still   will  die,   I,  John,  let  s   'em."— 

J.  M.   N. 


leadership  by  adapting  itself  to  new  conditions. 
For  a  new  lease  of  physical  and  spiritual  life  the 
College  decided  to  move  west,  and  after  many 
efforts  a  site  in  Pall  Mall  East  was  chosen  and  a 
new  house  was  built.  The  new  College  was  opened 
on  June  25th,  1825,  under  the  presidency  of  Sir 
Henry  Halford.  The  magnificent  ceremony,  at 
which  were  present  five  Royal  princes,  most  mem- 
bers of  the  government  and  many  leading  figures 
in  national  and  intellectual  life,  symbolized  the 
decision  of  the  College  to  reaffirm  its  leadership. 
Fellows  ceased  to  be  recruited  exclusively  from  the 
ranks  of  Oxford  and  Cambridge  graduates.  They 
were  no  longer  limited  to  London  practitioners,  but 
were  chosen  from  all  parts  of  Britain  and  the  Em- 
pire. Lectures,  more  extensively  read  than  attend- 
ed, often  gave  the  last  word  in  medical  problems. 
The  examinations  maintained  their  high  quality. 
Hospitals  required  College  diplomas  for  staff  ap- 
pointments. 

In  all  its  activities  the  College  maintained  the 
triple  standard  laid  down  by  the  16th  century  Fel- 
lows, and  particularly  the  cultural  humanistic  back- 
ground for  physicians  which  was  endangered  dur- 
ing the  mechanistic  19th  century. 

Associations,  such  as  the  British  Medical  Asso- 
ciation, have  undoubtedly  rendered  and  are  render- 
ing great  services  to  medicine,  but  history  teaches 
that  science  and  art  can  not  be  organized  on  a 
majority  principle.  The  College  which,  endowed 
with  such  great  will  to  power,  has  guided  British 
medicine  to  the  heights  can  not  fade  away.  His- 
torical thinking,  the  only  mode  of  thinking  that 
directs  action,  indicates  that  the  College  will  main- 
tain its  centralizing  and  integrating  functions,  the 
Associations  of  today  like  the  Faculties  of  old 
keeping  for  themselves  certain  branches  of  medical 
organization.  The  solution  will  be  collaboration, 
not  opposition. 

The  finding  of  this  modus  vivendi,  the  solution 
of  this  new  crisis,  dominates  the  activities  of  the 
College  today.  As  in  the  entire  course  of  its  his- 
tory, spiritual  fermentation  in  the  College  is  bound 
up  with  the  physical  need  for  change,  for  moving 
the  seat  of  the  institution.  It  is  at  this  turning- 
point  that  the  bombs  of  the  Huns  attempted  the 
destruction  of  the  College.  The  building  has  been 
damaged,  but  the  spirit,  far  from  being  subdued 
by  the  barbaric  insult,  has  acquired  an  added  stim- 
ulus to  its  work  in  the  organization  of  that  most 
civilizing  of  human  activities,  the  art  of  Medicine. 


NUTRITION  AND  LONGEVITY 
(J.  B.   Fitts,  Atlanta,  in  Med.  Times,  Nov.) 
Two  years  ago  it  occurred  to  me  that  perhaps  something 
could   be   learned  from   the  study  of   the  food  habits  of 
aged  people.    I  have  studied  the  dietaries  of  100  individ- 
uals in  the  age  group  80  to  100  years. 


684 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


What  are  the  conclusions  that  can  be  drawn  from  the 
dietaries  of  these  old  folks?  They  are  free  from  food 
fads.  Their  diet  is  representative  of  the  modern-day  diet. 
It  contains  adequate  protein,  carbohydrate  and  fats.  Their 
diets  are,  in  calcium  and  phosphorus,  far  better  than  of  a 
middle-aged  group,  because  of  the  amount  of  milk  used. 
The  group  is  light  in  weight,  averaging  135  pounds.  They 
retained  as  many  or  more  teeth  than  a  similar  number  of 
the  middle-aged  group. 

In  my  opinion  the  real  secret  of  the  old  age  of  this 
group  lies  in  the  quality  of  their  foods  in  the  first  five 
decades  of  their  lives.  From  1750  to  1850  there  was  a 
good  supply  of  home-grown  food  pleasantly  varied.  Ma- 
chine milling  was  not  introduced  into  this  country  until 
1870. 

The  individuals  in  the  group  study  were  born  between 
1835  and  1860.  In  those  days  there  was  no  white  flour, 
no  white  sugar,  no  white  rice,  no  canned  goods.  They  ate 
the  coarsely-ground  whole  grains  and  lean  meats. 

The  oldest  group  needs  minerals  and  vitamins  as  vitally 
as  a  growing  child.  We  can  encourage  the  use  of  whole 
grain  in  bread  and  cereal,  the  wider  use  of  fresh  vege- 
tables and  fruits,  the  greater  use  of  dairy  products  and 
lean  meat;  and  we  can  restrict  the  excessive  intake  of 
energy-producing  foods. 


PUBLIC  HEALTH 

N.  Thomas  Ennett,  M.D.,  Editor,  Greenville,  N.  C. 


P.UBLIC  HEALTH  MILESTONES 
(Continued  from  last  month) 

1896 — Board  passed  a  resolution  requiring  chemical 
and  bacteriological  examinations  of  munici- 
pal water  supplies.  Dr.  Venable,  of  Chapel 
Hill,  undertook  the  chemical,  Drs.  Anderson 
and  Pate  the  bacteriological,  examination. 
Board  also  directed  Mr.  John  C.  Chase,  the 
engineer  member,  to  inspect  all  municipal 
water  plants  in  the  state.  Annual  appro- 
priation, $2,000. 

1897 — General  Assembly  inacted  law  requiring 
county  superintendents  of  health  to  be  elect- 
ed by  county  commissioners  and  reduced 
term  of  office  to  one  year.  Annual  appro- 
priation, $2,000. 

1898— The  address  of  the  President  of  the  N.  C. 
Medical  Society  this  year  by  Dr.  Francis 
Duffy  of  New  Bern  was  devoted  almost  ex- 
clusively to  the  promotion  of  public  health. 
It  marked  an  epoch  as  sounding  an  advanced 
note  in  the  advancement  of  human  progress. 
The  State  Health  Officer,  Dr.  R.  H».  Lewis, 
devoted  a  great  deal  of  time  and  energy  to 
trying  to  arouse  the  people  of  the  state  to 
the  necessity  for  vaccination  against  small- 
pox. 

1899 — General  Assembly  improved  the  laws  pro- 
tecting public  water  supplies.  Smallpox 
prevailed  extensively  in  the  state.  Dr.  Henry 
F.  Long,  and  later,  on  Dr.  Long's  resigna- 
tion, Dr.  Joshua  Tayloe,  was  employed  to 
travel  over  the  state,  consulting  with  and 


advising  the  local  sanitary  authorities  as  to 
proper  means  for  protecting  the  public. 
Annual  appropriation,  $2,000. 

1900 — State  Board  of  Agriculture,  on  request  of 
State  Board  of  Health,  agreed  to  examine 
samples  of  water  from  public  water  supplies 
until  Board  of  Health  could  provide  its  own 
examiner.    Annual  appropriation,  $2,000.. 

1901 — State  Board  of  Embalmers,  with  represent- 
atives of  State  Board  of  Health,  established. 
County  health  work  placed  in  the  hands  of 
county  sanitary  committees  composed  of 
county  commissioners  elected  to  serve  with 
them.  Term  of  office  of  county  superin- 
tendent of  health  made  two  years.  Annual 
appropriation,  $2,000. 

1902 — This  year  will  be  long  remembered  for  the 
widespread  prevalence  of  smallpox  in  viru- 
lent form.  It  caused  many  deaths  in  differ- 
ent sections  in  the  early  months  of  the 
year.  In  one  county  at  least  50  persons 
died,  including  many  of  the  well-to-do.  Not 
having  any  system  of  vital  statistics  reports, 
it  is  impossible  to  even  estimate  the  number 
of  cases,  except  from  physicians'  voluntary 
reports  and  death  notices  in  the  newspapers. 

1903 — General  Assembly  enacted  law  permitting 
Board  of  Health  to  charge  $5.00  for  each 
analysis  of  a  public  water  supply,  this  fee 
to  be  used  in  paying  Dept  of  Agriculture 
for  services  of  examiner.  Dr.  Charles  War- 
dell  Stiles,  U.S.P.H.S,  before  the  State 
Medical  Society  at  Hot  Springs,  called  atten- 
tion to  prevalence  of  hookworm  disease  in 
the  South.  Dr.  J.  H.  Nicholson  and  Dr. 
W.  S.  Rankin,  working  under  State  Board 
of  Health  during  fall  of  1903  and  spring 
of  1904,  showed  great  prevalence  of  this 
disease  in  North  Carolina.  Annual  appro- 
priation, $2,000. 

1904 — A  stenographer  was  employed.  One  hun- 
dred and  twenty  thousand  pamphlets  on 
tuberculosis  were  printed  and  distributed. 
There  was  a  renewal  and  an  extension  of 
cooperative  work  between  the  Board  of 
Health  and  the  State  press,  a  number  ol 
articles  dealing  with  the  hygenic  and  sani- 
tary subjects  being  furnished  the  papers 
and  published  in  them.  Annual  appropria- 
tion, $2,000. 

1905 — General  Assembly  established  State  Labo- 
ratory of  Hygiene;  imposed  water  tax  of 
$64  on  all  public  water  companies;  voted 
$600  annually  for  the  support  of  laboratory. 
Small  appropriation  made  it  necessary  for 
the  Department  of  Agriculture  to  continue 


December,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


to  assist  State  Board  of  Health.  Annual 
appropriation,  $2,000. 
1906 — The  North  Carolina  Association  for  the 
Study  and  Prevention  of  Tuberculosis  was 
organized.  Annual  appropriation,  $2,000. 
(To  be  continued) 


A  BULLET  IN  THE  BRAIN  3%  YEARS 

(O.  L.  Yeach,  Sheridan,  Wyoming,  in  Rockv  Mountain  Med.  Jl 

Oct.) 

Housewife,  31,  on  Jan.  10th,  1938;  while  riding  in  a  car, 
pulled  a  .22  calibre  pistol  from  under  the  seat,  grasping  it 
by  the  barrel.  The  gun  was  discharged,  the  bullet  striking 
her  under  the  right  eye.  She  was  brought  to  the  hospital 
an  hour  afterwards,  partly  conscious  and  could  be  aroused 
to  answer  questions. 

Seen  two  hours  after  the  injury  she  remembered  reach- 
ing for  the  gun.  She  complained  of  headaches  right  frontal 
and  occipital.  There  was  a  bleeding  point  one  inch  below 
the  orbital  margin  on  the  right.  The  right  eye  was  prop- 
tosed;  upper  and  lower  lids  were  swollen,  tense  and  ecchy- 
motic.  The  lids  could  not  be  opened  sufficiently  to  see  the 
eyeball.  The  left  eye  was  clear  and  showed  no  change 
when  viewed  with  the  ophthalmoscope.  There  was  no 
bleeding  from  either  ear  or  from  the  nose.  A  left  hemi- 
plegia and  right  facial  paralysis  were  present;  the  patellar 
reflex  on  the  left  side  was  exaggerated,  but  normal  on  the 
right. 

Rontgenogram  of  the  head  showed  a  foreign  body  re- 
sembling a  bullet  in  the  upper  posterior  part  of  the  cranial 
cavity,  slightly  to  the  right  side  and  very  close  to  the 
inner  table  of  the  skull. 

Two  days  later  she  was  less  stuporous.  After  28  days, 
right  eye  was  shrunken  and  sightless,  some  injection  pres- 
ent and  tender  to  palpation.  No  signs  of  sympathetic  irri- 
tation in  the  opposite  eye,  but  removal  of  the  right  eye 
was  advised  because  of  the  possibility  of  sympathetic  oph- 
thalmia. 

Mentality  remained  normal  throughout  convalescence. 
The  bullet  passed  through  the  entire  length  of  the  brain 
without  producing  complete  loss  of  consciousness.  The 
only  severe  damage  consisted  of  the  loss  of  an  eye  and 
hemiplegia  on  the  opposite  side,  from  which  she  has'almost 
completely  recovered.  The  bullet  remains  in  the  cranial 
cavity  without  producing;  symptoms,  and  the  patient  is 
alive  and  well  3%  years  after  the  injury. 


KELOIDS  AND  THEIR  TREATMENT 
(M.  J.  Costello,  New  York,  in  Med.  Rec,  Sept.  17th) 

Ix  Africa  and  Australia,  certain  dark-skinned  tribes 
use  this  cicatrization  as  a  means  of  ornamentation  which 
gives  those  so  endowed  an  advantage  over  their  rivals 
Keloids  stand  out  best  on  the  dark  skin.  The  pale-skinned 
races  have  sought  an  outlet  for  this  desire  of  ornamenta- 
tion by  tattooing  the  body. 

Histologically  a  keloid  is  a  hard  fibroma.  Keloids  are 
notorious  for  their  tendency  to  recur  after  surgical  exci- 
sion. At  times,  especially  in  the  beginning,  they  are  pain- 
ful and  tender. 

The  electric  cautery  is  less  likely  to  cause  keloid  than  is 
the  electrodcsiccation  needle,  nitric  acid  or  acid  nitrate  of 
mercury.  Subjecting  an  operative  wound  to  too  great  ten- 
sion in  approximating  its  edges  is  likely  to  lead  to  keloid 
formation.  Cases  of  overgrowth  of  pyloric  scars  have  been 
recorded  in  Negroes,  and  of  the  tongue  and  lips  in  both 
races. 

If  an  incision  is  to  become  keloidal  or  if  a  keloid  is 
going  to  recur,  it  will  usually  do  so  within  three  months 
after  the  operation  or  injury.  At  the  first  suggestion  of 
Keloid  formation  x-rays  or  radium  are  imperative-  the  se 


lective  action  of  these  rays  is  on  the  young  connective  tis- 
sue cells. 

The  superiority  of  x-rays  over  any  other  treatment  for 
keloid  is  conceded. 

The  most  satisfactory  results  are  obtained  in  beginning 
and  in  young  keloids  (less  than  six  months  old)  and  in 
the  flat  superficial  keloids  following  burns  which  often  lead 
to  painful  and  disabling  contractures.  When  a  keloid  is  of 
slow  evolution,  old,  hard  and  stationary,  it  is  radioresist- 
ant. 

The  small,  young,  soft,  pea-  to  cherry-size,  flattened, 
superficial  lesions  respond  well  to  subintensive  doses  of 
unfiltered  x-rays  given  at  six  weeks  to  two-month  inter- 
vals, and  cosmetic  deformity  is  negligible.  Unfiltered  x- 
rays  also  are  beneficial  in  the  treatment  of  extensive,  su- 
perficial, soft  keloids  spread  out  diffusely  and  following 
extensive  burns.  The  bands  causing  contractures,  ectropion 
and  distortions  of  the  face  are  loosened  by  this  type  of 
x-rays.  When  a  keloid  disappears  there  is  usually  a  broad- 
ening of  the  scar  which  is  quite  soft  allowing  relaxation  of 
the  parts.  A  broad,  white  line  of  dense  fibrous  tissue 
should  be  removed  surgically  since  it  is  recalcitrant  to  any 
form  of  x-rays  or  radium.  Thick,  hard  old  keloids  cover- 
ing a  large  area  should  not  be  treated  bv  irradiation. 


OUTLOOK  FOR  CORONARY  THROMBOSIS  IS 

GENERALLY  QUITE  FAVORABLE 

(E.  F.  Bland  and  P.  D.  White.  Boston,  in  Jour.  A.  M.  A.,  Oct. 

4th) 

A  ten-year  analysis  of  the  after-history  of  200  patients 
with  coronary  thrombosis  indicates  a  favorable  outcome  in 
a  large  percentage  of  cases. 

Of  the  entire  series,  one-fifth  died  during  the  four  weeks 
after  their  initial  attack  and  one-third  of  the  162  who  sur- 
vived the  acute  attack  recovered  completely  without  car- 
diac symptoms.  Of  this  group  more  than  half  survived  the 
first  decade.  Of  those  who  died  after  temporary  "complete" 
recovery,  coronary  insufficiency  accounted  for  most  of  the 
deaths.  Of  the  188  patients  who  succumbed  to  failure  of 
the  coronary  circulation.  11  had  another  and  fatal  occlu- 
sion; 6  died  suddenly,  presumably  of  acute  coronary  in- 
sufficiency and  1  died  during  severe  angina  pectoris.  Only 
1  in  the  group  who  completely  recovered,  later  had  conges- 
tive failure. 

A  second  group  of  63  were  limited  thereafter  by  angina 
pectoris  on  effort.  Nevertheless,  19  survived  the  ten-year 
period.  A  slightly  higher  proportion  (34  of  44  patients,  or 
77  per-  cent)  died  later  of  cocronary  insufficiency.  Of  these 
34,  11  had  a  subsequent  fatal  occlusion,  14  died  of  increas- 
ingly severe  angina  pectoris  and  9  died  suddenly.  Again  it 
is  of  interest  that  only  2  later  had  progressive  congestive 
failure. 

Finally,  among  the  remaining  44  patients,  dyspnea  on 
exertion  was  chiefly  responsible  for  limitation  of  activity, 
although  some  had  both  angina  pectoris  and  dyspnea. 
None  with  dyspnea  survived  the  ten-year  period. 

Thirty-three  of  the  50  patients  who  survived  the  first 
decade  were  limited  by  angina  pectoris  as  they  entered  the 
second  decade,  and  9  of  these  had  one  or  more  later  at- 
tacks of  coronary  thrombosis;  the  remaining  17  were  with- 
out cardiac  symptoms,  although  6  had  further  attacks  of 
coronary  thrombosis,  from  which  they  completely  recov- 
ered. 


TUBERCULOSIS  AND  INSANITY.— In  every  mental 
institution  tuberculosis  is  a  problem  of  first  order.  Of  the 
deaths  from  tuberculosis  in  the  United  Slates.  S.2  per  cent 
occur  in  mental  hospitals  while  only  15.9  per  cent  arc  in 
tuberculosis  hospitals— M.  Pollak,  M.D.,  el  al„  Amer.  Rev. 
of  Tuber.,  March.  1941. 


6S6 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


SOUTHERN  MEDICINE  &  SURGERY 

Official  Organ 

TRI-STATE  MEDICAL  ASSOCIATION  OF  THE 

CAROLINAS  AND  VIRGINIA 

James  M.  Northington,  M.D.,  Editor 

Department  Editors 
Human  Behavior 

James  K.  Hall,  M.D Richmond,  Va. 

Orthopedic  Surgery 
William  Tate  Graham,  M.D Richmond,  Va. 

Urology 

Raymond  Thompson,  M.D Charlotte,  N.  C. 

Surgery 

Geo.  H.  Bunch,  M.D Columbia,  S.  C. 

Obstetrics 

Henry  J.  Langston,  M.D Danville,  Va. 

Ivan  M.  Procter,  M.D Raleigh,  N.  C. 

Gynecology 

Chas.  R.  Robins,  M.D Richmond,  Va. 

G.  Carlyle  Cooke,  M.D Winston-Salem,  N.  C. 

Pediatrics 

G.  W.  Kutscher,  Jr.,  M.D Asheville,  N.  C. 

General  Practice 

J.  L.  Hamner,  M.D Mannboro,  Va. 

W.  J.  Lackey,  M.D Fallston,  N.  C. 

Clinical  Chemistry  and  Microscopy 

C.  C.  Carpenter,  M.D.  )  ....    ,      c  ,        .,    „ 

VWrnston-Salem,  N.  C 
R.  P.  Morehead,  B.S.,  M.A.,  M.D.  | 

Hospitals 

R.  B.  Davis,  M.D Greensboro,  N.  C 

Cardiology 

Clyde  M.  Gilmore,  A.B.,  M.D Greensboro,  N.  C. 

Public  Health 

N.  Thos.  Ennett,  M.D Greenville,  N.  C. 

Radiology 
Wright  Clarkson,  M.D.,  and  Associates  ...Petersburg,  Va. 

R.  H.  Lafferty,  M.D.,  and  Associates Charlotte,  N.  C. 

Therapeutics 

J.  F.  Nash,  M.D Saint  Pauls,  N.  C. 

Tuberculosis 

John  Donnelly,  M.D Charlotte,  N.  C. 

Dentistry 

J.  H.  Guion,  D.D.S Charlotte,  N.  C. 

Internal  Medicine 

George  R.  Wilkinson,  M.D Greenville,  S.  C. 

Ophthalmology 

Herbert  C.  Neblett,  M.D Charlotte,  N.  C. 

Rhino-Oto-Laryngology 

Clay  W.  Evatt,  M.D Charleston,  S.  C. 

Proctology 

Russell  von  L.  Buxton,  M.D Newport  News,  Va. 

Insurance  Medicine 

H.  F.  Stars,  M.D Greensboro,  N.  C. 

Dermatology 
J.  Lamar  Calloway,  M.D Durham,  N.  C. 

Offerings  for  the  pages  of  this  Journal  are  requested  and 
given  careful  consideration  in  each  case.  Manuscripts  not 
found  suitable  for  our  use  will  not  be  returned  unles  author 

As  is  true  of  most  Medical  Journals,  all  costs  of  cuts, 
etc.,  for  illustrating  an  article  must  be  borne  by  the  author, 
encloses  postage. 


THE  COMING  TRI-STATE  MEETING 
FEBRUARY    16th-17th 

It  will  be  remembered  that  the  membership  of 
the  Tri-State  Medical  Association  of  the  Carolinas 
and  Virginia  have,  within  the  past  year,  been  can- 
vassed as  to  their  opinion  on  the  desirability  of 
holding  the  annual  meetings  at  a  time  of  year 
promising  better  weather.  Replies  from  the  mem- 
bers express  a  preference  for  holding  the  meeting 
at  the  time-honored  dates  in  February. 

So  you  members  are  being  reminded  that  the 
place  of  meeting  for  1942  is  the  good  city  of  Green- 
ville, S.  C,  the  days  the  sixteenth  and  seventeenth 
of  February. 

President  Brenizer  has  spent  a  good  part  of  1941 
in  Boston  and  New  York  and  has  availed  himself 
of  opportunities  thus  afforded  for  obtaining  for  the 
meeting  just  the  kind  of  speakers  from  afar  that 
you  would  wish  to  hear,  on  just  the  subjects  which 
merit  most  attention  right  now. 

These  guests  will  bring  us  the  best  of  medicine 
and  surgery  of  the  day — all  of  it  solid,  some  of  it 
sensational. 

The  members  are  reminded  that  there  are  some 
vacancies  on  the  program,  and  urged  to  write  the 
secretary  promptly  for  place. 

However  many  medical  meetings  you  attend,  the 
Tri-State's  unique  attractiveness  and  usefulness 
bring  together  the  faithful  year  after  year,  always 
with  an  eager  group  of  new  members,  themselves 
soon  to  become  Tri-State  addicts. 

Be  planning  to  make  your  attendance  certain. 
Write  for  place  on  the  program.  Have  your  doctor 
friends  old  and  new  send  in  applications,  and  bring 
them  with  you. 


CASES  IN  WHICH  BILLS  IN  INDUSTRIAL 
CASES  ARE  REDUCED 

North  Carolina  doctors  who  have  the  care  of 
industrial  cases  are  requested  to  keep  accurate 
records  of  all  such  cases  in  which  their  bills  are 
not  paid  in  full.  This  request  is  made  by  the 
Chairman  of  the  Committee  appointed  by  the  State 
Medical  Society  to  deal  with  these  matters. 

The  records  show  that  fees  allowed  for  this  class 
of  work  are  30  per  cent  higher  in  South  Carolina 
and  23  per  cent  higher  in  Virginia,  than  in  North 
Carolina.  Also  our  information  is  that  the  compa- 
nies selling  this  class  of  insurance  are  paying  out 
less  than  half  the  amount  of  the  premiums  paid 
in.  Clearly,  premiums  should  be  reduced  or  more 
should  be  paid  for  medical  and  surgical  care  of 
the  insured. 

There  appears  no  good  reason  why  North  Caro- 
lina doctors  should  be  paid  less  for  the  same  kind 
of  work  than  are  doctors  of  neighboring  states. 


December,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


687 


This  Committee  of  The  State  Medical  Society 
is  taking  its  duties  seriously.  With  the  proper  co- 
operation of  the  doctors  over  the  State  who  do  this 
work  this  wrong  will  be  righted. 


THE  TRESENT  STATUS  OF  SULFONAMIDE 
THERAPY 

Those  marvelous  sulfonamides!  What  will  they 
not  do?  That  they  mark  an  advance  in  therapy 
which  will  hold  high  place  among  the  achievements 
of  Medicine  for  all  time,  there  can  be  no  doubt. 
But  so  much  is  written  about  them  as  to  confuse 
the  doctor  who  seeks  to  know  what  they  will  and 
what  they  will  not  do;  which  of  them  is  best  in 
certain  cases;  how  much  to  give  and  how  often. 

Here'  is  just  that  information. 

Sulfanilamide — The  highest  blood  levels  are 
found  at  the  end  of  4  hours,  all  the  drug  is  ex- 
creted at  the  end  of  24  hours;  it  should  be  given 
q.  4  h.  Effective  blood  concentration  for  severe 
infections  are  10-15  mgms.  %,  less  severe,  5-10 
mgms.  %.  It  saturates  the  tissues  in  same  concen- 
tration as  the  blood  and  readily  passes  into  the 
spinal  fluid  in  three-fourths  of  the  blood  concen- 
tration. An  excellent  drug  to  treat  certain  types  of 
meningitis. 

Sulfa-pyridine  is  irregularly  absorbed  both  in  the 
same  patient,  and  in  different  patients.  This  some- 
times makes  it  necessary  to  give  the  drug  intra- 
venously as  the  sodium  salt.  Blood  levels  of  from 
4  to  6  mgms.  %  are  effective.  The  drug  is  hard  to 
excrete  by  the  kidneys,  may  block  the  kidneys  by 
crystal  formation. 

Suljathiazole  is  more  rapidly  absorbed  and  ex- 
creted by  the  kidneys  than  is  sulfanilamide.  Effec- 
tive levels  lie  between  2  and  6  mgms.  %. 

Sulfaguanidine  is  very  soluble  in  the  gastrointes- 
tinal tract  but  is  poorly  absorbed.  Only  low  blood 
levels  of  from  2  to  5  mgms.  %  are  reached.  The 
small  amounts  absorbed  are  excreted  by  the  kid- 
neys'. 

Sulfadiazine,  only  recently  released  for  general 
use,  is  less  rapidly  absorbed  than  either  of  the 
other  three;  its  acetyl  salt  is  more  easily  excreted, 
even  in  the  presence  of  kidney  damage.  This  may- 
mean  that  it  will  be  the  best  drug  to  use  where 
kidney  damage  is  present.  Blood  levels  of  from  6 
to  9  mgms.  '/,,  are  effective.  Every  4  h.  during  the 
first  24  hours,  q.  6  h.  thereafter;  very  effective  in 
meningitis. 

Suggested  initial  dose  for  an  adult  weighing  150 
pounds  with  a  moderately  severe  infection:  sul- 
fanilamide 60  to  90  grains;  suljathiazole  45  to  60; 
suljapyridine  45  to  60;  sulfadiazine  60  to  75;  sul- 
faguanidine  60  to  90. 

1.  J.  N.   Compton,  Little  Rock,  in  //.  Ark.  Med.  Soc,  Nov. 


The  maintenance  dose  is  15  to  20  grains  q.  4  h., 
day  and  night,  with  the  exception  of  sulfadiazine 
where,  after  24  hours,  the  dose  should  be  given  q. 
6  h.  In  most  cases,  it  is  recommended  that  large 
amounts  of  water,  and  sodium  bicarbonate  two  to 
three  drams,  be  given  in  24  hours. 

Sulfanilamide  can  not  be  given  intravenously 
but  can  be  given  subcutaneouslsy  in  an  .8%  solu- 
tion of  normal  saline,  or  may  be  given  by  rectum 
in  about  a  1%  solution  of  saline.  Sulfapyridine, 
sulfathiazole  and  sulfadiazine  may  be  given  intra- 
venously as  the  sodium  salt  in  a  5%  solution  in 
distilled  water. 

Sulfonamides  stop  the  growth  of  susceptible  bac- 
teria but  do  not  kill  those  already  present. 

Sulfanilamide  is  the  drug  of  choice  in  all  hemo- 
lytic streptococcic  infections.  Sulfadiazine  may 
prove  even  more  effective. 

In  urinary-tract  infections  due  to  Group  B  hem- 
.  olytic  streptococci  and  bacillus  proteus,  sulfanila- 
mide seems  to  be  more  effective  than  other  deriva- 
tives. It  is  the  best  derivative  in  the  treatment  of 
chancroids,  lymphogranuloma  venereum,  and 
trachoma.  Favorable  reports  in  the  treatment  of 
actinomycoses,  undulant  fever,  ulcerative  colitis. 

Sulfapyridine  cure  of  the  pneumococcic  pneumo- 
nias is  dramatic,  the  mortality  rate  is  reduced  from 
25  to  50%  to  less  than  10%.  Because  it  is  much 
less  toxic,  however,  sulfathiazole  has  replaced  sul- 
fapyridine in  the  treatment  of  the  pneumococcic 
pneumonias.  In  some  cases  it  is  necessary  to  sup- 
plement chemotherapy  with  type-specific  antipneu- 
mococcic  serum.  A  specimen  of  sputum  should  be 
collected  before  therapy  is  started,  and  if  typing  is 
not  practicable  at  once,  the  specimen  should  be  re- 
frigerated for  future  possible  typing  in  case  there 
is  no  response  to  drug  therapy  in  36  to  48  hours. 
A  blood  culture  should  be  taken  before  therapy  is 
started,  if  possible,  since  more  intensive  treatment 
is  generally  necessary  if  the  culture  is  positive. 

While  sulfathiazole  is  the  drug  of  choice  in  the 
pneumococcic  pneumonias,  sulfapyridine  is  the  best 
drug  in  all  other  pneumococcic  infections. 

In  the  treatment  of  staphylococcic  or  pneumo- 
coccic meningitis,  sulfapyridine  is  the  drug  of 
choice. 

Sulfathiazole  is  best  in  all  staphylococcic  infec- 
tions, such  as  carbuncles,  cellulitis,  osteomyelitis, 
and  staph,  pneumonia;  it  has  cut  the  mortality 
mia  it  is  the  best  drug;  it  has  cut  the  mortality 
rate  in  half.  Any  focus  of  infection  feeding  the 
blood  stream  should  be  drained  as  early  as  possible. 

In  the  treatment  of  male  gonorrhea,  sulfathia- 
zole is  perhaps  the  drug  of  choice.  In  female  gon- 
orrhea, sulfapyridine  still  seems  to  be  the  favorite. 

In  the  prevention  and  treatment  of  wound  infec- 
tions by  local   application   a  combination  of  sul- 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


fathiazole  and  sulfanilamide  is  highly  effective. 

In  experimental  gas  gangrene,  sulfathiazole  lo- 
cally, or  a  mixture  of  sulfathiazole  and  sulfanila- 
mide, are  most  effective  in  prevention,  and  anti- 
serum is  most  effective  in  treatment.  Local  sul- 
fonamide application  seems  more  effective  than 
oral  medication.  These  drugs  may  be  used  locally 
in  a  saturated  solution,  or  in  powder  form. 

Sulfadiazine  seems  just  as  effective  as  other 
sulfonamides  in  the  treatment  of  pneumococcic, 
staphvlococcic  and  streptococcic  pneumonias,  men- 
ingococcic  meningitis,  acute  infections  of  the  upper 
respiratory  tract,  including  sinusitis  and  erysipe- 
las; very  effective  against  B-coli  infections  of  the 
urinary  tract,  and  in  acute  gonococcal  arthritis. 
It  is  a  much  less  toxic  drug.  There  is  less  nausea, 
vomiting,  drug  fever  and  rash.  The  levels  of  the 
drug  in  the  blood  are  higher.  It  is  excreted  with 
less  damage  to  the  kidneys,  and  its  insoluble  acetyl 
salt  more  easily  excreted. 

Sulfaguanidine  has  proved  effective  in  acute  ba- 
cillary  dysentery.  In  surgery  of  the  large  bowel, 
pre-  and  post-operative  use  of  sulfaguanidine  is 
thought  to  prevent  complications  of  peritonitis,  and 
to  permit  rapid  healing  of  the  sectioned  bowel. 

The  following  diseases  are  not  favorably  influ- 
enced by  the  sulfonamides:  Influenza,  common 
colds,  rheumatic  fever,  typhoid  fever,  malaria,  tu- 
berculosis, non-hemolytic  streptococcic  infections, 
anerobic  streptococcic  infections,  tularemia  and 
chronic  sinusitis. 

There  is  no  contraindication  except  a  history  of 
sensitivity  to  one  of  these  drugs.  Sensitive  to  one, 
likely  sensitive  to  another.  Cautious  use  of  small 
doses  at  first. 

Mild  toxic  symptoms  are  nausea,  vomiting, 
cyanoses,  mild  psychoses,  and  acidosis. 

Moderately  severe  fever  and  rash,  the  most  fre- 
quent. Usually  on  5th  to  9th  day.  Hematuria  oc- 
curs 3  times  as  often  from  sulfapyridine  as  from 
sulfathiazole.  Very  severe  toxic  symptoms  require 
stopping  the  drug  at  once,  forcing  fluids  and  alka- 
lies. Slow  hemolytic  anemia  may  not  require  stop- 
ping. Transfusions  mav  be  necessary,  however,  if 
severe  infection  is  present  and  drug  therapy  needed 
badly. 

Severe  toxic  symptoms — 2^  of  cases — acute 
hemolytic  anemia  in  24  to  72  hours,  fever  and 
pulse  rise  rapidly,  pallor  followed  by  jaundice; 
urine  and  feces  dark  with  urobilin,  marked  increase 
in  the  white  count  with  a  marked  decrease  in  the 
red  count  and  hemoglobin.  Drug  must  be  stopped 
immediately  and  a  transfusion  given,  to  be  repeat- 
ed p.  r.  n. 

Acute  granulocytosis,  usually  12th  or  14th  day — 
less  than  y2%    of    cases.    Moderately    decreased 


white  count  with  some  granulocyte  reduction,  not 
infrequent  at  the  onset  of  sulfonamide  therapy,  is 
no  contraindication  to  continuance  of  therapy.  No 
deaths  reported  from  disturbances  of  the  white 
cells  within  the  first  12  days  of  sulfonamide  ther- 
apy. Acute  agranulocytoses  comes  at  the  end  of 
the  second  week,  with  return  of  fever,  increasing 
prostration,  sore  throat  or  gums,  followed  by  ulcer- 
ation, and  should  alarm  the  physician.  If  blood 
counts  are  not  done  routinely  during  sulfonamide 
therapy,  they  should  be  done  at  least  after  the 
10th  day. 

Acute  toxic  hepatitis  occurs  usually  in  the  sec- 
ond week.  Jaundice  develops  without  pallor.  The 
feces  are  light  instead  of  dark  as  in  acute  hemolytic 
anemia.    The  drug  must  be  stopped  at  once. 


DOCTOR  COOPER  LAYS  ASIDE  THE  PEX 

Xigh  to  twenty  years  ago  it  was  that  to  Dr. 
George  M.  Cooper's  responsibilities  as  a  member 
of  the  staff  of  the  State  Health  Officer  was  added 
the  editorship  of  the  North  Carolina  Health  Bul- 
letin; and  well  has  he  discharged  all  these  respon- 
sibilities. The  increase  in  the  demands  on  his  time 
and  strength  in  the  discharge  of  his  other  State 
Health  duties  now  necessitates  his  relinquishing 
the  editorial  goose-quill. 

Many  public  officers,  probably  most,  fulsome 
oratory  proclaims  as  having  unselfishly  devoted 
their  best  to  the  public  good.  With  truth  these 
words  may  be  spoken,  and  will  be  spoken  all  over 
the  State,  of  Dr.  Cooper.  A  deep  satisfaction  must 
be  his  to  realize  that  his  labor  has  not  only  been 
wise  and  devoted,  but  that  it  has  been  of  tremen- 
dous accomplishment.  And  it  must  be  satisfying 
lo  him  to  know  that  the  mantle  of  his  editorship 
falls  on  the  shoulders  of  one  who  will  continue  the 
good  work  in  a  highly  competent  manner  without 
change  of  plan. 

Dr.  John  H.  Hamilton,  for  years  Director  of 
Laboratories  of  the  State  Board  of  Health,  will 
take  over  the  duties  of  editor  of  The  Health  Bulle- 
tin.   A  happy  consummation  it  is. 

All  praise  to  Dr.  Cooper  for  his  score  of  years  of 
fruitful  labor  in  spreading  the  Gospel  of  Health  in 
North  Carolina.  Congratulations  to  Dr.  Hamilton 
on  his  opportunity  to  take  over  this  work  as  a 
going  concern  and  carry  it  forward  in  his  own 
competency. 


DOCTOR  REYNOLDS  APPOINTED  TO  HIGH 
OFFICE 

From  its  inception  to  the  present  time  the  office 
of  Health  Officer  of  North  Carolina  has  been  filled 
by  men  of  unusual  ability  and  distinction.  The 
present  occupant  of  that  office,  Dr.  C.  V.  Reynolds, 
already  Vice  President  of  the  State  and  Provincial 


December,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


689 


Health  Authorities  of  North  America,  has  been 
appointed  Chairman  of  the  Subcommittee  on 
Health  under  the  Procurement  and  Assignment 
Agency  recently  established  by  the  President.  Thus 
the  fine  tradition  is  carried  on. 


DOCTOR  GREER  BAUGHMAN 

The  sad  news  has  just  come  of  the  death  of  this 
lovable  and  much  loved  doctor.  No  one  could  be 
in  intimate  association  with  Dr.  Baughman  and 
not  come  under  the  spell  of  his  charm. 

An  incident  of  many  years  ago  will  give  to  those 
who  were  not  so  fortunate  as  to  know  him  a  true 
picture  of  this  warm-hearted  man.  A  group  of 
Medical  College  of  Virginia  students  were  standing 
before  a  board  on  which  the  names  of  those  who 
had  been  given  pass  marks  on  a  recent  examination 
had  just  been  posted.  Dr.  Baughman  came  up  with 
his  bright  smile  and  said,  "I  want  to  rejoice  with 
them  that  d  orejoice";  whereupon  some  student 
added  "and  weep  with  them  that  weep?"  All  the 
happiness  went  out  of  Dr.  Baughman's  face;  tears 
came  to  his  eyes  as  he  answered,  "I  do  indeed,  I 
do  indeed,"  and  walked  slowly  away  with  his 
hands  behind  his  back. 

Dr.  Baughman  taught  many  subjects  at  "the 
old  school,"  and  he  taught  them  all  well. 

His  practice  early  in  general  medicine,  and  later 
for  many  years  in  obstetrics,  was  one  in  which 
were  blended  the  best  of  the  Science  and  the  best 
of  the  Art  of  Medicine.  In  his  joyous  presence  was 
healing. 

His  service  in  the  uniform  of  a  soldier  of  his 
country  was  arduous  and  devoted. 

It  is  hard  to  think  of  one  of  his  buoyancy,  his 
enthusiasm,  his  love  of  life  and  of  his  fellows,  as 
beinc;  dead. 


.IS  A  CHRISTMAS  PRESENT— A  year's  sub- 
scription to  this  journal  will  remind  your  doctor 
friends  each  month,  will  keep  them  reminded  of 
your  friendship  and  of  your  thought  to  supply 
them  with  the  most  useful  of  journals  of  General 
Medicine  and  Surgery.  In  groups  of  10,  $2.00  per 
year. 


THE  ESTROGENS 

What  may  the  estrogens  be  counted  on  to  do  for 
our  patients?  Claims  of  many  are  extravagant. 
There  is  much  disagreement  and  confusion  about 
the  merits  of  estrogenic  substance.  This  was  in- 
evitable, for  their  usefulness  of  whatever  degree 
nearly  always  concerns  the  reproductive  organs. 

At  a  big  New  York  hospital  these  agents  have 
been  tried  out  sufficiently  to  enable  the  investi- 
gator i l  to  arrived  at  some  conclusions.  These  con- 
clusions are  here  printed  for  the  benefit  of  those 
of  our  readers — and  they  must  be  many —  who  are 
in  a  fog  about  the  usefulness  of  estrogens. 

The  estrogens  have  been  widely  used  in  almost 
every  ailment  that  woman  is  heir  to. 

In  my  opinion,  the  applicability  of  estrogens  is 
limited  to  the  following  uses — 

Gonorrhea  of  infants  and  prepuberal  adolescents, 
as  an  aid  to  chemotherapy.  They  effect  keratini- 
zation  of  the  vulva  and  vagina.  The  gonococcus 
can  not  exist  upon  such  epithelium. 

Menopause — relief  of  the  neurovascular,  diges- 
tive, arthritic  and  local  atrophic  symptoms. 

The  estrogens  available  for  therapeutic  use  are 
Estrone,  Estradiol,  and  Estriol.  These  are  absorb- 
able by  mouth  (larger  doses  required);  by  sub- 
cutaneous injection;  by  inunction;  by  implanta- 
tion; and  vaginally,  in  the  form  of  suppositories. 
With  due  allowance  for  the  portal  of  entry,  for  the 
chemical  nature  of  the  estrogen,  and  for  variation 
in  dosage,  the  effect  is  the  same  whatever  the  mode 
of  administration.  Therefore,  except  when  local 
effects  for  gonorrhea  of  children  or  for  senile  va- 
ginitis are  desired,  for  both  of  which  I  employ 
vaginal  suppositories  of  estrone,  I  use  and  recom- 
mend the  oral  exhibition  of  alpha  estradiol,  in 
tablet  form.  In  the  menopause,  30  tablets,  each 
containing  y2  mg.  of  alpha  estradiol,  are  prescrib- 
ed in  the  following  way:  1  tablet,  3  times  a  day 
for  4  days;  1  tablet,  twice  a  day  for  5  days;  1 
tablet  once  a  day  for  5  days;  and  1  tablet  every 
other  day  for  3  doses.  The  therapy  is  then  inter- 
mitted until  the  flushes  reappear.  During  this  in- 
terval, it  is  advantageous  to  give  phenobarbital,  J4 
of  a  grain,  one  to  3  times  a  day.  As  soon  as  the 
flushes  reappear,  another  course  is  given.  Everv 
effort  should  be  made  to  increase  the  time  inter- 
vening between  courses  until  therapy  may  be  dis- 
continued. 

"To  some  of  you,"  the  writer  goes  on  to  say, 
"the  limits  of  estrogenic  therapy  which  I  have  set 
may  appear  absurdly  rigid.  Nevertheless  they  are 
based  upon  trial,  experience  and  reflection,  and  in 
my  opinion,  arc  fully  valid.  To  me  the  present  ex- 
cesses appear  as  unwarranted,  as  if  you  attempted 
to  treat  these  same  diseases  with  insulin  or  para- 
thormone." 


Dec 


1.  R.  T.  Frank,  New  York  City,  in  Jl.  Mt.  Sinai  Hosp.,  Nov. 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


NEWS 


SEABOARD  MEDICAL  ASSOCIATION 

At  its  annual  meeting  this  month  at  Virginia  Beach,  this 
Association  elected  Dr.  George  Erick  Bell,  of  Wilson,  N. 
C.|  President,  succeeding  Dr.  Waverly  R.  Payne,  of  New- 
port News,  Va.  Others  officers  elected  were  Dr.  A.  A. 
Burke,  of  Norfolk,  First  Vice-President;  Dr.  Joshua  Tay- 
loe,  of  Washington,  N.  C,  Second  Vice-President;  Dr.  John 
R.  Hamilton,  of  Nassawadox,  Va.,  Third  Vice-President; 
Dr.  Joseph  Smith,  of  Greenville,  N.  C,  Fourth  Vice-Presi- 
dent, and  Dr.  Clarence  Porter  Jones,  of  Newport  News, 
re-elected  Secretary-Treasurer. 

The  meeting  next  year  will  be  held  at  Wilson,  N.  C. 

Papers  were  presented  as  follows: 

Dr.  C.  F.  Strosnider,  of  Goldsboro,  N.  C,  The  Hook- 
worm as  a  Cause  of  Inflammation  of  the  Duodenum ;  Dr. 
Frank  Newby  Mullen,  Jr.,  of  Norfolk,  Congenital  Obliter- 
ation of  Biliary  Tract ;  Dr.  Oscar  Cranz,  of  Kinston,  N. 
C,  Accessory  Abdominal  Testicle;  Dr.  J.  Warren  Sayre,  of 
Newport  News,  Congenital  Hypertrophic  Pyloric  Steno- 
sis; Dr.  R.  S.  Anderson,  of  Rocky  Mount.  N.  C,  Exoph- 
thalmic Goiter;  Dr.  John  L.  Rawles.  of  Norfolk,  Extra- 
mammary  Breast  Carcinoma;  Dr.  R.  Henry  Temple,  of 
Kinston,  N.  C.  Gastric  Hypoacidity,  and  Dr.  H.  Hudnall 
Ware,  Jr.,  of  Richmond,  Management  of  the  Toxemias  of 
Pregnancy. 


THIRD  (S.  C.)   DISTRICT  MEDICAL  SOCIETY 
Clinton,  S.  C,  November  18th 
Program: 

1.  Victory     (Chorus    and    Boy    Scouts — State    Training 
School). 

2.  Invocation. 

3.  Dinner  (Divertissements1). 

4.  Remarks  (B.  O.  Whitten,  M.D.,  Superintendent  State 
Training  School) . 

5.  Papers — F.  K.  Shealy,  M.D.,  presiding. 

(a)  Surgical    Treatment     of    Varicose    Veins 
Scurry,  M.D.,  Greenwood. 

(b)  Acute     Interstitial     Pneumonitis — Hugh 
M.D.,  Greenville. 

(c)  Minor     Disorders     of     Pregnancy — Oren    Moore, 
M.D.,  Charlotte. 

1.  Divertissements 

(a)  "Scare  Crow  Song"'  from  "Wizard  of  Oz." 

(b)  "It's  Foolish  But  It's  Fun"  from  "Spring  Parade." 

(c)  "Gypsy  Life"  from  "The  Bohemian  Girl." 

(d)  "The  Hopak"  (Russian)   Chorus  and  Dance. 


-C.    J. 


Smith, 


THIRD  DISTRICT  (N.  C.)  MEDICAL  SOCIETY 
SAMPSON  COUNTY  MEDICAL  SOCIETY 
The  Sampson  County  Medical  Society  and  the  Third 
District  Medical  Society  held  a  joint  banquet  meeting  at 
the  Rufus  King  Hotel,  Clinton,  the  evening  of  December 
2nd.  The  scientific  program  was  given  by  Dr.  Tinslcy 
Harrison,  Dr.  H.  H.  Bradshaw  and  Dr  Leroy  J.  Butler, 
of  the  Bowman  Gray  Medical  School  of  Wake  Forest  Col- 
lege Dr.  Harrison  talked  on  Cardiovascular  Emergencies. 
Dr.  Bradshaw  on  Cancer  of  the  Lung,  and  Dr.  Butler  or. 
The  Care  of  Premature  Infant.  Short  talks  were  made  by 
Dr.  F.  Webb  Griffith,  President  of  the  State  Medical  So- 
ciety; Dr.  Roscoe  McMillan,  Secretary  of  the  State  Med- 
ical Society;  Dr.  John  B.  Wright,  of  Raleigh,  and  Dr.  J.  B. 
Sidbury,  of  Wilmington,  past  presidents  of  the  State  Med- 
ical Society;  Dr.  Wm.  M.  Coppridge.  President  of  the 
State  Board  of  Medical  Examiners;  Dr.  G.  M.  Cooper,  As- 
sistant State  Health  Officer;  Brigadier  General  H.  C. 
Coburn,  Chief  Medical  Officer  of  Fort  Bragg;  Col.  E.  D. 
Quinnell,  Chief  Medical  Officer  of  Camp  Davis;   and  Dr. 


B.  A.  Cockerell,  Chief  Medical  Officer  of  Veterans'  Hos- 
pital. Fayetteville. 

In  the  business  sessions  Dr.  W.  P.  Starling,  of  Roseboro, 
was  elected  President  of  the  Sampson  County  Medical 
Society.  Dr.  J.  M.  Lee,  Newton  Grove,  Vice-President,  and 
Dr.  G.  E.  Best,  Clinton,  Secretary-Treasurer;  Dr.  J.  Street 
Brewer,  Roseboro,  was  elected  President  of  the  Third  Dis- 
trict Medical  Society,  Dr.  A.  N.  Johnson.  Garland,  Vice- 
President,  and  Dr.  W.  P.  Starling.  Roseboro,  Secretary- 
Treasurer. 

Officers  of  the  County  Society  for  1941  were:  Dr.  J.  H. 
Williams,  Clinton,  President;  Dr.  W.  P.  Starling,  Roseboro, 
Secretary-Treasurer.  Officers  for  the  District  Society  for 
1941  were:  Dr.  W.  C.  Mebane.  Wilmington,  and  Dr.  S.  C. 
Cox,  Harrell's  Store,  Secretary -Treasurer. 


SEVENTH  DISTRICT  MEDICAL  SOCIETY 
Gastonia,  N.  C,  November  Sth. 

OFFICERS 

Dr.  N.  E.  Lubchenko,  Harrisburg,  President;  Dr.  L.  N. 
Glenn,  Gastonia.  Vice-President;  Dr.  H.  C.  Thompson, 
Shelby,  Secretary;  Dr.  R.  H.  Crawford,  Rutherfordton, 
Councilor. 

Papers:  The  Management  of  Occiput-posterior  Position, 
Dr.  W.  W.  McChesney.  Gastonia;  Bleeding  During  Preg- 
nancy, Dr.  Oren  Moore,  Charlotte;  Effective  Therapy  in 
Chronic  Alcoholism,  Dr.  T.  B.  Mitchell.  Shelby;  Diagnosis 
and  Treatment  of  Cardiac  Arrhythmias,  Dr.  L.  Emmett 
Madden,  Columbia,  S.  C;  The  Procurement  of  Doctors  for 
the  Reserve  Corps  of  the  Army,  Maj.  Roy  C.  Tatum, 
Knoxville,  Tenn.;  Suggestions  for  the  Use  of  Chemotherapy 
in  the  Practice  of  Pediatrics,  Dr.  Jasper  S.  Hunt,  Char- 
lotte. 

At  the  dinner  at  the  Gaston  Country  Club:  Address  of 
Welcome,  Dr.  W.  M.  Roberts,  Gastonia;  Response,  Dr. 
W.  C.  Bostic,  Sr.,  Forest  City. 

Addresses:  The  Welfare  of  Our  State  Society,  Dr.  F. 
Webb  Griffith,  Asheville,  President,  Medical  Society  of 
the  State  of  North  Carolina ;  The  Evolution  of  Tubercu- 
losis, Dr.  Paul  H.  Ringer,  Asheville,  President  of  the  South- 
ern Medical  Association. 


RICHMOND  ACADEMY  OF  MEDICINE 
New  officers  elected  December  10th  are:  Dr.  Arthur  S. 
Brinkley,  President-elect;  Dr.  Emmett  Ferrell  and  Dr.  A. 
E.  Turman,  First  and  Second  Vice-Presidents,  respectively, 
for  1942;  and  Dr.  G.  R.  Maloney  and  Dr.  William  R. 
Jordan  to  the  Board  of  Trustees,  1942. 

President  for  1942,  elected  last  year,  is  Dr.  Beverley  R. 
Tucker,  who  will  take  office  at  the  first  stated  meeting  in 
January.  Dr.  William  Branch  Porter,  1941  president,  pre- 
sided over  the  meeting. 


NORTHERN  VIRGINIA  MEDICAL  SOCIETY 
Modern  methods  of  treating  pneumonia  were  discussed 
on  December  9th,  by  Dr.  Dean  B.  Cole,  of  Richmond,  at  a 
meeting  of  the  Society  at  Front  Royal.  Dr.  John  B.  Mc- 
Kee,  of  Winchester,  presided.  Other  speakers  were  Drs.  O. 
W.  Carper  and  L.  K.  Woodward,  of  Front  Royal,  and  Les- 
lie N.  Bell  and  McKee,  of  Winchester. 


SOUTHERN  SURGICAL  ASSOCIATION 
Dr.  Barney  Brooks,  of  the  Vanderbilt  University  Hospi- 
tal, Nashville,  Tenn..  is  president  for  1941;  Dr.  Frank  S. 
Johns,  of  Richmond,  Va.,  and  Dr.  Foy  Roberson,  of  Dur- 
ham, N.  C,  vice  presidents;  Dr.  Alton  Ochsner,  of  Tulane 
University,  secretary,  and  Dr.  Charles  A.  Vance,  of  Lex- 
ington, Ky.,  treasurer. 

Dr.  Harry  H.  Kerr,  of  Washington,  retiring  president,  is 
a  member  of  the  council  to  replace  Dr.  Harvey  B.  Stone, 
of  Baltimore. 


December.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


691 


IREDELL-ALEXANDER   COUNTIES  MEDICAL 
SOCIETY 

Iredell-Alexander  Counties  Medical  Society,  in  a  meeting 
Dec.  10th,  elected  officers  and  passed  a  resolution  offering 
the  services  of  the  society  to  the  government  in  the  pres- 
ent national  emergency. 

Dr.  J.  S.  Talley  was  elected  president  to  succeed  Dr.  C. 
B.  Herman.  Dr.  J.  Y.  Templeton  was  elected  vice-presi- 
dent. Dr.  J.  S.  Holbrook  was  re-elected  secretary-treas- 
urer. Dr.  G.  W.  Taylor  was  named  delegate  to  the  state 
convention  with  Dr.  R.  S.  McElwee.  alternate. 


The  Association  of  American  Medical  Colleges  met 
at  the  Jefferson  Hotel,  Richmond,  on  October  27th-29th. 
The  following  officers  were  elected  for  the  coming  year: 
President.  Dr.  Loren  R.  Chandler,  Dean  and  Professor  of 
Surgery.  Stanford  University  School  of  Medicine,  San 
Francisco;  President-elect,  Dr.  W.  S.  Leathers,  Dean  and 
Professor  of  Preventive  Medicine  and  Public  Health,  Van- 
derbilt  University  School  of  Medicine,  Nashville;  Vice- 
President.  Dr.  E.  M.  MacEwen.  Dean  and  Professor  of 
Anatomy,  State  University  of  Iowa  College  of  Medicine, 
Iowa  City;  Treasurer,  Dr.  Arthur  C.  Bachmeyer,  Associate 
Dean,  the  School  of  Medicine,  University  of  Chicago;  Sec- 
retary, Dr.  Fred  C.  Zapffe,  5  South  Wabash  Avenue,  Chi- 
cago. 

The  University  of  Louisville  was  designated  as  the  place 
of  meeting  for  next  year. 


The  following  officers  of  the  Mental  Hygiene  Society 
op  Virginia  were  elected  at  the  annual  meeting  of  the  So- 
ciety held  in  Richmond,  October  29th:  President,  Dr. 
Frank  H.  Redwood,  Wainright  Building,  Norfolk;  Vice- 
President,  Mr.  W.  Daniel  Ellis,  3400  Patterson  Avenue, 
Richmond;  Secretary,  Dr.  J.  J.  Scherer,  Jr.,  1603  Monu- 
ment Avenue.  Richmond;  Treasurer,  Mrs.  Donna  Banting 
Bcmiss.  1001  East  Clay  Street,  Richmond;  Executive  Sec- 
retary. Mr.  F.  W.  Gwaltney,  309  North  12th  Street,  Rich- 
mond. 


DR.  ROYSTER  GIVES  DINNER 

The  evening  of  November  19th,  the  Raleigh  Academy  of 
Medicine  was  entertained  by  Dr.  Hubert  A.  Royster,  at  a 
dinner  commemorating  his  70th  birthday,  at  his  home. 
"Woodland,"  on  Beech  ridgve  Road,  Raleigh. 

Following  an  epicurean  repast,  a  session  was  held  with 
papers  presented  on  medical  topics.  Dr.  Chauncey  L.  Roys- 
ter, of  Raleigh,  nephew  of  the  host,  discussed  Early 
Diagnosis  of  Shock.  The  host's  two  sons,  both  of  Phila- 
delphia, also  presented  papers:  Dr.  Henry  P.  Royster  on 
Nutrition  in  Surgical  Patients,  and  Dr.  Hubert  A.  Royster, 
Jr.,  on  Resuscitation  of  the  New-Born. 

Out-of-town  guests  included  Dr.  W.  deB.  MacNider,  of 
Chapel  Hill;  Dr.  Foy  Roberson.  of  Durham;  Dr.  B.  C. 
Willis,  of  Rocky  Mount,  and  Dr.  Donnell  B.  Cobb,  of 
Goldsboro.  Nearly  all  the  fifty  members  of  the  Academy 
were  present,  including  three  descendants  of  the  founders. 
Dr.  John  S.  McKee.  Dr.  Hubert  B.  Haywood  and  Dr. 
Royster. 

The  Academy  presented  Dr.  Royster  with  a  handsome 
chair  and  a  neon-light  desk  lamp. 

The  Raleigh  Academy  of  Medicine  has  the  distinction  of 
being  the  oldest  local  medical  organization,  which  has 
preserved  its  continuous  existence,  in  North  Carolina.  Its 
first  stated  meeting  was  held  February  2nd,  1870. 

Charter  members  were  Drs.  William  G.  Hill,  Charles  E. 
Johnson.  Fabius  J.  Haywood.  E.  Burke  Haywood,  Richard 
B.  Haywood.  F.  J.  Haywood.  Jr..  W.  H.  McKee,  William 
Little  and  W.  I.  Royster.  Children  and  grandchildren  of 
all   these  eminent  physicians  arc  now  living  in  Raleigh. 

The   Academy   meets  quarterly  and  the  anniversary   of 


Founders'  Day  in  February  always  is  celebrated.  Officers 
for  the  current  year  are  Dr.  C.  B.  Wilkerson,  President; 
Dr.  J,  J.  Combs,  Secretary,  and  Dr.  A.  S.  Oliver,  Treas- 


POPULAR  PHYSICIAN  TO  GO  TO  STATE  SENATE 
Dr.  J.  D.  Hagood,  of  Clover,  Va.,  chairman  of  the  Hali- 
fax County  Board  of  Supervisors,  has  been  declared  the 
nominee  of  the  Democratic  party  for  the  State  Senate  to 
replace  Lieutenant  Governor-elect  William  M.  Tuck,  re- 
signed.  Nomination  is  equivalent  to  election. 

Dr.  Hagood  has  been  practicing  medicine  and  surgery  in 
Halifax  County  for  twenty-seven  years,  first  at  Scottsburg 
and  at  present  at  Clover.  At  the  latter  place  he  heads  the 
Little  Retreat  Hospital,  taking  over  after  Dr.  R.  H.  Fuller 
removed  to  South  Boston  to  operate  the  South  Boston 
Hospital. 

Since  removing  to  Halifax  from  his  native  Mecklenburg 
for  practice,  Dr.  Hagood  has  served  on  the  County  School 
Board,  then  the  Board  of  Supervisors.  He  has  been  active 
in  the  State's  defense  set-up,  and  is  now  serving  as  a  mem- 
ber of  the  regional  defense  board  by  appointment  from 
Governor  Price.  He  was  a  member  of  the  county  examin- 
ing board  during  the  last  World  War. 


Dr.  H.  C.  Henry,  Director  of  Virginia  State  Hospitals, 
has  been  appointed  a  member  of  a  committee  which  will 
prepare  a  history  of  American  Psychiatry  for  the  Amer- 
ican Psychiatric  Association.  Dr.  Gregory  Zilboorg,  of 
New  York,  heads  the  committee. 


Dr.  Thomas  H.  Brantley  announces  the  opening  of  of- 
fices on  December  1st — Cannon  Building,  Concord,  N.  C, 
and  Professional  Building,  Kannapolis,  N.  C,  for  the  prac- 
tice of  Urology  and  Urological  Surgery. 


Dr.  Glenn  L.  Hooper,  of  Dunn,  was  elected  president 
of  the  Harnett  County  Medical  Society  at  its  annual  busi- 
ness meeting,  held  Dec.  1st,  at  Shug's  Place,  between  Dunn 
and  Erwin.  Dr.  Paul  G.  Parker,  of  Erwin,  the  retiring 
president,  served  as  toastmaster  at  the  banquet.  Dr.  W.  W. 
Stanfield,  of  Dunn,  was  elected  vice  president,  and  Dr. 
W.  B.  Hunter,  of  Lillington,  was  named  secretary. 


Dr.  Wm.  deB.  MacNioer,  Kenan  research  professor  of 
pharmacology  in  the  University  of  North  Carolina,  is 
president  for  1941-2  of  the  Society  for  Experimental  Bi- 
ology and  Medicine. 


Dr.  Charles  M.  Caravati,  Richmond,  announces  the 
opening  of  his  offices  in  the  Professional  Building;  practice 
limited  to  Internal  Medicine  with  emphasis  on  diseases  of 
the  gastrointestinal  tract. 


Dr.  W.  R.  Bracey,  of  Richmond,  is  the  new  president 
:>f  the  Seaboard  Air  Line  Railroad  Surgeons. 


Dr.  John  S.  McKee,  Jr.,  for  the  past  eight  years  a 
member  of  the  medical  staff  of  the  Stale  Hospital  at  Mor- 
ganton,  has  resigned  to  engage  in  private  practice  in  Mor- 
ganlon. 


MARRTED 


Dr.  Robert    Irving   Mills  and   Miss  Kathcrine   Elizabeth 
Scherer.  both  of  Richmond,  wen-  married  November  29th. 


Dr.  Cleon  Walton   Goodwin  and   Miss  Margaret   Dixon 
Abbitt,  both  of  Wilson,  were  married  on  November  29th. 


692 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


Dr.  John  Cochrane  Reece,  of  Newton,  formerly  of 
Statesville,  and  Miss  Adelaide  Trotter,  of  Winston-Salem, 
were  married  on  November  29th.  Dr.  Reece  is  stationed 
at  Fort  Bragg  as  a  Lieutenant  in  the  Medical  Corps  of 
the  Army. 


for  years  was  the  leading  doctor  of  the  Southern  Robeson 
community  that  his  son  was  to  help  build  into  the  town 
of  Fairmont. 


Dr.  William  Walton  Kitchin  and  Miss  Nancy  Phillips 
Brewer,  both  of  Wake  Forest,  were  married  on  December 
2nd.  Dr.  Kitchin,  a  son  of  Dr.  Thurman  D.  Kitchin, 
President  of  Wake  Forest  College,  is  a  Lieutenant  in  the 
Medical  Corps  of  the  United  States  Army  and  is  stationed 
at  Charleston,  South  Carolina. 


Dr.  Joseph  Page  Holland,  United  States  Navy,  and  Miss 
Mary  Ruth  Walker,  of  Burlington,  were  married  in  Pensa- 
cola  on  November  28th. 


DIED 

Dr.  Francis  Waylcs  Shine,  67,  one  of  the  nation's  distin- 
guished eye,  ear,  nose  and  throat  specialists,  died  Septem- 
ber 24th  at  University  of  Virginia  Hospital  on  the  campus 
of  the  school  founded  by  his  great-great-grandfather, 
Thomas  Jefferson. 

Dr.  Shine  will  be  buried  in  the  private  grounds  of  the 
Jefferson  family  on  the  slope  of  Monticello  Mountain. 

Before  his  retirement  from  active  medical  practice  in 
1939,  Dr.  Shine  was  executive  surgeon  for  eleven  years  of 
the  New  York  Eye  and  Ear  Infirmary. 

He  was  born  on  June  25,  1874,  in  Orlando,  Fla.,  a  son 
of  Thomas  J.  Shine,  a  captain  in  the  Confederate  Army, 
and  Virginia  Eppes  Shine,  a  great-granddaughter  of  Jef- 
ferson. His  great-grandmother  was  Maria,  youngest 
daughter  of  the  third  President,  and  wife  of  John  Wayles 
Eppes,  who  represented  Virginia  in  both  branches  of  the 
Congress.  He  entered  the  University  of  Virginia  in  1892, 
and  received  his  Doctor  of  Medicine  degree  in  1898.  He 
took  a  leading  part  in  student  activities  at  the  University 
of  Virginia  and  played  on  the  great  football  team  of  1893, 
which  within  two  weeks  defeated  Trinity,  Georgetown, 
Navy,  V.  M.  I.  and  North  Carolina. 

Dr.  Shine  made  his  home  for  many  years  in  New  York, 
and  since  his  retirement  had  been  living  at  his  home  at 
Farmington,  near  Charlottesville. 

During  (he  World  War  he  served  with  the  United  States 
Army  as  captain  with  the  New  York  Hospital  Unit.  He 
was  promoted  to  the  rank  of  major  and  became  consultant 
for  the  American  Hospital  in  Paris. 


Dr.  William  Moore  White  died  at  his  home  at  Lenoir, 
N.  C,  on  October  31st,  at  the  age  of  81. 


Dr.  E.  LeRoy  Kellum.  42,  chief  of  the  medical  staff  of 
Grace  Hospital,  Richmond,  was  killed  instantly  in  a  two- 
car  crash  in  North  Carolina  on  Thansgiving  Day.  Dr.  Kel- 
lum's  wife  suffered  a  fractured  pelvis  and  multiple  cuts 
and  bruises.  Mrs.  Fred  D.  Morris,  a  passenger  in  Dr. 
Kellum's  automobile,  died  in  a  Durham  hospital  four  hours 
after  the  accident.  Fred  D.  Morris,  fourth  passenger  in 
the  Kellum  car,  and  said  to  have  been  the  driver  at  the 
lime  of  the  accident,  sustained  a  fractured  spine  and  a 
ruptured  kidney  in  the  crash. 

Dr.  Kellum,  a  native  of  New  Bern,  was  graduated  from 
the  University  of  North  Carolina  and  later  in  medicine 
from  the  University  of  Pennsylvania.  He  served  seven 
years  at  the  Mayo  Clinic. 


Dr.  John  P.  Brown,  77,  retired  physician  and  more  than 
any  other  man  responsible  for  the  town  of  Fairmont,  N. 
was  the  son  of  a  physician  and  his  father,  Dr.  John  Brown, 
C,  died  at  his  home  there  on  December  8th.    Dr.  Brown 


OUR  MEDICAL  SCHOOLS 


University  of  Virginia 

The  newly-formed  Virginia  Branch  of  the  Society  of 
American  Bacteriologists  met  in  Charlottesville  on  Satur- 
day, November  1st.  Papers  covering  a  wide  range  of  sub- 
jects including  milk,  water,  and  shellfish  bacteriology,  med- 
ical bacteriology  and  mycology  were  presented  at  morning 
and  afternoon  sessions. 

At  the  recent  meeting  of  the  American  Public  Health 
Association  in  Atlantic  City,  a  report  of  the  work  of  the 
Committee  on  Whooping  Cough  was  presented  by  Dr. 
George  McL.  Lawson,  Professor  of  Preventive  Medicine 
and  Bacteriology  of  the  University  of  Virginia.  This  com- 
mittee is  designed  to  evaluate  public  health  administrative 
practices  in  the  control  of  whooping  cough  and  to  act  as  a 
correlating  agency  for  research  in  this  field  in  North 
America. 

On  October  20th  Dr.  Claude  E.  Forkner  of  the  Cornell 
University  Medical  School  delivered  the  second  annual  Phi 
Beta  Pi  Medical  Fraternity  lecture.  He  spoke  on  The 
Diagnosis  and  Treatment  of  the  Leukemias. 

Dr.  Fletcher  Woodward  presented  a  paper  before  the 
American  Academy  of  Ophthalmology  and  Otolaryngology 
in  Chicago  on  October  23rd,  on  Complete  Cicatricial  Sten- 
osis of  the  Esophagus:  Permeation  Made  Possible  by  Ex- 
ternal Operation  in  Certain  Cases.  On  November  11th  he 
spoke  before  the  Danville  and  Pittsylvania  County  Med- 
ical Society  on  Diseases  of  the  Esophagus. 

Dr.  W.  W.  Waddell  attended  the  meeting  of  the  Amer- 
ican Academy  of  Pediatrics  in  Boston,  October  7th-llth, 
and  took  part  in  the  Round  Table  discussion  on  the  sub- 
ject Hemorrhage  in  the  Newborn. 

Dr.  Samuel  Vest  was  guest  speaker  at  the  meeting  of 
the  North  Carolina  LTrological  Society  held  at  Sedgefield, 
October  27th.  He  spoke  on  the  Advancement  in  Endo- 
crinology Concerning  the  Prostate,  and  on  Experimental 
Surgery  of  the  Kidney. 

During  the  meetings  of  the  Southern  Medical  Associa- 
tion in  St.  Louis,  November  10th  to  13th,  Dr.  David  E. 
Wilson  gave  the  Chairman's  Address  in  the  Section  on 
Neurology  and  Psychiatry,  speaking  on  the  subject,  The 
Psychiatrist  Looks  at  War;  Dr.  Edwin  P.  Lehman  took 
part  in  a  panel  discussion  on  the  Diagnosis  of  Gastro- 
intestinal Diseases;  Dr.  Dudley  C.  Smith  presented  a  pa- 
per before  the  Section  on  Dermatology  and  Syphilology  on 
The  Treatment  of  Vincent's  Infection  with  Fuadinj  Dr. 
Oscar  Swineford  spoke  on  Cottonseed  Sensitivity  before 
the  Section  on  Allergy;  Dr.  Charles  J.  Frankel  presented 
a  paper  before  the  Section  on  Bone  and  Joint  Surgery  on 
The  Palliative  Treatment  of  Irreducible  Congenital  Dislo- 
cation of  the  Hip. 

Lehigh  University  conferred  the  honorary  degree  of 
Doctor  of  Science  on  Dr._  Harvey  E.  Jordan  at  Convoca- 
tion on  October  3rd. 

The  School  of  Surgery  and  Gynecology  has  received  a 
grant  of  $2,000  from  the  John  and  Mary  R.  Markle  Foun- 
dation, for  support  of  further  investigations  on  Heparin  in 
relation  to  peritoneal  adhesions  and  other  tissue  reactions, 
under  the  direction  of  Dr.  Edwin  P.  Lehman  and  Dr. 
Floyd  Boys. 

Dr.  Brock  Dear,  'OS,  of  Washington,  Conecticut,  re- 
cently retired  from  active  practice  in  Bronx ville.  New 
York,  has  made  a  gift  of  his  large  collection  of  obstetrical 
instruments  to  the  Department  of  Obstetrics  and  Gyne- 
cology.   Dr.  Dear,  during  his  student  days  at  the  Univer- 


December,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


693 


sity  of  Virginia,  was  befriended  by  the  late  Dr.  Joseph 
Bryan,  of  Richmond,  and  he  has  made  his  gift  in  grateful 
remembrance  of  Dr.  Bryan. 

Dr.  Fletcher  D.  Woodward  spoke  before  the  Roanoke 
Academy  of  Medicine  on  Monday  night.  December  1st,  on 
the  subject.  The  Treatment  of  Malignant  Tumors  about 
the  Head  and  Neck." 

Dr.  J.  Edwin  Wood.  Jr.,  addressed  the  Mercer  Medical 
Society,  Princeton,  W.  Ya.,  October  9th.  His  subject  was 
Anesthesia  and  the  Cardiovascular  System. 

At  the  meeting  of  the  Association  of  Surgeons  of  the  C. 
&  0.  Railway  at  White  Sulphur  Springs,  on  October  25th, 
Dr.  J.  Edwin  Wood  spoke  on  The  Management  of  Cer- 
tain Cardiovascular  Conditions  Before  and  After  Opera- 
tion. 

The  Neuropsychiatry  Society  of  Virginia  held  its  Octo- 
ber meeting  in  the  Amphitheatre  of  the  University  Hos- 
pital, on  the  22nd.  Appearing  on  the  program  were  Dr. 
William  Gayle  Crutchneld,  University,  who  spoke  on  the 
Neurosurgical  Clinic;  Dr.  David  C.  Wilson,  University, 
whose  subject  was  Treatment  of  Various  Personality  Re- 
actions by  Electro-Shock;  Dr.  Henry  B.  Mulholland,  Uni- 
versity, who  spoke  on  The  Latest  Developments  in  Our 
Knowledge  of  Vitamins,  with  an  especial  consideration  of 
their  relationship  to  the  Central  Nervous  System;  and  Dr. 
Walter  Freeman.  Washington,  D.  C.  who  conducted  a 
Clinical-pathological  Conference. 

On  November  14th  Dr.  Chester  M.  Jones,  Clinical  Pro- 
fessor of  Medicine,  Harvard  University,  delivered  an  ad- 
dress before  the  Virginia  Alpha  Chapter  of  Alpha  Omega 
Alpha.  He  spoke  on  The  Influence  of  the  Nervous  System 
on  Digestive  Tract  Symptoms. 

A  bequest  of  §13,432  has  been  received  from  Mr.  Wil- 
liam E.  Hopkins,  the  income  from  which  is  to  be  used  for 
the  purchase  of  medical  books  and  medical  journals  for 
the  library  and  medical  school 

The  Twenty-eighth  Postgraduate  Clinic  Symposium  on 
Gastro-Enterology  was  held  at  the  University  of  Virginia 
Hospital  on  Friday  and  Saturday,  November  14th  and 
15th.  Lectures  were  given  by  Dr.  Porter  P.  Vinson,  Pro- 
fessor of  Bronchoscopy,  Esophagoscopy  and  Gastroscopy, 
Medical  College  of  Virginia;  Dr.  Julian  M.  Ruffin,  Asso- 
ciate Professor  of  Medicine.  Duke  University;  Dr.  Chester 
M.  Jones,  Clinical  Professor  of  Medicine,  Harvard  Univer- 
sity: Dr.  T.  T.  Mackie,  Assistant  Clinical  Professor  of 
Medicine,  College  of  Physicians  and  Surgeons;  Dr.  Warren 
T.  Yauehan.  Director.  Yaughan-Graham  Clinic,  Richmond, 
Virginia;  Dr.  William  Osier  Abbott,  Associate  in  Medicine, 
University  of  Pennsylvania. 

Dr.  Vincent  Archer  attended  the  meeting  of  the  Amer- 
ican Roentgen  Ray  Society  at  Atlantic  City,  New  Jersey, 
on  November  16th.  He  was  the  chairman  of  the  Scientific 
Exhibit  Committee  and  a  member  of  the  Program  Com- 
mittee. 

The  Eighth  Annual  Postgraduate  Course  in  Ophthalmol- 
ogy and  Otolaryngology  was  given  at  the  Medical  School 
on  the  four  days,  December  2nd  to  5th.  Lectures  were 
given  by  Dr.  Frank  B.  Walsh,  Associate  Professor  of  Oph- 
thalmology, Johns  Hopkins  University;  Dr.  Derrick  Vail, 
Professor  of  Ophthalmology.  University  of  Cincinnati;  Dr. 
Algernon  B.  Reese.  Attending  Surgeon.  Institute  of  Oph- 
thalmology, New  York  City;  Dr.  Edward  A.  Looper,  Pro- 
fessor of  Diseases  of  the  Nose  and  Throat,  University  of 
Maryland;  Dr.  Eugene  Landis,  Professor  of  Medicine,  Uni- 
versity of  Virginia;  Dr.  E.  P.  Lehman,  Professor  of  Sur- 
gery, University  of  Virginia;  Dr.  Louis  H.  Clerf,  Professor 
of  Laryngology  and  Broncho-Esophagology,  Jefferson 
Medical  College;  Dr.  Karl  M.  Houser.  Professor  of  Oto- 
laryngology, University  of  Pennsylvania;  Dr.  H.  B.  Mul- 


holland. Professor  of  Practice  of  Medicine,  LTniversity  of 
Virginia;  Dr.  J.  Edwin  Wood,  Professor  of  Practice  of 
Medicine;  Dr.  W.  H.  Pearson,  Orthodontist  to  the  Univer- 
sity of  Virginia  Hospital. 

On  November  25th  Dr.  Hugh  Hampton  Young,  Director 
of  the  Brady  Urological  Clinic,  Johns  Hopkins  University 
Hospital,  delivered  an  address  before  the  Pi  Mu  Chapter 
of  Phi  Chi.  He  spoke  on  The  Problems  in  Prostatic  Sur- 
gery, and  Some  Hermaphrodites  I  have  Met  and  Opera- 
tions Carried  Out  to  Make  Them  Happy. 

Dr.  Edwin  P.  Lehman  presented  a  paper  before  the 
meeting  of  the  Southern  Surgical  Association  in  Pinehurst, 
North  Carolina,  on  December  9th-llth,  on  the  subject  An- 
nular Pancreas  As  a  Clinical  Problem. 

Medical  College  of  Virginia 

Dr.  P.  N.  Pastore,  of  the  class  of  1934,  will  join  the  staff 
of  the  college  January  1st.  1942,  as  professor  of  otolaryn- 
gology. Doctor  Pastore  received  his  A.B.  degree  from  the 
University  of  Richmond  before  entering  medicine.  He 
served  two  years  as  an  interne  in  the  hospitals  of  the  col- 
lege and  has  been  at  the  Mayo  Clinic  since  1936.  In  1939 
he  received  the  M.S.  degree  in  his  specialty  from  the  Uni- 
versity of  Minnesota. 

The  New  Jersey  Obstetrical  Travel  Club  visited  the  ob- 
stetrical department  of  the  college  recently.  Dr.  H.  H. 
Ware,  Jr.,  associate  professor  of  obstetrics  and  acting  head 
of  the  department,  acted  as  host  to  the  visitors.  The 
morning  was  spent  in  the  hospital  division  with  clinics  in 
the  afternoon.  The  visiting  physicians  were:  Dr.  Walter 
B.  Mount,  Montclair;  Dr.  Carl  H.  Ill,  Newark;  Dr.  Nelson 
H.  Bigelow,  South  Orange;  Dr.  Robert  A.  Mackenzie,  As- 
bury  Park;  Dr.  J.  Carlisle  Brown,  Atlantic  City;  Dr.  Ed- 
ward G.  Waters,  Jersey  City;  Dr.  S.  A.  Cosgrove,  Jersey 
City;  Dr.  Arthur  W.  Bingham,  East  Orange;  Dr.  Raymond 
T.  Potter,  East  Orange;  Dr.  Alfred  Meurlin,  East  Orange; 
Dr.  Everette  L.  Campbell,  New  York  City,  and  Dr.  Dan 
Geary,  Morristown. 

The  United  States  Public  Health  Service  has  made  a 
grant  of  $6,000.00  for  the  Saint  Philip  school  of  nursing. 

Dr.  Wortley  F.  Rudd,  dean  of  the  school  of  pharmacy, 
recently  returned  from  an  extended  southern  trip. 

Dr.  Harvey  B.  Haag,  professor  of  pharmacology,  ad- 
dressed the  American  Pharmaceutical  Manufacturers'  Asso- 
ciation on  the  subject  of  The  Role  of  Pharmacology  in  the 
Development  of  Medicines,  in  Washington  on  December 
Sth. 

Miss  E.  Louise  Grant,  dean  of  the  school  of  nursing, 
has  returned  from  a  four  weeks'  tour  on  a  travel  grant  of 
the  nursing  schools  of  the  country,  including  the  Univer- 
sity of  Toronto. 

Recent  college  visitors  have  been:  President  Charles  E. 
Lawall  and  Dean  Edward  J.  Van  Liere,  of  West  Virginia 
University;  Dr.  Maurice  B.  Vischer,  professor  of  physiol- 
ogy, University  of  Minnesota;  Dr.  George  H.  Whipple, 
Dean  of  the  University  of  Rochester  medical  school;  Dr. 
Harlan  Horner,  secretary  of  the  American  Council  on 
Dental  Education,  and  Dr.  H.  G.  Grant,  dean  of  the  school 
of  medicine,   Dalhousc  University,  with  several  associates. 

Dr.  C.  C.  Coleman,  professor  of  neurological  surgery, 
Dr.  I.  A.  Bigger,  professor  of  surgery,  Dr.  Harry  J.  War- 
then,  associate  professor  of  surgery,  and  Dr.  Frank  S. 
Johns,  professor  of  clinical  surgery,  attended  the  meeting 
of  the  Southern  Surgical  Association.  Pinehurst,  North 
Carolina,  on  December  9th.  Doctor  Coleman  presented  a 
paper  on  Treatment  of  Compound  Fractures  of  the  Skull 
and  Doctor  Warthen  spoke  on  Gas  Gangrene.  Dr.  Frank 
Johns  was  elected  vice-president  of  the  association  and 
Dr.  H.  Page  Mauck.  professor  of  clinical  orthopedic  sur- 
gery, was  elected  to  membership  \r\  the  association. 


694 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


Dr.  William  B.  Porter,  professor  of  medicine,  and  Dr. 
I.  A.  Bigger,  professor  of  surgery,  attended  the  meeting  of 
the  Seaboard  Medical  Association  at  Virginia  Beach.  Doc- 
tor Porter  read  Dr.  Bernard  Kinlaw's  paper  at  the  meeting 
due  to  Doctor  Kinlaw's  untimely  death. 

Dr.  Porter  P.  Vinson,  professor  of  bronchoscopy,  at- 
tended the  annual  meeting  of  the  Alumni  Association  of 
the  Mayo  Foundation  recently.  His  presidential  address 
was  Traditions  in  Medicine.  Doctor  Vinson  also  gave  a 
paper  on  Diagnosis  and  Treatment  oj  Cardiospasm  at  the 
meeting  of  the  Calhoun  County  Medical  Society,  Anniston. 
Alabama,  and  another  at  the  symposium  on  gastroenter- 
ology at  the  University  of  Virginia  on  Diseases  of  the 
Esophagus. 

Dr.  C.  C.  Coleman,  professor  of  neurological  surgery, 
attended  the  meeting  of  the  Seaboard  Air  Line  Surgeons' 
Association  at  Jacksonville,  Florida,  giving  a  paper  on 
Prevention  of  Infection  of  Acute  Head  Injuries. 

Alpha  Omega  Alpha  honorary  medical  society  presented 
Dr.  Edward  D.  Churchill,  John  Homans  Professor  of  Sur- 
gery, Harvard  Medical  School,  on  its  annual  lectureship. 
Doctor  Churchill  spoke  on  Some  Fundamental  Principles 
underlying  Surgery  of  the  Lungs,  in  the  Simon  Baruch 
Auditorium.  Following  the  afternoon  lecture  a  banquet  for 
initiates  was  held  at   the   Commonwealth   Club. 


BOOKS 


SYPHILIS  IN  PRIVATE  PRACTICE  IN  1938  AND  1940 

(C.    K.    Weil    &    H.    T.    Climo.    Montgomery,   in   //.    Med.    Assn.   of 
Ala.,    Oct.) 

1938      1940 

Total  number  of  serologic  tests 362         615 

in,  iics 

Serologic  tests  196        288 

Positive 12  12 

Percentage    6  1  4.1 

Ncq.-oes 

Serologic  tests  166        327 

Positive  57  55 

Percentage    27.1  17 

Number  of  spinal  fluid  examinations....     20  28 

Number  of  darkfield  examinations 8  10 

These  figures  bring  out  the  following  comparisons:  1. 
There  were  almost  twice  as  many  serologic  tests  in  1940  as 
in  1938.  2.  The  percentage  of  positives  in  white  patients 
dropped  from  6.1  in  1938  to  4.1  in  1940.  3.  The  percentage 
of  positives  in  negroes  dropped  from  27.1  in  1938  to  17  in 
1940.  4.  These  figures  indicate  a  reduction  of  the  incidence 
of  syphilis  in  white  patients  by  about  30%  and  among  ne- 
groes by  about  37%. 

This  may  have  been  partly  due  to  a  greater  index  of 
suspicion  on  the  part  of  the  physician,  but  it  certainly 
suggests  a  decrease  in  the  incidence  of  the  disease.  Such  a 
decrease  is  probably  a  result  of  the  syphilis  campaign. 


A  policeman  stopped  the  patient  at  Hamlet  as  he  was 
coming  to  the  Sanatorium  for  an  examination.  "Take  it 
easy.    Don't  you  see  that  notice,  'Slow  Down  Here'?" 

Patient:  "Yes,  officer,  but  I  thought  that  was  just  a 
description  of  your  town." — Sanatorium  Sun. 


A  distinguished  speaker  who  had  been  a  patient  was 
asked  to  address  a  few  remarks  to  the  patients  in  the 
auditorium.  Beaming  with  pleasure  the  great  man  got  up 
to  speak. 

"My  dear  friends."  he  started,  "I  will  not  call  you  ladies 
and  gentlemen  because  I  know  you  too  well." — Sanatorium 
Sun. 


MEDICAL  CLINICS  OF  NORTH  AMERICA:  Mili- 
tary Medicine — November,  1941.  Vol.  25 — No.  6,  418  pages 
with  50  illustrations.  Paper,  $12.00  per  Clinic  Year;  Cloth. 
$16.00  per  Clinic  Year.  W.  B.  Saunders  Company,  Phila- 
delphia and  London. 

The  Foreword  is  written  by  Rear  Admiral  Ross 
T.  Mclntire,  Surgeon  General,  U.  S.  X.  Then  fol- 
lows articles  on: 

The  Physician  in  Selective  Service  and  the 
Army;  Medical  Organization  in  the  Permanent 
Camp  and  in  the  Field;  Communicable  Diseases 
and  Military  Medicine;  Cardiovascular  Disease 
and  Military  Medicine;  Medical  Abdominal 
Emergencies;  Military  Ophthalmology:  War  In- 
juries of  the  Ear,  Xose  and  Throat;  Military 
Dermatology  and  Syphilology;  Xutritional  Aspects 
of  Military  Medicine:  Psychiatric  Aspects  of  Mili- 
tary Medicine;  Improvised  Dressings  and  Trans- 
portation of  the  Wounded;  X-Ray  Examinations 
of  the  Chest  for  the  United  States  Army;  Chemo- 
therapy of  Acute  infections;  Management  of  Shock 
and  Treatment  of  Burns;  Treatment  of  Minor 
War  Injuries;  Disorders  of  the  Foot  in  Relation  to 
Military  Service;  and  Gastro-intestinal  Problems  in 
Military  Medicine. 

Each  of  these  essays  is  by  a  medical  officer  of 
the  Armv  or  Navy  especially  qualified  to  write  on 
the  subject  assigned  him. 

Doctors  who  are  in  any  way  participating  in 
the  selection  of  men  to  wear  the  uniform  and  all 
those  others  who  are  interested  to  know  about 
these  important  matters  will  find  answers  here 
to  many  questions  that  come  to  mind. 


"Was  her  marital  trouble  incompatibility?" 
"No,  just  the  first  two  syllables." — The  Chaser. 


ARTHRITIS  IN  MODERN  PRACTICE,  by  Otto 
Stetnbrocker,  B.S.,  M.D.,  Assistant  Attending  Physician 
and  Chief  Arthritis  Clinic,  Bellevue  Hospital,  Fourth  Med- 
ical Division,  New  York  City.  With  Chapters  on  Painful 
Feet,  Posture  and  Exercises.  Splints  and  Supports,  manip- 
ulative Treatment  and  Operations  and  Surgical  Procedures 
by  John  G.  Ktjhns,  A.B..  M.D.,  F.A.C.S..  Chief  of  the 
Orthopedic  and  Surgical  Service.  Robert  Breck  Brigham 
Hospital;  Assistant  Visiting  Orthopedic  Surgeon,  Boston 
Children's  Hospital.  606  pages  with  321  illustrations.  W. 
B.  Saunders  Company,  Philadelphia  and  London,  1941. 
Price  SS.00. 

The  aim  is  to  evaluate  the  various  methods  of 
treatment  of  arthritis  and  to  provide  in  one  vol- 
ume the  useful  procedures  not  yet  to  be  found  in  a 
textbook. 

It  is  pleasing  to  see  that  the  book  is  dedicated 
"To  the  Patients."  Also,  it  is  fitting,  for  study  of 
its  contents  will  inure  to  the  great  benefit  of  the 
legion  of  sufferers  from  arthritis. 


December.  1941 


SOUTHERN  MEDICINE  &  SURGERY 


Striking  chapter  subjects  are: 

Rheumatic  Disorders  as  a  Medico-Social  and 
Economic  Problem. 

The  Painful  Shoulder. 

The  Neuralgias  in  Rheumatic  Disorders. 

Pain  in  Diagnosis  and  Treatment. 

Local  and  Regional  Infections. 

Painful  Feet. 

The  book  was  conceived  and  written  to  be  of 
the  greatest  help  to  doctors  in  taking  care  of  the 
special  needs  of  their  arthritic  patients.  Where  it 
can  not  offer  means  of  restoring  to  health,  it  is 
careful  to  offer  means  of  preventing  the  develop- 
ment of  a  worse  condition,  and  to  describe  means 
of  promoting  the  patient's  comfort. 

SYNOPSIS  OF  ALLERGY,  by  Harry  L  Alexander, 
A.  B.,  M.D.,  Professor  of  Clinical  Medicine,  Washington 
University  School  of  Medicine,  St.  Louis;  Editor  of  The 
Journal  of  Allergy.  Illustrated.  The  C.  V.  Mosby  Com- 
pany, St.  Louis.  1941.  $3.00. 

Some  time  ago  an  allergist  was  heard  to  say  to  a 
meeting  of  doctors  that  allergy  was  responsible  for 
more  than  half  of  the  cases  of  illness  for  which  the 
services  of  doctors  were  sought.  Maybe  so.  Any- 
how, it  is  encouraging  to  learn  that  an  authority 
puts  out  what  he  regards  as  the  needful  knowledge 
of  this  subject  in  a  small  book  of  200  pages. 

It  is  by  the  use  of  books  such  as  this  that  the 
general   practitioner  can  diagnose  and   treat   ade- 


quately in  80  to  90  per  cent  of  the  cases  coming  to 
him. 


SNYOPSIS  OF  GENITOURINARY  DISEASES,  by 
Austin  L.  Dodson,  M.D.,  F.A.C.S.,  Richmond,  Virginia. 
Professor  of  Genitourinary  Surgery,  Medical  College  of 
Virginia;  Genitourinary  Surgeon  to  the  Hospital  Division. 
Medical  College  of  Virginia.  Third  edition,  with  112  illus- 
trations. The  C.  V.  Mosby  Company,  St.  Louis.  1941.  $3.50. 

The  first  edition  was  written  with  the  end  in 
view  of  supplying  medical  students  and  family  doc- 
tors with  a  reliable  text  on  urology,  containing  es- 
sential information  on  all  but  the  highly  special- 
ized diagnostic  and  therapeutic  procedures.  This 
end  was  well  served.  The  second  edition  followed 
the  same  plan,  as  does  this,  the  third,  edition, 
which  the  author  says  is  put  out  largely  to  give 
the  latest  information  on  the  use  of  new  drugs  in 
this  field  of  practice.  A  book  that  every  doctor  in 
general  practice  should  have. 


IMMUNOLOGY,  by  Noble  Pierce  Sherwood,  Ph.D., 
M.D.,  F.A.C.P.,  Professor  of  Bacteriology,  University  of 
Kansas,  and  Pathologist  to  the  Lawrence  Memorial  Hos- 
pital, Lawrence,  Kansas.  Second  edition,  illustrated.  The 
C.  V.  Mosby  Co.,  3S23-2S  Pine  Boulevard.  St.  Louis.  1941. 
$6.S0. 

First  the  reader's  acquaintance  with  infection 
and  infectious  agents  is  enlarged;  then  the  host- 
parasite  relationship  is  discussed.  Inflammation  and 
leucocyte  response,  individual  resistance,  the  retic- 


BIPEPSONATE 


Calcium    Phenolsulphonate   2  grains 

Sodium   Phenolsulphonate  2  grains 

Zinc  Phenolsulphonate,  N.  F 1  grain 

Salol,  U.  S.  P 2  grains 

Bismuth  Subsalicylate,  U.  S.  P 8  grains 

Pepsin,  U.  S.  P 4  grains 

Average    Dosage 

For  Children — Half  drachm  every  fifteen  minutes  for 
six  doses,  then  every  hour  until  relieved. 
For  Adults — Double  the  above  dose. 

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SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


ulo-endothelial  system,  natural  and  acquired  im- 
munity, immunity  mechanisms,  antibodies,  comple- 
ment, blood  groups,  mechanism  of  certain  reac- 
tions, precipitins,  toxins  and  antitoxins,  serum  re- 
actions, biologic  and  antigenic  specificity,  modified 
and  conjugated  antigens,  complement-fixation,  the 
various  tests  for  syphilis,  hypersensitiveness,  col- 
loids— all  these  subjects  are  given  one  or  more 
chapters  each. 

The  whole  of  the  difficult  subject  is  discussed 
with  a  degree  of  clarity  and  comprehensiveness  to 
make  the  book  one  of  unusual  value. 


THE  TOXEMIAS  OF  PREGNANCY,  by  William  J. 
Dieckmann,  M.D.,  Associate  Professor  of  Obstetrics  and 
Gynecology,  The  University  of  Chicago;  Attending  Physi- 
cian, The  Chicago  Lying-in  Hospital  and  Dispensary;  At- 
tending Gynecologist,  Albert  Merrit  Billings  Memorial  Hos- 
pital of  the  University  of  Chicago;  Associate  Editor  of  the 
American  Journal  of  Obstetrics  and  Gynecology.  Fifty  Text 
illustrations  and  three  color  plates.  The  C.  V.  Mosby 
Company,  St.  Louis.  1941.  $7.50. 

It  is  acknowledged  that  differentiation  between 
the  toxemias  of  pregnancy  presents  many  difficul- 
ties. The  author  declares  his  intentions  in  writing 
the  book  were  two:  to  acquaint  the  obstetrician 
with  recent  contributions  to  the  physiology  of  ob- 
stetrics; and  to  acquaint  the  investigator,  untrain- 


ed in  obstetrics,  with  some  of  the  physiology  and 
pathology. 

The  data  compiled  convince  the  author  that  the 
toxemias  of  pregnancy  are  diseases  of  civilization, 
largely  amenable  to  proper  prenatal  care.  The 
great  variation  in  blood-pressure  reports  is  attrib- 
uted to  the  readings  being  made  by  persons  with- 
out proper  instruction. 

The  pituitary  and  thyroid  seem  to  be  associated 
with  toxemia,  but  the  mechanism  is  unknown. 
None  of  the  reports  of  hormone  studies  has  fol- 
lowed patients  long  enough  to  confirm  the  diagno- 
sis as  to  kind  of  toxemia.  Some  patients  put  on 
much  weight  in  each  pregnancy  and  may  develop 
edema,  but  as  a  rule  no  other  symptoms  appear. 
Water  balance,  sodium  and  chloride  balance,  blood 
volume  and  pressure,  changes  in  the  endocrine 
glands,  climatic  effects  and  liver  disease  are  given 
as  factors  in  the  development  of  eclampsia. 

Eclampsia  is  usually  associated  with  increased 
blood  pressure.  Many  complications  of  pregnancy 
predispose  to  eclampsia. 

Half  to  one  per  cent  novocaine  locally  is  the 
safest  anesthetic.  If  bleeding  is  found  necessary,  it 
should  be  under  aseptic  precautions  and  the  blood 
should  be  stored  for  possible  reinjection. 

(To   Page  698) 


OPTAURAL 

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SAMPLES  ON  REQUEST 
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TAYLORS,  SOUTH  CAROLINA 


December,  1941 


SOUTHERN  MEDICINE  &■  SURGERY 


A    PLACE    IN    THE    SUN 

The  pages  of  history  reflect  the  struggles  of  peoples  and  individuals  to  get  their  place  in  the  sun  —  to  pursue 
happiness,  to  achieve  success,  to  win  position  and  power.  In  that  unending  struggle  very  few  can  overcome  the 
handicap  of  impaired  health,  a  handicap  which  is  all  the  more  serious  when  unrecognized,  as  in  subclinical  multi- 
vitamin deficiencies.  Such  deficiencies  are  not  confined  to  the  underprivileged,  and  in  fact  they  may  be  found 
among  persons  in  the  highest  socio-economic  groups.  Your  prescription  of  Vi-Penta  Pedes  or  Vi-Penta  Drops 
may  be   the   means  of  restoring   glowing  health   in   cases  of  vague   illness   dependent   on  vitamin   deficiencies. 

Vi-Penta  Perles  Roche  and  Vi-Penta  Drops  Roche  merit  your  specification,  not  only  from  the  standpoint  of 
quality,  potency,  and  convenience,  but  also  because  they  are  advertised  only  to  the  profession.  Perles  are  supplied 
in  boxes  of  25  and  100,  and  bottles  of  250.  Drops  are  supplied  in  calibrated-dropper  vials,  15  cc  and  60  cc. 
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VI-PE  NTA      PERLES     ■ 

Patronage  of  our  Adverti. 


VI-PE  NTA      DROPS 

a   Mark   of  Friendship  lu  the  Journal 


SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


Various  specially  named  treatments  are  describ- 
ed and  evaluated. 

Section  I,  Classification,  Incidence,  and  Path- 
ology of  the  Toxemias  of  Pregnancy;  Section  II, 
Normal  and  Abnormal  Physiology;  Section  III, 
The  Etiology  of  Eclampsia;  Section  IV,  Clinical 
Aspects  of  the  Toxemias  of  Pregnancy;  Section  V, 
The  Treatment  of  the  Toxemias  of  Pregnancy; 
Section  VI,  Maternal  and  Fetal  Prognosis  and  Pre- 
natal Care. 


CHUCKLES 


Doctor's  Wife:  "I  don't  see  why  you  couldn't  send  the 
corkscrew  over  to  Dr.  Brown  instead  of  hurrying  over 
with  it  yourself." 

Doctor:  "Darling,  your  attitude  shows  why  women  are 
unfit  to  lead  armies  and  make  lightning  decisions;  when  the 
psychological  moment  arrives  they  don't  know  what  to  do 
with  it." 


Said  one  eye  to  the  other:    "Just  between  us.  there  is 
something  that  smells. — ///.  Med.  Jour. 


Foreigners  listening  to  our  radio  must  be  astonished  to 
hear  such  heart-stirring  eloquence  wasted  on  laxatives. — 
Clinical  Med. 


Mrs.  Gubbins:  "I'm  glad  to  'ear  your  'usband's  up  and 
about  again,  Mrs.  Miggs." 

Mrs.  Miggs:  "Yes.  the  doctor  says  'e  'as  marvelous  pow- 
ers of  vituperation." — The  Doctor. 


A  cop,  watching  a  tipsy  celebrant  rapping  on  a  lamp 
post  with  his  cane,  suggested  that  there  probably  wasn't 
anybody  home. 

"Yes,  wrong  there,  ossifer,"  retorted  the  drunk,  "cant'sh 
see  the  light  upstairs?" 


"Do  you  eat  a  plentiful,  varied  diet?" 

"Yes,  doctor,  but  I  am  always  hungry." 

"Do  you  drink  intoxicating  liquors?" 

"Oh.  no,  doctor.    I  detest  strong  drink." 

"Do  you  often  lose  your  temper  and  swear?" 

"Positively,  never!" 

'•Do  you  run  around  nights  and  keep  late  hours?" 

"I  retire  every  night  at  eight,  punctually." 

"Tell  me  the  truth;  are  you  in  love  with  anyone?" 

"No,  indeed !    The  other  sex  does  not  interest  me." 

"Do    you    occasionally    have    a    feeling    of    constriction 

around  the  head,  just  above  the  ears?" 

"Yes,  Doctor,  I  do.    I  can't  understand  it." 

"Well,   I   understand   it.    The  cause   of  your   trouble   is 

evident.    Your  halo  is  too  tight." 


"Pass  me  the  butter" 
"If   what?   Willie." 
"If   vou  can   reach   it" 


"Bertie,  dear,  am   I  the   only  girl — " 

"Now,  dearest,  don't  ask  me  if  you  are  the  only  girl  I 
ever  loved.     You  know  as  well  as  I  do  that — " 

"Oh.  that  wasn't  the  question  at  all,  Bertie,  I  was  just 
soing  to  ask  if  I  was  the  only  girl  that  would  have  you." 


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COLWELL    PUBLISHING    CO. 
University  Ave.,  Champaign,  111. 


DDMILYIL©<E 


December,  1941 


SOUTHERN  MEDICINE  &  SURGERY 


699 


•      1941      • 

FLORIDA'S  NEWEST  —  FINEST  &  LARGEST 

Ail-Year  Hotel 


THE     RIVIERA 

Near  Daytona  Beach. 

Ideal  Convention  or  Conference  Headquarters.     Capacity  400. 

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SOUTHERN  MEDICINE  &  SURGERY 


December,  1941 


THEY  CAN'T  WAIT  MUCH  LONGER 
Stricken  Civilians  in  England 
and  Allied  Countries 
Need  Your  Help  TODAY! 


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.Mlied  Countries.) 


Both  the  first  aid  kits  and  opera- 
ting sets  have  been  approved  as  to 
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December,  1941  SOUTHERN  MEDICINE  &  SURGERY 


Southern  Railway' s 

SOUTHERNER 


Built  of  high-tensile  steel,  with  sheathing  of  stainless  steel,  THE  SOUTHERN- 
ER which  will  operate  as  three  Diesel-powered  trains,  includes  all  the  latest  refine- 
ments for  the  ultimate  in  safety,  speed  and  comfort.  Each  train  will  consist  of 
Straight,  Partition  and  Baggage-Dormitory  Chair  Cars,  Dining  Car  and  Lounge- 
Tavern-Observation  Unit,  all  reflecting  the  latest  ideas  in  structural  development 
and  modern  styling  and  beauty. 

Passenger  units  have  thermostatically  controlled  heating  and  air  conditioning, 
are  insulated  throughout.  Judicious  use  is  made  of  a  number  of  advancements  favor- 
ing gracious  living.  A  good  part  of  the  luxury  picture  appears  in  the  comfortable 
seating  arrangement  in  all  cars,  the  commodious  and  up-to-date  dining  car  arrange- 
ments and  the  facilities  for  en  route  enjoyment  offered  in  lounge,  tavern  and  obser- 
vation rooms. 

Diesel  locomotives  for  the  trains  are  built  by  the  Electro-Motive  Corporation, 
a  subsidiary  of  General  Motors. 

Particularly  interesting  from  the  standpoint  of  detailed  comfort  planning  is  the 
fact  that  chair  cars  have  twin-rotating,  reclining-type  seats,  cushioned  and  attrac- 
tively finished.  The  dining  car  has  accommodations  for  48  persons  in  satin  metal 
framed  chairs  with  rubber  seats  and  back  cushions.  Settees,  lounge  chairs,  writing 
desk,  card  section  and  refreshment  facilities  have  been  planned  to  fit  the  comfort 
and  utility  requirements  of  passengers  in  the  Lounge-Tavern-Observation  unit. 

A  rich  decorative  treatment  has  been  designated  for  all  units  of  THE  SOUTH- 
ERNER the  basic  colors  being  blue,  green  and  beige  in  light,  medium  and  dark 
tones.  Blue  and  beige  are  distributed  in  straight  chair  car  planning,  each  car  carry- 
ing out  variations  of  the  same  color  treatment  throughout .  Partition  chair  cars  em- 
phasize beige  and  the  Baggage-Dormitory-Chair  Cars  are  done  in  tones  of  blue. 
Green  is  the  predominating  scheme  in  dining  car  and  Lounge-Tavern-Observation 
units. 

The  whole  scene  is  enriched  with  an  attractive  arrangement  of  photo-murals 
which  have  been  especially  planned  to  heighten  the  atmosphere  of  luxury  and  beauty 
in  THE  SOUTHERNER. 


December,  1941  SOUTHERN  MEDICINE  &  SURGERY  703 


INDEX  1941 


ADDRESSES,  ORIGINAL  ARTICLES  AND  CASE  REPORTS 

Ablatio  Placentae,  E.  J.  Cathell  &  J.  M.  Andrews 57 

Acidosis — Physiological  Basis  and  Treatment    F    B    Marsh  ,,1 

Address  of  the  President  of  the  Tri-State  Medical  Association  of  the  Carolinas  and  Virginia, 

C.   J.  Andrews   101 

Age,  On  Some  of  the  General  Problems  of  Old,  L.  F.  Barker  132 

Aging  as  a  Problem  of  Industrial  Health,  E.  J.  Stieglitz  -S46 

Alcoholism,  Effective  Therapy   m  Chrcmc    T   B    Mitchell  -  £S5 

Allergic  Reaction  to  Silver  Nitrate,  G.  R.  Laub 328 

Anemia    The  Importance  of    Before  and  After  Operation  662 

Antithetical  Views  on  Twinning  Found  in  the  Bible  and  Shakespeare,  Grosbeck  Walsh  &  R.  M. 

Po°l  Ill 

Anxiety,  A  Concept  of,  J.  G.  N.  Gushing  i 

Appendicitis,  Forty-two  Years  of,  R.  L.  Gibbon  417 

Appendicictis,  The  Basic  Problems  of  Acute,  F.  F.  Boyce  &  H.  E.  Nelson  5SS 

Appendicitis.  Sulfathiazole  in  Suppurative  651 

Background  and  Treatment  of  Hypertensive  Disease,  The,  E.  A.  Hines,  Jr 301 

Base  Hospital  No.  65,  The  Organization  and  Service  of  Hospital  Unit  O  and,  A,  G.  Brenizer 

&  F.  M.  Hanes  l0_j 

Blood  Plasma,  John  Elliott  252 

Calcium  in  the  Treatment  of  Prolonged  Labor  Due  to  Uterine  Dvstocia,  B.  C.  Nalle 14 

Cancer,  and  Do  We  Need  to  Fear  It?,  What  is,  Paul  Kimmelstiel 324 

Cancer  Dissemination    Unnecessary,  Wright  Clarkson,  et  al  4?i 

Cancer,  Factors  in  the  Diagnosis  and  Treatment  of  Uterine,  J.  A.  Kelly  602 

Carbon  Dioxide  Culture  Method  in  the  Diagnosis  of  Gonorrhea  and  Undulant  Fever    J    M 

„      Feder  .'. 426 

Cardiac  Pain  and  Its  Differentiation  From  Chest  Pains  of  Radicular  Origin,  The  Mechanism, 

T.   IF.  Baker  '  241 

Cardiovascular  Emergencies,  T.  R.  Harrison  ""  533 

Cataract  With  Preliminary  Iridectomy,  Some  Refinements  in  the  Extracapsular  Methods  of 

Extraction  of  Uncomplicated  Senile    >V    H.  Turner  .,.,„.,  "  4^ 

Chigger  Disease.  Rotenone  in  the  Treatment  of.  J   I    Calla-.'iiy    et  al  193 

Chan  Wounds   A  Consideraticn  of  Healing  in  Presumably    Win-  H    Fnoleau  .?;.; 

Clinic  on  Certain  Nervous  and  Mental  Conditions,  Wesley  Taylor  &  J.  F.  MerrUl..... ..........  ...  368 

Clinic  on  Rheumatic  Fever,  C.  M    Gilmori ""  355 

Complications  of  Pregnancy,  Some:  Creighton  Wrenn  o 

Concept  cf  Anxiety    A,  J.  C     fy    Cuchint,  \ 
Coronary -Artery  Disease  in  General  Practice    F    L.  Copley                                                             58^ 
Cough  Flats  Method  for  the  Early  Diagnosis  of  Whooping  Cough    Further  studios  on  a  Sim- 
plified   /.  S.  Barksdale.  et  al ,-- 

Cutaneous  Epitheliomas,  The  Roentgen  Treatment  cf   Alhn  Bark;:-    ?l   il  ;>g 

Death  From  Natural  Causes,  Sudden,  E.  B.  Saye  42q 

Diabetss,  Surgery  in,  C    T   Tyler,  Jr  '", 

I.'i:  -  tiv:  Trast    Physiology  of  the  First  Portion  of  the   J.   ,an  d:  Evvs  £-< 

Distention    Fo  topuative,  /    6    I.tnton  .,.,,,,  j,4 

Dystocia,  Frolonged  Labor  Due  to  Uterine,  Calcium  in  the  Treatment  B    C    *mlh  14 

Edema  and  Their  Clinical  Implications,  Some  Underlying  Factors  in.  Win.  II.  Higgins  196 

Electrolysis,  Hypertrichosis  With  Particular  Reference  to,  P.  G.  Reque  376 

Encephalography  in  the  Diagnosis  of  Subdural  Hematoma,  The  Use  of,  W.  R.  Pitts... 188 

Endocrinology     Some  Fraotioal  Aspects  of    Arthur  Crollman  .■->"(. 

Epidemic  Respiratory    Diseases    li    L.  Cecil  ccc, 

Epithiliomas,   Th.  Roentgen  Treatment  of  Cutaneous   Allen  Barker   :t  al  ?;u 
Extracapsular   Method   of    Extraction    of   Uncomplicated    Senile    Cataract    With"  Preliminary 

Iridectomy.  Some  Refinements  in  the,  N.  H.  Turner  "    47- 

Fcver  Therapy,  The  Present  Status  of,  A.  D.  Taylor  SgS 

Forceps.  An   \ut0nt2tn  Ligature  Passing    E   F   Mallitt  "    kc? 

Forty  two  Years  of  Appendicitis,  R.  I.  Gibbon  -  4,  , 

Fractures,  The  Patient  and  the  Surgeon  in  Wounds  and,  H.  W.  Orr  ........  '".  237 

Glaucoma  in  the  General  Practice  oi  Medicine,  //.  C.  Neblett  ,22 

Gonorrhea  and  L'ndulant  Fever.  CO.  Culture  Method  in  the  Diagnosis  of! "7.  M ''"'p'edt '■','• 426 

Gonorrheal  Vaginitis  in  Girls.  R.  A.  Moore  60 

Gout  and  the  Negro,  Abraham  Cohen  ,,. 

Gunshot  Wounds  of  the  Pregnant  Uterus.  T.  C    Bos-  ijo 

Gynecologic  Fraotioe,  Fresent-Day  Trends  in  Obstotrio  and,  R    C    Douglas  \1\ 


SOUTHERN  MEDICINE  &  SURGERY  December,  1941 

Hand   Injuries,  J    W.  Davis    258 

Healing  in  Presumably  Clean  Wounds,  A  Consideration  of,  W.  H.  Prioleau 233 

Hematoma,  The  Use  of  Encephalography  in  the  Diagnosis  of  Subdural,  Win.  R.  Pitts 188 

Hemorrhage,   Pulmonary,   Karl  Schaffle   245 

Home  Obstetrics,  W.  J.  Lackey  553 

Hospital  Unit  O  and  Base  Hospital  No.  65,  The  Organization  and  Service  of,  A.  G.  Brenher 

&  F.  M.  Hanes  104 

Hyperparathyroidism,  R.  Z.  Query,  Ir 599 

Hypertensive  Disease,  The  Background  and  Treatment  of,  E.  A.  Hines,  Jr 301 

Hypertrichosis  With  Particular  Reference  to  Electrolysis,  P.  G.  Reque  376 

Hypoglycemia:,  Spontaneous,  Report  of  Cases,  F.  R.  Keating,  Jr.,  &  R.  M.  Wilder 125 

Industrial  Health.  Aging  as  a  Problem  of,  E.  J.  Stieglitz  546 

Injuries,  Hand,  J.  W.  Davis  258 

Insulin-Shock  Therapy,  Otto  Billig  646 

Insulins.  Therapeutic  Applications  of  the  Various,  F.  B.  Peck  539 

Iodine,  The  Potent  Drug,  J.  G.  Johnston  312 

Ligature-Passing  Forceps,  An  Automatic,  E.  P.  Mallett  552 

Lipodystrophy-,  Progressive,  A  Case  Report  and  Discussion  of  the  Problem,  G.  R.  Wilkinson  315 

Mechanism  of  Cardiac  Pain  and  Its  Differentiation  From   Chest  Pains  of  Radicular  Origin, 

The,   T.  W.  Baker  241 

Medicine,  Some  Problems  and  Progress  in,  C.  J.  Andrews  101 

Mental  Conditions,  Clinic  on  Certain  Nervous  and,  Wesley  Taylor  &  J.  F.  Merritt 368 

Myomas  and  Polyps  of  the  Uterus,  The  Diagnosis  of,  W.  B.  Norment  &  E.  D.  Apple 373 

Nervous  and  Mental  Conditions,  Clinic  on  Certain,  Wesley  Taylor  &  J.  F.  Merritt 368 

Obesity:  A  Clinical  Point  of  View,  F.  A.  Evans  307 

Obstetric  and  Gynecologic  Practice,  Present-Day  Trends  in,  R.  G.  Douglas  171 

Obstetrics,  Home,  W .  J.  Lackey  553 

Occiput-Posterior  Positions,  The  Diagnosis  and  Management  of,  W.  T.  Head 185 

Old  Age,  On  Some  of  the  General  Problems  of,  L.  F.  Barker  132 

Oophorragia,  R.  H.  &  M.  L.  Owen  480 

Organization  and  Service  of  Hospital  Unit  O  and  Base  Hospital  No.  65,  The,  AG.  Brenizer 

&  F.  M.  Hanes  104 

Parenteral  Anterior  Pituitary  Extracts.  A  Syndrome  Responding  to,  J.  A.   Wilson 370 

Patient  and  the  Surgeon  in  Wounds  and  Fractures,  The,  H.  W.  Orr 237 

Physiology  of  the  First  Portion  of  the  Digestive  Tract,  J.  van  de  Erve 63 

Placentae,  Ablatio,  E.  J.  Cathell  &  J.  M.  Andrews  57 

Plasma,  An  Analysis  of  Fifty  Cases  of  Shock  Treated  With.  C.  S.  White,  et  al 250 

Plasma,  Blood,  John  Elliott   252 

Pneumonia,  The  Present  Status  of  the  Treatment  of,  P.  F.  Whitaker  181 

Postoperative  Distention,  /.  G.  Linton  194 

Potent  Drug  Iodine,  The,  J.  G.  Johnston  312 

Practical  Aspects  of  Endocrinology,  Some,  Arthur  Grollman  536 

Pre-  and  Post-Operative  Care  662 

Pregnancy,  Some  Complications  of,  Creighton  Wrenn  9 

Pregnant  Uterus,  Gunshot  Wounds  of  the,  T.  C.  Bost  318 

Present-Day  Trends  in  Obstetric  and  Gynecologic  Practice  ,R.  G.  Douglas 171 

President  of  the  Tri-State  Medical  Assciation  of  the  Carolinas  and  Virginia,  Address  of  the. 

C.  J.  Andrews  101 

Problems  of  Old  Age,  On  Some  of  the  General,  L.  F.  Barker  132 

Problems  and  Progress  in  Medicine,  Some,  C.  J.  Andrews  101 

Progressive  Lipodystrophy — .  A  Case  Report  and  Discussion  of  the  Problem,   G.  R.   Wilkin- 
son    315 

Prostatic  Surgery:   The  Present  Status  of,  Analysis  of  Our  Last  Hundred  Cases.   Raymond 

Thompson  256 

Pulmonary  Hemorrhage,  Karl  Schaffle  245 

Respiratory  Diseases,  Epidemic,  R.  L.  Cecil  650 

Rheumatic  Fever,  Clinic  On,  C.  M.  Gilmore  365 

Roentgen  Treatment  of  Cutaneous  Epitheliomas,  The,  Allen  Barker,  et  al 326 

Rotenone  in  the  Treatment  of  Chigger  Disease.  J.  L.  Callaway  199 

Shock  Treated  With  Plasma,  An  Analysis  of  Fifty  Cases  of,  C.  S.  White,  et  al 250 

Silver  Nitrate    Mler&ic  Reaction  to.  C    R    Laub  .  z?,% 

Spontaneous  Hypoglycemia:  Report  of  Cases,  F.  R.  Keating,  Jr.,  &■  R.  M.  Wilder 125 

Stones,  X-Ray  Shadows  Simulating,  W.  E.  Daniel  604 

Stress  and  Disease,  M.  W.  Thewlis  484 

Subdural  Hematoma,  The  Use  of  Encephalography  in  the  Diagnosis  of,  W.  R.  Pitts 188 

Submucosal  Myomas  and  Polyps  of  the  Uterus,  The  Diagnosis  of,  W.  B.  Norment  &  E.  D. 

APPle  373 


1941  SOUTHERN  MEDICINE  &  SURGERY  705 

Sudden  Death  From  Natural  Causes.  E.  B.  Save  429 

Sulfathiazole  in  Suppurative  Appendicitis  662 

Sulfonamides,  The  Local  Use  of,  W.  St.  J.  Jervey  643 

Syndrome  Responding  to  Parenteral  Anterior  Pituitary  Extract,  A,  J.  A.  Wilson 370 

Therapeutic  Application  of  the  Various  Insulins,  F.  B.  Peck  539 

Thyroidectomy,  Paul  McBee  56 

Th\roid  Gland,  Diagnosis  of  Enlargement  of  the  663 

Tuberculous  Pericarditis,  Primary,  C.  C.  Dale 658 

Twinning  Found  in  the  Bible  and  Shakespeare,  Antithetical  Views  on,   Groesbeck   Walsh  & 

R.  M.  Pool  Ill 

Underlying  Factors  in  Edema  and  Their  Clinical  Implications,  Some,  W.  H.  Higgins 196 

Undulant  Fever,  CO.,  Culture  in  the  Diagnosis  of  Gonorrhea  and,  J.  M.  Feder 426 

Undulant  Fever.  The  Incidence  of  662 

Unnecessary  Cancer  Dissemination,  Wright  Clarkson,  ct  al 423 

Uterine  Cancer.  Factors  in  the  Diagnosis  and  Treatment  of,  J.  A.  Kelly 602 

Uterine  Dystocia — Prolonged  Labor  Due  to.  Calcium  in  the  Treatment.  B.  C.  Nolle 14 

Uterine  Prolapse.  Vaginal  Hysterectomy  in  the  Management  of,  R.  A.  Ross 487 

Vaginal  Hysterectomy  in  the  Management  of  Llterine  Prolapse,  if.  .4.  Ross 4S7 

Vaginitis  in  Girls.  Gonorrheal,  R.  A    Moore  60 

Whooping  Cough.  Further  Studies  on  a  Simplified  Cough-Plate  Method  for  the  early  Diag- 
nosis of.  I.  S.  Barksdale,  et  al 176 

Wounds  and  Fractures,  The  Patient  and  the  Surgeon  in,  H.  W .  Orr  237 

X-Ray  Shadows  Simulating  Stones,  W.  E.  Daniel 604 

EDITORIALS 
{Unsigned  Editorials  are  by  the  Editor) 

Abstracts  of  the  Sciences — 1858-1859,  Interesting  and  Instructive  Bits  Found  in 568 

Adhesions,  Prevention   of  Abdominal 82 

Advances  in  the  Diagnosis  and  Treatment  of  Heart  Disease,  Recent  402 

Aging  Heart.  The  346 

Allan,   Professor   404 

American  Psychiatric  Association,  Anent  Dr.  James  K.  Hall  and  the.  B.  R.  Tucker 350 

Anesthetic'",  "Will  His  Heart  stand  the  348 

Anesthetics  By  the  Non-Specialist.  The  Administration  of  283 

Artificial  Insemination  in  the  United  States  34 

Autocracy,  A  Threat  of  459 

Baughman,  Doctor  Greer  689 

Bell,  Royster  Rings  the  401 

Bills  in  Industrial  Cases  Are  Reduced,  Cases  in  Which  686 

Buxton's  Department,  Dr 404 

Cancer,  C.  C.  Little  282 

Cancer  of  the  Stomach  32 

Cancer.  The  General  Practitioner  in  the  Cure  of  220 

Care  of  Patients,  The  Place  of  the  Hospital  in  the    623 

Cause,  Loose  Thinking  as  to  SI 

Chronic  Indigestion.  The  Treatment  of 218 

Colby.  Doctor  Charles  DeWitt  627 

Compensability  in  Heart  Disease  Conditions  625 

Cooper  Lays  Aside  the  Pen,  Doctor  688 

Crying.  The  Curative  Value  of  153 

"Disgraceful"  Showing  of  Our  Young  Men,  The  570 

"Epilepsy"  is  a  Terrible  Thing:,   A   Right   Diagnosis.   A   Wrong   Diagnosis   "Epilepsy"   is   a 

Horrible  Thing   284 

Estrogens,  The   689 

Eyes,  Wrong  Glasses  Will  Not  Injure 84 

Fallacies  in  the  Treatment  of  Heart  Disease 460 

Gasoline  and  Lives,  Save  461 

General  Practitioner  in  the  Cure  of  Cancer  The  220 

Glasses  Will  Not  Injure  Eyes,  Wrong  84 

Gout  Not  a  Rare  Disease 150 

Greensboro,  The  Tri-State  Meeting  at   150 

Hall  and  the  American  Psychiatric  Association.  Anent  Dr.  James  K.,  B.  R.  Tucker 350 

Head  and  Hands,  Use  Your,  Don't  Run  for  a  Pulmotor:   349 

Health  Program.  A  Modern  151 


SOUTHERN  MEDICINE  &  SURGERY  December,  1941 

Heart   Disease   Conditions,   Compensability   in    625 

Heart  Disease,  Fallacies  in  the  Treatment  of  460 

Heart  Disease,  Recent  Advances  in  the  Diagnosis  and  Treatment  of  402 

Heart,   Examination   of   the   511 

Heart  Sounds.  A  Method  of  Recording  and  Reproducing  403 

Heart  Stand  the  Anesthetic?",  "Will  His  S4S 

Heart,  The  Aging  346 

Hernia  Diagnosis,  Intelligence  vs  Cocksureness  in  347 

Hess'  Trip,   As  Puzzling  as  549 

Hospital  in  the  Care  of  Patients,  The  Place  of  the  623 

Houck,  Doctor  Albert,  J.  W .  Davis  85 

Indigestion,  The  Treatment  of  Chronic  218 

Infection,    Virus    220 

Influenza,  Our  Knowledge  Concerning  S2 

Insemination  in  the  United  States,  Artificial  34 

Intelligence  vs  Cocksureness  in  Hernia  Diagnosis  347 

Interesting  and  Instructive  Bits  Found  in  Abstracts  of  the  Sciences — 185S-1859  56S 

Kutscher,  Jr.,  Dr.  George  William  2S6 

Labor,   prolonged    286 

Lives,  Save  Gasoline  and  461 

Long,  Doctor  Thomas  W.  M 87 

Loose  Thinking  as  to  Cause  81 

Making  a  Living  by  Practicing  Medicine,  A  Point  as  to  284 

Meeting  at  Greensboro,  The  Tri-State  150 

Meeting  Next  Month,  The  Tri-State  31 

Money,  Might  Save  You  571 

Norris,  Doctor  Henry,  R.  H.  Crawford  628 

Post-Graduate  Courses  Offered  Near  Home,  Two  Excellent  286 

Practicing  Medicine,  A  Point  as  to  Making  a  Living  by  284 

Pressly,  Doctor  George  William  86 

Prevention  of  Abdominal  Adhesions  82 

Professor  Allan   404 

Program,  A  Modern   Health 151 

Prolonged    Labor    286 

Pulmotor:,  Don't  Run  for  a,  Use  Your  Head  and  Hands  349 

Puzzling  as  Hess'  Trip.  As  349 

Rare  Disease,  Gout  Not  a  150 

Recent  Advances  in  the  Diagnosis  and  Treatment  of  Heart  Disease 402 

Recording  and  Reproducing  Heart  Sounds,  A  Method  of  403 

Reynolds  Appointed  to  High  Office,  Doctor  688 

Royster  Rings  the  Bell  401 

Save  Gasoline  and  Lives  461 

Save  You  Money,  Might  571 

Smallpox  in  the  United  States  33 

Stomach,  Cancer  of  the  32 

Sulfonamide  Therapy,  The  Present  Status  of  687 

Threat  of  Autocracy.  A  459 

Tri-State   Meeting   in    Greensboro    150 

Tri-State   Meeting  Next   Month,  The  51 

Tri-State  Meeting,  The  Coming  686 

Virus    Infections    220 

Wrong  Glasses  Will  Not  Injure  84 

Young  Men,  The  "Disgraceful"  Showing  of  Our  570 

SURGICAL  OBSERVATIONS 

Altitudes,  The  Human  Being  at  High  606 

Anesthesia,    Spinal    454 

Breast,  Radical  Amputation  of  the  456 

Carcinoma  of  the  Prostate  Gland  138 

Diabetic  Diet  in  Retrospect,  The  202 

Diaphragmatic  Hernia  Developing  Six  Years  After  a  Knife  Wound  in  the  Left  Chest 508 

Diaphragmatic  Hernia  in  a  Child  Eleven  Months  of  Age,  A  Case  of  456 


December.  1941  SOUTHERN  MEDICINE  &  SURGERY  707 

Duodenal  Diverticulum,  An  Unusual  Case  of  Perforation  of  65 

Dysmenorrhea,  Presacral  Neurectomy  for  the  Relief  of  606 

Empyema  of  the  Thorax,  The  Treatment  of  Simple  454 

Femur  Following  Dislocation,  Necrosis  of  the  Head  of  the  555 

Femur  Following  Injury  in  the  Aged  and  Infirm,  Separation  of  the  Nhck  of  the 555 

Fractures  of  Bones,  Sulfanilamide  in  the  Treatment  of  Compound  202 

Fractures,  The  Internal  Fixation  of  201 

Gas  Bacillus,  Preventive  and  Curative  Treatment  of  Infection  With  the  202 

Gonorrhea  Cured?,  When  Is  201 

Hemorrhoids,  The  Treatment  of  556 

Hernia  Developing  Six  Years  After  a  Knife  Wound  in  the  Left  Chest,  Diaphragmatic 508 

Hernia  in  a  Child  Eleven  Months  of  Age,  A  Case  of  Diaphragmatic  456 

Human  Being  at  High  Altitudes,  The  606 

Hyperthyroidism.  The  Management  of  Severe  Cases  of  64 

Intussusception,  The  Diagnosis  of  607 

Keloid  Scars,  The  Treatment  of  64 

Knee  Joint,  Surgery  of  the  65 

Menopausal  Syndrome.  The  Treatment  of  the  508 

Necrosis  of  the  Head  of  the  Femur  Following  Dislocation  555 

Pelvic    Examination    274 

Phlebitis  by  Paravertebral  Injections  of  Procaine  Solution,  The  Treatment  of  Acute 607 

Progress  in  General  Medicine,  General  Surgery  and  the  Specialties  During  1940,  A  Review  of 

Some  of  the  17 

Prostate  Gland,  Carcinoma  of  the  138 

Prostatic  Resection.  The  Post-Hospital  Treatment  of  Patients  Who  Have  Had  a  Trunsureth- 

ral   136 

Review  of  Some  of  the  Progress  in  General  Medicine,  General  Surgery   and  the   Specialties 

During  1940,  A  17 

Scars.  The  Treatment  of  Keloid  64 

Separation  of  the  Neck  of  the  Femur  Following  Injury  in  the  Aged  and  Infirm 555 

Smith-Peterson  Nail  in  Fractures  of  the  Hip  Joint.  Improvements  in  the  Details  of  Insertion 

of   the   344 

Spinal  Anesthesia  454 

Stereoscopic  Over  Flat  X-Ray  Films  of  the  Chest,  The  Advantages  of  64 

Sulfanilamide  in  the  Treatment  of  Compound  Fractures  of  Bones  202 

Syphilis.  The  Treatment  of  455 

Thymus,  The  344 

Undulant   Fever   382 

Undulant  Fever,  The  Incidence  of  509,  607 

Yitallium   Bones  plates  64 

Davis  Hospital  Staff 

CLINICS 

Amebiasis  68 

Appendicitis    ■ 6S 

Cancer,   Thyroid   457 

Gallstones  68 

Glaucoma   135,  272 

Goiter  Colloid  380 

Goiter,   Exophthalmic   380 

Heat    Exhaustion    554 

Hematocele      555 

Measles,  German  135,  272 

Thyroid   Cancer   457 

Department  Editor— F.  R.  Taylor 


SOUTHERN  MEDICINE  &  SURGERY  December,  1941 

DEPARTMENT  EDITORIALS 

(Unsigned  Department  Editorials  are  by  the  Editor  of  the  Department ;  in  Departments  in  which 
there  is  more  than  one  Editor,  each  editorial  is  signed) 

HUMAN  BEHAVIOUR 

American  Psychiatric  Association,  The  203 

Balm  in  Gilead?,  Is  There  19 

Barringei,  Doctor  Paul   Brandon   69 

Bucke  of  Canada:   Dr.  Richard  Maurice,  Heroism  260 

Civic  Tragedy,  A  139 

Exclusive?    Inclusive?   20 

Fatal  Plumbic  Psychotherapy  490 

Freedom  of  Worship,  On  557 

Gilead?,  Is  There  Balm  in  19 

Heroism:  Dr.  Richard  Maurice  Bucke  of  Canada  260 

Hypothyroidism,  Unrecognized   20 

Inclusive?    Exclusive?    20 

Iitinerary,  A  Medical   680 

Marriott,  Dr.  Henry  Battle  329 

Mars  and  Psyche  385 

Memoir:,  A,  Doctor  William  G.  Spiller  436 

Nut-Cracker,   The   Great   617 

Plumbic   Psychotherapy,  Fatal   490 

Prudence  Instead  of  Persecution  19 

Psyche  and  Mars  383 

Spiller — Doctor  William  G.,  A  Memoir  436 

Spinal  Cord  Trauma  660 

Tragedy,  A  Civic  139 

Williams   Returns,   Dr.   Tom 557 

Worship,  On  Freedom  of  557 

Department  Editor — /.  A'.  Hall 

UROLOGY 

Bilateral   Renal  Tuberculosis,  Prognosis  in  665 

Bladder,  Herpes  of  the  442 

Carbarsone  Suppository  in  Vagina   Casting  X-ray  Shadow   Mistaken   for  Stone  in   Bladder, 

H.  M.  Daniel  208 

Chronic  Urethritis  in  Women,  W.  E.  Daniel  502 

Heart  in  Urology  442 

Herpes  of  the  Bladder  442 

Stone  in  Bladder,  Carbarsone  Suppository  in  Vagina  Casting  X-ray   Shadow  Mistaken   for, 

H.  M .  Daniel  208 

Urethritis  in  Women,  Chronic,  W.  E.  Daniel  502 

Department  Editor — Raymond  Thompson 

SURGERY 

Abscess  of  the  Pancreas  557 

American   Board   of   Surgery,  The   141 

Appendix  Which  Ruptures  in  Delivery,  The  Acutely  Diseased  500 

Ascites  Complicating  Cirrhosis  of  the  Liver,  The  Treatment  of  271 

Cancer  of  the  Lip,  The  Treatment  of  666 

Cancer  of  the  Thyroid  77 

Cirrhosis  of  the  Livcer,  The  Treatment  of  Ascites  Complicating  271 

Contaminated  Wounds  With  Sulfathiazole  Powder,  The  Treatment  of  444 

Foreign  Body,  The  Treatment  of  Ingested  330 

Mineral  Oil  as  a  Laxative  After  Laparotomy  618 

Pancreas,  Abscess  of  the  557 

Plasma  as  an  Agent  for  Transfusion  in  War  20 

Pylephlebitis        390 

Spleen,  Rupture  of  the  207 

Sulfathiazole  Powder.  The  Treatment  of  Contaminated  Wounds  With   444 

Thyroid.  Cancer  of  the  77 

Transfusion  in  War,  Plasma  as  an  Agent  for  20 

Department  Editor — G.  H.  Bunch 

OBSTETRICS 

Apnea  Neonatorium,  /.  M.  Procter  25 

Maternal  Mortality  in  Southern  States,  /.  M.  Procter  71 

Puerperal  Infection,  H.  J.  Langston  503 

Skin  Test  for  the  Diagnosis  of  Pregnancy,  A.  H.  J.  Langston  397 

Vascular  Lesions  of  the  Toxemias  of  Pregnancy  and  Their  Clinical  Significance,  Remote,  H.  J. 

Langston    209 

Department  Editors — H.  J.  Langston  &  I.  M.  Procter 


December,  1941  SOUTHERN  MEDICINE  &  SURGERY  709 

GYNECOLOGY 

Benign  Gj'necologic  Hemorrhage,  G.  C.  Cooke  27 

Empiric  Versus  Specific  Treatment,  G.  C.  Cooke  399 

Hemorrhages,  Benign  Gynecologic,  G.  C.  Cooke  27 

Male  May  Have  Trichomonas  Infection,  The,  G.  C.  Cooke  27 

Specific  Treatment,  Empiric  Versus,  G.  C.  Cooke  399 

Trichomonas  Infection,  The  Male  May  Have,  G.  C.  Cooke  27 

Department  Editors — C.  if.  Robins  &  G.  C.  Cooke 

PEDIATRICS 

Eczema,  Diets  in  35 

Infantile  Paralysis  Provides  Splints,  National  Foundation  for  341 

Pneumonias,  The  Need  for  Typing  80 

Poliomyelitis,  Early  Diagnosis  of  (Abs.)   387 

Depratment  Editor — G.  W.  Kutscher  (deceased) 

GENERAL  PRACTICE 

Abdominal  Conditions  Among  Infants  and  Children,  Emergency,  J .  L.  Hamner 493 

Acne  Vulgaris,  W.  J.  Lackey  211 

Adopted  Children,  Some  Problems  Involved  in  Selecting  and  Rearing,  W.  J.  Lackey 332 

Aged,  Treatment  of  Diabetes  in  the,  J.  L.  Hamner  445 

Anal  Sphincter,  Section  of  the,  W.  J .  Lackey 505 

Anesthesia  in  the  Home,  Obstetric,  W.  J.  Lackey  444 

Anesthetics,  The  Choice  of,  W.  J.  Lackey  675 

Angina,  Ludwig's  J.  L.  Hamner  622 

Anorectal  Diseases,  Common  Errors  in  the  Diagnosis  and  Treatment  of,  W.  J.  Lackey 211 

Antacids  for  Treating  Peptic  Ulcer,  The  Choice  of,  J.  L.  Hamner  669 

Arsenotherapy  of  Early  Syphilis  by  Intravenous  Drip  Method,  Massive-Dose,  W.  J.  Lackey....  567 

Arthritis,  Physical  Therapy  Compared  With  Other  Measures,  J.  L.  Hamner 612 

Asthma,  Aminophyllin  in,  J.  L.  Hamner  343 

Cancer,  Causes  of,  J.  L.  Hamner  565 

Cancer,  Lip,  J.  L.  Hamner  613 

Cardiac  Emergencies  and  Their  Treatment,  IK.  J.  Lackey  505 

Cold,  The  Common,  /.  L.  Hamner  140 

Diabetes  in  the  Aged,  Treatment  of,  /.  L.  Hamner  445 

Digestive  Complaints  Usually  Need  No  Specialist,  Personality  Disorders  Causing,  /.  L.  Ham- 
ner    342 

Discomforts  of  Pregnancy,  Minor,  J.  L.  Hamner  269 

Doing  More  of  Our  Own  Work  With  Better  Drugs  Lowers  Cost  of  Treatment,  W.  J.  Lackey    36 

Emergency  Abdominal  Conditions  Among  Infants  and  Children,  /.  L.  Hamner 493 

Eye,  Ear,  Nose  and  Throat  Field,  Practical  Points  in  the,  /.  L.  Hamner 270 

Gonorrhea  in  the  Male  With  Sulfathiazole,  Treatment  of,  J.  L.  Hamner 388 

Indications  for  Sulfonamide,  More,  W.  J.  Lackey  443 

Infant,  Care  of  the  Premature,  W.  J.  Lackey  396 

Insects  in  Hospitals  and  Homes,  W.  J.  Lackey  504 

Intractable  Pain,  Treatment  of,  W.  J.  Lackey  27 

Legs  With  the  Use  of  Unna's  Paste  Boot,  Treatment  of  Chronic  Ulcers  of  the,  /.  L.  Hamner  445 

Ludwig's  Angina,  J.  L.  Hamner  622 

Mistakes,  Lessons  to  be  Learned  From  Reporting  Our,  W.  J.  Lackey  614 

Newborn,  Resuscitation  of  the,  /.  L.  Hamner  446 

Obstetric  Anesthesia  in  the  Home,  W.  J.  Lackey  444 

Paroxysmal  Tachycardia  in  General  Practice,  Diagnosis  and  Treatment  of,  W.  J.  Lackey 76 

Peripheral  Vascular  Disease,  Advances  in  the  Treatment  of,  J.  L.  Hamner  670 

Personality  Disorders  Causing  Digestive  Complaints  Usually  Need  No  Specialist,  J.  L.  Ham- 

»er  342 

Peptic  Ulcer,  The  Choice  of  Antacids  for  Treating,  /.  L.  Hamner  669 

Pimply-faced  Youth,  Hope  for,  W.  J.  Lackey  211 

Practical  Points  in  the  Eye,  Ear,  Nose  and  Throat  Field,  J.  L.  Hamner 270 

Pregnancy,  Minor  Discomforts  of,  J.  L.  Hamner  269 

Premature  Infant,  Care  of  the,  TV.  J.  Lackey  396 

Puerperal  Sepsis,  The  Prevention  and  Cure  of,  W .  J.  Lackey  156 

Pulmonary  Tuberculosis,  Diagnosis  and  Treatment  of,  J.  L.  Hamner  341 

Resuscitation  of  the  Newborn,  J.  L.  Hamner  446 

Roseola  Infantum  (Exanthem  Subitum),  J.  L.  Hamner  343 

Section  of  the  Anal  Sphincter.  W.  J.  Lackey  ! 505 

Selecting  and  Rearing  Adopted  Children,  Some  Problems  Involved  in,  IP.  J.  Lackey 332 

Sepsis,  The  Prevention  and  Cure  of  Puerperal,  W.  J.  Lackey 156 

Snake  Bite,  First  Aid  Treatment  of,  J.  L.  Hamner  341 

Sudden  Death,  /.  L.  Hamner  670 

Sulfathiazole,  Treatment  of  Gonorrhea  in  the  Male  With.  /.  L.  Hamner  388 

Sulfonamides.  More  Indications  for.  W.  J .  Lackey 443 

Syphilis  by  Intravenous  Drip  Method,  Massive-Dose  Arsenotherapy  of  Early,  W.  /,  Lackey....  567 


SOUTHERN  MEDICINE  &  SURGERY  December,  1941 

Syphilis:,  Think  of,  Then  Take  Appropriate  Action,  W.  J.  Lackey 395 

Tachycardia  in  General  Practice,  Diagnosis  and  Treatment  of  Paroxysmal,  W.  J.  Lackey 76 

Thrush  With  Nitrate  Silver,  Treatment  of,  J.  L.  Hamner  342 

Tonsillectomy,  Hemorrhage  Following,  W.  J.  Lackey  262 

Tuberculosis,  Diagnosis  and  Treatment  of  Pulmonary,  /.  L.  Hamner  341 

Unna's  Paste  Boot,  Treatment  of  Chronic  Ulcers  of  the  Legs  With  the  Use  of,  /.  L.  Hamner  445 
Work  With  Better  Drugs  Lowers  Cost  of  Treatment,  Doing  More  of  Our  Own,  W.  J.  Lackey    36 
Department  Editors — J.  L.  Hamner  &  W.  J.  Lackey 

CLINICAL  CHEMISTRY  AND  MICROSCOPY 

Calcium  Unbalance  in  the  Body,  A  Simple  Test  of,  W.  C.  Thomas S66 

Department  Editors — C.  C.  Carpenter  &  R.  P.  Morehead 

HOSPITALS 

Don't  Lock  the  Stable  Door  After  the  Horse  is  Stolen  389 

Fault,  It  Is  Their  147 

Graduate  Nurse,  The  Scarcity  of  the  450 

Hospitals  in  the  Future  204 

Lock  the  Stable  Door  After  the  Horse  is  Stolen,  Don't  389 

Private  Nurse  Be  Helped?,  Can  the  502 

Public  Deceive  You,  Don't  Let  the  679 

Scarcity  of  the  Graduate  Nurse,  The  450 

Shrinkage,  Hospital  611 

Sides,  There  Are  Two  266 

Tax  the  Sick  Man?,  Why  29 

Department  Editor — R.  B.  Davis 

CARDIOLOGY 

Bursitis,  Subacrominal,  Hilmar  Schmidt   676 

Congestive  Heart  Failure,  The  Combined  Use  of  Ouabain  and  Digitalis  in  the  Treatment  of....  149 

Coronary  Artery  Disease,  Experimental  Surgery  in  674 

Diuretic  for  Oral  Administration,  A  New  Mercurial  331 

Endocarditis,  Streptococcus  Viridans  206 

New  Mercurial  Diuretic  for  Oral  Administration,  A  331 

Ouabain  and  Digitalis  in  the  Treatment  of  Congestive  Heart  Failure,  The  Combined  Use  of....  149 

Rheumatic  Fever,  The  Prevention  of  Recurrences  of  206 

Streptococcus  Viridans  Endocarditis  206 

Department  Editor — C.  M.  Gilmore 

PUBLIC  HEALTH 

Diphtheria  Vaccination,  The  Pre-School  Examination  and  141 

Immunization  Certification   265 

Merit  System,  State  Public  Health  and  the  391 

Milestones  in  North  Carolina  Public  Health  498,  619 

(Under  Public  Health  Milestones)  ! 684 

Pre-School  Examination  and  Diphtheria  Vaccination,  The  141 

Rabbit  Fever,  Tularemia — ,  or  21 

Swimming  As  Related  to  Public  Health  336 

Tularemia— Or  Rabbit  Fever  21 

Department  Editor — N.  T.  Ennett 

RADIOLOGY 

Cancer  of  the  Stomach  in  the  Young,  Hilmar  Schmidt  443 

Diaphragmatic  Hernia,  Edith  Miller  510 

Department  Editors — Wright  Clarkson  &  Associates 

R.  H.  Lafferty  &  Associates 

THERAPEUTICS 

Alcohol  Addiction,  Chronic  Alcoholism  and  386 

Army,  Immunization  Against  Infectious  Diseases  in  the  United  States 339 

Back,  Procaine  Injections  in  Muscular  Sprains  of  the  Lower  338 

Bismuth  in  Syphilis.  Protective  Value  of  25 

Bronchial  Foreign  Bodies.  Symptomless  Period  of  677 

Burns  With  Scarlet  Red  Bandage  and  Moist  Sulfanilamide  Dressings,  Treatment  of  Fresh 338 

Cirrhosis,  The  Glucose — Insulin  Treatment  of  Advanced  268 

Cotton  Sickness  440 

Deliria,  The  Treatment  of  Acute  24 

Enterogastrone,  Urogastrone,  Present  Conceptions:  The  Meulengracht  vs  The  Sippy 619 

Fingers  and  Toes,  The  Management  of  Some  Minor  Surgical  Lesions  of  the 621 

Fits  in  Adults  212 

Fractures  of  the  Malar  Bones,  Early  Care  of  Depressed  213 

Glucose-Insulin  Treatment  of  Advanced  Cirrhosis,  The  268 

Gonorrhea  in  the  Male  78 

Gynecology,   office   438 

Immunization  Against  Infectious  Diseases  in  the  United  States  Army  339 


December,  1941  SOUTHERN  MEDICINE  &  SURGERY 

Inclusion  Blennorrhea  386 

Influenza  Epidemic,  Lessons  From  268 

Malar  Bone,  Early  Care  of  Depressed  Fractures  of  the  213 

Menopause.  Treatment  of  the  214 

Meulengracht  iu  The  Sippy,  The  619 

Minor  Surgical  Lesions  of  the  Fingers  and  Toes,  The  Management  of  Some 621 

Office   Gynecology   438 

Old,  Surgery  of  the  678 

Pregnancy,  The  Prevention  of  Toxemia  in  142 

Procaine  Injections  in  Muscular  Sprains  of  the  Lower  Back  338 

Pyrethrum  in  Medicine  79 

Scarlet  Red  Bandage  and  Moist  Sulfanilamide  Dressings,  Treatment  of  Fresh  Burns  With 338 

Sprains  of  the  Lower  Back,  Procaine  Injections  in  338 

Surgery  in  General  Practice  495 

Syphilis,  Protective  Value  of  Bismuth  in  25 

Toxemia  in  Pregnancy,  The  Prevention  of  142 

Varicose  Veins  and  Ulcers  Cured  in  Office  560 

Vesicular  Eruptions  of  the  Hands  and  Feet  677 

Department  Editor — /.  F.  Nash 

TUBERCULOSIS 

Abscess,  Treatment  of  Pulmonary  447 

Artificial  Pneumothorax  in  Tuberculosis  Treatment  214 

Artificial  Pneumothorax,  Indications  for  Discontinuance  of  392 

Case-Finding  in  Tuberculosis  145 

Charlotte  Tuberculosis  Clinic,  The  561 

Closed  Intrapleural  Pneumolysis   501 

Cor  Pulmonale  As  a  Contributory  Cause  of  Death  in  Tuberculosis  613 

Examination  in  Pulmonary  Tuberculosis,  The  Physical  334 

Hoarseness  in  Tuberculosis  22 

Intestinal   Tuberculosis   263 

Intrapleural  Pneumolysis,  Closed  501 

Malignant  Tumors  of  the  Lung,  Primary  668 

Physical  Examination  in  Pulmonary  Tuberculosis,  The  334 

Pulmonary  Abscess,  Treatment  of  447 

Tuberculo-Asepsis  72 

Department  Editor — John  Donnelly 

DENTISTRY 

Abscessed  Teeth  Cured  by  Their  Removal,  Keratitis  Caused  by  23 

Crooked  Teeth,   About _ 394 

Dental  Caries,  Domestic  Water  and  270 

Dental  Caries  in  High  School  Children  148 

Devitalized  Tooth;  The,  A  Factor  in  Ophthalmology 21S 

Education,  New  Plan  of  Dental  77 

Focal  Infection,  On  Dental  335 

Forensic  Aspects  of  the  Teeth  and  Jaws  147 

Keratitis  Caused  by  Abscessed  Teeth  Cured  by  Their  Removal  23 

Ophthalmology,  The  Devitalized  Tooth  a  Factor  in  215 

Tooth    Decay    - 667 

Water  and  Dental  Caries,  Domestic  270 

Department  Editor — /.  U.  Guion 

INTERNAL  MEDICINE 

Coronary  Occlusion,  Factors  Influencing  Immediate  Mortality  Rate  Following  Acute 448 

Eight-Hour  Day  Physiological?,  Is  the  670 

Essential  Hypertension,  The  Problem  of  217 

Gastric  Disease,  Diagnosis  and  Treatment  of  448 

Mortality  Rate  Following  Acute  Coronary  Occlusion,  Factors  Influencing  Immediate 448 

Department  Editor — G.  R.  Wilkinson 

OPHTHALMOLOGY 

Color  of  the  Eyes  and  Puberty  453 

Cornea,  Penetrating  and  Non-Penetrating  Foreign  Bodies  of  the  28 

Eye  Wash  and  Other  Ingredients  for  Lids  and  Eyesacs,  The  Layman's  Viewpoint  of  a  Cleans- 

„    i"e  497 

Foreign  Body  in  the  Crystalline  Lens,  Prolonged  Retention  of  a  391 

Glaucoma  in  the  United  States,  The  Incidence  of  \  610 

Headache  Not  of  Ocular  Origin  ""  265 

Inclusion  Blennorrhea  453 

Inflammatory  Edema  of  the  Conjunctiva  672 

Keratitis  in  Young  Children,  Interstitial  ZZ....Z.".',.  146 

Medical  Quotient  in  Refraction,  The  "     75 


SOUTHERN  MEDICINE  &  SURGERY  December,  1941 

Mirrow-Writing  and  Word-Blindness  w 340 

Penetrating  and  Non-penetrating  Foreign  Bodies  of  the  Cornea  28 

Puberty,  Color  of  the  Eyes  and  4S3 

Refraction,  The  Medical  Quotient  in  75 

Retention  of  a  Foreign  Body  in  the  Crystalline  Lens,  Prolonged  391 

Visual  Deficiency?,  What  Percentage  of  People  Are  Aware  of  Their  564 

Visual  Examination  in  Office  Practice,  Routine  208 

Department  Editor— H.  C.  Neblett 

RHINO-OTO-LARYNGOLOGY 

Deafness,  Prevention  of  22 

Estrogens  in  Atrophic  Rhinitis  390 

Nose    Bleed    672 

Otitis   Hemorrhagica   264 

Rhinitis,  Estrogens  in  Atrophic  390 

Tonsillectomy,  Indications  for  74 

Department  Editor — C.  W.  Evatt 

PROCTOLOGY 

Anorectal  Diseases  331 

Department  Editor — R.  von  L.  Buxton 

INSURANCE  MEDICINE 

Asthma  on  Insurability,  Effect  on  398 

Dyspnea  663 

History-Taking,  Insurance,  E.  S.  Williams  608 

Hypertension  Personality,  A.  R.  Dawson  563 

Insurance  Medicine   267 

Insurance  Medicine,  Harry  Dingman  336 

Premature  Contractions  on  Insurability,  The  Effect  of  ~ 491 

Time  as  a  Factor  in  Medical  Selection,  Albert  Seaton  441 

Department  Editor — H.  F.  Starr 

DERMATOLOGY 

Acne  Vulgaris,  Management  of  394 

Dermatophytosis,  The  Management  of   446 

Dermatitis  Herpetiformis   673 

Mouth,  Recurring  Aphthous  Ulcers  of  the  562 

Pyogenic  Skin  Diseases,  The  Management  of  492 

Ulcers  of  the  Mouth,  Recurring  Aphthous  562 

Urticaria,  The  Management  of,  P.  G.  Reque  609 

Department  Editor — /.  L.  Callaway 

HISTORIC  MEDICINE 

Mercurius'  Plague-Tract  (Abs.),  W.  B.  McDaniel  499 

Metallic  Sutures  and  Metallic  Ligatures  in  Surgical  Operations,  On  the  Use  of  (Abs.),  J-  Y. 

Simpson   558 

Saint-Simon's  Memoires,  The  Medical  Aspects  of  (Abs.),  J.  D.  Rolleston  450 

THE  TRI-STATE  MEDICAL  ASSOCIATION  OF  THE  CAROLINAS  AND  VIRGINIA 

Meeting  in  Greensboro,  The  Tri-State  150 

Meeting  Next  Month,  The  Tri-State  31 

Opening   Session   279 

Proceedings  of  Meeting  279 

Royal  College  of  Physicians  of  London  (Abs.),  A.  P.  Cawadias  681 

MEMORIAL  SERVICE 

Barret,  Doctor  Harvey,  Wm.  Allan  515 

DeLaney,  Doctor  Charles  Oliver,  G.  C.  Cooke  275 

Heinitsh,  Doctor  Harry  Ernest,  Jr.,  W.  B.  Lyles  27S 

Hill,  Doctor  Emory,  W.  J.  Rein 275 

Hines,  Doctor  Edgar  Alphonso,  Robert  Wilson  276 

Hunter,  Doctor  James  Wilson,  Jr.,  C.  J.  Andrews  517 

Lassiter,  Doctor  Henry  Grady,  W.  G.  Suiter  276 

Munroe,  Doctor  John  Peter,  J.  M.  Northington  516 

Ray,  Doctor  William  Turner,  O.  H.  Jones  518 

Tucker,  Dr.  John  Hill,  J.  M.  Northington  516 

White,  Doctor  Joseph  Augustus,  N.  H.  Turner  277 

Wolfe,  Doctor  James  Thurston,  C.  S.  White  278 


December.  1941 


SOUTHERN  MEDICINE  &■  SURGERY 


713 


Andrews,  C.  J 101 

Andrews,  J.  M 57 

Apple,  E.  D 373 

Baker,  T.  W 241 

Barefoot,  S.  W 199 

Barker,  Allen  326 

Barker,  L.  F 132 

Barksdale,  I.  S 176 

Billig,  Otto  646 

Bost.  T.  C 318 

Boyce,  F.  F 588 

Brenizer,  A.  G 104 

Callaway,  J.  L 199 

Cathell,  E.  J 57 

Cecil,  R.  L 650 

Clarkson,  Wright  423 

Cohen,  Abraham  654 

Collins,  J.  L 250 

Coplev,  E.  L 585 

Cushing,  J.  G.  N 1 

Dale,  G.  C 658 

Daniel,  W.  E 604 

Davis,  J.  W 258 

Douglas,  R.  G 171 

Elliott,  John  252 

Evans,  F.  A 307 

Feder,  J.  M '. 426 

Fuster,  L.  B 176 

Gibbon,  R.  L 417 

Gilmore,  C.  M 365 

Grollman,  Arthur  536 

Hanes,  F.  M 104 

Harrison,  T.  R 533 

Head,  W.  T 185 

Higgins.  VV.  H 196 

Hines,  E.  A.,  Jr 301 

Jervey,  W.  St.  J 643 

Johnston,  J.  G 312 

Keating,  F.  R.,  Jr 125 

Kelly,  J.  A 602 

Kimmelstiel.  Paul  324 

Lackey,   W.   J 553 

Laub,  G.  R 328 

Linton,  I.  G 194 


Mallett,  E.  P 552 

Marsh,  F.  B 51 

McBee,  Paul  56 

Merritt,  J.  F 368 

Miller,  Edith  423 

Mitchell,  T.  B 656 

Moore,  R.  A 60 

Mullenix,  G.  K 176 

Nalle,  B.  C 14 

Neblett,  H.   C 322 

Nelson,  H.  E 588 

Norment,   W.   B 373 

Orr,  H.  W 237 

Owen,  M.  L 480 

Owen,  R.  H 480 

Peck,  F.  B 539 

Peterson,  C.  H 326 

Pitts,  W.  H 188 

Pool,  R.  M Ill 

Prioleau,  W.  H 233 

Query,  R.  Z.,  Jr 599 

Reque,  P.  G 376 

Ross,  R.  A 487 

Saye,  E.  B 429 

Schaffle,   Karl    245 

Schmidt,  Hilmar  423 

Smith,  C.  D 326 

Stieglitz,  E.  J 546 

Taylor,  A.  D S9S 

Taylor,  Wesley  368 

Thewlis,  M.  W 484 

Thompson.  Raymond   256 

Turner,  N.  H 477 

Tyler,  G.  T.,  Jr 6 

van  de  Erve,  John  63 

Walsh,  Groesbeck  Ill 

Weinstein,  Jacob  250 

Whitaker,  P.  F 181 

White,  C.  S 250 

Wilder,   R.   M 12s 

Wilkinson,  G.  R 315 

Williams,  P.  L 199 

Wilson,  J.  A 370 

Wrenn,   Creighton    9 


714 


PROFESSIONAL  CARDS 


December,  1941 


GENERAL 


Nail*  Clinic   Building 


THE  NALLE  CLINIC 

Telephone— 3-2141    (//  no  answer,  call  3-2621) 


412  North   Church   Street,  Charlotte 


General  Surgery 

BRODIE  C.  NALLE,  M.D. 
Gynecology  &  Obstetrics.. 
EDWARD   R.   HIPP,   M.D. 

Traumatic  Surgery 

PRESTON  NOWLIN,   M.D. 

Urology 


Consulting  Staff 

DRS.  LAFFERTY,   BAXTER  &  PARSONS 
Radiology 
BARRET  LABORATORY 
Pathology 


General  Medicine 


LUCIUS   G.   GAGE,  M.D. 

Diagnosis 


LUTHER   W.   KELLY,   M.D. 
Cardio-Resptratory   Diseases 


J.  R.  ADAMS,  M.D. 
Diseases  of  Infants  &  Children 


W.  B.  MAYER,  M.  D. 
Dermatology  &  Syphilology 


C— H— M   MEDICAL   OFFICES 

DIA  GNOSIS— SURGER  Y 

X-RAY— RADIUM 

Dr.  G   Carlyle  Cooke — Abdominal  Surgery 

&  Gynecology 
Dr.  Geo.  W.  Holmes — Orthopedics 
Dr.  C.  H.  McCants — General  Surgery 
222-226  Nissen  Bid.  Winston-Salem 


WADE   CLINIC 

Wade  Building 
Hot  Springs  National  Park,  Arkansas 


H.  King  Wade,  M.  D. 
Charles  S.  Moss,  M.D. 
Jack  Ellis,  M.D. 
Frank  M.  Adams,  M.D. 


Urology 

General  Surgery 

General  Medicine 

General  Medicine 


N.  B.  Burch,  M.D.  Eye,  Ear,  Nose  &  Throat 
Raymond  C.  Turk,  D.D.S.  Dental  Surgery 
A.  W.  Scheer  X-ray  Technician 

Etta  Wade  Clinical  Pathology 

Marjorte  Wade  Bacteriology 


INTERNAL  MEDICINE 


ARCHIE  A.  BARRON,  M.  D.,  F.  A.  C.P. 
INTERNAL  MEDICINE— NEUROLOGY 
Professional  Bldg.  Charlotte 


JOHN  DONNELLY,  M.D. 

DISEASES  OF  THE  LUNGS 

324K  N.  Tryon  St.  Charlotte 


CLYDE   M.    GILMOkE,   A.  B.,   M.D. 
CARDIOLOGY— INTERNAL    MEDICINE 
Dixie  Building  Greensboro 


JAMES  M.  NORTHINGTON,  M.D. 
INTERNAL    MEDICINE— GERIATRICS 
Medical  Building  Charlotte 


ORTHOPEDICS 


HERBERT   F.   MUNT,   M.D. 
ACCIDENT  SURGERY  &  ORTHOPEDICS 

FRACTURES 
Nissen  Building  Winston-Salem, 


December,  1941 


PROFESSIONAL  CARDS 


715 


NEUROLOGY  and  PSYCHIATRY 


J.  FRED  MERRITT,  M.D. 

NERVOUS  and  MILD  MENTAL 
DISEASES 

ALCOHOL  and  DRUG  ADDICTIONS 

Glenwood   Park   Sanitarium  Greensboro 


EYE,  EAR,  NOSE  AND  THROAT 


H.  C.  NEBLETT,  M.D. 

OCULIST 

Phone  3-5852 

Professional  Bldg.  Charlotte 


AMZI  J.  ELLINGTON,  M.D. 

DISEASES  of  the 
EYE,  EAR,  NOSE  and  THROAT 

Phones:  Office  992— Residence  761 

Burlington  North   Carolina 


UROLOGY,   DERMATOLOGY  and  PROCTOLOGY 

THE  CROWELL  CLINIC  of  UROLOGY  and  UROLOGICAL  SURGERY 

Hours— Nine  to  Five  Telephones— 3-7101— 3-7102 

STAFF 

Andrew  J.  Crowell,  M.  D. 

(1911-1938) 

Angus  M.  McDonald,  M.  D.  Claude  B.  Squires,  M.  D. 

Suite  700-711  Professional  Building  Charlotte 


Raymond  Thompson,  M.  D.,  F.  A.  C.  S.  Walter   E.  Daniel,  A.  B.,  M.D. 

THE  THOMPSON  -  DANIEL  CLINIC 
of 


UROLOGY  &■  UROLOGICAL  SURGERY 
Fifth  Floor  Professional  Bldg. 


Charlotte 


C.  C.  MASSEY,  M.D. 

PRACTICE  LIMITED 

TO 

DISEASES   OF   THE   RECTUM 


Professional   Bldg. 


Charlotte 


L.  D.  McPHAIL,  M.  D. 
RECTAL  DISEASES 


Professional   Bldg. 


WYETT   F.   SIMPSON,   M.D. 

GENITO-URINARY   DISEASES 

Phone   1234 

Hot  Springs  National  Park  Arkansas 


PROFESSIONAL   CARDS 


December,  1941 


SURGERY 


R.  S.  ANDERSON,  M.  D. 

GENERAL  SURGERY 

144  Coast  Line  Street  Rocky  Mount 


R.    B.    DAVIS,    M.D.,    M.  M.  S.,    F.A.  C.P. 
GENERAL  SURGERY 

AND 
RADIUM   THERAPY 
Hours  by  Appointment 

Piedmont-Memorial  Hosp.  Greensboro, 


WILLIAM    FRANCIS    MARTIN,    M.D. 

GENERAL  SURGERY 

Professional   Bldg.  Charlotte 


OBSTETRICS  &  GYNECOLOGY 


IVAN  M.  PROCTER,  M.D. 

OBSTETRICS  &   GYNECOLOGY 

133   Fayetteville   Street  Raleigh 


SPECIAL  NOTICES 


THE  EDITING  OF  MEDICAL  PAPERS 

This  journal  has  arranged  to  meet  the  demand  for  the  service  of  editing  and  revis- 
ing papers  on  medicine,  surgery  and  related  subjects,  for  publication  or  presentation 
to  societies.  This  service  is  rendered  on  terms  comparing  favorably  with  those  pre- 
vailing generally  in  other  Sections  of  the  Country. 

SOUTHERN  MEDICINE  &  SURGERY. 


DO  YOU  WRITE? 

Book  Manuscripts  Wanted — All  subjects  for  immediate 
publication.  Booklet  sent  free.  Meador  Publishing  Co., 
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