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OP-13370
SOUTHERN
Medicine
Surgery
Official Organ
of the
Tri-State Medical Association
of the
Carolinas and Virginia
and the
Medical Society of the
State of North Carolina
Volume XCVIII
Edited and PubHshed by
James M. Northington, M.D.
Digitized by the Internet Archive
in 2010 with funding from
North Carolina History of Health Digital Collection, an LSTA-funded NC ECHO digitization grant project
http://www.archive.org/details/southernmed981936char
North Carcdina
Journal
of
SOUTHERN MEDICINE & SURGERY
\'oI. XCVIII
Charlotte, N. C, January, 1936
No. 1
Stricture of the Rectum: Carcinoma of the Rectum*
Harvey B. Stone, M.D., Baltimore, Maryland
STRICTURES of the rectum may be classi-
fied as congenital, traumatic, infectious and
neoplastic.
The defect in the mechanism of union between
the proctodeum and hind-gut in embryologic devel-
opment that sometimes results in imperforate anus
may in other instances lead to an incomplete open-
ing of the rectum. This takes various forms. An
annular stenosis at the upper end of the anal canal
is met with occasionally. In other cases the rec-
tum may not open in its normal position at all but
may communicate with the vagina in the female,
the urethra or bladder in the male. Such abnor-
malities are often accompanied by an inadequate
orifice of the rectum in its abnormal location. In-
fants thus afflicted have varying degrees of dif-
ficulty in defecation, ranging from nearly complete
obstruction to chronic constipation. Such disturb-
ances of normal bowel function may immediately
threaten life or in their less complete forms lead to
dilatation of the large bowel — one form of mega-
colon. It is obvious that the more severe grades
of such obstruction require prompt surgical relief,
the precise form of which will depend upon the
case. Those patients with a simple narrowing of
an otherwise normal anal outlet may be carried
along by local dilatations and care for the regular-
ity of defecation.
Urder the head of traumatic stricture, lesions
may result from various agencies, the trauma being
due to mechanical, thermal or radiation injuries.
^Mechanical injury may result from accidents —
falls on sharp objects, stabs, shots, swallowed or
introduced foreign bodies — resulting in wounds that
heal with a constricting scar. Experience leads to
the uncomplimentary opinion, however, that the
most common form of trauma leading to stricture
^ is surgical operation. Previous operation for fis-
sure, fistula, tumor, but particularly for hemor-
rhoids and more particularly the Whitehead type
of hemorrhoid operation, is the usual history ob-
tained from patients with traumatic rectal stric-
tures. It will not do to infer from this that all
such operations were necessarily badly done. It is
true that a properly planned and executed operation
will greatly lessen the chances of subsequent stric-
ture but there seem to be certain individuals with
a keloidal tendency who are very prone to develop
annoying stenosis even after an apparently unex-
ceptionable operation. This is one of the reasons
why careful post-operative attention with digital
examinations and dilatations is so important a part
of the proper care of rectal surgical cases. Early
and adequate stretching will in most cases prevent
serious stricture from developing. When traumatic
strictures are first seen often they are already firmly
and fully established, and a plastic surgical cor-
rection is usually necessary.
Strictures due to thermal injuries also most com-
monly follow a therapeutic measure, namely, the
giving of a hot enema. The writer has seen five
such cases, all acquired as a result of enemata
given to induce voiding of urine after some surgical
procedure. It need scarcely be said that such an
occurrence can only result from incompetence or
carelessness on the part of some attendant; but,
since such things do happen, the physician who
gives or orders a hot enema should see to it that
this term is not loosely interpreted by nurse or
orderly, and should specify the maximum temper-
ature that he desires used.
In recent years, with the greatly increased use
of x-ray and particularly radium in the treatment
of lesions of the prostate, uterus, rectum, etc., there
has arisen a new form of rectal stricture due to
radiation burns. The clinical history of such cases
is that of long and severe pain, very difficult to
relieve, following the application of radiation, and
then the onset of symptoms of difficulty in defeca-
tion, straining, ribbon- or pencil-stool, increasing
constipation, etc. Examination shows a contract-
ed, densely scarred rectum, with a peculiarly un-
yielding induration. The best treatment is ob-
viously prophylactic, the avoidance when possible
•Pre.sentHd Ijefore the Postgradu
1st and 2nd, 1935.
ite Meeting, Duke University, Durham, North Carolina, October 31st-November
STRICTURE— CARCINOMA OF THE RECTUM— Stone
Januan-, 1936
of those types and doses of irradiation that may
result in such injury. It is quite possible, however,
that in some situations even the hazard of such a
serious sequel as a rectal burn and stricture must
be taken in order properly to treat a life-threaten-
ing disease. The writer is not sufficiently familiar
with the technical methods of radiant therapy to
I:ave an opinion on this point. He does know
that such burns and strictures are extremely diffi-
cult to treat and may ultimately require such dras-
tic recourses as colostomy and partial rectal resec-
lion.
Of all the forms of rectal stricture other than
cancer, the most common is that due to infection.
Any of the known infectious agents that attack thj
bowel — tubercle bacillus, gonococcus, treponaema
pallidum, entamoeba histolytica, etc. — may on oc-
casion produce ulcerative lesions in the rectum
that in healing form scar tissue enough to produce
stricture. In the course of years, a man who does
a great deal of rectal work may see a few such
easels They. ar^sent certain difficulties in diagno-
sis, but when bacteriologic, histologic or serologic
evidence is clear, their nature can be determined.
In addition to local treatment, by operation or
dilatation, as the case may require, they also call
tor the appropriate general and constitutional treat-
ment of such diseases. But these specific infec-
tions do not make up the bulk of the infectious
rectal strictures. The usual lesion of this group is
a disease found especially in colored women from
twenty to forty-five years of age. who have a muco-
sanguino-purulent rectal discharge, rectal pain and
tenesmus, difficulty and straining at stool, and
often fistulae, ulceration and associated vulval ele-
phantiasis. Such cases are common in every rectal
clinic in locations with large Negro populations.
In the past, and even now by some, they have been
regarded as perhaps syphilitic or gonorrheal. In
the last few years a new conception of this condi-
tion has rapidly gained popularity. This view re-
gards such rectal lesions as due to the same infec-
tion that causes lymphogranuloma inguinale and
vulval elephantiasis or esthiomene. Transmission
is believed to be by venereal contact and the agent,
not yet demonstrated, is regarded as probably a
filterable virus, A specific skin recation, the Frei
test, has been developed from the uncontaminated
pus of buboes of hmphogranuloma inguinale. The
infection spreads from the fourchette or posterior
vaginal wall into the perirectal lymphatics and
causes fibrosis, stricture and ulceration of the rectal
mucosa. The accepted general treatment for the
infection is the intravenous administration of tartar
emetic. In our experience, with something over a
hundred cases covering about four j'ears, this drug
has seemed to improve the patient's general health,
with gain of weight in many cases, and has dimin-
ished to some extent ulceration and induration, but
in well developed strictures has not led to any note-
worthy improvement in the strictures themselves.
They require constant and indefinitely continued
dilatation by soft rubber bougies. This disease in
its severer forms is a serious condition. It may
require colostomy, and in some cases no measures
suffice to save the patient from ultimate death.
Of all the types of rectal stricture perhaps the
most common, and surely the most serious, is that
due to malignant disease. In any consideration of
the subject of stricture it would command important
consideration. But since the development of stric-
ture is only a subordinate phase of the problem of
cancer of the rectum, this part of the paper will
consider rectal cancer from its general aspects, not
confining discussion to strictures from this cause.
Cancer is a highly important subject in the whole
field of medicine, and the rectum is one of the most
frequently involved organs in the body. Cancer
in this region exhibits certain peculiarities that need
emphasis. It tends to metastasize more slowly than
in many other locations, it involves an organ that
permits extensive surgical removal without grave
disturbance of necessary functions, and it is acces-
sible to such examination that it can practically
alw-ays be diagnosed. For these reasons, the possi-
bilities of good results of treatment in this form
of cancer are greater than in many other anatomical
regions, and these possibilities are realizable if we
strive for early diagnosis of the disease. Unfortu-
nately, here as elsewhere cancer has no pathogno-
monic signs or symptoms, and indeed may give
little or no evidence of its presence until far ad-
vanced. The symptoms are due to secondary effects
of the cancer, such as ulceration, infection and
obstruction, and these may appear only late in the
progress of the lesion. Hence, it is important that
all of us, particularly the general practitioner, be
aware of these symptoms and alert to suspect and
investigate them.
There are two such symptoms that stand out,
the presence of blood in the stools and changes in
bowel regularity. Of course, there are many other
lesions, especially hemorrhoids, that cause blood in
the stools, but in this field of work no greater mis-
take can be made than to assume that such bleeding
is due to hemorrhoids and to dismiss the matter
with some local prescription without even the at-
tempt at an examination, T/ic patient who com-
plains of blood in the stools requires a rectal exam-
ination. Similarly persistent alteration in bowel
habits calls for investigation. When a patient
states that he has continuing constipation or diar-
rhea, or alternates between these states, he should
be examined rectally. Close questioning may bring
Januan', 1936
STRICTURE— CARCINOMA OF THE RECTUM— Stone
out the fact that he has frequent urgent desires to
defecate, but when attempting to do so passes often
nothing but gas with a little bloody mucus. This
history should be a red-light signal of danger. It
may be due to other things but is highly suggestive
of rectal cancer. There are other evidences of
rectal cancer — feeling of weight, or pressure, or
aching in the rectum, pencil- or ribbon-stools, loss
of weight, abdominal cramps, etc. — but these are
often late symptoms and are less important than
blood and bowel irregularities.
A proper examination will nearly always reveal
the existence of rectal cancer. Most cases can be
reached by ordinary digital examination. The feel-
ing of a stony-hard stenosis, of a crater ulcer with
hard, irregular edges, or a tumor projecting into
the lumen of the bowel are all highly suspicious
fmdings. The proctoscope confirms and supple-
ments the digital examination and exposes the
higher rectum that may not be within reach of the
examining finger. Experience in the use of the
proctoscope teaches the observer the appearance of
cancer — its irregular surface, often bleeding easily,
and ulcerated, with nodulations and purplish dis-
coloration. In cases of doubt, a piece of tissue
removed for biopsy will be helpful.
The diagnosis once established, the question of
treatment comes up. For practical purposes this
may be considered under two headings, namely,
those cases seen early enough to be suitable for
radical surgical treatment and those no longer
within that stage. In the first group, various types
of operative attack have been developed, which will
not be described in detail. The principle involved
is to remove the disease with as wide a margin as
possible. To do this, when the location of the
lesion is in the upper portion of the rectum, it is
necessary to approach it from the abdomen, and
the most drastic form of removal is to divide the
sigmoid, make a permanent terminal colostomy,
and remove completely the lower sigmoid, the en-
tire rectum, anus, fat and glands. This, the ab-
domino-perineal or Miles' type of operation, is to
be preferred when conditions are favorable, as it
gives the greatest number of lasting cures. Where
the situation of the growth is low in the rectum,
many surgeons prefer an attack upon the lesion
from the perineum with resection of the rectum as
far upward as seems necessary and the attempt to
bring down the upper end of the resected bowel to
the skin to form a new anal orifice. Between these
two types of operation there are several modifica-
tions and combinations for special cases. In all
of them the principle of wide removal should be
paramount, if there is hope of a radical cure, and
in most cases this entails the partial or complete
destruction of the sphincter muscle. Therefore,
patients with whom these forms of operation seem
best should be forewarned tactfully that control of
bowel movement will probably be lost or damaged,
but that this is incidental to the effort to save their
lives. (It may not be amiss to state here that a
terminal colostomy in the sigmoid may often give
very little trouble after the patient learns to man-
age it properly.)
In those cases of carcinoma of the rectum in
which radical cure seems hopeless because of the
advanced stage of the disease, palliative surgery is
at times required to relieve the pain and misery
of partial or complete obstruction of the bowel by
the growth, and to diminish bleeding and discharge.
The customary method of doing this is to perform
a colostomy in the sigmoid above the disease, thus
affording an outlet for intestinal contents and to
some extent permitting the gr^^ vth rest and freedom
from the irritation of fecal m,.<cter passing over it
constantly. Colostomy in such cases may afford
great relief and be a decidedly useful palliative
measure.
In considering the palliative treatment of inoper-
able cancer of the rectum, and indeed the treat-
ment of certain operable cases, one must take into
account the possibilities of radiation methods — x-
ray and radium. Concerning the first of these
problems, the palliation of inoperable cancer of the
rectum, radiation should always be given a trial,
provided one can secure the help of a competent
and experienced radiotherapist with adequate equip-
ment. Stress should be laid on this point, as ill-
advised radiation of this field may not only fail of
its purpose to exert a palliative effect on the dis-
ease but may greatly increase the patient's distress
by adding radiation burns to his other troubles.
Such disasters rarely occur now, however, under
competent direction of the treatment. As to the
effectiveness of radiation, there seems at present to
be no positive criterion by which this may be pre-
dicted. It depends entirely upon the radio-sensi-
tivity of the tumor cells in each case, and although
there are certain general factors that can be recog-
nized as playing a part in this — such as the histol-
ogical picture of the tumor, the degree of differen-
tiation of the cells, the location of the growth, etc.
— the real test of the matter is the actual applica-
tion of radiation treatment and observation of the
results. At times these are little short of miracu-
lous with complete disappearance of the local tumor
and entire cessation of all symptoms for the time
being. Unfortunately, even in many of these very
favorable cases the patient later succumbs to dis-
tant metastases or later local recurrence.
This leads to a short discussion of the use of
radiation as the primary method of treatment in
cancer of the rectum that seems suitable for radical
STRICTURE— CARCINOMA OF THE RECTUM— Stone
January, 1936
surgery. In general, the writer feels that such a
choice is unwise for reasons to be deduced from
what has already been said; namely, that even
when the local growth completely disappears under
radiation, distant extension may go on unchecked,
and the best method now known to forestall this is
the wide surgical removal of the related tissues,
especially lymphatic vessels and glands. It will
not do, however, to take too dogmatic a stand in
the matter, as each case should be judged on all
the facts concerned. Thus, even if the growth itself
seems favorable for operation, there may be condi-
tions in the patient's general physical status, such
as constitutional disease, advanced age, extreme
obesity, or other disciualifying factors, that make
operation unwise and radiation the method of
choice. In short, in treating this grave lesion, one
must follow the general rules of all good medical
treatment, and use selective judgment and common
sense, based upon experience of the disease and a
careful study of each individual patient.
The Treatment of Hemorrhoids by Galvanism
(Fred Harvey, Chicago, in Clin. Med. and Surg., Dec.)
He should be given a complete physical examination,
including blood examination and urinalysis, which will
greatly aid the doctor in determining the etiologic factors
producing the hemorrhoids, and whether any other illness
is present accompanying the rectal pathosis.
Usually a complete bowel movement is all that is neces-
sary before a rectal examination, but if the rectum has
not been completely emptied an enema should be given.
Wait 2 or 3 hours before examination, as some patients
require considerable time to completely expel it.
A careful digital examination should be made using the
index finger, with a rubber glove or finger cot and plenty
of vaseline. If the anus is tender, Nupercaine ointment
should be used in the place of vaseline. Slowly insert the
finger anteriorly and examine for enlarged veins, ulcers,
carcinoma, polyps and also the condition of the coccyx.
It is necessary to examine with a speculum to determine
the presence and extent of internal hemorrhoids. It will
be necessary for the operator to examine manj- normal
rectums and many hemorrhoids of all types, as well as
fissures, fistulae, polyps, tags and cases of pruritus ani,
before he will be able to determine the normal and partic-
ular pathologic conditions.
Cover the tip of the speculum with vaseline and insert
it slowly, with steady pressure, directly forward for about
2 inches, after which the speculum is directed back toward
the hollow of the sacrum. Withdraw the obturator and
inspect the rectum for any pathoses of the colon and any
sign of inflammation, ulceration or cancer. The speculum
is then partly withdrawn, so that the lower part of its
hollow extends down to the papillary line. If a hemor-
rhoid is present, it will distend into the gap of the spec-
ulum. They are usually light-blue.
To examine other sides of the rectum, reinsert the ob-
turator to push hemorrhoid out of speculum, turn the
speculum and withdraw the obturator.
.\t times, it may be advisable to have a gastro-intestinal
x-ray examination.
Negative Galvanism Method:
A galvanic machine which produces absolutely smooth
galvanic current produces a better treatment. If the cur-
rent is rough the patient will experience discomfort and
pain, and will not be able to stand high enough milliamper-
age to give satisfactory results.
Use a SxS-inch pad, which should be very moist for
good contact with the patient and a galvnnic needle,
which comes in 3 sizes, and a handle for it. The needle
is insulated with bakelite and has an insulated shoulder 1
inch long. No part of the needle is exposed except the
tip, when the needle is inserted in the handle. Tips come
in in 1/8, 3/10 and 1 4-Lnch lengths, and the shoulder of
the needle is especially constructed to hold all of the hydro-
gen gas in the hemorrhoid during the treatment.
Proper light.
Rectal speculums, medium and large sizes.
One pair of rubber-covered cords.
Tuberculin syringe with extension arm and lock, to
prevent needle from being pushed off while inserting the
plunger.
Antiseptic solution and cotton applicators.
A jar of sterile vaseline.
Rubber examining gloves.
Record cards.
Table for e.xamination and treatment.
The lower colon completely empty, the patient on the
table, left side down and thighs flexed at right angles. The
pad, well moistened with water, is placed well under the
buttock, so that there will be firm contact on the entire
pad. Insert the speculum slowly. Withdraw the obturator
and have the generator running at zero. Locate the hem-
orrhoid to be treated, cleansing it with a small amount of
antiseptic solution on a cotton applicator. Insert the needle
just internal to the papillary line ; as this location has few
sensory nerves, it should not be painful to the patient.
The needle should be inserted superficially, 1 16 of an inch
beneath the mucous membrane, with the point in the same
plane as the speculum. Hold the needle firmly, with its
hilt pressing against the mucous membrane. The needle
point must not perforate the opposite side of point of
entrance, for if it does so the hydrogen wiU escape.
After inserting the needle, and with the generator run-
ning, advance the current slowly ; in one minute it should
reach 12 to 15 milliamperes. If the current is not advanced
slowly and turned back slowly, especially while turning
back the last 3 or 4 milliamperes, it will produce discom-
fort to the patient. Do not allow the needle to touch the
speculum during the treatment. If a slight burning or
sticking sensation is present, shift the direction of the
needle, and if it still continues, reduce the current 1 or 2
milliamperes. If pain is still present ,turn the current back
to zero slowly and discontinue treatment, for there must
have been some error in inserting the needle.
After the needle has been inserted properly, and there is
no pain, advance the current slowly and continue treatment
for from 5 to 10 minutes, when a color change will take
place in the hemorrhoid. At first a light-colored bubble
of hydrogen will appear around the hilt of the needle,
after which the hemorrhoid will turn dark blue. The
treatment is terminated at this point by slowly turning the
current back to zero, and the needle is withdrawn. If the
hemorrhoid is large, another treatment may be given with-
out withdrawing the speculum.
Before treating very nervous patients, introduce the
gloved finger, covered w'ith Nupercaine ointment 1%, into
the rectum, dilating the internal and external sphincter. If,
after the speculum is inserted, the patient stUl has some
pain, I inject the hemorrhoid with 0.5 c.c. of 1% Novo-
cain solution, using a tuberculin syringe which has a special
extension arm with lock. This holds the small needle
(Continued to p. 6)
January', 1936
SOUTHERN MEDICINE AND SURGERY
Glomus Tumor*
Case Report
Guy W. Horsley, M.D., Richmond, Virginia
From the Surgical Department, St. Elizabeth's Hospital
UNTIL 1933 notliing had been written in
English about glomus tumor, and up to the
present time only forty-three cases in all
have been reported. In the International Journal
oj Medicine and Surgery, September, 1933, Keas-
bey gave a brief summary of the work done on
this type of tumor. In May, 1934, Mason and
'A'eil made the first report of a case of glomus
tumor in this country, and they collected six other
cases. Since then there have been seevral other
reports made in American literature. Adair re-
ported several cases in July, 1934, Raisman and
Mayer three in June, 1935.
Tumors of the glomic body were not known as
such until 1924 when Pierre ]\Iasson, a Frenchman,
made an exhaustic study of this subject. From
this study it was apparent that these tumors had
been seen and successfully treated but that they
had been wrongly diagnosed, and had gone under
various names — angioma, perithelioma, angiosar-
coma, false neuroma, etc. Masson, after extensive
studies and using his special nerve stains, came to
the following conclusions: these tumors are benign
outgrowths of a structure normally present in the
skin and subcutaneous tissue of the entire body,
and this structure has in all probability been in-
completely described under the name Organ of
Ruffini.
As you will recall from histology and the recent
work of Popoff, these are small organs under the
skin termed glomus bodies or glomi. The function
of these bodies is not definitely determined, but
they are thought to have some regulative effect on
the skin temperature. These bodies are sometimes
spoken of as neuromyoarterial glomi and are a
form of arteriovenous anastomosis, consisting of
dilating and contracting blood vessels which con-
nect certain small arteries directly with veins with-
out the interposition of the usual capillary bed. If
the tactile region of the skin requires warmth, the
glomic vessels contract and receive no blood, there-
by forcing the blood into the skin capillaries; con-
trariwise, if the skin capillaries become too con-
gested the glomic vessels open and the blood is par-
tially shunted away from the skin.
The following is a description of glomic tumors
by Hopf of Bern, Switzerland:
".\n afferent arteriole carrying blood from the interior
of the body forms the major part of the glomus by divid-
ing into from two to four thick-walled branches with nar-
row lumens. From two to six vasa efferentia with wide
lumens and much blood complete the glomus and unite it
to the venous capillaries and veins of the skin. The thick-
ened wall of the afferent arteriolar branches forms the
major histologic feature of these bodies. Their lumens are
narrow and empty only because of the absence of the
'elastica interna,' and collapse unless special precautions are
taken. The endothelium consists of large cells with homo-
geneous protoplasm and large nuclei full of chromatin.
Next to the endothelium are four or five layers of spmdle
cells arranged circularly. These cells are short and thick,
with oval nuclei. On the periphery of their lightly staining
protoplasm are myofibrillae, which are found ui greater
profusion nearer the endothelium than away from it. This
circular layer of muscle fibers forms one-half of the thick-
ness of the wall. The other half, not sharply demarcated
from it, consists of irregularly placed long pale cells with
oval nuclei, and others which are larger and more regular
and look like epithelioid cells. The former are thickened
opposite the nuclei and send out, as ganglion cells do, pro-
toplasmic projections which often unite on the periphery to
compact bundles of fibers, and form a network which en-
circles the arterioles. They are called nonmyelinated nerve
fibers by Masson because they have thin collagenous sheaths
and some rodlike nuclei. These fibers are in communication
with the much less well constructed network of peri-arte-
rial sympathetic fibers of the afferent artery. Between the
cells which form the wall of the vessel are some very fine
collagenous fibers and also a few elastic fibers. The struc-
ture of the walls of these vessels is similar to that of a
normal artery, but with the characteristic changes due to
the local differentiation. The walls of these arterioles form
a unified neurovascular system called by Masson the 'neu-
romyo-arterial glomus'."
The clinical characteristics are so striking that
after seeing the first glomus tumor one will never
again be in doubt as to the diagnosis. A diagnosis
can be definitely determined before the microscopic
examination has been made. They are. small, well-
encapsulated, oval and bluish, and usually less than
1 cm. in diameter. They are found on the extremi-
ties, usually under the nails but frequently on the
fingers and wrists, and are always attached to the
skin. There has been only one case reported on
the body proper and that was in the skin over the
clavicle. Occasionally these tumors erode the bone
of the phalanges, but this erosion is merely from
pressure and is not a true invasion. These tumors
are so exquisitely tender that the patient will often
cry out with pain if the skin or nail over the tumor
is touched. They usually occur in adults, only one
•eting of the Atnerican A.s.sociation for tlie .Study of Neoiilastiu Diseases, Washington, D. C,
GLOMUS TUMOR— Horsley
January, 1936
case having been reported in a child, and the dis-
tribution between sexes is about equal.
The exact etiology is unknown, although about
40 to 50 per cent, of the cases reported give a
definite history of trauma, followed by the slow-
growing, painful tubercle. These tumors often
exist for some time and it is only the pain which
causes the patient to seek relief. The average
duration is ten years and as they grow the pain
increases. Fingers have been amputated because
of a mistaken diagnosis of malignancy.
Microscopically, the tumors seem to be filled
with dilated blood vessels, the walls of the sinu-
soids being made up of relatively large elongated
cells, having an epithelioid appearance. The lining
of the sinusoid is made up of endothelium support-
ed by a few smooth-muscle cells and fibrils which
are apparently of nervous-tissue origin. These sin-
usoids are ensheathed in from two to seven layers
of glomus cells.
The treatment is very simple. Since it is a be-
nign lesion, excision is all that is necessary. If the
tumor is under the nail, it is probably best to excise
the nail also, allowing a new nail to grow. Local
anesthesia is usually sufficient. Radiation has been
tried in one case reported by Adair without success,
and from this he surmises the cells are radioresist-
ant. After excision no case has been known to
recur, and the patients have always been complete-
ly relieved of their symptoms.
Case Report
A woman, aged 27 years, complained of a painful knot
in the palm of the right hand, present about fifteen years
and the discomfort gradually increasing. There was a defi-
nite history of trauma, the injury having been caused by a
bruise from a can-opener. The immediate soreness follow-
ing the bruise subsided after several days and in its place
appeared a small tubercle which had persisted and slowly
enlarged. The patient experienced great pain when any-
thing touched the palm of her hand. Examination showed
a small, purple, very tender tumor, the size of a pea, in
the central portion of the palm of the right hand. On
slight pressure it would blanch, it appeared to be a small
angioma except for the fact that it was hard. Under local
anesthesia the tumor was excised. The surrounding tissue
was exceedingly vascular, the tumor solid and definitely
encapsulated. On microscopic examination it was diagnosed
by Dr. John S. Horsley, jr., as a glomus tumor. Since
operation, which was done about nine months ago, the
patient has been completely symptom-free.
I report the case because of the increasing inter-
est in this type of tumor and because I believe we
have been seeing these tumors without recognizing
the type. Following the work by ^lasson in 1924
and the recently published articles, there should be
no further trouble either in diagnosis or treatment
of glomus tumor.
The Treatment of Hemorrhoids by Gai.\tntsm
(Continued from p. 4)
firmly, preventing it from being pushed off into the rec-
tum.
The hypodermic needle should be inserted with the bev-
eled edge toward the mucous membrane and just beneath
it. Novocain so injected will produce a whitish swelling
around the point of injection. No bleeding will follow the
withdrawal of the needle, unless it has been inserted too
deeply, in which case there will be little anesthesia and
considerable bleeding upon withdrawal of the needle. After
injection of novocain, the hemorrhoid needle is quickly
inserted in the same opening to prevent any oozing. The
injection will cause the hemorrhoid to become temporaril\-
larger, but it shortens the time of treatment and is more
effective, because of the increased amount of fluid in the
hemorrhoid.
No bowel movements for several hours after treatment.
Mineral oil once or twice daily, stool at regular hours; i
to 4 days between treatments, the number of treatments
from 7 to 10.
If much pain I prescribe Nupercaine ointment to be ap-
plied to the rectum after each defecation. Hemorrhoids
which come out while the patient is at work or at stool
should be reinserted immediately. If possible, the patient
should lie down for a few minutes following reinsertion, so
that the mass will not again be expelled.
Protruding internal hemorrhoids are treated while pro-
truding as often as possible. After straining them out at
toilet, the patient lies on the table and the hemorrhoids
are treated.
External hemorrhoids cannot be treated by negative gal-
vanism, the nerve supply would make the treatment ver\-
painful.
Following treatment, the hemorrhoids are reinserted into
the rectum by gentle but firm pressure by the gloved fin-
gers of the operator, while the patient is still lying on the
table. Instructions are given to the patient to keep the
hemorrhoids with the external sphincter.
During previous years I removed hemorrhoids by the
clamp and cautery, by excision and suture, and by the
electric cauterj-; in 1930 I began treating by negative gal-
vanism. I have had over 300 patients with hemorrhoids
since that time, and have treated them with negative gal-
vanism. To my knowledge none of these patients has had
bad results nor recurrence.
-\d vantages :
No recurrence of hemorrhoids reported. Little discom-
fort. No abscesses, no scar tissue, normal mucous mem-
brane, no infections. Does not require hospitalization. No
loss of time from work.
Polyps in the cervix or corpus uteri do not produce
uterine enlargement.
.\CUTE .^SEPTIC MeNIXGITIS
(S. W. Ginsburg, New York, in Jl. Mt. Sinai Hosp., Xiiv.-
Dec.)
Two cases of acute aseptic meningitis are reported. The
cases are exceptional in the fact that both patients had an
episode of unconsciousness. In the first case the findings
in the cerebrospinal fluid were uncertain because of the
presence of traumatic blood. The lymphocytic pleocytosis
on subsequent lumbar and cisternal punctures and the
prompt recovery of the patient are characteristic of this
condition. The second case, except for the episode of un-
consciousness, is typical of the syndrome of acute aseptic
meningitis.
.Aseptic meningitis must be differentiated from tuber-
culous meningitis. Normal sugar and chloride contents in
the cerebrospinal fluid point to the former, but not always
so. In our second case sugar was absent from the cerebro-
spinal fluid. The patient's unexpected recovery establishes
the diagnosis.
Januar>', 1936
SOUTHERN MEDICINE AND SURGERY
Surgical Complications of Amebiasis*
Report of Sixteen Cases of Amebic Liver Abscess
Frank K. Boland, M.D., Atlanta, Georgia
Surgical Department, Einor>- University School of Medicine
DURING the past few years we have added
materially to our knowledge of amebic
dysentery and amebiasis, and have had
several false impressions corrected. It is now well
established that the disease, caused by Entamoeba
histolytica, while most frequent in tropical and
semitropical countries, is by no means confined to
such localities. It may occur anywhere, as was
seen in the epidemic in Chicago in 1933, in which
300 cases were reported. The commonest surgical
complication is abscess of the liver, but the term
tropical abscess is a misnomer. Sir Leonard Rog-
ers,^ one of the best known authorities on the dis-
ease, objected to the name as long ago as 1902, but
it has continued to be used in many textbooks.
Also, it has been taught that amebic abscess of
the liver is always solitary, while bacterial abscess
is multiple. This is an error. Either abscess may
be solitary or multiple, but it is true that 60 per
cent, of amebic abscesses are solitary. Again, it is
claimed that alcohol addiction is a predisposing
factor in the etiology of amebic abscess. In our
small series of 16 cases of amebic liver abscess
only one patient gave a history of drinking alcohol
to excess. It is agreed that males are far more
subject to the disease than females. Males are
more exposed to amebiasis, but one of the reasons
given for the greater incidence among males is that
ihey are more apt to be users of alcohol. Is this
true today?
One of the most important points to emphasize
in the diagnosis of amebic hepatic abscess is that
the lesion may exist without the patient giving a
history of previous dysentery. In the reports of
large numbers of cases, published by the world's
leading authorities, probably not more than half
the patients have had dysentery. Among our 16
patients with liver abscess only eight had dysen-
tery. Often the disease, and especially its com-
plications, are difficult to recognize, especially in
areas where only a sporadic case is seen. The
ameba or its cysts may be found in the stools of a
patient suffering from the dysentery, but when
complications such as ulcerated colon, or abscess of
the liver, lung and other parts develop, the para-
site may disappear from the stools. The ameba
seems to have a predilection for hiding itself in
ulcers and abscess walls. In 13 of our cases amebas
or cysts were demonstrated in the pus of liver ab-
scess in seven cases, and amebas in the abscess wall
only in six cases. I have observed patients with
dysentery in whom amebas were found in the
stools. Later the amebas disappeared, and the pa-
tients died. Autopsy then revealed large colonic
ulcers teeming with the parasites.
It is estimated that liver abscess occurs in from
1 to 5 per cent, of the cases of amebiasis. Ulcer-
ative amebic colitis is not a surgical condition,
although it frequently results in perforation, peri-
tonitis and death. The ulcers usually are too
large and numerous to justify operative interfer-
ence. Lung abscess is the second most common
complication, but occurs far less often than liver
abscess, and usually is secondary to liver abscess
rupturing through the diaphragm. Lung abscess
also may arise from migration by way of the blood
stream without passing through the stage of hepatic
abscess. Abscess of the brain probably comes next
in frequency, but is rare, while abscess of the spleen,
kidney and other organs is so unusual as to con-
stitute a surgical curosity. Skin ulceration from
amebiasis is seen occasionally.
It is just lately that we have realized that amebic
dysentery is only one manifestation of amebiasis.
As stated, many cases of liver abscess have been
reported without a history of previous dysentery.
Other viscera may be similarly affected. The
ameba enters the body in its cystic form. If it
entered in its precystic form the gastric secretions
would destroy it. Therefore cysts are the infesting
agents. Patients with dysentery usually do not
have cysts, and are harmless as carriers. Carriers
are persons whose symptoms have disappeared.
Cysts of amebas pass through the alimentary
canal, and lodge in the mucosa of the colon, where
amebas emerge and propagate. The small intestine
rarely shows infestation by the parasites, which
probably is another illustration of the resistance of
the small intestine to disease as compared with the
large intestine. Any part of the colon may be in-
volved. Craig,- whose exhaustive monograph was
consulted frequently in the preparation of this
paper, states that the cecum and rectum are the
commonest sites of infestation, and Ochsner and
DeBakey-* believe that "the relatively large number
of patients with amebic hepatitis and abscess who
the Postgraduate .Meeting, Duke University, Durham. Xurtli (/arolina, October 31st-Novembcr
SURGICAL COMPLICATIONS OF AMEBIASIS— Boland
January, 1936
give no histor)' of previous dysentery may be ac-
counted for on the basis of a slight amebic infes-
tation of the bowel, which is limited to the right
half of the colon, and which does not cause dysen-
tery. The dysentery encountered in amebiasis is
the result of irritation and ulceration of the colon
by Entamoeba histolytica. In those cases in which
the lesion is limited to the left side of the colon, a
relatively slight infestation with an abnormal secre-
tion of fluid results in frequent evacuations of
watery stools. A lesion located in the right side
of the colon, however, even though it may produce
a similar exudation of fluid into the colon, is not
associated with dysentery because the fluid is ab-
sorbed in its passage to and through the uninvolved
and normally functioning left side of the colon."
The immunity of certain of the organs to infes-
tation by Entamoeba histolytica in the vast major-
ity of individuals is well known, but unexplained.
The liver is regarded as such an organ, in spite of
the fact that liver abscess is the commonest surgi-
cal complication. If one considers the large num-
ber of people infested with this parasite, and the
very small percentage who ever develop abscess of
the liver, it is evident that this organ must possess
an immunity to infestation, for it is impossible to
believe that amebas do not reach the liver fre-
quently through the portal circulation, because they
are often observed within the blood-vessels in the
coats of the intestine, even in cases showing slight
intestinal lesions. That the parasite may be present
in the liver without abscess production is demon-
strated by those cases in which an injury to the
liver has been followed within a few days or weeks
by an amebic abscess of the liver, even in persons
who had shown no evidence of an intestinal infes-
tation. In such cases as these Craig thinks that
the injury so decreased the natural resistance of the
liver to infestation that amebas, reaching the organ
from the intestine, colonized, and produced the
abscess; or that the injury to the tissue of the
liver allowed amebas already present to multiply
rapidly and cause the lesion.
To illustrate how well concealed the plasmodium
of amebiasis may be, Pauline Williams'' reports a
case of abscess of the liver and lung first diagnosed
at autopsy. The patient showed no previous mani-
festations of amebiasis, nor was there any history
of exposure to a known source of infestation. The
pathologist's attention was directed to a considera-
tion of the presence of pathogenic amebas by the
characteristic gross appearance of the abscess. The
bloody bowel contents and the edematous and hem-
orrhagic intestinal mucosa increased the suspicion.
The routine postmortem examinations, embracing
smears, cultures and the study of tissues from the
usual locations failed to reveal amebas. Finally
they were observed in sections from involved por-
tions of the diaphragm.
The occurrence of symptoms in amebiasis de-
pends very largely, if not entirely, upon the amount
of resistance of the affected person to the infesta-
tion rather than upon the difference in virulence
between different strains of Entamoeba histolytica.
Individuals between the ages of 20 and 40 are most
subject to the disease. It is said that the white
race is more apt to be infested than the Negro.
In the Grady Hospital (municipal) of Atlanta,
during the past ten years there have been 16 cases
of amebic liver abscess among Negroes, and only
four cases among white patients. The number of
cases of amebiasis in the two races is not stated.
Pathology of Liver Abscess
Amebas reach the liver through blood-vessels,
peritoneum or lymphatics, usually the portal vein.
The right lobe is most frequently affected, espe-
cialh' when the abscess is single. The abscess may
show externally, or it may be hidden. The liver
may be normal in size, but usually is enlarged, up-
ward and somewhat to a point, as shown in the
roentgenogram by elevation of the diaphragm. Con-
trast this picture with carcinoma of the liver in
which the organ is larger than in amebic liver ab-
scess, but the enlargement is downward. Abscesses
may vary in extent from a few millimeters to the
size of a child's head.
It is important, from a therapeutic standpoint,
to realize that a definite and well-marked period of
hepatitis exists before the formation of an abscess.
This period lasts from two to four weeks and, ac-
cording to Rogers and other writers, this is the
time to inaugurate prophylactic treatment against
abscess. If the condition is recognized, abscess
formation may be prevented, if proper treatment
is given. Early diagnosis is unusual in localities
where only occasional cases of amebiasis are en-
countered.
The preabscess stage of hepatitis presents va-
rious-sized, soft, greenish-brown areas, having a
moth-eaten appearance. Section shows cytolysis
of the tissue, accumulation of fibrin, lymphocytes,
connective-tissue cells and red blood corpuscles,
lying in a connective-tissue framework, with amebas
scattered here and there. Such areas present the
earliest visible stage in the formation of liver ab-
scess. The contents of the abscess depend upon
the presence or absence of mixed infection. If
amebas are present in pure culture the material is
a very characteristic grumous, semifluid, yellowish-
red or chocolate-colored mass, containing shreds of
necrotic liver tissue, blood and cytolyzed tissue. If
secondary infection with bacteria exists the abscess
contents may consist of a mixture of the materials
mentioned, with pus; while if abscesses are present
Januarj', 1936
SURGICAL COMPLICATIONS OF AMEBIASIS— Boland
due entirely to bacteria the contents are yellowish,
or greenish-yellow, pus. During the past ten years
we have had in the colored division of Grady Hos-
pital, in addition to the group of amebic liver ab-
scesses, nine cases of pyogenic liver abscess, in
which there were five deaths.
It should be emphasized that "the contents of a
hepatic abscess due entirely to Entamoeba histoly-
tica is not pus, but cytolyzed liver mixed with blood
and shreds of partially cytolyzed tissue, and it is
only when a mixed bacterial infection is present
that the abscess cavity really contains pus. In a
hepatic abscess all trace of liver tissue may be lost
except the connective-tissue framework of the or-
gan, which, being more resistant to the cytolytic
action of the ameba than the other tissue elements
still persists as bands of tissue crossing the abscess
cavity." (Craig).
Not only is the ameba often absent from the
stools in amebic dysentery, but it is often absent
from the pus in liver abscess. In many cases, how-
ever, the parasite may be found in the abscess
walls, particularly in the zone of necrosis, and not
so frequently in the dense connective tissue of the
abscess wall. As previously stated, in nine cases
in the series of liver abscess herewith reported
amebas were recovered in the pus, and in seven the
parasite was recovered only from the abscess wall.
For the purpose of insisting upon the best treat-
ment, when possible, it should often be repeated
that the contents of amebic abscess, when no sec-
ondary bacterial infection is present, are bacteriol-
ogically sterile. Thus, patients with ruptured liver
abscess involving the peritoneum do not have true
bacterial peritonitis, which accounts for cases of
this character being reported as getting well. How-
ever, mixed infection is the rule in such instances.
S\-MPTOMs OF Liver Abscess
J n a cute abscess the onset is sudden, with severe
abdominal pain, which appears to be worse at night.
The commonest location of the pain is in the liver,
although it may be in the epigastrium or shoulder.
Pain may come on so suddenly and violently as to
imitate gallstone colic, or perforated peptic ulcer
with subphrenic abscess formation. Fever is high
and irregularly intermittent, the decline being ac-
companied by profuse sweating. Remissions in the
temperature may mean secondary infection. Chills
are frequent, and taken with the fever, may sug-
gest malaria. Enlarged liver may seem to develop
rather suddenly, but the enlargement probably has
been in process for several days. Nausea and vom-
iting may be marked. The skin generally is sallow,
but jaundice is uncommon. Acute liver abscess due
to Entamoeba histolytica may be so violent as to
result fatally in a few days. Dyspnea suggests
invohement of the pleura or lung, a complication
which is more apt to go unrecognized until autopsy
than is abscess of the liver. Leucocytosis ranges
from 15,000 to 30,000. The polymorphonuclear
count ordinarily is low in pure amebic abscess and
high when mixed infection is present.
The chronic variety may exist for many months
or years, with alternating appearance and subsi-
dence of symptoms from time to time. There is
apt to be cough, night sweats and weakness, and
tuberculosis is suspected. Roentgen-ray is a val-
uable aid in diagnosing either the acute or chronic
form. If the liver is not definitely enlarged, it is
remarkable how many cases of liver abscess are
diagnosed by roentgenology as pulmonary or pleural
lesions. Lateral as well as antero-posterior views
should be made, the former bringing out the full
curve of the diaphragm, and thus differentiating
between lesions below and above the diaphragm.
In chronic liver abscess, after recognizing enlarged
liver, the problem may be to eliminate syphilis,
carcinoma and cirrhosis. Positive Wassermann re-
actions in the Negro race are of little significance
in our community, since 40 per cent, of the colored
population give such reactions.
The incidence of appendicitis as a complication
of amebiasis is stated by various authors as be-
tween 7 and 40 per cent., the former figure prob-
ably being more accurate. The symptoms more
nearly resemble the chronic form, although acute
appendicitis may be simulated. It is essential to
recognize the nature of the lesion, if possible, since
amebicidal medication is indicated rather than
operation. Gallbladder and urological sequelae are
seldom met in amebiasis, but constipation and in-
testinal obstruction may result from peritonitis.
Ochsner and DeBakey, in a recent paper," pre-
sent a discussion of the pleuropulmonary complica-
tions of amebiasis, in which they report 153 collect-
ed cases and 15 personal cases. Such complications
occurred in 15 per cent, of 2500 cases of liver ab-
scess. They take place as a rule as a result of an
extension of amebic hepatic abscess. Perforation
of the abscess seldom occurs into the free pleural
space, but more frequently into the lung or bron-
chus. Exceptionally hematogenous pulmonary ame-
bic abscesses may develop. The clinical manifesta-
tions of pleuropulmonary amebiasis consist chiefly
of cough and expectoration, fever, dysentery, en-
larged and tender liver, pain in the chest and
cachexia. The expectoration of chocolate-colored
pus is indicative of a communication between a
liver abscess and a bronchus, and is of diagnostic
importance. Pulmonary manifestations consist of
consolidation and cavitation. Roentgen examina-
tions shows elevation and fixation of the diaphragm
and a shadow at the right base, particularly in
those cases in which a pulmonary abscess extends
SURGICAL COMPLICATIONS OF AMEBIASIS—Boland
January, 1936
from a liver abscess. The shadow may show a
characteristic triangular shape with the base below
and the apex above. Diagnosis can be definitely
established by the typical chocolate-colored pus and
finding amebas in the sputum and aspirated mate-
rial, ^lortality in the collected cases was 41 per
cent.
Abscess of the brain due to amebiasis furnishes
less than 1 per cent, of complications. Infestation
takes place in the brain through the blood stream,
one or both cerebral hemispheres being involved,
with symptoms of headache, nausea, vomiting, de-
lirium and convulsions. Fever may be absent, and
the cerebrospinal fluid may be clear. Death gen-
erally ensues in a few days.
Treatment and Results
Emetine or one of the newer drugs, as treparsol
or chiniofon, is believed to be specific for amebia-
sis and its complications. Emetine, however, is
generally recommended in the treatment of liver
abscess and other complications. The dose is one
grain daily, hypodermically, for not more than ten
or twelve days. Some patients seem to possess an
idiosyncrasy for emetine, so that its administration
must be watched carefully. Nausea, vomiting,
cramps and prostration may develop. The irriga-
tion of abscess cavities with any kind of amebicidal
drug is of doubtful efficiency.
Rogers and other authorities insist that the safest
and most effectual treatment for hepatic and other
amebic abscesses is by aspiration and the adminis-
tration of emetine. In a series of 2661 cases of
liver abscess treated by open drainage the mortal-
ity rate was 56 per cent.; in 111 cases treated by
aspiration and emetine the mortality was 14 per
cent. Ochsner collected a series of 4035 cases of
liver abscess treated by open operation, with a
mortality of 47 per cent., and 459 cases treated by
aspiration and emetine, with a mortality of 6.9 per
cent.
The patients in these groups who were treated
by aspiration were supposed to have pure amebic
infestation, with no bacterial infection. If mixed
infection is found to be present all authors agree
that open operation and drainage should be insti-
tuted. Naturally patients with mixed infection are
more seriously sick, and a higher death rate would
be expected. The argument put forward by Rogers
and others in advocating treatment by aspiration
is that open operation converts a bacteriologically
sterile abscess into one with mLxed bacterial infec-
tion. The treatment and the results of treatment
of hepatic abscess and other complications is some-
what analogous to the situation in regard to em-
pyema in the army cantonments during the World
War. The mortality rate in this fearful epidemic
did not depend so much upon the therapy adopted,
whether by aspiration or by open operation and rib
resection, as it did upon the virulence of the infec-
tion. In amebic abscess, therefore, is it not fair
to say that the mortalitj- rate depends to some
extent upon the resistance of the patient as well as
upon the method of treatment employed? The pa-
tients included in the large numbers of cases re-
ported lived in tropical and semitropical countries
where amebiasis is very common, and has been
present for a long time. Is it not possible that
such patients could develop an immunity to the
disease which would keep the death rate low, in
spite of the choice of treatment?
I mention the choice of treatment and the results
somewhat in explanation of the high mortality rate
reported by surgeons in regions removed from the
centers of amebiasis, where cases are seen only spo-
radically, and where patients could not have gen-
erated such a possible immunity. While all the
patients in our series were not studied bacteriologi-
cally as thoroughly as they should have been (and
will be in the future), they were all critically ill,
and it is difficult to conceive of achieving in them
a mortality rate as low as 7 or 14 per cent, by any
method of treatment. Probably the emetine was
not given a fair trial. It was used in a few cases
but did not seem to affect the course of the disease,
so was abandoned. Another explanation for the
apparently poorer results obtained by members of
the profession who in a life-time treat only a few
patients with amebic abscess lies in the fact that
they cannot be expected to diagnose such cases as
early as men who treat them by the hundreds.
Rogers found the pus sterile in 86 per cent of
his cases, which must have been seen early in the
disease. He is of the opinion that in large thick-
walled amebic abscesses destruction of the liver
does not progress, although the liver may get larger
and compress the the liver substance. If, however,
the abscess cavity becomes secondarily infected,
which invariably occurs if open drainage is insti-
tuted, the microorganisms are apt to penetrate the
limiting wall, with resulting extension beyond the
abscess itself into the surrounding liver parenchyma.
It is on account of this invasion of the uninvolved
portions of the liver that the patients may develop
a severe, frequently a fatal, toxemia. The infec-
tion of such a sterile abscess with its deleterious
effects has been compared to the change which
occurs in a tuberculous abscess that has been
drained and in which secondary infection takes
place. Whereas the majority of amebic abscesses
of the liver are surgically sterile, there may be bac-
teria in the pus, which, however, are not virulent.
Only exceptionally are virulent organisms obtained
from the abscess at the time of drainage. The sec-
ondary infection occurs following open drainage in
Januan-, 1936
SURGICAL COMPLICATIONS OF AMEBIASIS— Boland
spite of meticulous care being exercised to prevent
contamination.
In aspirating a liver abscess for diagnosis and
treatment it is advised that the needle enter the
tenth intercostal space in the anterior axillary line,
and be directed upward, medially and backward.
In performing such an operation it is understood
that there is always danger of entering the perito-
neum or pleura. If the abscess can be entered post-
peritoneally such a risk may be avoided. Some-
times it may become necessary to introduce a trocar
into the abscess cavity because the pus is too thick
to pass through an aspirating needle. Gessner"
warns of the danger of hemorrhage from puncture
of an acutely inflamed and excessively hyperemic
liver, while Ochsner tells of aspiration being per-
formed upon a 72-year-old man without previous
treatment with emetine resulting in death from
hemorrhage. In aspirating a patient with multiph
hepatic abscesses, the procedure is more valuable
as a diagnostic than as a therapeutic means. How-
ever, cure of the patient depends more upon the
administration of emetine than upon aspiration.
The drug should be given both before and after
aspiration or open operation. It is advised to give
emetine intramuscularly immediately after aspira-
tion because following the release of the tension
within the abscess there is believed to take place an
exudation into the abscess of lymph containing the
injected emetine which destroys the amebas.
Noland, in his discussion of Gessner's paper,
sfwke of the work of Herrick in Panama, and
stated that no surgeon had secured better results
in the treatment of amebic liver abscess. He be-
lieved that Herrick "s success was due largely to the
fact that he had abandoned exploratory aspiration
of the liver transpleurally far earlier than did most
surgeons. He gave up aspiration largely because
of two complications: first, on account of the num-
ber of secondary pleural infections following leak-
age from abscesses into the pleural cavity, and sec-
ond, because of the fact that in many cases multiple
abscesses were missed. He first located the abscess
accurately through laparotomy, and then closed the
abdomen and opened the abscess through the dia-
phragm, the diaphragm being sutured to the inter-
costal muscles before the abscess was opened. No-
land affirmed that exploratory aspiration of the
liver in suspected cases of abscess is a dangerous
and unwarranted procedure in the majority of
cases.
Pleuropulmonary abscess may disappear spon-
taneously by rupture through a bronchus. This
abscess is treated on the same principles as liver
abscess. Open drainage should not be done except
in cases with secondary infection. In his series of
pleuropulmonary abscess Ochsner states that 100
per cent, of his patients treated with emetine recov-
ered, whereas only 43 per cent, of those not so
treated recovered.
In a previous article' the details of fourteen cases
of amebic liver abscess were put on record from the
Grady Hospital, Atlanta, from 1925 to 1930, all in
Negro patients. From 1930 to 1935 two more pa-
tients were treated, as follows:
Report of Cases
No. 15.— .\ man, aged 28, admitted June 29th, 1931,
complaining of cramping pain in the right lower quadrant
of abdomen, which had existed for the past three months.
Severe diarrhea developed after two months (one month
before admission) with from IS to 20 stools daily, no
nausea or vomiting. Temperature on admission 102, which
dropped to normal after operation. Leucocytes 15,000 —
polys. 84%. Laparotomy was performed the day after
admission, and what was thought to be a distended gall-
bladder proved to be an enlarged liver, containing an ab-
scess which was opened and drained of chocolate-colored
pus. Entamoeba histolytica was not recovered from the
pus, but later was found in the stoob. Patient left hospital
in one month, apparently well.
No. 16. — Man, aged 43, admitted April 12th, 1933, gave
history of having had five attacks of severe pain in past
lew months, worse at night, involving the epigastrium and
right shoulder. He drank one pint of whiskey a month.
Weight had dropped from 186 to 146 pounds during the
past 18 months. There was no history of dysentery, but
blood was found in the stools, without amebas. The first
diagnosis was pleurisy, later changed to cholecystitis, a
diagnosis which was strengthened by the appearance of a
shadow in the region of the gallbladder which looked like a
stone, but which later proved to be a calcified mass in the
liver. The liver did not appear especially enlarged on
roentgenogram. Right rectus incision over liver showed
abscess which was packed off, and opened the ne.xt day,
when it discharged thick yellow pus. Four days later there
was a discharge of 1500 c.c. typical chocolate-colored pus,
from which amebas were recovered. The case ran a septic
course during the patient's two-months' stay in the hos-
pital, with temperature from 99° to 102° and leucocytes
from 11,000 to 17,000. He left the hospital with sinus still
discharging; returned in a few days, and had the ninth
rib secected for better drainage. The septic course con-
tinued to fatal termination in the hospital four months
later.
SUIVIMARY
Of the total of 16 cases in the series^ there were
13 males and three females, the ages from 17 to 47
years. Five cases were classed as acute and 11 as
chronic. Eight patients gave no history of dysen-
tery. Entamoeba histolytica, or its encysted form,
was recovered from 13 patients; three patients pre-
sented such typical clinical findings of amebic ab-
scess that the diagnosis seemed warranted. The
abscess invariably was located in the right lobe,
in three cases multiple abscesses. In eight patients
the approach to the liver was through the abdomi-
nal wall; in six the liver was reached through rib
resection. One patient refused operation, and one
was too near death for operation. The pleura was
incised in three patients, once accidentally, with a
SURGICAL COMPLICATIONS OF AMEBIASIS— Boland
January, 1936
fatal outcome. Two-stage operations were em-
ployed in four cases. In the first stage the liver
was sutured to the abdominal or thoracic wall, or
the wound packed, so as to isolate an area for open-
ing the abscess 24 hours later. There were six
deaths, a mortality of 3 7.5 per cent.
Bibliography
1. Rogers, L.: Amoebic Liver .i^bscess: Its Pathology,
Prevention and Cure. Lancet, vol. i, pp. 463, 569, 677,
March 11th, 18th, 25th, 1922.
2. Cr-UG, C. F.: Amebiasis and Amebic Dysentery, 1934.
Charles Thomas, PubUsher.
3. OcHSNER, A., and DeBakey, M.: Diagnosis and Treat-
ment of Amebic Abscess of the Liver. Amer. Jour.
Digestive Diseases and Nutrition, vol. n, no. 1, pp. 47-
51, 1935.
4. WiLLiAiis, p.: .Amebic Abscess of the Liver: Report
of Fatal Case in Which Etiology Was First Demon-
strated in Tissue Sections of Diaphragm, Following .Au-
topsy. Sou. Med. Jour., vol. xxvin, pp. 902-905, Oct.,
1935.
5. OcHSNER, A... and DeB.\kev, M.: Pleuropulmonar>'
Comphcations of .Amebiasis. Unpublished paper read
before the .\mer. .\ssn. for Thoracic Surgery, New
York, 1935.
6. Gessner, H. B.: Abscess of the Liver. Trans. Sou.
Surg. Assti., vol. XLV, pp. 455-464, 1932.
7. BoL.\ND, F. K.: Abscess of the Liver. Annals of Surg.,
Oct., 1931.
Fn^E Stubborn Skin Diseases
(Wm. J. MacDonald, Boston, in Urol. & Cuta. Rev., Dec.)
A. Rosacea caused by the Demodex Folliculorum. One
of the characteristics is the presence of pin-head size pus-
tules. With a small knife transfer the entire pustular con-
tent to a glass slide and examine with the low power micro-
scope. Usually at least 1 or 2 and not infrequently more
demodeces folliculorum will be found. This parasite is
cigar shaped. The cephalic end is blunt and four very
active legs on each side. I say active, for if the mite is
now gazed at under the high power lens, very energetic
movement of the limbs will be observed. The caudal end
tapers to a point.
I suggest a condemnation of the beauty parlor products
and the substitution of a specific ointment. Women gener-
ally are emphatic about the irritability of soap and water
upon their skin. The first shot to be fired is right at the
soap and water bugbear. The face having been washed
vigorously at night is then briskly rubbed with the oint-
ment. At first it will be mildly irritative. Gradually, how-
ever, this passes off and with the improvement that in-
evitably follows, this sense of irritation wears away. The
ointment I suggest with certain variations at times is
I. Beta-naphthol
B. Sycosis Vulgaris. Everj' physician meets this disease
with moderate frequency. It is a staphylococcal infection
of the chin or upper lip and less frequently the whole
mandibular region. The pustular lesions superimposed
upon an erythematous and, at times, quite painful base, are
readily recognized. ."An ointment containing chlorhydroxy-
quinoline, benzoyl peroxide, eucalyptol and oil of thyme
can be obtained now as Unguentum Quinolor Compound.
In my own personal experience it has been undeniably
satisfactory. Where my patients have persisted with its
use, they have promptly recovered.
C. Perleche. Have you ever noticed a fissured painful
lesion at the angles of the mouth? This simple disease is
called Perleche. It is quite common and is due to infection
with Monilia albicans or an allied type of yeast organism.
It is often very stubborn. A confrere of mine being af-
flicted most stubbornly with the disease suggested radium.
.\ brief exposure of 5 minutes with half strength plaque,
with no filtration, caused a slight erythema. Following
this the lesion completely disappeared for the first time in
several years. It is an apparently quite useful procedure.
D. Dioxyanthranol 1-S in Psoriasis. Psoriasis of the
scalp is very resistant to any remedy. Yet, here we possess
an agent which does achieve remarkable results. Of 29
cases IS underwent complete involution. The remainder
improved to a greater or less extent. Its use in psoriasis
in other parts of the body is equally satisfactory. It is'
especially valuable in ver\- obstinate crusted cases. The
ointment is obtainable as Anthralin Ointment. It is dis-
pensed in three strengths, 0.1, 0.25 and 0.5%.
Dio.xyanthranol 1-8 in Other Dermatoses. My own ex-
perience is that it is the most valuable form of medication
for stubborn and chronic fungus lesions on the fingers,
hands and feet. Mycotic disease of the hands appears to
be definitely and seriously on the increase today. It is
very resistant, by virtue of the hyperkeratotic condition
present, to Whitfield's ointment, x-ray or any other remedy.
In clinic work and private practice I find Dio.x>-anthranol
1-S more than satisfactor^^ Some patients cannot tolerate
the drug, but the majority are cured, temporarily at least.
I have not used it in the vesico-pustular type of the erup-
tion (epidermophytosis) preferring milder remedies. But
its value in the hyperkeratotic and resistant type of mycotic
disease cannot be gainsaid.
This drug has been used in various other dermatoses.
Some quote its value in ."Mopecia Areata, Parapsoriasis, Fol-
liculitis, Seborrheic Eczema and Pityriasis Rosea. I have
not used it in these diseases.
My object in emphasizing the value of Dioxyanthranol
1-8 is principally to stress its use in psoriasis and certain
forms of fungus infection.
Rectified Spirits
Mb;
II. Balsam Peru
01. Olivi
Mix
III. Sulph. Praecip
Ung. Aq. Rosae, ad
MLx
I & II are mixed thoroughly, then III is added. It is
essential in rosacea to make a correct diagnosis. Eczema
of the face, lupus er>-th. and other skin diseases rebel if so
treated.
gr-
ui
m
m
m
XX
.m
XX
-gr
. V
^1
oz.
Aenor^ialities ix Feminixity Corrected by Surgery
(From Current Recordings in Med. Rec, Dee. 4th)
Dr. Frank HLnman, San Francisco, listed aversion to
marital relationship, despondency, suicidal tendency and a
general tendency toward masculine traits, hirsutism and
deepened voice changes brought about either by a tumor
in the cortex of the adrenal glands or by overactivity of
the cortex. By a new surgical technique, the normal ap-
pearance, as well as feminine traits is restored to the pa-
tient, either by the removal of the tumor, or if there is
none, by the excision of about 2/3rds of the 2 adrenal
glands. Dr. Hinman said that l/'3rd left is sufficient to
carry on the normal processes, but if an insufficiency re-
sults, it is remedied by the occasional injection of cortin,
the hormone secreted by the adrenal cortex.
Januar>-, 1936
SOUTHERN MEDICINE AND SURGERY
Osteomyelitis of the Vertebrae
G. C. Dale, IM.D., Goldsboro, North Carolina
OSTEOMYELITIS in this discussion is lim-
ited to the disease produced by pus-form-
ing organisms. There is a paucity of cases
of such types of osteomyelitis, due perhaps to some
lack of dissemination of knowledge of the condition
and to the infrequency of its discussion in Amer-
ican literature.
Important communications made by Hahn in
1895 and 1899 listed one case of vertebral osteo-
myelitis in 661 compiled cases of osteomyelitis in
general. The development of the x-ray has made
diagnosis simpler and more certain. It is agreed
that diagnosis is difficult, that there is great danger
in the disease because of complications within the
spinal canal, and that this form of osteomyelitis is
a part of a general infection, pyemia.
The disease is somewhat more common in males
than in females varying from SS to 72 per cent, in
favor of males. It is most frequently seen in adol-
escence, rarely appearing beyond 30 years of age.
The lesion is a metastatic lesion associated di-
rectly with a bacteremia, which has as its focus
bacterial infection somewhere in the body, possi-
bly even in the alimentary or genito-urinary tract.
The focus may be a boil of the skin, a tonsillar
or pharyngeal infection, an infection in the genito-
urinary or any other system. The lesion is the
result of a subsidiary and secondarily infected
thrombus which has been transplanted by the cir-
culating blood into an end artery. Bone tissue is
peculiarly prone to this process because of its vas-
cular structure. Trauma is a factor in facilitating
metastatic lesions. The effect of the invasion is a
nutritional disturbance of the bone cells and sub-
sequent necrosis. Vertebral lesions are relatively
few and follow no particular plan, because of the
arrangement of local blood vessels and because of
essential anatomical conditions.
Unlike other bones, the vertebrae have no defi-
nite membranous periosteum. The function of the
periosteum is largely taken over by tendinous,
tibrous and ligamentous structures, all of which
are essential in supporting a flexible spine and in
maintaining its strength. The anatomical arrange-
ment of these structures determines in large meas-
ure the planes along which infection spreads.
The vertebral bodies have a more abundant vas-
cular arrangement than have the pedicles and
laminae. By a large number of vessels correspond-
ing generally in number with the spinal t.egment
and derived from the basilar in the neck, the inter-
costal and other branches in the thorax, and the
lumbar vessels in the loin, they are supplied in a
double manner. One group of vessels perforates
the bodies from the outer side, breaks up into a
network and supplies the adjacent bone with blood.
These vessels anastomose with branches which have
entered the spinal canal. The lateral spinal
branches enter the spinal canal through the inter-
vertebral foramina and divide into two branches,
one of which supplies the spinal cord and its mem-
branes, the other dividing into branches which an-
astomose with similar branches from above and
below to form two lateral chains on the posterior
surface of the bodies. From these the periosteum
and bodies are supplied and branches anastomose
above and below to form a central chain on the
posterior surfaces of the bodies. The pedicles,
laminae and processes are principally fed from ter-
minal anastomosing vessels from the spinal arteries
inside the canal and their blood supply is much
less abundant than that of the bodies.
The disease more frequently involves the arches
and processes in the lumbodorsal region and the
bodies in the cervical region. The initial lesion is
of small size, usually superficial, but occasionally
penetrates into deeper bone structure. Sequestra
are rarely formed, due to abundant vascular anas-
tomoses. Abscess formation is the rule and sup-
puration follows fascial planes and in directions
according to anatomical configurations.
In the cervical spine the bodies of the vertebrae
are most frequently involved. Suppuration on the
anterior body surface travels beneath the preverte-
bral fascia upward toward the skull or downward
into the mediastinum. This is one of the causes
of retropharyngeal abscesses. When the abscess
develops in the lateral pedicles it points in the pos-
terior triangle of the neck, being diverted there by
the prevertebral fascia. An abscess developing on
the anterior surface of the transverse process is
similarly diverted into the posterior triangle of the
neck. One developing in the posterior aspect of
the transverse process, the laminae, or the spinous
processes, spreads backward and is reached deeply
in the muscle spaces of the neck.
In the thoracic spine foci of infection develop
most frequently in that part of the spine posterior
to the bodies. Suppuration of the anterior portions
of the pedicles and lateral processes usually follows
the fascial sheath of the iliopsoas muscle and ap-
pears as an iliopsoas abscess. It may appear in the
posterior mediastinum or retropleurally. Suppura-
tion of the posterior portions of the transverse
OSTEOMYELITIS OF THE VERTEBRAE— Dale
Januar>', 1936
processes, the laminae or the spinous processes,
appears in the space between the spine and the
bend of the ribs and is deep-seated. Suppuration
arising in the exterior surfaces of the bodies of the
vertebrae accumulates in the posterior mediastinum,
where it may localize or spread into the pleural sac
or produce a suppurative pericarditis.
In the lumbar spine osteomyelitis most commonly
affects the transverse processes, the arches and
the spinous processes. Abscess formation on the
anterior surface of the transverse processes, on the
pedicles or on the anterior portions of their bodies,
may locahze here and may be felt by abdominal
palpation, or may spread out under the diaphragm
to form a subphrenic abscess, or may appear fur-
ther down as a perinephritic abscess.
Foci of infection developing along the posterior
parts of the arches, transverse and spinous proc-
esses appear as suppurations in the spinal muscles
in the small of the back.
Osteomyelitis of the posterior sacrum or coccyx
appears as a subcutaneous abscess and is easily
accessible. Osteomyelitis of the anterior sacrum
and coccjTi suppurates into the hollow of the sacrum
and points either in the space between the coccyx
and anus, in the gluteal muscles, or as a paraanal
abscess; or it may follow along the crest of the
ileum upward and point above Poupart's ligament.
Suppuration breaking into the spinal canal may
accumulate between the bone and dura mater com-
pressing the cord or may localize as a subperiosteal
abscess or may rupture the dura and produce a
spinal meningitis.
The symptoms of osteomyelitis of the vertebrae
are markedly varied. These are made complex
frequently because of the fact that the spinal pic-
ture is overshadowed by the picture of a generalized
infection. The average clinical picture is that of a
piofound toxemia with sepsis. This may rapidly
progress to a fatal termination. Especially is this
the case where organisms from the spinal focus are
being rapidly liberated into the blood stream. The
condition may be confused with typhoid fever, cere-
brospinal meningitis or some unknown infection.
Milder forms appear in which there is no bac-
teremia and without clinical signs of a general in-
fection, the bacteremia having disappeared with
the subsiding vertebral focus. In such cases there
is tenderness and rigidity of the affected portion
of the spine, spontaneous or provoked pain and a
tendency of the patient to assume a supine position.
All cases eventually show local signs which point
to the seat of infection, provided the patient is not
overwhelmed by the toxemia before they appear.
The great majority of cases in a short time pre-
sent the signs and symptoms of abscess formation.
When lesions develop in the posterior portions of
the vertebrae there is swelling, local edema, cen-
trifugal induration and finally central softening
along the posterior aspects of the back. Abscesses
of the anterior portions of the vertebrae are deep-
seated and are difficult to diagnose. One is guided
in these cases by the general condition of the pa-
tient and by local spinal rigidity. Lesions devel-
oping deeply in the vertebral arches present the
neurological evidences of cord compression and de-
generation or of inflammation of the meninges.
Complications arising from local extension of
the disease are: 1) abscess of the neck, 2) retro-
pharyngeal abscess, 3) extrapleural or retropleural
abscess, 4) mediastinal abscess, S) pleurisy with
and without effusion, 6) empyema of the thorax,
7) pericarditis of various forms, 8) iliopsoas and
intraabdominal abscesses, 9) pelvic abscesses —
ischiorectal, paraanal and gluteal abscesses, 10)
many forms of disease of the spinal canal, 11)
complications associated with the general infection
— including osteomyelitis in other bones, infections
of joints, peritonitis, pericarditis, meningitis, endo-
carditis, lung abscess, renal infarct, etc.
The average mortality of vertebral osteomyelitis
is 53 per cent.
Prognosis is dependent upon the location of the
infection in relation to the spinal canal and vital
organs, the direction of extension and the speed of
interference.
Treatment in the vast majority of instances is
purely surgical. Suppuration which can be easily
located requires only simple incision and drainage.
It is neither safe nor practical to resort to radical
bone surgery. No attempt at removal of sequestra
should be made because of the fact that so often
sequestra do not form and simple drainage of a
subperiosteal abscess is quite sufficient. It is also
very difficult to demarcate diseased bone from
healthy bone and in the spine all healthy bone is
essential for preservation of strength and contour.
If sequestration does occur it is usually small and
when completely separated it will extrude itself or
can be readily lifted out. Intrathoracic and ab-
dominal accumulations, pelvic abscess and their ex-
tensions are handled according to best surgical
judgment. Suppurations into the spinal canal in-
volving the meninges and cord are too often be-
yond control and one is lost in the neurological
manifestations. A case, however, is reported in
which an abscess of the vertebrae was opened, the
wound later exuding cerebrospinal fluid, with spon-
taneous closure of the fistula without any untoward
manifestations.
A few cases, as the one reported here, in which
the focal process subsides or becomes dormant as a
result of clearing the blood stream of infection, can
January-, 1936
OSTEOMYELITIS OF THE VERTEBR.\E—Dale
IS
be handled by simple orthopedic measures for fixa-
tion or by absolute rest in bed.
Case Report
A married woman, aged 27 years, was admitted to the
hospital with a chief complaint of weakness of back and
hips. She was well until January, 1934, when, following
the birth of a child, she had chills and fever every other
day. There were no symptoms at this time referable to
the genital organs and no abdominal tenderness. She was
treated by her physician for malaria, but to no avail and
was admitted after a few weeks to a large hospital in the
State where a diagnosis of septicemia was made. After
three weeks' stay in this hospital during which time she
received nine blood transfusions she was discharged and
was told that she had had a severe illness.
Upon discharge she and other members of her family
noticed that she showed stiffness of the spine. When she
sat down she was perfectly erect; when she arose she stood
rigidly ; if she stooped she would fall and, having fallen,
she was unable to get up without assistance. There was
no sign of severe pains in the back, certainly no more than
few pains in the legs and sacral region. She has been ex-
tremely nervous and sleepless. No drug that she has taken
has produced sleep. She has lost ten pounds after having
gained ten pounds with the rest in the hospital.
These episodes of back pain with rigidity having been
repeated somewhat frequently, in alarm she returned to
the hospital, where she was examined and told that her
ailments were purely of an imaginary character and was
directed to get out of bed at any cost and to assume other
interests in life for combatting her depressive state. All
this was futile and she went to an osteopath who advised
rest in bed. This gave some improvement.
Upon entering our hospital she was very emotional and
cried at the least provocation. Her digestion apparently
was good ; constipation was moderate. There were no
symptoms referable to the urinary system, no cough, no
pleuritic pain. Menstrual periods had been regular and
normal. She is the mother of two children, both breech
deliveries. The last was not unusually long. The past
medical and family histories are unessential. Physical ex-
amination revealed a heart normal in size, p. 146, b. p.
104/74, abdomen negative. Vaginal examination dis-
closed nothing abnormal. On examination of the back there
was found to be tenderness in the lumbar region on a level
with the third and fourth lumbar vertebrae, the patient
could not iJex the spine without pain ; after stooping half
way to a chair she would fall the remainder of the distance
and was unable to rise from this position without assist-
ance. Tenderness did not extend to hips or legs. Extrem-
ities were negative throughout. The blood Wassermann
reaction, tuberculin skin test and catheterized urine speci-
men were negative; w. b. c. 6,000; hgb. 90% and r. b. c.
4,300,000.
X-ray examination of the spine revealed osteomyelitis of
third and fourth lumbar vertebrae.
The patient was referred to Dr. Donnell B. Cobb, who
applied a body cast with the spine slightly extended. This
was removed in about six weeks and examination made.
Considerable improvement was observed. Patient felt a
great deal better and there was evidence in the x-ray plate
of further ankylosis and another cast was applied, the pa-
tient being allowed to be about her normal duties. Eight
or ten weeks later when the last cast was removed she
could walk with ease and could almost touch the floor
with hands without pain. Other x-ray plates showed a
great deal of callus formation which appeared to be suffi-
cient to produce a stable ankylosis. The intervertebral
space v.as obliterated.
References
Wileksky: Annals of Surgery, vol. Lxxxix, no. iv, p.
561, April, 1929.
Wilensky: Annals of Surgery, vol. Lxxxn, no. v, p.
731, May, 1929.
Henry: The Journal of Bone and Joint Surgery, vol.
No. m, p. 536, July, 1929.
Carson: The British Journal of Surgery, vol. xvni, no.
71, p. 400, Jan., 1931.
The Effect of Exercise on Menstruation
We are taught to believe menstruation is a physiological
function, that it should not be attended with pain. Here
are the results of the study of 500 girls over a 2-year period.
At this time all students were permitted to participate
in activity on the gymnasium floor during the menstrual
period with the exception of 3 students who had prolonged
menstrual flow of S to 12 days. No student fainted during
any class period or immediately after.
Medications that were employed when necessary consisted
of bronsalLzol, viburnum, acetylsalicylic acid and occasion-
ally atropine. The medicine was given infrequently. Four
hundred and twenty-sLx reported as feeling better because
of taking exercise, 52 as seeing no change and 22 claimed
to have felt worse after exercise; 310 claimed there was no
noticeable change in flow, 106 claimed there was an appre-
ciable increase the first 2 days, 32 claimed the flow was
lengthened and more profuse up to 4 days' length and 3
napkins increased first 2 days; 41 showed no increase first
2 days, but the period lasted more profusely the last 2 or 3
days; 11 showed decrease in length of time, but increase
of flow during period.
It was definitely concluded that the patient felt more fit
if she exercised during her menstrual period. The fact that
so httle increase in metrorrhagia was noticed makes this
factor seem practically negUgible. Therefore, through our
study we conclude that exercise during the menstrual period
is beneficial to the young woman.
Headache From Tobacco, Drugs, etc.
(Alex. Lambert, New York, in Bui. N. Y. Academy of
Med., Aug.)
As far as smoking the tobacco is concerned, the delete-
rious effect on the human organism is more due to some
element in the tobacco, other than nicotine, than to the
nicotine itself.
There is no question that the blood pressure rises during
smoking, and in animal experimentation, small amounts of
nicotine cause a rise in the blood pressure, and the coro-
nary, pulmonary and hepatic vessels are constricted there-
by.
The work of Sulzberger and Harkavy, and others, has
produced ver\' strong evidence that the clinical effects of
tobacco are due to hypersensitization by some substance
in the tobacco itself, more than in the smoke.
Many headaches which are laid to smoking are unques-
tionably due to other substances, they may be due to other
solids or fluids taken the night before, and are blamed on
the tobacco. But headache from tobacco does occur, and
is dependent for its occurrence on the quantity taken, and
on the sensitiveness of the person indulging in it. We
cannot gauge these two factors, we cannot say how fre-
quent it is. It is quickly evident in some, it is never evi-
dent in others. It may be produced by the nicotine, it
may have nothing to do with the nicotine, we do not
know.
An individual may be sensitive to only one kind of to-
bacco, not to other kinds.
SOUTHERN MEDICINE AND SURGERY
January, 1936
The Management of Nervous Indigestion*
Paul F. Whitaker, ^I.D., F.A.C.P., Kinston, North Carolina
THE treatment of nervous indigestion, in
fact the treatment of nervous disorders in
general, is much neglected. When one gets
away from time to time to take ward rounds or
attend clinics or meetings in the larger medical cen-
ters of the country, seldom does he hear anything
on the subject, and the curricula of the medical
schools have little to offer the student along this
line. JNIedical students at present are splendidly
trained in the science of medicine, but are woefully
lacking in the art. This is, indeed, an unfortunate
situation — unfortunate for the young practitioner
who starts out under the severe handicap of having
not even a general idea of handling the nervous
patient, and unfortunate for the suffering individual
with a functional digestive condition who wanders
from one physician to another and then more often
than not into the field of quackery.
That the subject is an important one no one can
deny. By their very number these patients de-
mand consideration. Leading gastroenterologists
estimate that more than half the patients that con-
sult them for chronic indigestion belong in the so-
called functional class. In our war-time army at
least one-third of the men hospitalized because of
digestive complaints suffered from neurosis. That
the field is often a disappointing one, no one with
even a moderate experience will deny, but the sat-
isfaction obtained by getting one good result more
than outweighs many disappointments. In twelve
years of clinical practice with especial interest in
gastroenterolog}' I am more convinced each year
that the medical student, the practitioner, the spe-
cialist and the consultant should take more time
with these people who make up a large percentage
of clinical practice, and should work out a rational
line of procedure to follow in their management.
Sometimes, even with the best of care, a cure is
not obtained; but all too often the patient's failure
to progress is because of ignorance or lack of inter-
est on the part of the doctor, or because the doctor
shows his feeling that, as a neurotic's troubles or-
iginate within himself, he should correct them un-
aided.
The term nervous indigestion is used to include
all those gastrointestinal disturbances for which no
organic cause can be found. They can be either
motor, sensory or secretory in nature. One should
make the diagnosis only after a careful and pains-
taking history, a thorough physical examination
and proper laboratory and x-ray procedures, and
often the opinion of a specialist in various fields is
necessary. Many conditions cause disturbed diges-
tion. Gallbladder disease, ulcer, appendicitis,
cancer and parasitic infestation are common
causes within the gastrointestinal tract, and eye-
strain, cardiovascular-renal disease, brain and cord
tumors, arthritis of the spine, diseases of the thy-
roid gland, tuberculosis and allergy frequently
cause indigestion. It is also well to remember that
functional and organic disease can be found to-
gether. All too often is a diagnosis of neurosis
made and later, to the detriment of the patient and
the regret and humiliation of the physician, it is
found that organic disease is present and accounts
for the symptoms.
The one fundamental principle in dealing with
patients with nervous indigestion is to treat the
patient behind the disease. In an organic condition .
we focus our attention directly on the lesion in
question; in a functional condition we must include
the whole patient — his mental and physical state,
and in so far as possible his environment. It is
hoped in this paper to bring out certain fundamen-
tal principles underlying the management of these
neuroses, realizing at the same time the futility of
attempting to discuss all the possible useful meas-
ures in combatting them. Under the first heading
may be considered the attitude of the physician to
the patient.
Physici.\x .\nd Patient
Neurotic people are as a rule sensitive, high-
strung and emotional and their first impression of
a doctor often decides his usefulness to them. As
the management of the nervous patient begins with
the examination it is highly important that the
proper relationship be established at this time. It
is obvious that the examination and the history
must be thorough and painstaking, also sympathetic
and reassuring to gain the patient's confidence and
faith which is so essential to success in treatment.
Once established, this relationship should be care-
fully fostered by the physician on every occasion.
FSVCHVOTHER.^PY, INSTRUCTIONS IN MeNT.41, .\ND PhYSIC.W.
Hygiene
Just as in organic disease we try to spare a dis-
eased organ by rest of its function, it is important
in functional disease to put the patient's mind at
rest. In some cases this is readily accomplished
by giving the patient a proper insight into his con-
dition. !Many develop symptoms and consult us
when thev hear of the illness of some friend, neigh-
♦Presented to the Seaboard Medical Association, meeting at Old Point Comfort. Va., December 3rd to 5th, 1935.
Januan-, 1936
.UAXAGF.MEXT OF XERVOUS INDIGESTION— WhUaker
bor or kinsman being diagnosed ulcer or cancer.
This type of patient usually loses interest in his
digestive tract when, after a careful study, no or-
ganic basis for his sj'mptoms is found. Far
less simple is the management of the case in
which the basis of the neurosis is some circum-
stance beyond the ability of any physician to con-
trol. The constitutionally inadequate individual,
the person harassed beyond measure by financial
insecurity, domestic unhappiness, or vain regrets —
each is an individual problem requiring individ-
ual guidance. The mental purgation of pouring
his troubles into the ear of an understanding
person is in itself of value. I often tell these
people that most everyone has a cross to bear in
life and if their problem cannot be solved at pres-
ent they will have to accept it in the best manner
possible and live with it as best they can. It is
both useless and foolish to tell them not to worry.
Tell them to worry as little as possible and do the
best that they can with a bad situation. So much
for the purely psychic element in the problem.
Where the neurosis is brought about by sheer men-
tal or physical exhaustion, then much is to be
gained by rest. Here again judgment and tact
must be used. It is foolish to tell the bread-winner
of a family that he must stop work entirely and
go to some expensive resort or sanatorium for a
rest. There could certainly be no mental rest un-
der a situation like that. Have him rest an hour
each day after the midday meal, remain in bed on
Saturday afternoons and Sundays, or have him
leave his work two afternoons a week for fishing
or golf or whatever he enjoys doing. Certain severe
cases require hospital care with complete bed rest,
forced feedings and isolation. The value of order,
px)ise and moderation can often be inculcated in the
classically unstable neurotic by the practice of con-
sistent hygienic habits. They must be taught the
futility of wearing themselves out and induced to
cultivate an attitude of calm and tranquillity.
Often a few more hours sleep than the patient is
getting may greatly aid in relieving his symptoms.
One person may get along very well with five or
si.\ hours sleep, whereas it will take eight to ten
hours for another. If they cannot sleep without
them, then, sedative drugs such as phenobarbital
or bromides should be unhesitatingly given in suf-
ficient dosage to get the proper effect.
Phvsiother.\py, E.xercise and Massage
These are at times valuable adjuncts in the treat-
ment of nervous indigestion. In the patient with
enteroptotic habitus certain orthopedic exercises are
of distinct value in improving posture and giving
tone to flaccid abdominal muscles. Where consti-
pation exists massage downward over the course
of the colon by the patient or a massuer t.ften gives
marked benefit. I am firmly convinced that a
properly fitted abdominal support benefits and
gives a sense of well-being to the enteroptotic typ)e
of individual. Ultraviolet radiation seems in some
cases to improve the appetite, increase resistance
to infection and increase the weight. A good coat
of tan improves the appearance of the patient and
makes him think that he has a healthier look. In
addition to the actual benefit derived from these
measures, they have the psychic effect upon the
patient of making him think that something is be-
ing done to help him.
Diet and Manner of Eating
I am convinced that the tv-pe of diet prescribed
is not as important as the manner of eating. Swal-
lowing our food whole, eating while discussing some
business problem or when emotionally disturbed,
eating amid wrangling and argument or when thor-
oughly fatigued — neither is conducive to good di-
gestion. If the patient is guilty of any of these
practices he should be told how the emotions may
affect digestion and urged to take plenty of time
with his meals, chew his food thoroughly and put
away care and worry while he is partaking of food.
Regular hours of eating should be insisted upon
and maintained. If the patient be guilty of glut-
tony he should be told to eat more sparingly. On
the other hand many a functional dyspeptic will be
found to have eliminated one article of diet after
another because he fancies that it disagrees with
him. Such a patient should be vigorously taken
in hand and made to retrace his steps until he is
again eating with relish and impunity everything
that he could use before the onset of the symptoms.
Since the time of Hippocrates a smooth diet has
been found to help many sufferers with indigestion.
.Alvarez, in his classic book. Nervous Indigestion,
emphasizes the virtues of such a diet and outlines
it in detail. It has been quoted practically ver-
batim in the latest edition of Beckman's Treatment
in General Practice, and it would be well worth
while for one interested in the management of di-
gestive neuroses to thoroughly familiarize himself
with it. The scientific basis for it is: first, that it
leaves a low residue; second, that cellulose is indi-
gestible; and third, that the normal gradient of
bowel irritability and rhythmicity is often reversed
in places, and that liquids will flow through re-
versed places while solids will not.
On the other hand I have seen functional dyspep-
tics with faulty elimination markedly benefited by
bran and prunes, and I respectfully submit that
Alvarez has possibly too vigorously denounced this
at-times-valuable substance. For the underweight
patient a pint of cream a day will usuallj' promptly
bring about the desired increase.
MANAGEMENT OF NERVOUS INDIGESTION— Whitaker
January, 1936
Drugs
Many cases of digestive neurosis are due to in-
somnia resulting from an anxiety neurosis and the
relief of this condition will of itself produce a cure.
It is necessary, however, that sleep-producing drugs
be continued over a sufficient period of time, for
weeks and at times for months. The various prep-
arations of bromides and barbiturates may be used.
Bromides if used over prolonged periods will often
produce a rash. The barbiturates are with certain
people both objectionable and dangerous; at times
instead of soothing the patient they make him
highly unstable. Particularly, have I noted this
with amytal and sodium amytal. Switching from
the bromides to the barbiturates and back again
often serves the purpose. The best of the barbi-
turates in my experience, the one that gives a more
restful sleep without an unpleasant hangover, is
ipral. The ordinary preparation of triple bromide
is as good a bromide preparation as we have, if
given in some unobjectionable vehicle. Another
excellent preparation is sulfotone, containing sul-
phur and a ^ of a grain of phenobarbital in each
tablet. If given one tablet three times a day and
at bedtime it seems to take the edge off a sensitive
nervous system without any depressing effect.
The various digestants are of doubtful value and
tonics and bitters are probably useless. One-half
to one ounce of whiskey taken before the midday
and evening meal certainly stimulates the appetite,
relaxes the patient and produces that sense of well-
being conducive to a good digestion. Insulin in
from 10- to 20-unit doses before each meal usually
produces, a. splendid appetite and quickly enables
the overwrought and underweight individual to put
on needed pounds. Particularly is the drug of
value in the patient hospitalized for a rest cure.
SirMTiIARY
In the management of cases of nervous indiges-
tion, I would emphasize: first, be sure of the diag-
nosis; and second, every doctor into whose hands
he falls treat every such patient with the same
respect that we treat a patient with organic disease.
Add to this sympathy and understanding and the
ordinary common sense in the selection of sugges-
tions and procedures to follow and the percentage
of satisfactory results will be gratifying.
Bibliography
1. Beckm.\n: Treatment in General Practice, Second Edi-
tion.
2. Alvarez: Nervous Indigestion.
3. Kantor: Treatment of Common Disorders of Diges-
tion.
4. NoYES: Modern Clinical Psychiatry.
5. Powe; Food Allergy.
6. Henry: Psychopathology.
The Pediatrician Looks at the Tonsil
(R. M. Pollitzer, Greenville, in Jl. S. C. IVIed. Assn., X-ag.)
Commonly in groping about for some cause of malnutri-
tion, loss of appetite, enuresis, epilepsy or what-not, the
doctor suggests that the tonsils should be removed.
.\ complete examination is time consuming and costs
money. The mother only too often is over-anxious to find
a short cut to the child's health. She wants something
done now. So the doctor then and there says "The tonsils
must come out."
Not enough judgment or discrimination is used in the
condemnation of tonsils.
Tonsillitis is common to all ages, especially so in child-
hood. .\t times there is abdominal pain, which often leads
to a mistake in diagnosis. Albumin in the urine is not
uncommon, and blood microscopically is not rare.
In my practice tonsillitis in infants between 7 months and
1 year has been extremely frequent. The diagnosis of ton-
sillitis, in my opinion is missed oftener by the doctor and
the mother, than any other with the possible exception of
otitis media. Where there is vomiting or diarrhea, and
even with abdominal pain not infrequently calomel or
castor oil has already been given.
Repeated attacks of tonsillitis are a menace to the child's
health, and probably the chief factor in hypertrophy of the
tonsil. Diseased or obstructive tonsils, not merely large
tonsils should be removed. "Repeated attacks of tonsillitis,
increasing in severity, with or without systemic disturbance
indicate disease." There is no evidence to support the
common practice of removal of tonsils for a susceptibility
to head colds, frequent sore throat, croup or asthma.
.\sthma is often thereby aggravated. Mere enlargement or
prominence without disturbance of breathing, without
glandular enlargement, and no history of disease is a con-
traindication to removal.
Where an infant has had several attacks of otitis media,
an adenoidectomy must be done. There is no reason why
one must operate on both tonsils and adenoids. Little ones
if possible should retain their tonsils for several years.
The operation should not be done during an acute illness,
or attack of tonsillitis, nor until at least 2 weeks have
elapsed. The best season is that time of the year when we
are free from cold weather, from much rain or strong
winds; for the little patient is going to be more exposed to
these for several weeks, and sinus involvement is not an
uncommon sequel. Where the child is being seriously dam-
aged or delay is considered dangerous, the tonsils may be
removed even during the first year. But where it is advis-
able three years is the minimum age for tonsillectomy.
I have known of 2 children who died in diabetic coma,
because the urine was not examined prior to the anesthetic.
Further there have been some deaths from hemorrhage,
which might have been prevented. Children with leukemia
have had their tonsils removed, and then soon after had
that diagnosis made. Minimum requirements are' a careful
history, a thorough physical examination of the whole
child, along with a urinalysis and a blood-study. This
last includes a leucocyte count, a differential count, a hemo-
globin estimation, and test for coagulability. After a ton-
sillectomy for several days, say 3 at least, the patient
should be kept in bed, and for several weeks after that,
he should be carefully protected from undue exposure, and
guarded from acute infections. Parents should be warned
that improvement will not be evident within a few days,
perhaps not for several months.
Nor should they be led to expect the cure of idiocy,
epilepsy, enuresis, and many other chronic ills.
(Continued on p. 22)
Januan', 1936
SOUTHERN MEDICINE AND SURGERY
The Selection of Obstetrical Anesthesia with Special Reference
to Local Infiltration*
W. Z. Bradford, :M.D., F.A.C.S., Charlotte, North Carolina
THE judicious choice of anesthesia is of
great importance in obstetrics. While the
role of anesthetics as a factor in infant and
maternal morbidity and mortality is difficult to
evaluate, certain baneful results of their misuse are
evident. Among these are the possible harm of
deep general anesthesia to the respiratory center
of an unborn infant prior to a difficult operative
delivery, particularly when that infant is already
partially asphyxiated; the influence of ether or
chloroform upon the maternal organs when in a
state of acidosis as is found in the toxemias of
pregnancy, or in the dehydration and exhaustion
state of prolonged labor; and the irritation with
resulting dissemination of infection from the use
nf these agents in the presence of acute or chronic
respiratory infections complicating labor.
For a number of years the influence of the Chi-
cago Lying-in, and more particularly of Dr. De-
Lee through his annual year book, has been af-
fecting medical thought in calling the attention
of the profession to the need of proper selection
of obstetrical anesthesia, and especially to the safe-
ty and wide field of application of local infiltra-
tion. The subject has grown to be of such im-
portance that, at the recent meeting of the Amer-
ican ^ledical Association, the section on Obstetrics
and Gynecology devoted an entire morning to a
symposium on anesthesia in obstetrics.
The passage of responsibility in this matter to
the anesthetist is begging the issue. The trained
anesthetist is available to only a limited number
of patients. In 1933 of the more than 75,000
births in North Carolina only 8 per cent, were in
iiospitals and in many of these institutions trained
anesthetists were not available. The problem of
evaluation and discrimination in the prevention of
pain at delivery is the responsibility of every phy-
sician assisting at childbirth.
There is no presumption that the discussion of
anesthetics which follows represents the last word
on the subject. This is a paper of personal experi-
ences and many of the conclusions are those of an
individual.
Ether
.\ wide margin of safety and low toxicity justi-
fies for this agent an extensive usage. This is
especially true when the physician is dependent
upon a nurse or an entirely untrained attendant
for administration. For relaxing a tonic uterus
where a slow fetal heart indicates anoxemia, ether
greatly improves the prognosis of the instrumen-
tally delivered infant. Its limitations are briefly
as follows; a long latent period prior to uncon-
sciousness forbids its prolonged use in the second
stage of labor, also the tendency to uterine inertia
inhibits the bearing-down effort of the perineal
stage; the irritating effect upon the respiratory sys-
tem prohibits its use in any infection of the upper
or lower respiratory tract; acting as a protoplas-
mic poison and increasing glycogen consumption,
its use in large quantities in the dehydrated and
exhausted state following a prolonged labor is open
to serious question. Our chief use for this drug
has been late in the first stage of a prolonged labor
— usually due to an occiput-posterior position —
by rectal instillation analgesia is obtained lasting
from 2 to 4 hours. With the odor of ether on the
patient's breath in S to 10 minutes, excellent an-
algesia and amnesia results, and the injection may
be safely repeated within a few hours.
Chloroform
The universal use of chloroform in obstetrical
anesthesia, from the days of Sir James Y. Simpson
where the sponsorship of royalty gave an impetus
which grew for many decades, makes any critic
of its use substantiate his argument. The late
John O. Polak said that in his entire experience
he failed to see harmful effects from chloroform
though used on thousands of patients on his ser-
vice. The prompt analgesia following 2-i drops
on an open mask and the lack of mucous mem-
brane irritation make it readily adaptable in the
second stage of labor; under its influence the co-
operation of the parturient materially shortens the
duration of labor. Harmful effects upon the child
have seldom been reported. While uterine inertia
frequently follows its sustained use over an hour, we
have employed chloroform by light drop intermit-
tently with contractions for over three hours upon
numerous patients without demonstrable injury.
Dr. Potter, I understand, uses this agent routinely
in delivery. It is certain that no anesthetic is capa-
ble of relaxing a uterus as promptly and as com-
pletely as chloroform and with the ease and success
of version dependent upon relaxation it follows that
usually the successful version exponent is a chloro-
form enthusiast. However, we are in accord with
•Presented to Seventh District (N. C.) Medical Society, meeting at Wadesboro, Novemljer ]2th, 1935.
SELECTION OF OBSTETRICAL ANESTHESIA— Bradjord
January, 1936
Rucker, that the preHminary administration of
adrenalin, 1 c.c. of 1:1000 solution, gives prompt
uterine relaxation and permits a successful version
under ether or nitrous-oxide anesthesia.
In the past four years I have seen three fatal
cases of acute liver necrosis or acute yellow atrophy,
and two cases of liver injury of an advanced degree
with recovery. Chloroform was employed for de-
livery in two of the fatal cases while in the third
the liver pathology was present prior to delivery.
In the group with recovery one was delivered under
low spinal anesthesia by vaginal hysterotomy and
the other permitted to deliver spontaneously with-
out relief. All of these women had both hemolytic
and obstructive jaundice, a high icterus index, and
were desperately ill. Stander has written exten-
sively on delayed chloroform poisoning in pregnancy
and the vulnerability of the liver of a pregnant
woman is manifest in the high percentage deaths
from chloroform and arsenic that occur in preg-
nancy. The low glycogen reserve, the secondary
anemia, the calcium depletion, the compensated
acidosis and other changes in body chemistry are
physiological components of pregnancy which pre-
dispose to liver injury from any toxic agent. Chlo-
roform is a protoplasmic jxiison with a predilection
for liver cells which produces further glycogen de-
pletion and further reduction in body pH. Chlo-
roform should never be used in the presence of
toxemia of pregnancy. The recent investigations
in the physiological chemistry of the pregnant wo-
man and the published clinical reports of liver
injury, from even small amounts of chloroform,
given to susceptible patients, make the routine em-
ployment of chloroform in obstetrical anesthesia
open to valid criticism.
Nitrous Oxide
Nitrous oxide with oxygen, administered by a
competent anesthetist, constitutes one of the joys
of the practice of obstetrics. The harmlessness of
the gas and the immediate analgesia permit its
intermittent use for hours without diminution in
the force or duration of uterine contractions. The
stimulating effect of a mixture rich in oxygen upon
mother and child is especially valuable prior to
forceps extraction. Maternal rebreathing at the
time of crowning of the fetal head produces a high
carbon-dioxide concentration thus stimulating the
infant's respiratory center and the welcome cry
usually promptly follows delivery. The expense
and necessity for a skilled assistant are its only
disadvantages. Its inability to relax a tonic uterus
limits is use in the presence of a contraction ring
or where the uterine cavity must be invaded as in
an impossible breech presentation, or doing a ver-
sion.
Cyclopropane
Our experience with cyclopropane has been lim-
ited to 12 to 15 cases. In the early group the high
oxygen content resulted in a long latent period
prior to the institution of respiratory effort by the
infant. One unexplained infant death occurred in
a section; the fetal heart sounds persisted 30 min-
utes but no effort at breathing could be initiated. No
autopsy was performed. The depth of anesthesia
obtained as well as expense of the gas prohibit its
intermittent use in the second stage of labor. In
a second smaller group results have been most satis-
factory. Cyclopropane requires an anesthetist skill-
ed in its administration.
Barbiturates Intravenously
Several years ago we reported at a staff meeting
our results on 15 patients given pernoston intra-
venously. This barbituric acid compound, syn-
thesized with a bromine radical, has been used
extensively at the Sloane Maternity Hospital in
New York and we aided in its experimental use
on approximately 100 deliveries at Bellevue Hos-
pital in 1930. The depth of anesthesia obtained
by this drug does not permit of artificial delivery
without restraint, but the remarkable analgesia and
amnesia satisfy the patient's demand for a pain-
less childbirth. This and all other intravenous de-
pressants were discontinued following the develop-
ment of cyanosis and the falling of respiration to
6 per minute required artificial stimulation for sev-
eral hours. Intravenous analgesics and anesthetics
once administered cannot be removed and there is
no field for their use in the conservative practice
of obstetrics.
Splnal Anesthesla
Prior to our interest in local infiltration we em-
ployed spinal anesthesia for delivery in the presence
of a number of obstetrical complications. Contrary
to the common experience little difficulty was ex-
perienced in making the spinal puncture, either
because of the abdominal tumor or the pains of
labor. Splendid results were obtained in a few
cases requiring major obstetrical surgery — includ-
ing cases of preeclamptic toxemia, active pulmonary
tuberculosis and upper respiratory infections. Fifty
mg. of novocaine without barbitage results in an-
esthesia sufficient for forceps, episiotomy and re-
pair. The only complication was marked uterine
atony with postparteuni hemorrhage requiring
packing and blood transfusion in two cases. This
tendency, and the lack of a trained assistant to
follow the patient's blood pressure and pulse, re-
sulted in the experiments in local infiltration and
local block.
That the pregnant woman is a poor spinal an-
esthesia risk has been stated repeatedly, and num-
Januar)', 1936
SELECTION OF OBSTETRICAL ANESTHESIA—Bradford
erous tragic illustrations of this fact have been
reported. In the Margaret Hague Maternity in
Jersey City, the largest maternity in this country,
this method of relief is used in from 40 to SO per
cent, of all deliveries. Dr. Cosgrove states that
the safety of spinal anesthesia in the pregnant
woman depends upon the following details: 1 —
Xo barbitage. 2 — Low injection. 3 — Novocaine
crystals. 4 — Nq Trendelenburg. S — Novocaine
and adrenalin. 6 — Proper selection of cases. The
anesthesia permits a beautiful abdominal section,
usually with a minimal blood loss. Our experience
has been limited to three cases.
Local Infiltration" and Local Block
In the past 12 months we have employed local
infiltration or local block in 29 major obstetrical
procedures, chiefly complications, in which, for eco-
nomic or other reasons, nitrous oxide could not
be satisfactorily obtained. The preliminary anal-
gesia in the first stage of labor was varied — mor-
phine and scopolamine, morphine and magnesium
sulphate, sodium amytal, sodium amytal and scopo-
lamine, sodium alurate, ether by rectum. The
harmlessness to mother and child, the adaptability
to home and hospital delivery, the minimum cost,
and the lack of need for a trained assistant justify
a detailed report of this experience.
Technique
A small intradermal wheal is made at a point
midway between the anus and an ischial tuberos-
ity. With the index finger of the left hand in the
vagina the needle is inserted in this wheal and,
while injecting, is advanced toward the ischial spine.
A slight resistance is felt when the fascia plane is
encountered, the plunger is withdrawn slightly to
make sure it is not in a vein, and approximately
20 c.c. of 1 per cent novocaine is injected in the
substance of the levator ani in the region of the
pudendal nerve, the point of the needle lying just
proximal to the ischial spine.
.'\ similar injection is made on the opposite side,
followed by superficial infiltration of the labia. A
total of approximately three ounces of the solution
used for the nerve block and the infiltration and
perineal relaxation and anesthesia are obtained suf-
ficient for perineal forceps, spontaneous delivery or
superficial episiotomy.
In cases requiring more extensive surgical pro-
cedures, as midpelvic forceps, manual rotation,
breech extraction, or extensive episiotomy and re-
pair, the parasacral or antesacral infiltration is used.
Technique: (After the method of Tucker and Bena-
ron of Chicago as reported in the June, 1934, issue
of the American Journal of Obstetrics and Gyne-
cology.) With the gloved finger in the rectum an
intradermal wheal is made at the level of the sacro-
coccygeal joint from lJ/^-2 cm. on either side of
the midline. The IS cm. needle is grasped by the
hub and introduced through the wheal. The point
of the needle is advanced over the edge of the
last sacral vertebra, and along the anterior aspect
of the sacrum in contact with the bone and parallel
to the midline. At a point from 6 to 7 cm. above
the sacro-coccygeal articulation the second sacral
foramen is encountered. If blood does not drip
from the needle, the syringe is attached, and as the
needle is withdrawn 60-70 c.c. of O.S per cent,
novocaine solution is deposited between the sec-
ond and fifth sacral foramina. The needle is then
withdrawn to the edge of the last sacral vertebra
and its direction changed to a slight angle up-
ward. It is advanced parallel to the midline and
at a point from 9 to 10 cm. above the sacro-coccy-
geal articulation the first sacral foramen is encoun-
tered. Approximately 1 ounce is injected here.
The needle is then withdrawn and approximately
10 c.c. is injected over the coccyx, between the
coccyx and rectum, thus blocking the sacro-coccy-
geal plexus of nerves. The procedure is repeated
on the right side.
No attempt is made to hit the individual sacral
foramina. The injection consumes from IS to 20
minutes. No difficulty is encountered from the en-
gaged head. Care should be taken not to perforate
the rectum. This method of infiltration is contra-
indicated where immediate extraction is indicated
because of fetal asphyxia and in the presence of
local pelvic infection or frank intrapartum sepsis.
In this group of 29 cases local anesthesia was
selected of choice in 20 and of arbitrary election
for investigative purposes in 9. In the latter group
it was augmented by nitrous oxide in 3 cases and
by ether in 1. There was complete failure of anes-
thesia in 1 patient and partial failure in 1, a sup-
plementary means being used in the other 2 cases
to produce unconsciousness at the time of delivery.
Following is a brief summary:
Total cases: 29 (pathological 21, non-pathological 8).
Source: Private 22, consultation 4, maternity clinic 3.
Maternal deaths 0, stillbirths 0, neonatal deaths 2 (pre-
maturity 1, pyelo-nephritis 1).
Therapeutic abortions 2.
Vaginal deliveries 27, abdominal deliveries 2.
Primipara 27, multipara 2.
White 27, Negro 2.
Delivery
Spontaneous delivery 3.
Therapeutic abortion 2.
Low forceps 13.
Mid-pelvic forceps 5 (all transverse arrests).
Kielland 7.
Barton 1.
Manual rotation and Hawkes-Dennen 2.
Breech extraction 1.
Spontaneous breech 1 (Piper forceps).
Episiotomy and repair 19.
SELECTION OF OBSTETRICAL ANESTHESIA— Bradford
January, 1936
Repair 2.
Third-degree laceration and repair 1.
Cesarean section 2.
Complicating Pathology — 20 cases
Eclampsia — 3 cases
No. 1 Induction of labor, convulsion with vertex on
perineum, fetal heart 200.
No. 2 Deep transverse arrest of posterior occiput, very
toxic, no progress for several hours.
No. 3 No convulsions for 5 days, sloughing of labia,
purulent vaginitis, cesarean section.
Pre-eclamptic toxemia — 6 cases
No. 1 Induction of labor, outlet forceps and episio-
tomy.
No. 2 Fetal heart slow to 60, meconium, fetal distress.
No. 3 Pulse 120, t. 100. Outlet forceps and episiotomy.
No. 4 Induction of labor. Low forceps and episiotomy.
No. 5 Induction. Upper resp. infection. Spontaneous
following episiotomy.
No. 6 Fulminating pre-eclampsia. Cesarean section.
Intercurrent Infections — 4 cases
No. 1 Osteomyelitis of mandible, purulent gingivitis
with internal drainage, t. 103, disproportion trans-
verse arrest.
No. 2 Influenza and asthma. Spontaneous delivery.
No. 3 Acute upper respiratory infection. Pulse 120.
Arrest at outlet. Outlet forceps and episiotomy.
No. 4 Acute upper respiratory infection with pre-
eclampsia. Spont. delivery. Episiotomy.
Acidosis and Maternal Exhaustion — S
No. 1 Labor 60 hours. Pathological contractions. Low
forceps and epis.
No. 2 Labor 38 hours, vomiting, pulse 120. Transverse
arrest. Manual rotation and midpelvic forceps.
No. 3 Laor 40 hours. Rapid pulse, manual rotation,
midpelvic forceps.
No. 4 Labor 48 hours. Persistent vomiting and dis-
tention, p. 150. Kielland forceps and episiotomy.
No. S Labor 24 hours. Vomiting, acetone odor to
breath. Low forceps.
All of this group were difficult obstetrical problems, all
occiput posteriors with hard difficult labors, all supported
with intravenous glucose and saline and analgesia during
first stage.
Prematurity — 1
Extraction following 48-hour labor, no progress for sev-
eral hours. Breech at inlet.
Active pulmonary tuberculosis — 1 (D & C)
Advanced cardiac disease — 1 (D & C)
No complicating pathology 9
Spontaneous breech (Piper forceps) No. 1.
Repair of laceration and episiotomy (vomiting, rapid
pulse) No. 2.
Nos. 3, 4, 5, 6, 7 Elective prophylactic forceps and
episiotomy following anterior rotation of occiput with
caput crowning.
No. 8 Episiotomy, spontaneous delivery, repair.
No. 9 Low forceps, third degree laceration, repair. Dem-
onstration case. Healing by primary union.
Summary
The need of evaluation and discrimination in
the choice of obstetrical anesthesia together with a
brief summary of the more popular anesthetics has
been discussed. The comparative safety and effi-
ciency of local block and local infiltration has been
presented through the medium of 29 major pathol-
ogical cases delivered by this method.
The Pediatrician Looks at the Tonsil
(Continued from p. IS)
Nothing in this paper should be construed or is intended
as a condemnation of the operation when indicated and
done by skilled men.
(Discussion by Dr. D. L. Smith, Spartanburg:)
No child should have the tonsils removed on one exam-
ination of the tonsils. The school nurse goes around and
looks at the tonsils and condemns them, the parents are
thoroughly educated, and the tonsils are removed. This is
being done in South Carolina and done frequently.
I think the tonsil has a definite mission in the body. It
is very desirable that the child retain his tonsils until the
second year of school life.
(Discussion by Dr. C. L. Kibler, Columbia:)
Whether it is a small tonsil or a large tonsil, whether it
is imbedded or not, whether it has crypts from which you
can squeeze out debris, pus, etc., it matters not. But if
you have a red Hne running all the way down on the ex-
ternal pillar, the tonsil is diseased. It is evidence of deep
infection, and I would unhesitatingly say, remove them.
(Discussion by Dr. J. W. Jervey, jr., Greenville:)
One thing I do consider as a contraindication for tonsil-
lectomy, hypertrophy of the lymphatic tissue in the lym-
phoid ring. When I see hypertrophy of all that tissue I
do not believe that tonsillectomy will accompUsh the desired
result.
(Discussion by Dr. M. R. Mobley, Florence:)
Let's bring this thing home to ourselves. If your little
girl comes home from school with a note saying her tonsils
should come out, do you telephone to an otolaryngologist
and say: "I want you to take my child's tonsils out"?
Anyone who advises removal of that tonsil needlessly is
thoughtlessly jeopardizing the life of that child. But when
that tonsil becomes so infected that it acts as a focus of
infection from which bacteria can be disseminated to the
various organs of the body, then is the time to remove that
tonsil, and not until then.
Infliience of Hygroscopic Agents on Irritation From
Cigarette Smoke
(W. F. Greenwald, New York, in Med. Rec, Dec. 4th)
A series of studies pointed to a most surprising fact —
that the main source of irritation from cigarette smoke
was not the tobacco but the hygroscopic agent added to
tobacco to maintain the moisture content. The hygroscopic
agent commonly used is glycerine. Burning glycerine forms,
among other smoke products, a highly irritating and toxic
substance. Diethylene glycol has all the desirable proper-
ties of a hygroscopic agent but cannot on combustion pro-
duce an irritant such as that produced by the burning of
glvcerine.
Use of Insulin in Non-Diabetic Tuberculous Children
By the use of insulin an acceleration of the rate of gain
in weight was obtained in 15 of 17 non-diabetic tuberculous
children. Of these 15, 13 maintained the gain of weight
induced by insuhn after the insulin was discontinued. This
follow-up period in most cases was three months.
The weight gained after the fourth week of insulin ther-
apy was too small to warrant its use for a longer period.
The subjective reaction of the children to the insulin is no
criterion of its efficacy.
Januarj', 1936
SOUTHERN MEDICINE AND SURGERY
Case Report
Cholecystostomy in January- Cholecystoduo-
denostomy in april- drainage of lumbar
Abscess in :May: Still a Problem
L. A. Crowell, M.D., F.A.C.S., Lincolnton, N. C.
Lincoln Hospital
A MATRON, aged 44, admitted to the Lincoln
Hospital January 11th, 1935, complained chiefly of
jaundice, and intense itching all over the body,
also of loss of weight and energy, and of having
passed clay-colored stools and, at times, dark red-
dish-brown urine. Additional factors were loss of
appetite, indigestion, flatulence, abdominal disten-
tion, irritability and extreme fatigue — the latter two
complaints from itching making sleep impossible.
She states that, with the exception of some at-
tacks of kidney colic prior to October, 1931, her
health was good. At this time, after a normal day
and going to bed feeling well, she awakened about
3 a. m. aching all over and feverish and vomited
a large quantity of fluid and undigested food. She
had three such attacks that fall, about one month
apart. There was no pain or jaundice with the
attacks. She felt well iDctween the attacks, had a
good appetite and her usual weight and strength.
From December, 1931, to December, 1933, she
had four or five similar attacks at longer intervals,
none lasting longer than a day or two. Between
these attacks, as between the first three, she was
well. From October, 1931, to December, 1933, she
was treated at intervals for stomach trouble and
anemia. During that two-year period the hemo-
globin fluctuated between 50 and 60 per cent.
In Christmas week of 1933 the palms and soles
began to itch. Itching persisted with slight in-
crease, and April 2nd, 1934, she first noticed jaun-
dice. From that time on the itching became pro-
gressively worse, until she was hardly able to rest
at all. At no time had there been pain.
On May 7th, 1934, x-ray pictures were taken
of the gallbladder area following the ingestion of
dye. The films showed a density of irregular shape
within the left kidney shadow which was diagnosed
as a calculus; no gallbladder shadow.
She had not complained of any pain in the kid-
ney area or anywhere else, but further questioning
revealed that she had had typical kidney colic on
the left in 1923, in 1925 and in September, 1933,
none lasting over three days, but each so severe
that morphine was required.
She continued to lose weight, become more ane-
mic, and the itching and indigestion became worse
and worse. In June, 1934, she was seen by a con-
sulting internist, who advised continuing the medi-
cal trea'ment.
Upon admission to the hospital January 11th,
1935, the following positive physical and laboratory
findings were recorded: t. 98; p. 88; r. 20; b. p.
110/70; there was an intense yellow pallor of the
entire skin with a suggestion of green in the sclerae,
the facies tired and drawn, tongue heavily coated.
The heart and lungs appeared normal, the liver
tender and enlarged to three finger-breadths below
the costal border. There was no tenderness in the
lumbar region. The w. b. c. was 16,800 — polys.
87; lymph. 10; bas. 3; the r. b. c. 750,000; the
hgbn. 35 per cent., clotting time 7 min. The urine
was acid and showed 1-plus albumin and ISO pus
cells to the 1. p. f. A single K. U. B. film showed the
coral stone in the left kidney to be larger. X-ray
of the gallbladder region, using the new intensifi-
cation technique of Illick and Stewart, showed no
gallbladder shadow.
The patient's condition growing steadily worse,
a tentative diagnosis of carcinoma of the head of
the pancreas was made, and the patient was oper-
ated on for three seasons: first, to afford tempo-
rary relief if the trouble should prove to be car-
cinoma; second, to give the benefit of the possi-
bility that the obstruction might be due to low-
grade inflammation of the head of the pancreas;
third, because of the possibility that the obstruc-
tion might be due to stone. In this connection.
Dr. Frank H. Lahey reports a case of persistent
and silent jaundice in which, on operation, a stone
was found in the common duct, the removal of
which cured the patient.
During the eleven days prior to the operation
an attempt was made to build up the patient's re-
sistance and to reduce the clotting time by the
administration of liver extract, iron and arsenic,
calcium chloride, and calcium lactogluconate.
During this period the hemoglobin was raised from
35 per cent, to 50 per cent., but the clotting time
remained at 7 minutes.
On January 21st, under ether anesthesia, an
oblique incision was made in the upper right abdom-
inal quadrant, and the liver found symmetrically en-
larged and soft, the gallbladder slightly distended
but not diseased, the gallbladder and ducts free of
palpable stones. The head of the pancreas was
diffusely enlarged and hard, but not definitely ma-
lignant. The gallbladder was opened and consider-
able dark thick bile was evacuated, no stones found.
A cholecystostomy was done.
Reaction to the operation was quite satisfactory;
bile flowed copiously from the wound, the jaundice
slowly diminished. The itching was less at the end
of a week and ceased between the third and
fourth week, but jaundice was apparent for four-
teen weeks.
SOUTHERN MEDICINE AND SURGERY
January, 1936
Six days after the operation blood began oozing
from the wound. Pain appeared in the knee and
elbow joints the same day. Calcium preparations
and hemostatic serum were given to no avail. The
bleeding from the wound increased, the gums be-
gan to bleed, blood appeared in the urine, was
vomited and passed by bowel. Pituitrin hypoderm-
ically, adrenalin and tannic acid solutions locally,
tight packing of the wound, more calcium and
hemostatic serum were used. The bleeding around
the wound was finally checked by searing with the
actual cautery, and the tannic acid and adrenalin
applications to the wound and to the gums finally
stopped the oozing. Between January 28th and
February 17th eight transfusions of citrated blood,
averaging 475 c.c. each, and a total of 750 c.c. of
normal saline solution, were given. The stools were
clay-colored from February 1st through the 18th,
except for three or four days after January 30th
when they were black with blood.
Digestive disturbance followed which, with the
dehydration from the loss of fluid from the biliary
fistula and the rather severe reaction from one of
the transfusion — the last one — reduced the patient's
condition almost to extremis.
After the bleeding was controlled, improvement
was gradual; the appetite and digestion bettered
and brought slight gain in strength. March 6th
the patient was able to sit up in bed and ten days
later she was out in a rolling chair for a short
time each day. During February and the early
part of March the amount of pus in the urine in-
creased greatly. This was combated with urinary
antiseptics and frequent bladder irrigations. There
was no pain in the lumbar region at this time.
By April 2nd, 70 days after the first operation,
the patient's condition was considered good enough
to permit steps to stop the copious drainage of
bile from the biliary fistula. On that date, under
local procain anesthesia, a new incision was made
along the line of the old one, the granulated tissue
dissected out, the gallbladder separated from
numerous adhesions and opened. Into this opening
the small end of a mushroom catheter was inserted
and fastened, the other end of the catheter being
pushed into the duodenum, an area of which had
first been encircled by stitches of catgut and then
punctured with the cautery. The peritoneal coats
of the gallbladder and duodenum were next brought
together by two lines of stitches and a tab of omen-
tum was tied over the suture line and the abdomen
closed. Button tension sutures and skin clips were
used to make the wound approximation more se-
cure. The patient experienced no pain and left the
table in good condition.
We chose to connect the gallbladder to the
duodenum rather than to stomach, jejunum or any
other part of the intestinal tract, because it seemed
sound physiology to revert the bile to that part of
the intestinal tract into which it normally is emp-
tied. While it is more difficult to anastomose the
gallbladder to the duodenum than to the stomach,
we thought the use of the mushroom catheter
would more than balance the technical difficulty.
The use of a mushroom catheter for making this
anastomosis is ideal. I would be afraid to make
an anastomosis of this kind without some device
to keep the passage patent, A ^Murphy button can
be used but we have no assurance which way the
button will pass when it sloughs out.
.Although we realized the poor operative risk,
something had to be done to stop the loss of fluid
and to restore the bile to the body economy. With
an external biliary fistula there is a waste of pig-
ment for hemoglobin formation; loss of calcium
with its influence on blood clotting and on harden-
ing of bone, and the increased tendency to tetany;
loss of sodium salts and impaired digestion and
waste of fat and of ingested calcium. In the ab-
sence of normal alkali, calcium of the food com-
bines with the fatty acids in the intestines, forming
an insoluble calcium soap, so that both the fat and
the calcium are lost to the body. Normally, cal-
cium is held in combintion by the bilirubin of the
bile.
The patient's condition, appetite and digestion
promptly improvved, gaseous distention promptly
ceased, bowel movements were normal in time and
color. Everything ran smoothly until .\pril 20th,
eighteen days after the cholecystoduodenostomy,
when she began to have fever — t. 99 to 102^/2.
The urine, which had become clear, showed pus
cells in increased numbers. On .April 24th her
weight was 84 pounds.
On May 2nd dull pain was felt in the left lumbar
region which radiated into the left lower abdominal
quadrant. The pain gradually increased with all
the signs of toxin absorption.
A mass appeared over the left kidney area May
13th, which gradually grew larger and tenderer.
.■\t this time the urine was loaded with pus, the
white cells were 19,000, with 91 per cent, polymor-
phonuclears.
A diagnosis of lumbar abscess was made, and on
May 18th, forty-five days after the gallbladder-
duodenum anastomosis, under local procain anes-
thesia, a transverse incision was made over the
center of the lumbar tumor. After cutting through
the quadratus lumborum muscle we entered a large
abscess cavity, from which was evacuated about
300 c.c. of thick yellowish-green pus. A hurried
examination of the cavity failed to reveal any
connection of it to the left kidney, but we are
reasonably certain there was such a connection.
Januarj', 1936
SOUTHERN MEDICINE AND SURGERY
2S
Although the patient complained of no pain at any
time during the operation, she fainted and, when
the cavity was entered, had a convulsion. The
pulse for a few minutes was 160 or more. The
cavity was quickly wiped clean and packed. On
leaving the table the pulse was 130 and the patient
was conscious.
Immediate improvement followed, the wound
draining freely. During the week following several
gravel passed by the natural route.
About July 1st, the abscess cavity began drain-
ing less freely. The t. and w. b. c. — with
polymorphonuclears predominating — began again to
rise, and signs of toxin absorption reappeared. On
July 22nd, 110 days after the cholecystoduodenos-
tomy, a bismuth subnitrate paste was introduced
by means of a catheter as deeply into the abscess
cavity as possible, and anteroposterior and lateral
films made. These showed that the cavity extend-
ed to and connected with the large coral stone pre-
viously mentioned. On the following day, under
local anesthesia supplemented by a small amount
of ether, the previous lurnbar incision was enlarged
and entered. From the bottom of the cavity there
was removed a stone weighing '4 oz. A large
quantity of pus escaped from behind the stone.
The wound was packed and closed up to the drain.
The patient's condition again improved prompt-
ly. She is free of fever now, has no signs of tox-
emia and has gained 24 pounds since the last oper-
ation. She sits up practically all day, walks about
one hour each day and is rapidly gaining strength.
She now weighs 108 pounds.
The question now is, What will be the future
course of this case? Can it be reasonably assumed
that no more trouble will be experienced in the
biliary tract? Nine months have elapsed since the
jaundice began disappearing. On April 2nd, when
the anastomosis was done, the head of the pancreas
was smaller and softer than when the first opera-
tion was done. Have we sufficient grounds to as-
sume that the lesion which obstructed the common
bile duct is not malignant?
I wish to emphasize the point that, at each oper-
ation, the patient's condition was too serious to
warrant very extensive procedure.
What will be the ultimate outcome of the nephro-
lithiasis? I think we feel safe in assuming that
the left kidney has been destroyed. X-ray pictures
show definitely the increase in the number and
density of the stones in the left kidney area, and,
what is more alarming, the appearance and rapid
increase in the number and density of stones in the
right kidney area. We have not made a cystoscopic
examination because we did not think the informa-
tion would justify the procedure. At a later date a
cystoscopy will be done, and if the left kidney is
found to be out of commission and the right kidney
is functioning, we will remove the left kidney and
thereby stop the drainage from this source.
Addendum. — Since this case was reported at the
Wadesboro meeting of the Seventh District Med-
ical Society on November 12th, 1935, the fistulous
opening in the left lumbar region has healed. We
believe that the use of Beck's paste had much to
do with this healing. The patient is now in good
condition except for occasional attacks of right
renal colic. Her present weight is 121 lbs.
Xanthomatosis: Schuller-Christian's Disease
(Jos. Dauksys, Excelsior Springs, in Jl. Mo. State Med.
Assn., Dec.)
Xanthomatosis (Schuller-Christian's disease) is a disturb-
ance of lipoid metabolism with an irregularly periodic in-
crease in blood cholesterol, followed by the deposition of
cholesterol, and its esters in the reticulo-endothelial sys-
tem, usually at places where either infection or trauma has
produced with subsequent nodule formation, fibrosis, foreign
body giant cell formation and sometimes hyalinization.
Clinically, it manifests itself by the presence of a com-
bination of all 3 or any 1 or 2 of the major symptoms,
viz., bony defects of the skull, diabetes insipidus and ex-
ophthalmos. There are frequently other symptoms present
depending upon the localization of the deposits.
The male sex is more susceptible in the ratio of 2:1. It
is usually found in the first decade of life, though the oc-
currence may be grouped in three age periods, infantile,
juvenile and adult. Mortality estimates range from 25 to
33%.
A successful scheme of treatment has not yet been evolv-
ed although roentgentherapy has shown remarkable results,
especially in the treatment of local lesions. The evaluation
of the results of treatment has been rendered difficult be-
cause of spontaneous regression in some cases. In spite
of the occurrence of remissions, the actual improvement
noted in cases where roentgentherapy was used speaks
strongly for its use.
A review of the literature brings to light 123 cases which
appear to conform to this group; the one here reported
makes 124.
Onion Odor Removable
Howard W. Haggard and Leon A. Greenberg, New Ha-
ven, Conn. {Journal A. M. A., June 15th, 1935), state that
the odor given to the breath by onion or garlic comes from
the essential oil contained in these vegetables. The oil does
not, as has been suggested, reach the breath from aeration
of the blood in the lungs, from pulmonary secretion, from
salivary secretion, or in air passed from the stomach. It
arises solely from particles of onion or garlic retained in
the structure about the mouth. Brushing the teeth and
tongue and washing the mouth with soap and water fail
to deodorize the breath. Washing the mouth with a 30
per cent, solution of alcohol is ineffective. The breath can
be immediately and completely rid of the odor by washing
the teeth and tongue and rinsing the mouth with a solution
of chloramine. The chlorine liberated in the mouth reacts
chemically with the essential oils and deodorizes them. It
is probable that many cases of foul breath from other
cau.ses would be amenable to the same method of treat-
ment.
SOUTHERN MEDICINE AND SURGERY
January, 1936
D EPARTMENT S
HUMAN BEHAVIOR
James K. Hall, M.D., Editor, Richmond, Va.
Cyclic Civic Financing
James Henley, so I read in a newspaper de-
spatch from Petersburg, must return to the state
penitentiary in Richmond and there spend the re-
mainder of the days originally allotted by the Lord
to him. Convicted of having slain a neighbor in
1916, he was sentenced to the penitentiary for life,
but after having served ei^teen years, he was pa-
roled a year or two ago upon condition that he
violate no law of the Commonwealth. He was so
sent out amongst his fellow mortals, perhaps be-
fore the State of Virginia had become a saloon-
keeper. While celebrating the anniversary of th''
birth of his Saviour a few days ago in Danville, he
was arrested for drunkenness, his identity was
established by scrutinization of the palmar aspect
of a thumb, and back to the prison for life he
must go.
And I fell to wondering. The whole punitive
ritual is too much for my psyche. Did Henley
buy his liquor in a store owned and operated by
the State of Virginia? If so, did he not render the
State a service and the bootlegger a disservice, and
thereby do his best to help to support the govern-
ment of which he is a constituent member? Should
he be punished for such a patriotic effort? And if
so punished, should he be punished with unusual
severity? I think I have heard that such punish-
ment is against the constitution.
Is it not to be considered that in so punishing
him the State may be discouraging some of its citi-
zens from patronizing State liquor stores, and
thereby lessening the accumulation of revenue in the
State's treasury? Without money — liquor money
and all other sorts — how can the State educate its
children, care for its physical and mental cripples,
and maintain its high standing amongst its sover-
eign neighbors? If the State sells to Henley or
another the stuff that makes him drunk does not
the State become particeps criminis? That prob-
lem, what becomes of the snaJke that succeeds in
swallowing itself, and all such other abstrusities I
shall have to leave to the legalistic and theological
luminaries. It is too difficult to begin the year
with. A apologize for its presentation to you. But
v/hat do you suppose James Henley thinks of Vir-
ginia's punitive ritual?
On Avoidance of Ingratitude
I invite the attention of the unsubsidized mem-
bers of the congregation to the following para-
graph:
''Contrasted with these well organized hospitals
are those built for profit. Their owners soon find
that they are unintentional philanthropists and they
use every possible means to curtail expense, thereby
lowering their standards of care. The scarcity of
patients who have been able to pay for hospital
service during the past few years has quite forcibly
removed thoughts of dividends on hospital invest-
ments. With no interest in the welfare of their
community and no prospect of profits, such hos-
pitals are rightfully passing out of existence."
The excerpt is from a piece in The Modern
Hospital, May, 1934, by Dr. Lucius R. Wilson,
Superintendent, John Sealy Hospital, Galveston,
Texas. The title of the article is: Southern Hos-
pitals fit Themselves to Serve more Adequately.
The content of the contribution is a eulogium of
the Duke Endowment and the Julius Rosenwald
Fund.
One should not be surprised. The hospital of
which Dr. Wilson is Superintendent is thoroughly
foundationized. He speaks in derogation of doctors
working for a profit. Does any one suppose that
his superintendency constitutes an eleemosynary
service?
A group of Indian braves, led by their chief,
visited Washington City, and the Great Chief in
the White House assigned an army officer to show
them the sights of the Nation's Capitol. The offi-
cer asked the Chief what he thought of the great
mural in a gallery — in which a clash on the plains
was portrayed betwixt a troop of cavalry and
mounted Indians. But the arresting item in the
scene was a private soldier holding his pistol to
the temple of an Indian whom he had unhorsed,
and upon whose prostate neck he pressed down one
of his military feet. After long meditation the
Chief remarked: "White man made that picture."
And the white man continues to make pictures,
many of which call for interpretation.
Dr. Lucius R. Wilson does not propose to run
the risk of having his Foundation say to him what
David the Psalmist said in his bitterness about one
of his ungrateful week-end guests: "Yea, mine
own familiar friend, in whom I trusted, which did
eat of my bread, hath lifted up his heel against
me."
On Psychiatric Mediaevalism
Out in Saint Louis the other day, at the meeting
of the Southern jNIedical Association, Dr. W. L.
Treadway, Assistant Surgeon General, Division of
Mental Hygiene, United States Public Health Ser-
vice, Washington, read a paper before the Section
on Neurology and Psychiatry. He discussed: The
Significance and Content of Mental Health Admin-
istration. The paper should be read by every phy-
January, 1936
SOUTHERN MEDICINE AND SURGERY
sician in the country and by all intelligent laymen.
I remember that Dr. Treadway remarked that
psychiatry, as a public health problem, is being
dealt with about as stupidly as public health folks
dealt with physical diseases eighty years ago. And
he added that there is no hope of the situation's
being any better so long as the management of
mental hospitals is controlled by politicians and
by other laymen who know nothing about medicine.
How can progress ever come out of ignorance?
Most State hospitals are managed by boards of
directors composed of laymen — politicians and so-
called business men. The responsibility of selecting
the medical superintendents of such hospitals is
given to such lay boards. And not infrequently
they elect as superintendent a physician who knows
no more about psychiatry than the family doctor
knows, and who knows nothing at all about hospital
administration. Here in Virginia the five State
hospitals and several allied institutions function in
a general way under the auspices of the State
Board of Public Welfare. But that is an organiza-
tion of laymen, untrained in psychiatry and inex-
perienced in hospital management. Per contra, the
State Board of Health is composed largely of phy-
sicians, and the President of the Board is a physi-
cian. Yet no intelligent person can believe that
the problems with which the Boards of Directors
of the State Hospitals deal are smaller or less com-
plex than those with which the State Board of
Health deals. Why are those conditions relating to
mental sickness handled by laymen, and those
caused by disease of the body cared for by physi-
cians? Who knows?
Time was, of course, and not so long ago, when
the medical colleges gave no instruction in the
diagnosis and the treatment of mental sickness.
But that time has passed. .All medical schools
now give some instruction in psychiatry, and the
younger physicians know something about the im-
portance of mental hygiene. I am wondering how
much longer the younger doctors are going to be
willing for laymen to have charge of every State's
biggest and most difficult medical problem — mental
sickners.
EYE, EAR, NOSE AND THROAT
For this issue, Neilson H. Turner, M.D., Richmond, Va.
Associate in Ophthalmology at the Med. Col. of Va.
Some Ophthalmological Pitfalls and How to
Avoid Them
Pitiful cases of hopeless blindness in which the
sight could have been saved — cases that I have
seen in my private practice and at the Medical
College of Virginia Dispensary — have prompted me
to carry this message to my fellow practitioners.
In addition to these terrible afflictions of blindness,
think of the number of such cases throughout the
entire country, and of the economic loss and the
burden placed upon the taxpayers in taking care
of them. In this paper no reflection is implied or
intended on any one, but it is hoped that by em-
phasizing a few simple rules, vision which in many
cases would be lost from a lack of proper attention
will be saved. These rules have been stressed
over and over, they are not repeated often enough
or as forcefully as the situation demands.
If a patient, one past middle life in particular,
complains of failing vision and if on throwing a
light into the pupillary space a grey reflex results,
do not jump to the conclusion that he is getting
cataract, and tell him to wait until it matures to
go to the ophthalmic surgeon to have it removed.
The grey appearance may be due to senile changes
(sclerosis) taking place in the lens. Or, if he
does have cataract there is always the possibility
of other serious intraocular or optic-nerve condi-
tions — such as extensive choroiditis, simple glau-
coma, optic atrophy, uveitis and optic neuritis —
being present, all of which seriously threaten vis-
ion. The visual defect may be due to one of these
causes, and in these cases early proper attention
is necessary to save vision. Even in the very early
stages the very best attention is needed.
On July 11th, 1934, a woman was brought to me by
her husband to have cataracts removed. She had been
referred by her sister-in-law, a patient of mine. On throw-
ing a light into the pupillary spaces there was a grey
reflex, but on examination with the ophthalmoscope each
lens was found to be transparent. Both eyes were in a
state of advanced glaucoma simplex — with the intra-ocular
tension in the right at 45 mm. and that in the left at SO
mm. — and she was hopelessly blind. As the husband
would not agree to an operation for the relief of the
pain, pilocarpine was ordered. At this point she said that
nearly a year ago when she complained to her family
doctor about her sight failing, he threw a light into her
eyes and then told her that she had cataract, but to "wait
until you become blind, then go to the eye doctor to have
them removed." Now, had this patient received the indi-
cated care early enough, her vision might have been saved,
or at least the evil day would have been postponed for
an indefinite period.
A gentleman, Si years of age, came to see me on Au-
gust 24th, 1931. His vision was 3/200 in his right eye and
7/200 in his left eye, no improvement with lenses. There
was extreme pallor of both optic discs with degenerative
changes in the fundi. The lens of each eye was unaffected
and the intra-ocular tension was normal by tactile sense.
On throwing a light into the pupillary space a grey reflex
resulted. This patient had also been told to wait until
the cataracts ripened and then go and have them removed,
but his trouble was optic atrophy, and it was so far ad-
vanced as to make saving of vision hopeless. Had this
patient been seen in time, a good vision might have been
the outcome, or the process arrested if degenerative changes
had taken place, or certainly the evil day could have been
postponed.
SOUTHERN MEDICINE AND SURGERY
January, 1936
If on throwing a light into the pupillary space
a grey picture results, especially in one past
middle life, don't jump to the conclusion that it is
a case of cataract — pass the responsibility to a
competent and experienced ophthalmologist.
Following the removal of a foreign body from
the eye, or at any other time, if you wish to em-
ploy a local anesthetic in an eye, do not order a
solution of cocaine for the patient. It may cause
an attack of acute congestive glaucoma in a person
with that tendency, and its repeated use will result
in exfoliation of the corneal epithelium, thus pro-
viding a fertile field for bacterial growth.
In August, 1926, a locomotive engineer, 57 years of age,
consulted me because of a very uncomfortable and a
badly inflamed right eye. Two days prior to this time
the company's physician had removed a foreign body from
the eye and prescribed a solution of cocaine for the dis-
comfort. This he had used ver>' freely. The whole an-
terior portion of the cornea was infiltrated, there was
desquamation of practically all of the epithelium, and he
had a suppurative keratitis. The prognosis was grave; he
had been told by another ophthalmologist that he was
going to lose that eye. Fortunately the eye was saved,
with 20/40 vision in an eye that formerly had 20/15.
The use of the cocaine solution and the infection
came very near resulting in loss of this eye — and
in a condition which, as a rule, causes very little
trouble to the competent oculist and to the patient.
So do not prescribe cocaine for the patient to use
in his or her eyes. It should be used only by the
physician under suitable conditions.
Atropine, homatropine and scopolamine solutions
or ointments should not be used in an eye until a
proper examination by one competent to make it
indicates that it is a safe procedure, for if there is
glaucoma or a tendency in that direction, the in-
stillation may cause acute congestive glaucoma,
which, unless properly treated immediately, will
lead quickly to hopeless blindness. So do not
employ any drug of this type in an eye unless you
know that no contraindication exists.
Recently at the Medical College of Virginia Dispensary
I saw a colored man with old well advanced case of glau-
coma simple.x, who having had some trouble with his
eyes called in his family doctor, who diagnosed the case
as iritis and prescribed atropine. The next day he was
brought to the dispensary suffering intense pain and head-
ache, m an attack of acute congestive glaucoma, induced
by the atropine. Fortunately no damage to vision could
result as he was already blind, but the same thing can
happen in a person with good vision.
Solutions of silver nitrate should never be pre-
scribed for a patient to use in his or her eyes. Its
injudicious employment in the eyes may result in
a permanently stained cornea, especially so if there
is a break in the corneal surface. Aside from other
considerations, a suit for damages may follow.
The use of organic silver compounds should be
strictly supervised by the physician, as prolonged
use may produce permanent staining or the con-
junctiva. In many this results from the patient
not returning as he was instructed by the physi-
cian, but continuing to use the drug. Cases of
argyrosis are not uncommon.
Only recently I saw at the dispensarv- a woman, 37 years
of age, totally blind in the right eye and practically so in
the left, with only light perception in the upper and tem-
poral fields. She had been having trouble with her eyes
for some time. Her physician gave her one intravenous
injection and told her to go to an optician to get some
glasses. She went to the optician several times about
her glasses and in the meantime she was getting progres-
sively worse. Her trouble was a luetic uveitis. The pupils
were contracted, dense posterior synechiae prevented com-
munication between the anterior and the posterior cham-
bers, resulting in iris bombe and secondary glaucoma.
From the increased tension in the structually weakened
right eye an anterior staphyloma resulted. Degeneration
of the retina and the optic nerve had also occurred and
the eye was hopelessly blind. The same condition, with
the exception of the staphyloma and the fact that she had
bare light perception in the upper and temporal fields, ex- >
isted in the left eye.
No physician should refer a patient to an opti-
cian to have an eye examination; to do so may
plunge the patient into life-long darkness, when the
attention for which an ophthalmologist is trained
would have preserved good vision. I have seen
cases of glaucoma, optic atrophy and other path-
ological ocular and optic-nerve conditions in which
the optician had continued to change the glasses
until the patient had become practically blind, then,
often too late, an ophthalmologist was consulted.
If a patient comes with a red eye, do not jump
to the conclusion that it is "pink eye" or con-
junctivitis, or that it is an iritis. It may be either,
but it may not: it may be an acute congestive
glaucoma, and if it is and is treated as an iritis or
as a conjunctivitis the result will be disaster to
the eye. If it be an iritis and it is treated as a case
of "pink eye", the outcome may be an eye with
dense posterior synechiae and an iris bombe, with
a secondary glaucoma, or obliteration of the pupil
and a blind eye. So be sure that you understand
the ocular affection before trying to treat it; better
still, refer the case to an experienced and compe-
tent ophthalmologist, let him have the responsibil-
ity.
So long as sight is being lost that C(juld be pre-
served, it is our duty to call attention to errors in
the diagnosis and treatment of ophthalmic condi-
tions, to illustrate some of the serious consequences
of these errors of omission and commission, and
to impress upon all doctors the necessity of ob-
serving simple rules to see that these patients re-
ceive proper medical service early.
—200 E. Franklin St.
Januar>', 1936
SOUTHERN MEDICINE AND SURGERY
Posture and Post-operative Treatment in Eye
Conditions
(J. B. Hamilton, Hobart, in Australian & New Zealand Jl.
of Surg., Oct.)
While acting as house surgeon both in Australian and
English ophthalmic hospitals, I was confronted by three
facts in the post-operative treatment of eye conditions, and
especially of patients with cataract:
1. Patients suffered great discomfort by being nursed
in a supine position, without any alteration for 7 to 10
days. This discomfort manifested itself by extreme pain
in the loins and shoulders.
2. This pain in the back invariably led to flatulence
and often to vomiting, with consequently disastrous results
to the eye that had been operated on in the form of intra-
ocular hemorrhage and prolapse of the iris.
3. This unnatural position often resulted in congestion
of the lungs, retention of urine, mania, and sometimes sud-
den death from cardiac failure. This sudden death was
due to sudden alteration of the patient's posture resulting
in coronary thrombosis.
I therefore suggested to my senior colleagues that Fow-
ler's position should be tried as an alternative in post-
operative treatment. Ultimately I was allowed to nurse in
the erect posture a few patients whose cataracts had been
extracted, and the results were just as I anticipated, that is,
post-operative convalescence was free from all complica-
tions and discomforts.
In all conditions except detachment of the retina, when
the patients are returned from the theatre (operating), I
superintend their move from trolley to bed in the supine
position. Then they are asked to sit erect very slowly,
their heads being supported with my hand. They are
bodily lifted towards the head of the bed about 12 inches
and seater on an air cushion. Pillows are then piled behind
them to keep them in this erect position and a "Fowler's
pillow," strapped to the head of the bed, is placed under
their knees to prevent them from slipping. At night their
hands are lightly tied by clove hitches to the sides of the
bed, and an electric bell is placed in one hand. Rest in
this posture is assisted by hypnotics given before and after
operation.
In dealing with cases of detachment of the retina the
patient's head is placed in such a position that the retinal
hole is in the most dependent portion of the eye, as rec-
ommended by Gonin. Patients who have been subjected
to general anesthesia are not placed in Fowler's position
until full consciousness has returned.
A woman entered the clinic and complained to the desk
attendant that she had "seen nothing" for 3 months. Re-
ferred to the eye clinic, she underwent a complete exam-
ination. "Madam," said the doctor, "there is nothing the
matter with your eyes; they are normal. Why did you
come to me?" "Well, Doctor, I told the girl at the desk,
but she would not listen to me; I haven't seen anything
for three months."
UROLOGY
For this issue, Ekmer Hess, M.D., F.A.C.S., Erie, Penn.
From the Urological Department of St. Vincent's and
Hamot Hospitals, Erie, Pennsylvania.
Is Nephritis a Medical or a Urological
Problem?
It has long been a question whether or not so-
called medical nephritis falls within the realm of
the internist or the urologist. Before scientific
urology made a place for itself among the medical
specialties, many of the diseases of the kidney were
considered medical.
There are many classifications of renal disease.
The pathologist recognizes the degenerative, the in-
flammatory and the sclerotic types in all of their
various manifestations. Clinically, it has been dif-
ficult to fit renal disease into any definite path-
ological classification. Any classification, to be use-
ful, must so clarify the nomenclature that the same
words will mean the same things to all. The Amer-
ican Urological Association, a few years ago, des-
ignated Montague Boyd and others to set a stand-
ard nomenclature for our use. Confusion has always
resulted in medical discourses because of this lack
of uniformity in nomenclature and particularly with
reference to renal disease and its proper classifica-
tion.
Volhard and Fahr's classification is, to me, the
most acceptable. Hinman, in his new book, at-
tempts to place all renal disease in two classes,
medical and surgical. Neither of these classifica-
tions has seemed to me quite as good as the one
which I offer, not as original with me, but a com-
bination of former classifications, practical and ap-
plicable to all renal disease.
I do not like to separate renal disease into med-
ical and surgical. A patient either has renal path-
ology or he does not. I do not see how diagnosis
and treatment of the urinary tract can be scien-
tifically accomplished without the use of the cys-
toscope. True, we will always need the help and
cooperation of the internist as well as the other
specialists, but in the last analysis the diagnosis
and treatment of any renal disease is essentially
urological regardless of the pathology.
Volhard and Fahr's classification is well known:
A. Degeneration Diseases: Nephroses, genuine and of
known etiology, without amyloid degeneration of
the vessels.
(1) Acute course
(2) Chronic course
(3) End stage: Nephrotic contracted kidney
without increased blood pressure.
B. Inflammatory Diseases: Nephritides.
(1) Diffuse glomerulonephritis with obligatory
increased blood pressure, course in three
stages.
(a) Acute stage
(b) Chronic stage without kidney insuf-
ficiency.
(c) End stage, with kidney insufficiency.
(All three stages may run a course.
(a) Without edema
(b) With edema, i.e., with marked
and diffuse degeneration of the
epithelium.)
(2) Focal Nephritis, without increased blood
pressure.
(a) Focal glomerulonephritis
(1) Acute stage
(2) Chronic stage
(b) Septic interstitial nephritis
SOUTHERN MEDICINE AND SURGERY
January, 1936
(c) Embolic focal nephritis
C. Arteriosclerotic Diseases: Scleroses.
(1) Benign Hypertension — pure sclerosis of the
kidney vessels.
(2) Malignant Hypertension — the combination
form, genuine contracted kidney — sclerosis
plus nephritis.
Volhard and Fahr's classification is incorporated
into the one which I offer and in which any clin-
ical or pathological renal entity can find a logical
position regardless of the mixed pathology, and
immediately the dominant clinical entity will be
qualified. I submit the main heading of nephrosis
as proper because this term means "any diseased
condition of the kidney," and under this general
classification come the principal subdivisions — (1)
Nephrostasis, (2) Nephrotoxicoses, (3) Nephro-
phlegmasias, (4) Nephrectasias, (5) Nephrosclero-
ses, (6) Nephro-anomalies, and (7) Nephro-neo-
plasias.
NEPHROSIS
1. Nephrostasis
(a) Orthostatic Albuminuria
(b) Congestive Albuminuria
2. Nephrotoxicoses
(a) Acute
(1) Toxic
(2) Lytic
(b) Chronic
(c) Terminal. Contracted kidneys without in-
crease in blood pressure or with increase in
blood urea and creatinin.
3. Nephrophlegmasias
(a) Diffuse Glomerulonephritis. (Increased blood
pressure and bilateral.)
(1) Acute. (With or without edema.)
(2) Chronic. (With or without edema and
without renal insufficiency.)
(3) Terminal. (With or without edema but
with renal insufficiency. A degenera-
tion of the epithelial cells.)
(b) Focal Nephritis. (Without increased blood
pressure. May or may not be bilateral.)
(1) Glomerulonephritis
(a) Acute
(b) Chronic
(2) Interstitial Nephritis. (Septic)
(3) Embolic Nephritis. (Focal)
(c) Pyelonephritis.
(1) Acute. (Bilateral or unilateral with or
without stasis or obstruction.)
(2) Chronic. (Unilateral or bilateral with or
without stasis due to obstruction.)
(3) Terminal. (Unilateral or bilateral with
or without stasis due to obstruction.)
4. Nephrectasias.
(a) Congenital or acquired.
(1) Hydroecstasias. (Bilateral or unilateral.)
(a) Acute — always obstructive.
(b) Chronic — always obstructive.
(c) Terminal — always obstructive.
(2) Pyoecstasias. (Bilateral or unilateral.)
(a) Acute — always obstructive.
(b) Chronic — always obstructive.
(c) Terminal — always obstructive.
5. Nephroscleroses
(a) Benign Hypertension. (Sclerosis of the renal
vessels and sympatheticotonias.)
(b) MaUgnant Hypertension. (Sclerosis plus
nephritis, cardio-vascular-renal disease.)
6. Nephro-anomalies
(a) Aplasia. (Unilateral or bilateral.)
(b) Hypoplasia. (Unilateral or bilateral.)
(c) Fetal-lobulated. (Unilateral or bilateral.)
(d) Double kidneys. (Unilateral or bilateral.)
(e) Horseshoe kidneys.
(f) Cystic kidneys. (Unilateral or bilateral.)
(1) Multilocular.
(2) Unilocular.
7. Nephro-neoplasias.
Nephrostasis
Orthostatic albuminuria is due to congestion of
a kidney as a result of pressure on the renal vein,
due to posture, the albumin disappearing upon the
relief of the pressure by change of posture. Many
of these cases are due to a lordosis and the albumin
disappears from the urine after a night's rest in
bed. A similar group of innocuous albuminurias
are those caused by fatigue, common in athletes
and soldiers after severe physical strain. Finally,
there are those individuals whose renal threshold is
low and albumin will spill into the urine following
heavy ingestion of albuminous foodstuffs. These
cases require complete urological surveys for diag-
nosis. Obstructive uropathies, infections of the
upper urinary tract, anomalies and ptoses of the
kidneys must be eliminated. Barring definite uri-
nary pathology, the patients should usually be re-
ferred to an orthopedic surgeon: if the lordosis is
complicated by active urinary disease, the latter
should have urological supervision. Again, a com-
plete urological study is necessary to rule out ab-
normalities of and pathology in the urinary tract,
and diet and exercise must be judiciously con-
trolled.
Nephrotoxicoses
These are the degenerative diseases, or the
nephroses of Volhard and Fahr. They fall in
the category of medical nephrosis in other classi-
fications. They are neither medical nor surgical
but urological conditions. These are tubular in-
volvements due to the toxins of inflammatory
disease, or to direct poisons. The pathology is best
represented by cloudy swelling, fatty and finally
amyloid degeneration. In the acute cases are the
toxemias of pregnancy and the renal picture often
seen in chronic infectious disease elsewhere in the
body, and in poisoning by the heavy metals. If
the toxic elements being eliminated through the
kidney are lytic, then the entire process is acute
and shortly terminal with rapid lysis of the renal
tubular epithelium.
This picture is typical in the toxemia of preg-
nancy where toxins, probably from the placenta
January, 1936
SOUTHERN MEDICINE AND SURGERY
31
and the new fetus, cause the morbid process to
assume an acute stage. The condition must be
differentiated from the nephritis or the pyeloneph-
ritis of pregnancy by complete urological study.
The same picture, much more acute in its mani-
festations, is also the result of bichloride poisoning
and may be produced by other poisons of extrane-
ous origin. The course in all of these conditions
may also be slow. This chronic type of the dis-
ease may also be found in syphilis, tuberculosis,
osteomyelitis, sinus and tonsillar infections, etc. In
these cases the toxins are constantly being released
into the blood stream in small quantities and the
tubular epithelium is very gradually poisoned.
Cloudy swelling and degeneration of the cells pro-
gress much more slowly but the end result is the
same. It is in these cases that cure of the renal
condition means the surgical and hygienic treat-
ment of the original focus after a thorough urologi-
cal and general systemic survey.
This is the work of allied medical groups, but
the diagnosis is urological and the kidney lesion
must be treated urologically in cooperation with
the internist, the surgeon or other specialist. The
quickest way to treat a toxemia of pregnancy is,
of course, to have the obstetrician or gynecologist
empty the uterus, when the renal condition will
usually improve immediately unless this procedure
has been postponed to the terminal stage. Much
can be done by the urologist to hasten renal im-
provement in these cases.
In mercury poisoning, after all measures to get
rid of the poison have been tried, the urologist
should come into the picture. Sodium thiosulphate
should be given intravenously, a solution of the
same drug should be adminstered orally, vaginally
and per rectum, cystoscopy should be done and
the renal pelvis lavaged with a continuous flow of
the same solution. In poisoning by the heavy
metals there is a definite insoluble chemical com-
pound formed with the protein of the renal cells
and this must be changed chemically so that the
cell may throw off the metal. The long-standing
chronic infections eliminate toxins that likewise
gradually destroy the epithelial cells of the tubules.
Certain of these toxic products seem to have a
definite selective activity upon these renal cells.
Of course, the treatment is the treatment of the
primary infection; but the differential renal diag-
nosis depends upon the urologist and local treat-
ment is often of great assistance. As a rule, all
of these conditions are bilateral; only occasionally
are they unilateral. .■Mso occasionally, denervation
and decapsulation aid in the ultimate recovery of
the individual.
The blond pressure is usually but little influenc-
ed unless complicated by some other type of neph-
rosis, and in the acute stage and at times in the
chronic, the blood chemistry findings will be of
prognostic as well as diagnostic significance. In
the terminal stage urea and creatinin will be high,
the urine scanty, highly albuminous and containing
casts of all varieties. At autopsy, the kidneys will
be small and contracted. There will be diffuse evi-
dence of cloudy swelling, fatty degeneration and
terminal amyloid degeneration throughout these
kidneys.
Nephrophlegmasias
Under this heading are classified all those dis-
eases which are due directly to infections with defi-
nite secondary infections of the kidney parenchyma
and the pelvis. We will not discuss subdivision
two or three because it is well recognized that the
diagnosis and treatment of these is purely urologi-
cal and is a medical, cystoscopic and operative com-
bination.
The first classification, however, I wish to dis-
cuss. Hinman identifies this group as a part of
his medical sub-group and claims that no organ-
isms are found in the urine in these cases. Vol-
hard and Fahr classify this group in their main
classification of the inflammatory diseases, the
nephritides.
The first subdivision then of the nephrophleg-
masias is that entity heretofore known as diffuse
glomerulonephritis (the old-fashioned Bright's dis-
ease, a name which I hope will be dropped forever
from our nomenclature) as a classification. This
disease is bilateral and is accompanied by increased
blood pressure. It is further subdivided into the
acute, chronic and terminal stages. These cases
usually fall into the hands of the medical man and
are often treated in their entirety by him. Many
internists today call in the urologist first, for as-
sistance in the differential diagnosis, and secondly,
to assist in the supervision of therapy. This is
particularly advantageous because often the path-
ology is extremely complicated. When these cases
consult me first I go ahead and make the complete
urological survey with a thorough physical exam-
ination in all its details and when I find I need the
services of the internist, the otolaryngologist, the
surgeon, or the cardiologist, I ask him to assume
mutual responsibility with me. When this type of
cooperation is an accomplished fact, it is surprising
how many of these cases of diffuse glomerulone-
phritis will improve and many of them will become
clinically cured.
It is hard for me to believe that organisms are not
present from time to time in the glomeruli and
urine, and that the disease is a combination of
glomerulitis caused by toxins and bacteria. The
acute type, if fulminating, may be accompanied by
edema or not, depending entirely upon the injury
SOUTHERN MEDICINE AND SURGERY
January, 1936
to the glomerular cells and incapacity of these cells
for taking salt and water from the blood, with up-
set of cell function in other organs, this affecting
every cell in the body. The acute condition may
soon become a terminal one, or resolution and re-
pair may take place to such a degree that the con-
dition becomes chronic. In these cases the degree
of permanent damage can be estimated only by
complete, thorough urological investigation — in the
vast majority of cases sufficiently accurately to es-
tablish rational methods of management. At times,
even clinical cure may be accomplished.
My beloved Professor of Medicine at the Univer-
sity of Pennsylvania, the late James Tyson, ad-
vised: "Never give a nephritic a wholly bad prog-
nosis but always give a guarded one. When I was
a young physician a man came under my care who
had an acute parenchymatous nephritis. His urine
was filled with blood and albumin. He had almost
a general anasarca. He was to my mind incurable
and I told him that he had better make his will
and straighten out his affairs as he had but a short
time to live at best. I told him he might possibly
live two years when he asked for his expectancy and
he asked' me to put my prognostication in writing.
This I did knowing full well that instead of two
years longevity, a year of life would be miraculous.
Gentlemen, for forty years on the anniversary of
my prognostication, the gentleman presented him-
self at my office and reminded me of my ignorance
by presenting my signed statement."
The urologist, in my opinion, is best equipped
to make the differential diagnosis in these cases
and to qualify the diagnosis. The treatment of
the case may best be managed by him or he may
be associated with one or more men from other
branches of medicine: but his should be the re-
sponsibility for the treatment of the renal lesion.
If he is fortunate to have a clever internist as his
collaborator even better for the patient. When the
chronic stage of the disease is reached there may or
may not be renal insufficiency, but who is as able
to estimate this as the well-trained urologist? Sure-
ly here, for the sake of accuracy, anything short of
a complete urological survey will not suffice. It is
in these cases that the laboratory is of so much
value.
Focal Nephritis
No one disputes that the conditions classified
under focal nephritis are usually diagnosed and
treated by urologists, nor are the cases under the
general classification nephrectasias under particular
discussion.
Nephroscleroses
In this group are two types of renal disease,
heretofore considered more or less medical prob-
lems, falling into the hands of the urologists only
when they were complicated by other renal path-
ology. Here there are two subdivisions. In one
there is sclerosis only, or constriction, of the renal
vessels. The process is usually limited to anything
which causes spasm of the renal arterial tree, such
as sympatheticotonia, or toxic products in the blood
which may have a special affinity for the renal ar-
teries causing a localized sclerosis.
For the sake of classification, we consider the
principal symptom as one of benign hypertension,
whose differential diagnosis can be arrived at only
by elimination. In these cases skillful urological
diagnosis is far more efficient than any medical
treatment. Foci of infection must be found and
eliminated. The ingestion of drugs and other in-
dustrial poisons must be taken into consideration.
Sympathetic imbalance must be corrected. This
very often can be done by separating the kidney
from its sympathetic ner\'e supply. Certain endo-
crine disturbances may be responsible for this con-
dition and if found to exist must be corrected, if
possible. Very often this condition is curable by -
surgical attack upon the kidney plus the elimina-
tion of the causative factor. The prognosis requires
difficult differential diagnostic study and may re-
quire the assistance of some other branch of medi-
cine.
The so-called malignant hypertension case is
possibly the only condition which may be consid-
ered purely medical, and many of these cases may
be benefited by a complete urological survey supple-
menting the medical treatment. This is not a local
condition. It is cardio-vascular-renal disease, the
renal disease being secondary and terminal as a re-
sult of the vascular sclerosis. The primary disease
is vascular, the heart and renal complications being
secondary. Added oftentimes is nephritis or cal-
culous disease, or some other process which further
cripples the kidney. This condition demands dif-
ferential diagnosis and very often appropriate local
treatment, either cystoscopically or surgically, to
relieve renal embarrassment, to make the patient
more comfortable and to prolong life.
Since the advent of insulin patients with diabetes
no longer die from starvation or coma, but from
vascular scleroses, usually by cardiac or renal fail-
ure. So, even here, it is the essayist's humble opin-
ion that many lives will be prolonged even with
malignant hypertension if they be turned over to a
competent urologist, first for a differential diagnosis
and then for secondary treatment locally, even
though the medical man may be in charge of the
situation.
It is inconceivable to me how any medical man
untrained in cystoscopy can feel that he can in-
telligently treat these cases without every bit of
Januan-, 1936
SOUTHERN MEDICINE AND SURGERY
aid that may be obtained from a careful urological
survey, the results of which must either verify his
therapeutic logic or cause him to change his ther-
apy in accordance with the facts found by such a
study.
Nephro-Anomalies
The anomaly itself seldom requires intervention,
but it usually comes under the supervision of the
urologist when a secondary nephrosis of any type
is added to the anatomic deformity.
One of this group requires special mention and
that is congenital bilateral cystic kidneys of the
multilocular type. The diagnosis can usually be
made only by pyelography; the supervision is
urological e.xclusively and may be surgical; the
question of surgical attack upon them can never
be anything else but urological. Many of these
cystic kidneys resemble very materially in their
findings the diffuse glomerulonephritic which we
have classified under the nephrophlegmasias. The
differential diagnosis can be made only by urologi-
cal survey supplemented with careful pyelographic
study. No one, of course, disputes any of these
nephro-anomalies as other than urological.
The last classification, the nephro-neoplasias, or
tumors of the kidney, pelvis and ureter, are not in
question. These in all of their various manifesta-
tions should be referred immediately to the urolo-
gist for diagnosis and treatment and should be re-
ferred for subsequent treatment usually to the
roentgenologist and radiologist rather than to the
internist.
Conclusion
1. I have offered you a new classification of
renal disease which is a modification of and an
addition to, and I believe an even better classifi-
cation than, that of Volhard and Fahr. I know of
no renal condition that cannot find a proper place
in this classification.
2. There is no renal condition that cannot bene-
fit diagnostically, prognostically and therapeutically
by a complete urological survey by a competent
urologist.
.3. There is no single renal pathological entity
that should not be under the supervision of the
urolo<iist rather than the internist; but urologist
and internist should cooperate in the management
of any renal disease regardless of the one directly
in charge of the case. The internist in treating
renal disease should never get along without urol-
ogical opinion, and the urologist handling renal dis-
ease cannot get along without cooperation with the
internist and other medical specialists, if the patient
is to be given the best of medical care.
SURGERY
Geo. H. Bunch, M.D., Editor, Columbia, S. C.
Operations Upon the Anemic
Before any major operation is undertaken ex-
perience proves the wisdom of being sure that the
patient's blood is of sufficient quantity and quality
to enable him to withstand the ordeal. Until the
blood volume has been restored by the intake of
fluid after acute hemorrhage the hemoglobin may
remain practically normal; ordinarily, however, the
hemoglobin is accepted as an accurate index to the
degree of anemia present.
Blood transfusion ranks with asepsis and anes-
thesia as a basic aid to modern surgery. In the
anemic, before the days of transfusion, one was
dependent upon the administration of organic iron
to build up the blood before operation. If there
was no blood loss from hemorrhage during treat-
ment this often proved effective. However, even
without hemorrhage, some patients did not improve
from iron therapy and the surgeon had to take the
chance of relief by operation or lose his patient
from the primary disease plus progressive anemia.
Experience showed 30 per cent, the lowest pre-
operative hemoglobin index compatible with rea-
sonable chance of survival from major operation.
If the hemoglobin reading could not be raised to
30 per cent, operation was not undertaken. With
such severe anemia, even though the patient sur-
vived the operation, convalescence was slow and
uncertain. Now, when transfusion may so readily
be done, we do not think major surgery should be
undertaken when the hemoglobin of less than 50
per cent., and if any operation is to be long with
the probability of considerable bleeding and shock
a donor should be typed and ready for transfusion
during operation. Practical experience proves Fra-
zier right in his assertion that shock, with or with-
out hemorrhage, is from blood volume loss and
can best be treated by transfusion.
The old classification of anemia into primary
and secondary types depending largely upon the
ability of the physician to find some causative
source of bleeding has been found to be inade-
quate. Now pathologists use the modern classifi-
cation based upon the size of the red cells and
their hemoglobin content. Although considerable
skill in microscopical study is necessary for proper
grading of the cells the work is worth while, for
effective treatment depends upon accurate diagno-
sis. Boyd says "Differences in the mean cell vol-
ume and the hemoglobin content of the erythro-
cytes are associated with fundamentally different
pathological disturbances in the formation of the
red blood corpuscles, and these differences may be
SOUTHERN MEDICINE AND SURGERY
January, 1936
used as a clue to the nature of the anemia and a
guide to the appropriate type of treatment."
In the modern classification there are four kinds
of anemia:
1. Macrocytic, in which both the average size
and the hemoglobin content of the red cell is in-
creased. It occurs in pernicious anemia, sprue and
the pernicious anemias of pregnancy and is best
treated by the administration of liver.
2. Normocytic, in which the red cells are of
normal size and hemoglobin content. The cell
count is low. In this group are acute blood loss,
malaria and the aplastic anemias. Blood trans-
fusion is a specific for hemorrhage.
3. Simple microcytic, in which there is a large
reduction in the number of red cells and a moderate
reduction in size and hemoglobin content. It is
the commonest of all the anemias and includes
chronic infections, bronchiectasis, chronic nephritis
and carcinoma without bleeding. In this group
neither iron nor liver is helpful.
4-.- HypeebfiOTwie- microcytic, in which there is
great reduction in the size of the red cells but a
greater reduction in hemoglobin content. It oc-
curs in chronic hemorrhage, hookworm infestation
and the simple achlorhydric anemias. It is best
treated by organic iron.
In conclusion: the anemic patient is a poor risk
for major surgery and every precaution should be
taken to get him in condition before operation is
done.
ORTHOPEDIC SURGERY
John Stuart Gaul, M.D., Editor, Charlotte, N. C.
Chronic Osteomyelitis
The solution of any particular problem of osteo-
myelitis which has reached the chronic stage re-
quires an understanding of the pathology present,
and a knowledge of the progress of the pathology
through its several stages.
The phases, in the following order, occur in any
given case. The infection is implanted either by
embolus through the blood stream or directly by a
traumatic force — such as in gunshot wounds or in
compound fractures. Inflammation follows with its
attendant edema and pressure, which occurring
within unyielding walls interferes with the circula-
tion within the bone. Necrosis of the bone follows,
which is nothing but gangrene of the bone. Nature
is endeavoring at this time to limit the spread of
the condition; to build new bone to replace that
which is being destroyed; and to break up and
expel the destroyed bone. The osteoclasts are at
work to break up the sequestrated bone and to
bore a hole to the surface through which they may
be extruded. With the rupture through the cortex,
the infected material starts abscess formation in the
soft tissue, with local signs of inflammation and
abscess formation in these tissues. Eventual rup-
ture through the skin follows and sinus formation
with subsequent discharge of pus, serum and se-
questrated bone. The sinus persists for years un-
less the diseased bone is properly treated. Man,
with misguided interference, has added to this story
by having the condition spread from its original
focus to involve the whole bone or adjacent bones
and joints. This interference has consisted in un-
timely surgery without regard to the pathology
present.
What then is timely surgery in this condition?
It, rationally, must be related to the pathology;
and a very wide experience, thus based, has con-
vinced me of the soundness of it.
In the early stage where the infection has just
been implanted and the early inflammation with its
attendant edema is being established, the clinical
course shows fever, a rising white cell count, and
a dull, boring, or throbbing pain in the bone which
the patient can localize for you, and over which he
cannot withstand sustained pressure, immediate
surgical intervention is indicated. An adequate in-
cision is made over that area and drill holes made
through the cortex. This relieves the tension, and
by so doing prevents the later cycle with destruc-
tion and necrosis of the bone because of the blocked
blood supply. With this done and hot fomenta-
tions maintained for a few days many of these
cases clear up without further damage. In those
which do not clear up the destruction and sequestra-
tion is minimized and may be adequately treated
in the following weeks.
If this valuable period of time has passed, the
surgery indicated is merely evacuation of forming
abscesses and practicing masterly inactivity wait-
ing until the gangrenous bone has its definite line
of demarcation as you would wait in gangrene of
the foot. This requires from six to ten weeks and
is well indicated by x-ray in which the sequestrated
bone shows greater density than the normal bone,
and is surrounded by a black line or gas shadow.
At this time the dead bone should be removed with
the least possible disturbance of Nature's protect-
ing wall of involucrum. With the removal of the
sequestra the operator will use his best judgment
in the method of treating the wound. To interfere
before the bone that is being destroyed is definitely
limited is to invite disaster by spreading the in-
fection through the limiting wall and involving the
entire bone and adjacent bones and joints.
Orthopedic sukgery means the surgery of the straight
child, the attention that keeps the child straight, prevents
it becoming crooked, or straightens it when it was born
crooked or has become crooked since birth.
Januarj', 1936
SOUTHERN MEDICINE AND SURGERY
OBSTETRICS
Henry J. Lanxston, M.D., Editor, Danville, Va.
We Seek Excuses
Many may think it foolish to discuss a subject
of this nature in a department that is supposed to
be dealing exclusively with obstetrical problems.
What is in mind is to face some of our problems
as physicians looking after expectant mothers.
About a year ago I started out with some ambitious
ideas as to this department for 1935, and my rea-
sons for not having, to a degree, realized some of
these ideas are personal sorrow, financial difficul-
ties, professional problems, and a court suit which
was from the onset groundless and in which I was
vindicated. Now, as I look back over the year's
work and the difficulties which I have had, I am
very sure they are more or less common in the lives
of physicians and now the problem presented to us
is how we are going to handle these difficulties and
at the same time perform our function as physi-
cians and our obligations to society at large.
We seek excuses because our patients are not
more considerate of us. While our patients are
sick they are profuse orally in their appreciation,
but after the baby, mother, son, daughter, father
or grandparent has recovered, one excuse or another
is offered for failure to compensate us for our ef-
forts. Consequently, many of us are going along
from year to year in financial straits; our wives
suffer; our children are deprived, and in a little
while human society places us on the shelf feeling
that it has done its duty to us. It is expedient
that we listen to these patients' excuses, but when
we have served them satisfactorily and well, while
this service is fresh in their minds, we should urge
settlement, for experience says gratitude is short-
lived. Particularly in the field of obstetrics, the
mother having been brought through pregnancy,
delivery and the lying-in period and given back to
her family in a healthy state, immediately the hus-
band should put forth effort to pay for this service.
In looking over my records I find that I have not
been able to collect for SO per cent, of such ser-
vices. In the face of such facts there is a cry
among certain groups in the laity that we, as doc-
tors, are not serving human society adequately.
This group is composed of people who are seeking
alibis and excuses of one kind or another instead
of using their own talents in an effort to pay for
these services; they are busy-bodies who have failed
in their own special fields and now they propose to
be millstones about our necks. We should be brave
enough and courageous enough to tell them to get
in their places and stay there.
There is another group that is very desirous of
hiding behind certain excuses to pass cert.iin laws
which aim to limit our activities and take away
from us certain rights which are inherently ours.
This group, as this department has emphasized be-
fore, is exceedingly anxious to limit reproduction
of offspring. We appreciate their sympathies, but
the motives back of these sympathies are not whole-
some; hence, it is imperative that we expose these
people who are so willing to criticise the efforts
of medical men, and tell them to get in their field
and do their duty and leave us alone, except for
cooperation and help we may call upon from them.
In the field of education, in practically all of
our institutions from the high school through the
university, there are certain faculty members who
are endeavoring to teach certain subjects like hy-
giene and biology who are not fitted to properly
teach the youth; hence, thousands of high-school
boys and girls and college and university students
are turned out yearly who have not been properly
instructed in these important health matters.
Health nurses employed by counties and cities have
taksn over practically altogether the examination
of eyes, ears and throats, and so on, and teachers
are sending slips home to parents about this action.
This service can be properly rendered, and the
teaching of these subjects can be properly done by
none but physicians who are adequately trained,
and there are plenty physicians for the jobs. Of
course I know that certain leaders in education say
that the physician does not have time for this, but
we have time for anything that is of value to the
building of the proper kind of human society, so
the excuse is only a kind of alibi because certain
individuals in education are afraid that someone
will get a little part of their leadership away from
them.
There is another group of the young and the old
who feel that because of economic conditions the
young people should not reproduce so early in
their marital life. In the past few months I have
had more young women, married and pregnant, to
apply to me in a most appealing manner to termi-
nate the pregnancy because the parents- felt that
they were economically unprepared for assuming
such responsibility at the time. This attitude rep-
resents a form of mental and physical laziness. In
this field we should take a positive stand and should
seek opportunity to publicly discourage such an
attitude and to encourage the positive attitude of a
wholesome nature.
As we review the history of the past twelve
months in the field of obstetrics, there is very little
evidence to show much improvement. Bacteria
have taken hundreds of expectant mothers; many
thousands of the women who have been delivered
are crippled more or less for life because of im-
proper care during the delivery and immediately
SOUTHERN MEDICINE AND SURGERY
Januar>', 1936
following; fetal mortality has been about the same
as in previous years; septic infection due to so
many abortions is probably greater this year than
the previous year, and children crippled because of
improper management during delivery will be about
the same as before. Some are saying that if the
doctors had taken care of them properly these things
would have been different. To a degree they are
right, and also wrong, for they forget that we
physicians who to an extent are fairly well educated
have to deal with so many people who are ignorant,
superstitious and have minds that do not grasp
what we try to teach them in the way of taking
care of themselves and going through the period
of pregnancy, labor and the lying-in period, carry-
ing out to the letter directions which we have given
them. However, we cannot excuse ourselves and
be indifferent to the situation. On the other hand,
we must take a philosophical attitude and be ready
to continue to give, and give, and give, until people
will take our instructions and carry them out.
Our main purpose in discussing these excuses is
to stir up our own selves and get our own houses
in order because of the various demands on our
time in the field of economics, sociology, finance,
raising of families, politics, science and religion,
and a thousand other things. We frequently excuse
ourselves from study and we get off of the main
line of the business of practice in the field of ob-
stetrics. There is an imperative need that we be
more diligent in the study of the principles. At
the same time it is urgent that we wake up to the
fact that there is more knowledge yet to be ac-
quired in the field of human reproduction which
has to do with all currents of society. If we do
not wake up to these facts, in a few decades society
will be broken down with the burden of the care
of irresponsible and abnormal species of humanity.
The business of understanding more completely and
thoroughly the internal secretory glands in the field
of obstetrics may be more important than any other
branch of medicine. It offers every challenge to
the imagination to do, as Tennyson has said: "To
strive, to seek, to find, and not to yield."
Just this one other excuse: We physicians are
constantly telling our creditors that we cannot pay
because our patients have not paid. This is due
to our own negligence, and it behooves us to be-
come more business-like in our dealings and not to
assume obligations and responsibilities unless we
can see the path clearly as to how we are going to
meet these obligations. Honesty in business deal-
ings is essential to the success of the physician in
serving expectant mothers, and we should so im-
press this fact as to convince men that the respon-
sibility for a family includes paying the bills in-
curred thereby.
This department extends to all physicians who
read our Journal a word of encouragement. We
have a real opportunity to make the field of practice
much more attractive to competent well trained
young men than our fathers had, and we should be
ready and willing to impart this attitude and stim-
ulation to young physicians. At the same time it
is imperative that we gently impress one fact that
seems not to have occurred to the young men com-
ing out for practice at this time — the fact that older
men in the profession may know a thing or two
worth while. Too many younger ones idle their
time away and complain, and if they do not get a
practice in a little while they move on to another
place.
So we come to the end of our discussion having
in mind many more things that we could bring to
our readers about this excuse business. Even
though the world is in a muddle, there is a way
out, but that way must be guided by certain funda-
mental principles of human life and our philosophy
must not be cluttered up with irrelevant matters.
This department wishes for every physician a
better year from every angle in 1936.
HOSPITALS
R. B. Davis, M.D., M.S., F.A.C.S., Editor, Greensboro,N. C.
A Hospital Daddy
In every well organized and well operated hos-
pital, whether private, community or sectarian,
there is one personality always to be found as the
lead horse. This person never ceases working for
the interest of the institution. Asleep he dreams
of the success of the hospital. His wakeful mo-
ments not taken up with his necessary business are
filled with planning for better service, greater suc-
cess and the expansion of the hospital. He is ever
ready to pour oil on troubled waters. Oftentimes
he sacrifices his personal income in order that the
institution may profit, and in no few instances he
gives financial support in order that some depart-
ment of the hospital may be developed. It is this
personality that the writer designates A Hospital
Daddy.
The statement has often been made that no hos-
pital can succeed without a daddy and it is ever-
lastingly true. The physicians who can qualify for
this position are rare jewels, and any institution
and community which is so fortunate as to possess
one of these individuals is to be envied. The editor
of this department in recent years has known of a
number of newly-erected hospital buildings which
were magnificently equipped and should have ful-
filled all of the needs and requirements of the com-
munity in which they were located, but occupied a
second place in prestige. The people whom these
January, 1936
SOUTHERN MEDICINE AND SURGERY
were built to serve did not have the confidence that
is so vitally necessary. Such an institution to all
intent and purposes, although thoroughly equipped
to do a man's job, is still a boy in knee pants.
It is indeed unfortunate that a community does
not obtain the services of a physician who is capa-
ble of qualifying as daddy of an institution, before
it decides to spend the great amount of money that
is necessary for an up-to-date hospital. Edgar A.
Guest says, "It takes a heap of living in a house
to make a home.'" It can be equally as well said
that it takes a heap of loving service to make a
hospital a home for the sick.
Because of some farsighted philanthropic finan-
cier and his enthusiasm the people of a certain dis-
trict are persuaded to add to his donation large
sums of money for the purpose of creating a public
institution. While these philanthropists are greatly
to be admired and respected they are making an
economic error by contributing to the formation of
an institution in the community which has not
qualified for their gifts by enlisting one who is will-
ing to pour his life's blood into the operation of
that institution after it is ready to render service.
All successful private institutions are founded on
this principle. It is seldom that a private hospital
goes broke and has to close its doors. The finan-
cial burden, however, has often become very great
and this frequently produces wear and tear upon
the physical stamina of the head of the institution.
For that reason he has often changed the economic
procedure of his institution which might cause
some to think that he had failed. This is not the
case. On the other hand he has been eminently
successful in rendering the very best type of service
to the sick of that community. No matter what
economic change may take place in that institution,
so long as the daddy lives and is able to take the
lead in service it will continue to be successful.
That institution will enjoy prestige and confidence.
If a community does not possess a proper per-
sonality to place in charge of the service to be ren-
dered its citizens, it would be far better that such
an individual be imported for that community even
if it cause some temporary feeling in the local pro-
fession. This superior character will soon iron out
any feeling that might have been created, and once
that has been done the hospital staff will be on a
sound service basis, free from petty jealousies and
selfish motives. The daddy assumes fathership,
wisely judging, unselfishly counseling and lovingly
serving all of those with whom it is his privilege
to work.
PUBLIC HEALTH
N. Thos. Ennett, M.D., Editor, Greenville, N. C.
Pitt County Health Officer
Hospital is taken directly from Late Latin, and is
closely related to hospice and hatel, each centering around
the basic idea of entertainment of a guest — Latin, hospes.
The Soci.al Security Act and Public Health
Policies
Is Organized Medicine Concerned?
Funds having recently been made available to
the State, through the Social Security Act for the
extension of public health work, it seems appro-
priate that the matter be discussed at this time.
I will quote freely from an article entitled "The
Social Security Act and Its Relation to Public
Health," by C. E. Waller, M.D., Assistant Surgeon
General, U. S. P. H. S., in the Am-erican Journal
of Public Health for November, 1935.
Doctor Waller states: "The general title of the
Social Security Act approved by the President on
August 14th, 1935, sets forth the purpose of the
Act as follows:
'To provide for the general welfare by establishing a
system of federal old-age benefits, and by enabling the
several states to make more adequate provision for aged
persons, dependent and crippled children, maternal and
child welfare, piMic health (italics N. T. E.), and the ad-
ministration of their unemployment compensation laws; to
establish a Social Security Board; to raise revenue; and
for other purposes.'
"The U. S. P. H. S. will administer the grants
to States for aid in establishing and maintaining
State and local health services."
"It is to be assumed that every feature of the
social Security Act will have some relation, either
directly or indirectly, to the public health."
"Under the Public Health Work Title of the Act
authority is granted for:
'1. An annual appropriation of not to exceed $8,000,000
for the purpose of assisting states, counties, health districts
and other political subdivisions of the states in the estab-
lishment and maintenance of adequate health services, in-
cluding the training of personnel for state and local health
work. 2. An annual appropriation of not to exceed $2,000,-
000 to the Public Health Service for research activities of
the Service and for the expense of co-operation with the
states in the administration of the federal funds to be
granted for aid in the establishment and maintenance of
state and local health services.'
"Responsibility for allotment of the proposed ap-
propriation of $8,000,000 for State and local health
services is placed upon the Surgeon General of the
Public Health Service. . . . The Surgeon General
must take into account ... the relationship of the
population of each State to the total population
of the United States; ... the inability of the States
to meet their health problems without financial as-
sistance; and special health problems imposing un-
usual burdens upon certain States."
"For the first time .... the Congress has made
a declaration of permanent policy under which it
SOUTHERN MEDICINE AND SURGERY
January, 1936
assumes in part responsibility for protection of the
health of the individual within the State, and has
made provision for participation of the Federal
Government in the establishment and maintenance
of administrative health service for this purpose."
Doctor Waller very pertinently remarks that the
significance of the appropriation lies in the Federal
policy enunciated. He calls attention to the fact that
the Social Security Act substantially leaves unsolv-
ed "the problem of medical care for the poor and
for the low-income family that can pay something
but not the whole cost of medical and hospital ser-
vice which it requires.''
Almost the sole object of my article has been to
call your attention to the last clause of the para-
graph just quoted.
It appears to me that unless organised medicine
proposes a plan of its own for "the medical care
of the poor and the low-income family" group, a
plan will be proposed by some other group or
groups less capable of solving the problem rightly,
which plan will be put into effect by National,
State or local legal act.
In my opinion, the implication in the following
paragraph from Doctor Waller's article contains,
for organized medicine, much food for thought.
Says Dr. Waller:
"I am not prepared to advocate at this time
(italics mine) that the health department shall act-
ually undertake to render with its own personnel
all (italics mine) medical care for the poor. I feel
that there is and should be a place for the practic-
ing physician in a medical relief program wherever
economic limitations (italics mine) will permit the
utilization of his services."
Doctor Waller further observes: "But I do not
believe we shall have a satisfactory solution of the
problem until the health department takes the lead-
ership in working out with the medical profession a
plan that will serve the need and at the same time
make a place for the services of the private doc-
tor."
It is my opinion that a better solution can be
made if organized medicine takes the leadership in
working out a plan with the various State health
departments. What I here mean by the term lead-
ership is that no plan should be adopted which does
not have the approval of organized medicine.
Without the sympathetic approval of organized
medicine no plan can be a success; and so high a
regard have I for the wisdom and unselfishness of
organized medicine that I venture the opinion that
a plan which does not meet its approval does not
deserve to succeed.
PEDIATRICS
G. \V. KuTSCHER, M.D., F.A.A.P., Editor, Asheville, N. C.
Ple.\s.\nt words are as an honeycomb, sweet to the soul
and health to the bones. — Proverbs 16:24.
The Georgia Pedl^tric Meeting
The third annual scientific meeting of the Geor-
gia Pediatric Society was held at Atlanta December
12th. As is their custom, the speakers were invited
guests of national reputation. Drs. Isaac Abt, J.
Lovett Morse, John Kolmer and Chas. Bills
(Ph.D.) read papers of unusual interest. The type
of program and the hospitality of the Georgia pe-
diatricans are making this annual event one of the
important meetings of the South.
Dr. Chas. Bills is head of the research depart-
ment of ]Mead Johnson Co. His two papers dealt
with various phases of vitamin D. Codliver oil
has been used as a folk remedy and later empiri-
cally for ISO years. 'Vitamin D was discovered in
1922 and today we learn that there are at least 6
chemically distinct forms of vitamin D.
Dr. John Lovett Morse endeared himself to many
new friends who had never before had the privilege
of hearing him speak. His abundance of good •
common sense plus his ever-ready Scotch wit makes
him one of the great teachers of the day. He has
the happy faculty of leaving out the unessentials
and stressing the important factors. He spoke on
one of his pet subjects. The Thymus Delusions.
The thymus gland atrophies in inanition, with age
and in every acute disease. "The x-ray picture of
the thymus does not lie, but those who read the
pictures ." The only correct interpretation
is that of the lateral exposure. "No one knows
what is the normal x-ray picture for any given
child." It varies in size with respiration and with
the amount of blood it contains at the time a pic-
ture is taken. The thymus shadow is very wide in
the newborn. To cause symptoms the gland must
produce pressure on various tissues. The veins and
arteries are too readily displaced to be constricted
by an enlarged gland. The right recurrent laryn-
geal nerve's position makes it impossible for it to
be. compressed by the enlarged thymus; very un-
usual pressure would be required to involve the left
recurrent nerve; and even great pressure would not
cause great change in the voice of a child. A noisy
inspiration (only) or a noisy expiration (only)
would not result from an enlarged gland. Such a
gland would produce noisy inspiration and expira-
tion. The x-ray may show an enlarged thymus,
but such a picture does not rule out other causes
for the symptoms presented. Pressure of the gland
would cause cyanosis of the head, neck and upper
extremities only, not generalized cyanosis. Noisy
respirations are more frequently due to hypertro-
phied adenoids and tracheitis. Inspiratory crow is
present in laryngeal stridor. Breath holding, laryn-
January-, 1936
SOUTHERN MEDICINE AND SURGERY
gismus stridulus, bronchitis and asthma have all
been mistaken for enlarged thymus. "Convulsions
are not due to thymic disorders." -An increase in
the size of the thymus does not mean an increase
in the secretion, because the gland does not possess
an internal secretion. There is apparently a con-
nection between the thymus and the adrenal glands.
It is now understood that status thymico-lym-
phaticus has no existence as a pathological entity.
Many sudden deaths have been attributed to status
lymphaticus, but it is not a proven cause of death.
"Such a diagnosis is frequently the easiest way
out." The x-ray does reduce the size of the gland
and from a recent report we learned that we can
"thank God that x-ray treatment for enlarged thy-
mus does no harm."
Dr. Morse's second paper was a gem of wisdom,
dealing with Diagnosis and Prognosis. Dr. Morse
again emphasized the importance of an adequate
history in such a way that such repetition was not
trite. The good history invariably directs you to
the part involved by a disease process and a good
physical examination must follow to confirm or
deny the impressions obtained. "Every child should
be stripped for examination or else don't try to treat
it for any condition." In diagnosis the case falls
under one of three headings. 1) We know what
is wrong with the child; 2) we know there is one
of two or three conditions present; or 3) we know
w'e don't know. In children there is usually only
one disease present. Most mistakes in diagnosis
are due to lack of care in making the study rather
than the lack of knowledge. Pure laziness and be-
ing in too great a hurry account for many grievous
mistakes. In prognosis most physicians are, and
rightly so, optimists. The child tends to recover
not only once but many times, but it dies but once.
The physician has no right to carry the worry of
an unfavorable prognosis alone. H,e should inform
some member of the family as sobn as he thinks
the outcome is unfavorable. The average parent is
not interested in the diagnosis except out of curios-
ity, — what they wish to know is, "Will the child
recover and how soon." The parent wants the
child made comfortable whether it is going to re-
cover or not.
Dr. Isaac Abt was introduced as the "Dean of
Modern Pediatrics." Dr. Abt is likewise an un-
usually capable teacher. In his lecture to the stu-
dents of Emory University on Pneumonia, he de-
scribed the disease under four different types, the
pulmonary, the cardiovascular, the atonic and the
pallid. He likened these four types to different
colors. The colors representing the color of the
skin in each type. The pulmonary type was de-
scribed as pink pneumonia, the cardiovascular type
as blue, the atonic type as gray, and the pallid type
as white. "More can be learned about the condi-
tion of a pneumonia patient by standing at the
foot of the bed and observing the patient than by
all the laboratory findings and the clinical charts
combined." The prognosis becomes more unfavor-
able as the colors change from pink to white. Dr.
.•\bt's first paper W'as on the History of Pediatrics,
dating back as far as 1600 B. C. The first pedia-
trician was Walter Harris of England, who lived
in the 1650's A. D. The paper was a fascinating
record, which did not lend itself to ready abstrac-
tion. His second paper was on Avitaminosis. In
three vitamin-deficiency diseases — beri-beri, scurvy
and rickets — the heart may be greatly hypertro-
phied.
Dr. John Kolmer, the originator of the attenu-
ated virus vaccine against poliomyelitis, certainly
won many friends in favor of his vaccine. It is
unusual for a physician-speaker to have to make a
curtain call after his speech, but that is exactly
what occurred in Atlanta. In part he said: A
filtrable virus has never been seen or so far culti-
vated on a dead medium. No State in the U. S.
is free of acute poliomyelitis. During the past SO
years the disease has become world-wide. Every
test for antibody content of an individual's blood
requires a monkey at a cost of $10.00 to $15.00
each. That is why a susceptibility test is not yet
practical. No other susceptibility test has been
devised. It has been shown that the newborn has
a degree of antibody protection which lasts only a
few months. The child between one and four years
has little or no immunity. At least 25 per cent,
of adults have no immunity. Therefore when adult
serum is used as a prophylactic agent, it must be
pooled serum. Dr. Kolmer has shown by careful
study that in the child the antibody content pro-
duced by the injection of three doses of his vaccine
has lasted for 1 1 months. In the monkey the anti-
body content is present after three years. He has
the record of over 11,000 individuals who have been
vaccinated, 10,250 of these records have been ana-
lyzed. None of these individuals had a severe re-
action following the vaccine injections. One lot of
the vaccine was contaminated with colon bacillus
and staph, albus with 16 abscesses developing at
the site of injections. Today all of his vaccine
contains 1-80,000 phenyl mercuric nitrate against
accidental bacterial contamination. This antiseptic
is bactericidal against ordinary organisms, but not
against the virus. Dr. Kolmer insists that to be
of value the vaccine must be of an attenuated and
not a killed virus. He has been no case of de-
myelinization encephalitis such as follows rabies
vaccinations. Dr. Kolmer respects his critics and
proudly names them as most eminent and well fitted
to criticise his work. He does feel that much of
SOUTHERN MEDICINE AND SURGERY
January, 1936
their criticism is premature. There have been 10
cases of poliomyelitis reported to have developed
following the use of his vaccine. In all of these
cases only one or two of the prescribed three injec-
tions were administered. Dr. Kolmer believes that
these 10 cases received their one or two injections
during the incubation period of the disease and
that the vaccine had nothing to do with the indi-
vidual's developing the disease. Dr. Kolmer be-
lieves that his vaccine is safe for the following three
reasons: 1) The passage of the virus through mon-
keys has caused the virus to lose much of its infec-
tivity for human beings; 2) the injections are made
subcutaneously; 3) small doses are used.
RADIOLOGY
Wright Clarkson, M.D., and Allen B.wker, M.D.,
Editors, Petersburg, Va.
Cervical ^Metastatic Epidermoid Carcinoma
The curability of the great majority of carcino-
mas about the mouth, pharyn.x and larynx by early
and skillful irradiation is conceded by most cancer
therapists. Yet these lesions, because treatment is
so often improper or delayed, rank with the dead-
liest of neoplasms. In many cases lymph drainage
areas are neglected entirely and as a result cervi-
cal metastases occur, and these also are neglected
or treatment is quite inadequate. The patient
with cervical node metastases presents a problem
which demands that therapeutic acumen which is
acquired only through special training and wide
experience in the treatment of cancer. It is, then,
obvious that one should not attempt to treat a
carcinoma of the upper mucous membranes unless
he is prepared to treat cervical metastases also.
The percentage of five-year cures of carcinomas of
the upper mucous membranes is directly propor-
tional to the percentage of patients presenting no
evidence of cervical metastases at the time of
treatment of the primary lesions, and individual
statistics improve greatly with experience and with
the ability of the individual physician properly to
treat metastatic nodes.
There are so many factors involved in evaluat-
ing the therapeutic measures in the treatment of
cervical metastatic lesions that the literature is
quite controversial. ^lany surgeons advise com-
plete block dissections of the neck, but the fact
remains that striking success has been credited this
procedure only in those cases with no clinical evi-
dence of metastases before operation. As irradia-
tion technique and the physical equipment for ad-
ministering the treatment have improved, the great
majority of these patients fall into the group suit-
able for radiation therapy. However, neither ra-
diation alone nor surgery alone is adequate in
every case, and the correct combination of surgery
and irradiation, determined by close consultation
between surgeon and radiologist, is the method of
choice in a large percentage of cases.
Biopsy of the primary lesion following prelimi-
nary irradiation should be performed in every case,
as the final choice of the method of treatment
should be determined by the grade of malignancy
and by the radiosensitiveness of the neoplasm,
which sensitivity can be quite accurately deter-
mined microscopically provided one has sufficient
knowledge of tumor pathology.
For practical purposes all cases may be divided
into three classes, namely; those having no palpa-
ble nodes, those with palpable nodes that are con-
sidered operable, and those with palpable nodes
that are inoperable.
For the first group many surgeons advise com-
plete block dissections of the neck, while radiolo-
gists as a group advocate external irradiation. Sta-
tistics show that prophylaxis is just as successful
with irradiation as with surgery, and irradiation
does not necessitate an operative procedure. Ex-
ternal irradiation should consist of high-voltage,
low-intensity radiation to both sides of the neck
given in fractional doses over a period of four to
six weeks for a total of 4,000 to 6,000 roentgen
units following the principles set forth by Coutard.'
If palpable nodes do not appear later, no further
treatment is given. The common practice of giv-
ing one erythema dose to the neck is worse than
useless, for it creates a false sense of security.
The management of the second group requires
the most critical judgment. Operability is often
difficult to determine, but the number of cases
placed in the surgical group diminishes in propor-
tion to the increased experience of the radiologist.
Quick's- criteria for operability are as follows:
"Surgical dissection of the neck, when done, is
unilateral, but the most radical possible. Dissec-
tion is limited to fully differentiated epidermoid
carcinoma, palpable involvement unilateral, capsule
of the node or nodes presumably intact in patients
presenting good physical condition and in whom
the primary growth is either controlled or gives
promise of complete controllability."
As stated above, the final choice of the method
of treatment must be determined by the grade of
malignancy, which also largely determines the prog-
nosis. From a histologic point of view implanta-
tion therapy is indicated in all cases except the
grade-iv, and even in most of these it is a valuable
precaution. Only the most radiosensitive metasta-
ses can be trusted to external irradiation alone.
All cases should be subjected to preliminary high-
voltage, low-intensity irradiation. After the skin
reaction has subsided the remaining palpable nodes
Januar>-, 1936
SOUTHERN MEDICINE AND SURGERY
should be implanted, through surgical exposure,
with platinum-filtered radium emanation for a total
of 3,000 to 10,000 millicurie-hours, depending on
the size of the metastatic mass. It has been
shown^ that it requires 7 to 10 skin-erythema doses
to all parts of a tumor mass to destroy a fully
differentiated carcinoma, and that it requires 10,-
000 millicurie-hours to deliver 10 skin-erythema
doses to a mass S cm. in diameter and 6 skin-ery-
thema doses to a mass 7 cm. in diameter. As a
large percentage of tumors arising from the upper
mucous membranes belong to this adult type of
lesion, one can determine from these figures the
amount of interstitial irradiation necessary to de-
stroy their metastases: but the dose must be accu-
rately calculated, and scientifically applied.
In certain selected cases of highly differentiated
carcinomas presenting a single accessible node, it
is wise to remove the node by means of electro-
surgery, and implant the node bed with radium
emanation. Patients with recurrent, operable low-
grade metastases following radiation therapy should
be subjected to radical neck dissections, because
the disease, as a result of previous treatment, has
become radioresistant, and any additional roentgen
or radium therapy is practically useless.
Inoperable cervical nodes are entirely a radiol-
ogical problem. Treatment of these cases consists
of a combination of external and interstitial irra-
diation, both being employed in massive doses.
With such treatment the glands usually decrease
in size, and the patient shows clinical improvement
which may persist for a few months and occasion-
ally for years.
Coexisting diseases — especially syphilis, diabetes,
arteriosclerosis and chronic cardiorenal disease —
make the prognosis of any malignancy unfavorable,
but little mention is made of this fact in the litera-
ture. A metastatic malignancy complicated by a
syphilitic infection is fatal in nearly 100 per cent
of cases. Therefore, if syphilis is present, it is
imperative that it be discovered early in the course
of treatment and that specific therapy be instituted
at once. Every patient should have a Wassermann
reaction determination before the beginning of
treatment, and a suggestive history or physical
signs of syphilis demand repetition of a negative
or doubtful reaction. In diabetics interstitial irra-
diation is strictly contraindicated until the quantity
of sugar in the blood is reduced to normal, and
none shows in the urine by ordinary tests, and the
disease must be completely controlled during radia-
tion therapy. Arteriosclerotic and cardionephritic
subjects must be placed in the hands of a compe-
tent internist during treatment.
Preservation of strength and appetite is as im-
portant in the successful treatment of cancer as in
any debilitating disease. The patient with far ad-
vanced carcinoma is already in a state of poor
nutrition, which becomes exaggerated after the in-
stitution of radiation therapy. In these cases, the
administration of insulin in daily doses of 15 to 45
units is invaluable. In many patients, appetite in-
creases almost immediately and it can be main-
tained throughout the course of treatment. A
mixed vitamin concentrate also helps raise resist-
ance to infection and inanition and patients with
advanced malignancy should be given one of these
preparations as a routine.
References
1. CouTARD, H.: Roentgen Therapy of Epitheliomas of
the Tonsillar Region, Hypopharynx and Larynx from
1920 to 1926. Am. Jl. Roentgenol, and Rod. Therapy,
1932, 28, 313-331.
2. Quick, D.: Radium in the Treatment of Metastatic
Epidermoid Carcinoma of the Cervical Lymph Nodes.
Am. Jl. Roentgenol, and Rod. Therapy, 193S, 33, 677-
681.
3. Martin, H. E., Quimby, E. H., and Pack, G. T.:
Calculations of Tissue Dosage in Radiation Therapy.
Am. Jl. Roentgenol, and Rad. Therapy, 1931, 25, 490-
506.
CARDIOLOGY
Clyde M. Gilmore, A.B., M.D., Editor, Greensboro, N. C.
Rheumatic Fever: Early Treatment
The degree of success in the treatment of rheu-
matic fever can accurately be gauged only by the
degree of cardiac damage after recovery. While
eventual damage to the heart can not be prevented
by any present means of treatment its degree may
be greatly lessened by proper treatment in the early
and active stage and by the prevention so far as
possible of recurrent attacks.
Treatment of the Acute Attack
Rest — By far the most valuable therapeutic
measure at our disposal in the management of this
and many other acute infections is rest. This can
be obtained only by the use of a hospital bed.
Mental and physical rest should be complete. The
patient should be put in an environment free from
disturbing events and nervous strain. Competent
nursing care is essential. Cardiac failure should
be anticipated and avoided if possible by treating
the case similarly to that of a far advanced decom-
pensation from the time the diagnosis of rheumatic
fever is definitely made until some time after the
active infection has subsided as evidenced by the
cessation of fever, the return to normal of the
white count and sedimentation time, the disappear-
ance of rheumatic nodules, and the absence of A-V
block in the electrocardiogram. Drugs must be
discontinued and a temperature record kept for
some days afterward before arriving at this conclu-
SOUTHERN MEDICINE AND SURGERY
January, 1936
sion. Regardless of symptoms, so long as there is
evidence (especially fever and leukocytosis) of
active infection the patient should be at absolute
rest in a hospital or cardiac bed.
Salicylate Therapy — Salicylates continue to be
used, not so much in the hope of influencing the
infection as for the comfort of the patient. It is
evident that any measure that will add to the
patient's comfort and his regimen of rest will assist
him in overcoming the infection. The drug should
be given in large doses during the acute stage, as
sodium salicylate or aspirin. Over long periods of
time our cases tolerate better the effervescent prep-
arations combining sodium salicylate with an alkali.
Salicylates may be given per rectum if not toler-
ated by mouth. Occasionally codeine may be nec-
essary for the relief of pain and sedatives should be
used to control nervousness, preferably phenobar-
bital or bromides, these being the least toxic.
Treatment oj Joint Symptoms — The affected
joints should be first kept in wet packs of magne-
sium sulphate solution until the acute pain is re-
lieved and then should be splinted or immobilized
with sandbags. Methyl salicylate ointment or lin-
ament is useful and heat from hot water bottles
or a strong electric light bulb gives added comfort.
It is characteristic of the joint lesions of rheumatic
fever that they clear up with no permanent damage
to the joint, so any therapeutic measures consid-
ered should be only for the relief of the pain and
radical measures such as tapping and drainage are
usually contraindicated.
Treatment oj Secondary Anemia — Early in the
disease there is usually secondary anemia and this
should be watched for and corrected quickly. A
combination of copper and iron-ammonium citrate
gives the quickest response in increasing hemoglobin
and red blood cells. Liver extract may be benefi-
cial in severe cases. In patients with extremely
low resistance frequent small transfusions are often
of value. It was for a time thought that transfu-
sions might promote immunity; but, since repeated
recurrences of rheumatic fever do not render the
individual immune from the infection, it is logical
to assume that no known therapeutic agent will so
serve, other than general measures directed to the
building up of his general condition.
Climatic Factors — That geographical location
has an effect on the incidence of rheumatic infec-
tion is generally agreed. The treatment of rheu-
matic fever by changing the patient to a subtropi-
cal climate has been advocated and tried in the
past few years with favorable results. There is
usually improvement while the patient is in a warm
dry climate, but recurrences are frequent when the
patient is returned to his former environment.
Diet — General diet is recommended after the
first few days and there is some evidence to sup-
port the theory that a diet high in vitamins in-
creases resistance to infection. We usually insist
on an added quantity of orange juice, milk, tomato
juice and fresh vegetables, with the addition of
codliver oil in some form during the winter months.
Non-specific Protein Therapy (Shock Therapy)
— Antistreptococcus serum therapy and vaccine
therapy have, to date, been failures. Immediate
and startling improvement frequently follows the
use of protein shock therapy, the improvement
being apparently contingent on the allergic response
to the agent employed, whether this be milk, pro-
tein extracts, bacterial extract or drugs such as
formaldehyde intravenously. One author reports
2>i cases of rheumatic fever treated by the use of
typhoid vaccine intravenously with good results.
While it is true that the arthritic symptoms are
usually promptly relieved by this procedure, it
would seem unwise to introduce such a potent
agent into the veins of a patient with an already
damaged heart since there is no way of controlling
the resulting protein shock. Typhoid vaccine or
one of the milk proteins intramuscularly would
seem much safer, and I believe is a valuable ad-
junct to drug therapy.
Removal oj Focal Injection — The disease is ag-
gravated by any focal infection and the frequency
of maxillary sinusitis in our series has been men-
tioned. As soon as the patient's condition will per-
mit the condition of the teeth, sinuses, tonsils and
pharynx should be thoroughly investigated with
drainage or removal of infected areas.
Convalescent Care — A part of the damage re-
sulting from rheumatic infection consists of the
fibrotic changes which occur in the tissues after the
active infection has become quiescent. For the
prevention of fibrosis potassium iodide in small
doses over a long period of time has been used for
years and its value apparently has been confirmed
by recent experimental work. Secondary anemia
should receive especial attention in this stage and
should be controlled b\" the measures outlined
above.
Editor's Note — This is the second of a series of articles
on rheumatic fever. CompHcations, recurrent attacks and
late sequelae will be discussed in subsequent issues.
The possibility of an aputrid PtjLMON.ytY necrosis (J.
Greenstein, Providence, in R. I. Med. JL, Dec.) should be
considered in those cases of pneumonia in which the x-ray
findings suggest a lung abscess and where marked differ-
ences exist between the clinical and the roentgenological
findings. In such cases it is suggested that s«rial roentgen
studies should be made and checked with the clinical
course. The diagnosis of aputrid pulmonary necrosis as
differentiated from lung abscess alters the treatment and
the prognosis.
January, 1936
SOUTHERN MEDICINE .\ND SURGERY
INTERNAL MEDICINE
W. Bernard Kinlaw, M.D., F.A.C.P., Editor Pro Tern,
Rockv Mount, N. C.
Paroxysmal Tachycaedia
This is a condition that can easily cause much
worry to the physician when the patient is seen
for the first time during an attack, and it is ap-
parently a rather common practice to use digitalis,
when it seldom appears to have any beneficial ef-
fect on the condition. I have seen only one case
of the ventricular type, and this is the only one
detected in 700 electrocardiograms that have been
run when organic disease was suspected. The
man was seen in 1930 and reported in this journal,
shqwing the very interestin,g electrocardiograms
with the ventricle contracting at a rate of 240
each minute. The patient would get nearly un-
conscious during the attack. He was found to
have several abscessed teeth and no free HCl.
Even though this type of tachycardia is associated
with organic heart disease in most every case, a
correction of these faults helped this man who is
now 48 j-ears old, and when seen a month ago he
stated that he was able to do most all of his work
as a farmer.
When we mention paroxysmal tachycardia, we
usually mean the auricular type and think of some
irritable focus in the auricle, ectopic to the sino-
auricular node, which for the time being (during
the attack) puts the heart under control of this
abnormal focus. The normal vagal control is lost
and the heart beats regularly and rapidly (rarely
exceeding 200 per minute) . From a study of cases
that I have seen and from reviewing reports on
various series of cases, I do not believe we are able
to state the cause of this condition. Foci of infec-
tion are always mentioned, but many cases never
reveal any foci; and, as the condition may continue
for many years without further sign of foci, al-
though we should naturally look for foci and re-
move all found, we should also try to find the one
thing that will stop the patient's attack. After
study of the heart, if possible, reassure the patient
and the family. Pressure over the vagus above the
clavicle seems to stop the attack most frequently.
It is true that these attacks may be associated with
organic heart disease, as also may extrasystoles,
but such attacks do not necessarily call for heart
treatment. It seems that most of these cases are
in women, and there is usually some emotional
disturbance associated with the attack. When we
remember that a hypothyroid patient may lose
weight and become run down as well as a hyper-
thyroid, it seems well to try and build the patient
back to a normal general health, trying to get away
from nervous instability.
This subject is well covered in good medical
books, and it is with the idea of trying to prevent
the abuse of digitalis in simple paroxysmal tachy-
cardia that I am mentioning it here. The detail
men for the various drug houses, each, naturally,
thinks his product the best and proceeds to tell
the doctor why. They come around so often that
digitalis is kept in the doctor's mind. It is a
great drug as we all know, but much abused. Its
dosage is just as simple to figure out as that of
atropine, and its indications are just about as clear-
cut as are the indications for the use of ergot, yet
patients are seen who are taking three drops t. i. d.
(the average person can eliminate IS m. daily)
and on up to as many as thirty or more drops
(not minims) every four hours for several weeks.
.■\t times with the large doses fibrillation begins,
cerebral or gastrointestinal symptoms appear, which
complicate the original condition, and the patient
is sent to the hospital on account of the symptoms
from over-digitalization. An interesting point in
this connection was recently brought out by F. A.
Willius at a staff meeting of the Mayo Clinic, name-
ly, that in such a case (over-digitalization) even
in the presence of edema, the proper procedure is
to force fluids, giving 1000 c.c. daily 10 per cent,
glucose, in the vein, and 2000 c.c. by mouth if
possible.
The attacks of paroxysmal tachycardia, coming
suddenly and stopping the same way, are interest-
ing, but not harmful in themselves, and when we
can tell our patients about an attack that lasted
29 days without apparent damage it will certainly
relieve some of the anxiety while we go quietly
about our business of trying to stop it and then
giving them more examination and study and less
drugs.
Mild Hypothyroidism
(R. O. Russell, Birmingham, in J I. Med. Assn. State of
Ala., Dec.)
These patients have a vague, poorly defined condition of
ill health, which begins insidiously and usually progressive-
ly. They feel sluggish physically and mentally. They
have to drive themselves to do things which they formerly
did with zest. There is slowness of thought and movement.
Another prominent symptom is constipation. Brown of
Baltimore reports the case of a woman sent for a resection
due to intestinal obstruction. She frequently went 9 days
without a stool and had other symptoms of hypothyroid-
ism. Brown advised postponing the operation 3 days and
began giving thyroid extract, grs. 6, daily. This started
normal bowel movements, reduced weight and brought
back mental and physical activity.
Other symptoms are loss of appetite, cold hands and feet,
difficulty in keeping warm in cold weather. Some give a
history of gaining weight, some of losing. The thyroid
may be slightly enlarged or no enlargement. Nervousness
and glandular enlargement may cause the physician to
mistake for hyperthyroidism or toxic goiter. Another oc-
casional symptom is a tingling or burning over the body.
A tendency to infections of the nose and throat is present
in some.
SOUTHERN MEDICINE AND SURGERY
January, 1936
Surgical Observations
A Column Conducted by
The Staff of the Davis Hospital
Statesville, N. C.
Pyloric Obstruction in Infants
Soon after birth symptoms of pyloric obstruc-
tion may be manifested in infants, and where per-
sistent, it is always a condition which calls for care-
ful study and prompt treatment.
The most common symptom, and usually the
first that is noticed, is vomiting. The onset fre-
quently occurs in the second or third week; al-
though it may begin earlier or later. The type of
vomiting ranges from simple regurgitation of food
to projectile expulsion.
Two types of lesions which should be thought
of in any vomiting in early case of infants are
pylorosj^asm without any great hypertrophy of the
pyloric structures, and congenital pyloric stenosis.
One curious fact is that pyloric obstruction oc-
curs far more frequently in boys, indeed only occa-
sionally in girls. The causes are unknown.
The onset may be gradual, or s3Tnptoms may
come on suddenly, usually \vith the regurgitation
of food which may progress to vomiting of the
projectile type. The vomiting may be regular in
time, or it may follow each feeding. Sometimes
there will be no vomiting until the child has nursed
two or three times, or has had two or three feed-
ings, and then the entire contents of the stomach
may be expelled. Along with the continued vomit-
ing comes a gradual loss of weight, constipation
and general malnutrition. With the child entirely
undressed and lying so that the light shines in the
proper way upon the abdomen, visible waves of
gastric peristalsis can usually be seen.
Careful palpation of the abdomen will often dis-
close the presence of a tumor in the region of the
pylorus. The exaggerated gastric peristalsis and
the tumor are usually diagnostic of congenital py-
loric stenosis.
The pathology that is present varies. In the
mild cases there may be only a spasm of the pyloric
muscles without any appreciable hypertrophy. It
is this type of cases that yields to medical treat-
ment. In the hypertrophic type there is a great
thickening of these muscular fibers, and on palpa-
tion the pylorus presents a hard, tumor-like forma-
tion which is usually fusiform in shape. This is
hard and fibrous and may close the pylorus so
tightly that nothing can pass through it. In a case
of this kind surgical treatment offers the only pos-
sibility of relief.
The medical treatment of pyloric obstruction
usually consists of giving the infant a small dose
of phenobarbital sodium 20 to 30 minutes before
each feeding. This may relieve the spasm or the
pylorus and allow it to act normally, permitting
the food to pass from the stomach into the intes-
tines. In mild cases seen early, before there is any
wasting or dehydration, this treatment may be tried
before surgical reatment is resorted to.
If medical treatment fails, surgical relief shoidd
be afforded promptly, before the child is too weak
to undergo an operation.
Where there is a fibrous, hypertrophic stenosis
with complete obstruction of the pyloric outlet of
the stomach, naturally death can be the only ter-
mination unless relieved by surgical treatment. As
in most other surgical conditions, delay in institut-
ing treatment increases the hazard, and with each
day of delay the mortality rises.
When surgical treatment is decided upon, the
infant should be plentifully supplied with fluids.
Glucose and saline solution, or saline solution alone,
may be given subcutaneously or intraperitoneally.
Intravenous treatment may be given under certain
circumstances, but is difficult in infants. Whole
blood from the mother given intramuscularly is of ■
help.
Operation should never be attempted until the
child is in the best possible condition, but the pre-
operative treatment requires only a very short time.
Through a small, high right-rectus incision the
tumor mass is exposed and it is very easy to retract
the liver upward and reach down and lift up the
pylorus and bring it into position so that the con-
stricting fibers can be incised. The incision is car-
ried down to the mucosa, great care being taken not
to injure the mucosa itself. The mass is then sep-
arated sufficiently to insure relief from the obstruc-
tion. The Fredet-Rammstedt operation is usually
the one of choice. An operation devised by A. A.
Strauss of Chicago, a variation of the Fredet-
Rammstedt technique, is useful in some types of
cases.
This operation is carried out under local infiltra-
tion anesthesia, as a rule requires only a few min-
utes, and the results are almost uniformly good. A
gastroenterostomy is not advisable in these cases
for obvious reasons.
Anyone who has examined the pylorus in a tv^ji-
cal case of congenital hypertrophic pyloric stenosis
will realize the futility of medical treatment in a
case of this kind.
The most important factor in saving infants with
this condition is an early diagnosis and prompt
treatment. Persisent, forcible or projectile vomit-
ing with constipation and beginning wasting, with
visible peristalsis of the stomach and a palpable
tumor in the region of the pylorus demand imme-
diate surgical treatment. Persistent vomiting with
the presence of a palpable tumor or a visible peris-
January, 1936
SOUTHERN MEDICINE AND SURGERY
45
talsis of the stomach should within themselves be
sufficient evidence of a surgical obstruction of the
pylorus in infants.
As in other surgical conditions, the condition of
the patient has much to do with the results. Where
the diagnosis has been early and there is very little
wasting the outlook is good. As the dehydration,
wasting and malnutrion increase the mortality rises.
After operation for the relief of pyloric obstruc-
tion improvement begins immediately, .'\fter the
first twenty-four hours the child begins to retain
nourishment, the bowels begin to move and recov-
ery is usually very rapid. So far as can be told,
there are no after-effects and the children grow up
well, and those that have been followed up for
years after these operations have usually shown no
further signs of pyloric trouble.
A SrupLE Classification op Pitlmonary Tuberculosis
(T. L. Havlicek, Sanator, S. D., in Jl. -Lancet, Dec. 1st)
Many do not readily recognize the cases of tuberculosis
for which institutional treatment is indicated.
When a patient comes into your office and you get the
history of contact, do a skin test — if negative no infection
present, if positive the individual has been infected with
the bacillus. The severity of the reaction, or the size of
the reaction, does not show the severity of the tuberculo-
sis.
Ne.xt an x-ray of the chest — -50% of positive reactors
will show the pulmonary lesion, and the other 50% to be
glandular, mesenteric, cervical or mediastinal. If the x-ray
shows the apices clear with calcium deposits along the
hilus, the patient has the first infection which is healed
and is only an observational case. He should have fre-
quent x-ray examinations, and if extension or infiltration
begins to spread a reinfection is taking place. The patient
may feel in exceptionally good health. This case is an
institutional one, or the patient should be placed under
therapy at home and placed at rest. If the lesion does
not show signs of regression within a few months some
form of collapse therapy is usually indicated and should
be immediately instituted. The exudative lesion gradually
advances and becomes caseous if treatment is not through,
and when extension is present in the other lung with
much destruction, collapse therapy, although still appMca-
ble in some cases, is, as a rule, useless.
A patient becomes an institutional case when secondary
infiltration shows itself in the lung, or when secondary
infection or reinfection takes place. To admit a patient
to the institution before this stage is a detriment to the
patient as in the first two stages mentioned above addi-
tional contact is harmful. Nothing is audible in the chest
with a stethoscope in the first two stages. When reinfec-
tion takes place, as a rule, rales are not present at the
beginning of the infection, some interrupted breath sounds
or dim sounds are heard but not enough to make a diag-
nosis. When the fourth stage is reached, however, symp-
toms are present and in most cases diagnosis can be made
with a stethoscope.
At present, 99% of the patients suffering from tubercu-
losis, reach the institutions in the fourth stage of the dis-
ease, and over 75% of this group are in the late fourth
stage.
The large number of fourth-stage cases keeps many third-
stage cases from being admitted OTid given a chance of
arrest and cure.
CoFPEE AND Turkish Coppee
(Editorial N. E. M. A. Quarterly, Dec.)
Coffee is invaluable in the home whether palace or hut.
The Turk has the advantage of all others in that his coffee
cup is very small and his proportion of coffee to liquid very
large. He sips the coffee from the grounds. He seldom
uses cream, though many Turks use sugar.
The Turk's cup is white porcelain and holds two fluid
ounces. The guest orders coffee, and after a few minutes
the waiter brings a small tray containing the empty cup
and saucer and a large glass of water. Then, from a small,
cone-shaped copper vessel, with a handle, is poured coffee
to fill the cup. If two guests be present, the copper vessel
is of a size to fill two cups. If four or six guests, the
vessel is of increased size and fills all the cups.
The vessel used in making coffee is always of one shape,
and is of such size as to exactly fiU the number of cups
ordered. I observed that when three cups were ordered
two vessels were employed, one for a single cup and the
other for two cups. In all cases the tray of empty cups
is brought the guest, and then, hot from the fire, come
the vessels with the smoking coffee.
In the typical native coffee-house the fire is artfully
manipulated. It consists of a bank of hot ashes, through-
out which glow small fragments of charcoal. No flame is
visible, and when at rest the pile of ash seems dead.
Into the one-cup copper vessel the native puts one tea-
spoonful of pounded coffee and one teaspoonful of gran-
ulated sugar, unless sugar is not wanted. Then the vessel
is filled to the top of this cone with cold water and the
mixture stirred. Then the projecting base of the vessel is
thrust beneath the ash heap, and in a few seconds projected
farther until the contents boil, when it is immediately
drawn back. Next the ashes are gradually drawn about
the base so as to encircle it, and soon the vessel is thrust
into the center of the heap, the manipulator watching it
closely. At the first sign of ebullition the vessel is with-
drawn, quickly thrust back, where it boils at once. The
contents are then poured into the cup, where the grounds
quickly settle. This same macerative-extractive method is
employed with the various-size vessels.
The entire contents of the extractor, grounds and all,
are poured into the cup. Turkish coffee is thus not clear,
but quite like a dirty emulsion. A scum rises to the sur-
face and the grounds slowly settle. The drinker, as a
rule, first takes a few swallows of cold water (a glass of
water is always served, if water is convenient), and then,
very slowly and deliberately, sips the liquid from beneath
the scum until the grounds are reached. Then he may
again take a swallow of cold water. This completes the
process. In all, not more than a full tablespoonful of
liquid coffee is swallowed. Hence, considering the fact
that the powdered coffee is but partly extracted by the
process of manipulation, and that the sugar dissolved takes
up some space, whilst the grounds hold much of the liquid,
the coffee actually consumed in inconsiderable.
The Turks do not favor grinding coffee in a mill. They
claim that the flavor is lost. If the pestle be not heavy
iron, a weight is affixed to the top so that the labor
required is an upward pull instead of a downward blow.
The flavor of Turkish coffee at first does not usually
appeal to one accustomed to European and American cof-
fee. The act of sipping the liquid from the grounds is an
art to be acquired. The absence of milk or cream is dis-
tasteful to persons accustomed to these accompaniments.
But very soon I experienced a craving for the peculiar
beverage, which carries no touch of bitterness, nor any
indication of rankness.
SOUTHERN MEDICINE AND SURGERY
January, 1936
Southern Medicine and Surgery
Official Organ of
Tri-State Medical Association of the
Carolinas and Virginia
Medical Society of the State of
North Carolina
James M. Northington, M.D., Editor
Department Editors
Human Behavior
James K. Hall, M.D Richmond, Va.
Dentistry
W. M. RoBEY, D.D.S - Charlotte, N. C
Eye, Ear, Nose and Throat
Eve, Ear and Throat Hospital Group Charlotte, N. C.
Orthopedic Surgery
0. L. Miller, M.D | Charlotte, N. C.
John Stuart Gaul, M.D.)
Urology
Hamilton W. McKay, M.D I Charlotte, N. C.
Robert W. McKay, M.D j
Internal Medicine
W. Bernard Kinlaw, M.D Rocky Mount, N. C.
Surgery
Geo. H. Bunch, M.D -^- Columbia, S. C.
Therapeutics
Frederick R. Taylor, M.D High Point, N.C.
Obstetrics
Henry J. Langston, M.D Danville, Va.
Gynecology
Cjias. R. Robins, M.D Richmond, Va.
Pediatrics
G. W. KUTSCHER, JR., M.D... Asheville, N. C.
General Practice
VViNGATE M. Johnson, M.D... _.. .Winston-Salem, N. C.
Clinical Chemistry and Microscopy
C. C. Carpenter, M.D. Wake Forest, N. C.
Hospitals
R. B. Davis, M.D Greensboro, N. C.
Pharmacy
W. L. Moose, Ph. G Albemarle, N. C.
Cardiology
Clyde M. Gii-MORE, A.B., M.D -.-.Greensboro, N. C.
Public Health
N. Thos. Ennett, M.D.. -. Greenville, N. C.
Radiology
Ai.LEN Barker, M.D. — . I Petersburg, Va.
Wright Clarkson, M.D.j
Offerings for the pages of this Journal are requested
and given careful consideration in each case. Manu-
.>>cr-ipts not found suitable for our use will not be returned
unless author encloses postage.
This Journal having no Department of Engraving, all
costs of cuts, etc., for illustratmg an article must be
tome by the author.
Unlawful for Corporations to Practice
Medicine
Once in a while a law court makes a decision
which might be used as evidence that Mr. Bumble
should have made some little reservation in pro-
nouncing "The Law is an ass."
In its last issue for 1935, the Journal oj the A.
AI. A. carried this information:
The Dr. Allison, Dentist, Inc., the plaintiff in this action,
entered into a contract with the defendant dentist wherein
the latter agreed, according to the record, "that he would
not practice operative dentistry for a period of three years
at any place within two miles of the corporate location."
Shortly thereafter the dentist opened a dental office directly
across the street from the corporate dental parlors and the
corporation sought to enjoin the violation of the agreement.
The trial court, in denying the injunction, held that the
plaintiff corporation was illegally practicing dentistry, that
the corporation's only damage would arise out of compe-
tion in a line of business which it could not lawfully follow,
and that therefore the petition of the corporation for an
injunction did not appeal to the conscience of a court of
equity. The corporation appealed to the Supreme Court of
lUinois, contending that Section ISa of the dental practice
act, which prohibits corporations from practicing dentistry,
was unconstitutional.
The Supreme Court, however, considered it to be unnec-
essary to pass on the constitutional question. The gist of
the corporation's complaint, and its claim to equitable relief,
was based on damages alleged to be feared through the
defendant's competition in practicing dentistry. The prac-
tice of a profession, said the court, is everywhere held to
be subject to licensing and regulation under police power
and not subject to commercialization or exploitation. To
practice a profession requires something more than the
financial ability to hire competent persons to do the actual
work. It can be done only by a duly qualified human
being, and something more than mere knowledge or skill
is essential to qualify. The qualifications include personal
characteristics, such as honesty, guided by an upright con-
science and a sense of loyalty to chents or patients, even
to the extent of sacrificing pecuniary profit, if necessar>'.
These requirements are spoken of generically as that good
moral character which is a prerequisite to the licensing of
any professional man. No corporation can qualify. It can
have neither honesty nor conscience, and its loyalty must,
in the very nature of its being, be yielded to its managing
officers, its directors and its stockholders. Its employees
must owe their first allegiance to their corporate employer
and cannot give the patient anything better than a second-
ary or divided loyalty.
The corporation, in its complaint, stated that the dentist
had acquired secrets and confidential information in regard
to the patrons of the corporation. It might be well in-
quired, said the court, in whom are these personal secrets
imposed when a corporation attempts to practice? Can it
be in the president alone, or is he under the corporate duty
of disclosing them to his directors? And are the directors
under the further corporate duty of disclosing them to
stockholders? This very allegation of the corporation
clearly demonstrates, the court said, the inappropriateness
of any corporate attempt to practice one of the learned
professions, involving personal and confidential relations,
and most clearly demonstrates that such practice is not and
cannot be open to commercial exploitation. The corporate
charter of the corporation, the court said, did not and could
Januar>', 1936
SOUTHERN MEDICINE AND SURGERY
not authorize it to practice dentistry, and the trial court
quite properly dismissed the complaint.
It will be seen that Illinois has a law specifically
prohibiting practice of medicine by a corporation.
Whether or not North Carolina has such a law, we
do not know: but it would seem that this is im-
material, for the trial court in this Illinois case
waved aside the alleged unconstitutionality of the
law and decided that principles "everywhere held"
made the practice of medicine by a corporation
illegal.
We believe a good deal of this would apply right
here in North Carolina to contracts sold by a cor-
poration, whether profit or so-called, non-profit,
under which the services of doctors are promised.
The concluding paragraph is a real joy. Nothing
as neat in a court's decision on a medical matter
has come to our attention since a Nebraska judge
denied a claim of a religious healer on Scripture
grounds, and recounted in detail how Simon got
to be a leper and the word simony originated.
We are glad to have the backing of the Illinois
Supreme tribunal in a long-held opinion that a
corporation ''can have neither honesty nor con-
science."
The Health Bulletin and Its Editor
In last month there came to this desk No. 12 of
Vol. SO of the Bulletin of the North Carolina State
Board of Health. For half a century has this
bulletin gone out over the State carrying health
information and inspiration. How it was started
and how it was made to grow through its infancy
and childhood is told by The Editor in a leading
article which every citizen should wish to read.
(This Bulletin will be sent free to any citizen of
the State upon request.) This article tells about
the work of Dr. Thomas F. Wood and Dr. Richard
H. Lewis. These were mighty men and deserving
of the highest praise; but we would say something
about the work of the present Editor of the Bulle-
tin, Dr. George M. Cooper.
A great number of State and National public
health periodicals come into our hands regularly.
Many of these are much more pretentious than the
one that is the work of Dr. Cooper; but not one
can be compared with his for solid worth.
Dr. Cooper says of himself that "since March
1st, 1923, he has been the responsible Editor of
the Health Bulletin." Dr. Cooper is much more
than "responsible:" he is able, energetic, resource-
ful, faithful — and many other things that all of us
admire in others and covet for ourselves.
We are most amazed at the faith revealed by
the evidences of sustained zeal through 23 years of
striving against ignorance and indifference, in an
endeavor to save people in spite of themselves.
Our own faith is of the kind that believes it can
remove mountains — but very little at a time. If
all of us doctors in private practice will put our
full strength into carrying out measures of disease
prevention such as The Bulletin advocates and
keeps fresh in our minds, then will the mountains
of preventable disease disappear rapidly and Dr.
Cooper's faith be justified.
Will we not water where he plants and all share
in the increase?
Reconsideration as to Chapel Hill and Wake
Forest Medical Schools
Abstracts of Minutes of Meeting Council on Medical
Education and Hospitals, Dec. 8th and 9th.
(From Journal A. M. A., Dec. 28th)
1. The meeting was called to order at 10 a. m.
Those present included Drs. Ray Lyman Wilbur
(chairman), Merritte W. Ireland, Frederic A.
Washburn, J. H. Musser, Fred Moore, Reginald
Fitz, William D. Cutter, Herman G. Weiskotten,
Carl M. Peterson, Oswald N. Andersen and Mr.
Homer F. Sanger.
2. It was resolved that the minutes of the busi-
ness meeting of Sept. 15th, 1935, be approved.
3. It was voted to reconsider the resolution
passed in September to the effect that after July
1st, 1938, the Council would no longer list two-
year schools and it was further voted that such
schools be considered individually.
4. It was voted that the nineteen sophomore
students at present enrolled in the University of
Mississippi School of Medicine may be accepted in
approved schools without prejudice to the standing
of the latter.
5. It was voted that the American Board of
Dermatology and Syphilology be approved.
6. It was voted that the American Board of
Radiology be approved.
7. It was voted that the list of pathologists as
submitted be approved.
8. It was voted to approve the lists of hospitals
and other institutions recommended by the staff.
WILLIAM D. CUTTER, Secretary.
A Heartening Incident
.4 s far back as our memory goes and on up to
now, church newspapers have been carrying many
and varied advertisements of "patent" medicines.
It has been alleged that the religious press is the
main prop of that business; but, after glancing
through recent issues of the big dailies of our State,
and after trying vainly to listen to a radio pro-
gram without hearing about our bowel movements
and body odors, we are disposed to doubt that the
church papers should be given chief place.
SOUTHERN MEDICINE AND SURGERY
January, 1936
The incident which heartens in this connection —
unique, so far as our knowledge goes — is that of a
church paper boldly announcing that it will no
longer carry this kind of advertising. An editorial
in the December 12th issue of Charity & Children,
a Baptist weekly published at Thoniasville, goes
like this:
The editor of Charity and Children has been accused of
rank inconsistency. We make public note of the charge
because the one making it proves his case most completely.
He is at the head of a great institution for people with
diseased minds. His charge is that Charity and Children
is strong against liquor and at the same time advertises
nostrums that are much worse than liquor. All that we
can say to that charge is that the doctor's point is well
taken. He says that he treats (until death) persons who
come to his institution because of taking some of the stuff
advertised in Charity and Children. We do not bow in
shame. We have long been shamed by the type of articles
sent in by our advertising agency that has a contract with
us. We thank the good doctor and all of the other physi-
cians for their forbearance with us and promise them here
and now that w'e are going to part company with the dis-
pensers of nostrums. Hereafter our Orphanage physician
will OK every medical advertisement that appears in this
paper. We may be tied up in a 90-day contract but we
will not accept a new medical advertisement without the
approval of our family physician and will discontinue all
that are objectionable to him within 90 days. Now! we
have said what we have longed to say and we feel like we
have had a good bath.
This stand would be praiseworthy under any
circumstances; when we consider the fact that it
is costing Charity & Children a large part of its
income, we are deeply impressed with this proof of
religion and morality. We hope that virtue will
net be penalized for long, and we promise to be
on the lookout for opportunities to steer in the
way of this honest paper the kind of advertising
an honest paper can accept.
COMMUNICATION
Wilson, N. C, December 24th.
Dear Dr. Northington:
I have just read your editorial on reducing highway fa-
talities, and I hasten to write you that your plan is the
sanest and most tenable and entirely practical that I have
seen anywhere. I hope you will continue to hold this up
in the face of every oificer of the law, and before the
public. I have been trying for several years to help work
up a public sentiment and moral influence against this
organized killing system and found it as you know very
hard and at times discouraging. But during this time I
have seen criticism of my efforts gradually fade and change
into commendation. I am proud of a iew accomplishments,
principal of which was a summer's work trying to get a
patrolman eliminated from our local force, which finally
succeeded, but not until after going to the Governor with
it. I don't mind letting the officers know that we expect
action from them and that I am willing to appear as
witness in any case that I see. I simply tell my critics
that when I look down upon a corpse of the road out of
my family I shall not have to suffer the agony of knowing
that I never did the first thing to try to prevent it. So,
many of the critics have experienced this anguish and have
been converted as the time and accidents piled up.
I believe yours will be the best Christmas present given
in North Carolina this year.
Hoping for you a happy Christmas this year and many
more in a long future.
Sincerely,
E. T. DICKINSON.
Dr. E. a. Hines, Secretary-Editor for the South Caro-
lina Medical .Association, writes that he brought this edi-
torial before the next meeting of his Civic Club and a
Committee was appointed to further the idea. We are
proud to have the approval and grateful for this backing
of such men as Dr. Hines and Dr. Dickinson. — Editor.
Obituary
Robert B. Babington
A Layman Who Contributed to Medicine
From time to time some layman has a vision of
service to his fellowmen which expresses itself in
the creation of an institution for making the bene-
fits of medicine and surgery available to the peo-
ple. It is evident from the history of medicine
that much of the advance made by medicine and
surgery has been due to the means, inspiration and
guidance furnished by laymen. Those of us
who work in the profession are truly grateful for
the enlarged opportunity thereby afforded to prac-
tice the art and render a type of service which
might otherwise have been denied us or at least
longer deferred.
This brief is written to express appreciation for
the life of Robert B. Babington — Citizen, and Foun-
der of The North Carolina Orthopaedic Hospital
for Crippled Children.
Some twenty-five years ago, !Mr. Babington be-
came interested in creating an institution for the
care of needy crippled children. He was truly a
pioneer in this movement which later spread so
generally over the country, resulting in the Shrin-
ers' chain of crippled children's hospitals, other
State institutions for orthopedic patients and con-
tributed largely to the progress of orthopedic sur-
gery.
The creation of the North Carolina Orthopaedic
Hospital was due solely to the vision and deter-
mination of this man. If one knew the many ob-
stacles overcome and the discouragements ignored
by Mr. Babington in his early years of work in
connection with raising funds for the proposed
State Hospital for Crippled Children his accom-
plishments would be appreciated even more. He
raised money at first through gifts of his own, by
penny contributions from children, by soliciting
small contributions at the County Fair, by enlist-
ing friends in the cause and, finally, by interesting
Januao'> 1936
SOUTHERN MEDICINE AND SURGERY
the State Legislature in a series of sizeable appro-
priations, making possible the erection of the first
units of the hospital.
Under a board of trustees and with Mr. Babing-
ton as president and prime mover the Orthopaedic
Hospital was opened for patients in the summer of
1921. Thirty beds were available then. These
were promptly taken by indigent crippled children
from Xorth Carolina and the hospital has been
full of needy children from that day to this.
The number of beds was soon increased to fifty.
In 1927 a building program brought the bed ca-
pacity to one hundred. Shortly thereafter the Ben-
jamin X. Duke Ward for the Colored was added
with a capacity of fifty beds and the hospital now
operates w-ith one hundred and fifty beds — one of
the largest hospitals of its kind in the country.
The Xorth Carolina Orthopaedic Hospital has
been the recipient of handsome appropriations from
the State, apparently gladly given, and substantial
gifts have been made by a number of individuals.
^Ir. B. X'. Duke gave, during his lifetime and later
through his will, some fifty thousand dollars to the
colored division. Mr. Edwin D. Latta left in his
will a bequest to the hospital estimated at two
hundred and fifty thousand dollars. The sum of
seventy-five thousand dollars has already accrued
to the institution from this estate. Many miscel-
laneous donations have come from other sources
until now a plant is in operation which has invested
in it a half-million dollars in money, the affection
and goodwill of thousands of patients and citizens,
and the confidence of a great State in its permanent
usefulness.
These things are briefly summarized (and they
far from tell the whole story) to show the results
of the diligence of one layman as he contributed to
medicine. He successfully promoted a good cause
which will bear fruit in the generations to come.
While not on so large a scale, but in spirit propor-
tionately, Robert B. Babington will go down in
history along with the Rockefellers, the Dukes and
other laymen who have substantially contributed
to the progress of medicine. Mr. Babington in his
active working days often termed himself Andrew
Tackson, whom he greatly admired, and one of the
favorite homely e.xpressions of the Founder of The
North Carolina Orthopaedic Hospital, when he
girded himself for action on behalf of any issue re-
lating to this institution, was: "I ganny, they ain't
nothing Andy Jackson can't do." And so he lived,
labored and wrought and erected for himself a fit-
ting monument of service to the handicapped and
underprivileged children of his native State.
—0. L. MILLER, M.D.
NEWS ITEMS
The Southe.4stern Surgical Congress will hold its sev-
enth annual assembly in New Orleans, March 9th- 10th-
11th, 1936, at the Roosevelt Hotel. The following doctors
have accepted places on the program: Arthur Hertzler,
Halstead, Kan.; Chevaher Jackson, Philadelphia; Francis
E. Lejeune, New Orleans; .Arthur \V. Allen, Boston; John
F. Erdmann, New York City; Jennings Litzenberg, Minne-
apolis; Joseph E. King, New York City; Fred Rankin,
Lexington, Ky.; C. C. Howard, Glasgow, Ky. ; George W.
Crile, Cleveland; Garnett W. Quillian, Atlanta; Paul Flo-
thow, Seattle; .\lan C. Woods, Baltimore; Virgil S. Coun-
seller, Rochester, Minn.; .Alfred h.. Strauss, Chicago; W. D.
Haggard, Nashville; Roger G. Doughty, Columbia; Thomas
E. Cormody, Denver; Charles 0. Bates, Greenville, S. C;
Guy Caldwell, Shreveport ; Gerry Holden, Jacksonville ;
Emmerich von Haam, New Orleans; Roger Anderson, Se-
attle; A. Street, Vicksburg; James S. McLester, Birming-
ham; Edgar Fincher, jr., Atlanta. There will be others.
American Board of Ophthalmology, Room 1417, 122
So. Michigan .Ave., Chicago, 1936 examinations, Kansas
City, May 11th (at time of meeting of A. M. A.), and
New York City, in October (at time of meeting of Amer-
ican Academy). All applications and case reports must be
filed at least 60 days before date of examination.
For information, syllabuses and application forms, please
write at once to Dr. Thomas D. Allen, .Assistant Secretary,
122 So. Michigan Ave., Chicago, 111.
The annual meeting of the Seventh District (N. C.)
Medical Society was held at Wadesboro, November 12th,
with Dr. L. A. Crowell, jr., president, in the chair. Dr.
Forest M. Houser of Cherryville, Councillor, called the
meeting to order. Following the afternoon program a
banquet was held at 6:30 to which an address of welcome
was given by Dr. Chas. I. Allen with a response by Dr.
D. A. Garrison, followed by an address by Dr. L. B.
McBrayer. The new officers are: president, Dr. J. M.
Davis, Wadesboro; vice president. Dr. McT. G. Anders,
Gastonia; secretary, Dr. C. H. Pugh, Gastonia; place of
meeting, Gastonia.
At the last meeting of the Richmond Academy of Med-
icine for the fiscal year ending on December 10th, the fol-
lowing officers were elected: president. Dr. Roshier W.
Miller; first vice president, Dr. Emory Hill; second vice
president. Dr. L. J. Stoneburner. Dr. Charles M. Cara-
VATi continues as secretary. The life of the Academy is in
excellent condition. The organization has 315 members, it
owns its own home, in which there is an excellent audito-
rium, in which the Miller Library is attractively housed,
and the Medical Society of Virginia has its offices in the
Academy bulding. In the basement of the building is a
refectory, in which the members mingle in intimate and
informal fashion around the refreshment table after each
meetinir. The new home of the Academy, with the price-
less Miller Library, is doing much to unify and to inspire
the members of the medical profession of Richmond.
Buncombe Count\- Medical Society, .Asheville, 40th
annual meeting. Grove Park Inn the evening of December
16th, President L. M. Griffith in the chair, 6S members
present, many visiting physicians from Oteen and from
adjoining towns.
Reports from the following com. were heard:
1) Public Health and Legislation, Dr. P. H. Ringer,
chr., reporting. Accepted and filed.
50
SOUTHERN MEDICINE AND SURGERY
Januar.', 1936
2) Medical Ethics, Dr. W. M. HoUyday, chr. Accepted
and filed.
i) Medical Economics, Dr. G. W. Murphy, chr. Ac-
cepted and filed.
4) Certified Milk Commission, Dr. G. W. Kutscher, sec-
treas. Accepted and filed.
5) Publicity Committee, Dr. C. H. Cocke, chr. Accept-
ed and filed.
6) Com. to Co-operate with Welcome to Asheville, Inc.,
no report submitted.
7) Medical Relief Advisory Committee, Dr. H. G.
Brookshire, chr. Accepted and filed.
8) Constitution and By-Laws, Dr. G. S. Tennent, chr.
For a change in by-laws, Chapter V, Sections 1 and 11, in
regard to the dues for 1936. Report accepted as informa-
tion.
9) Obituaries, Dr. M. L. Stevens, chr. Accepted as
presented.
10) Asheville Cancer Clinic, Dr. C. C. Orr, chr. Ac-
cepted and filed.
Auditing Committee, Dr. J. W. Huston, chr., reported
that the books of the treasurer had been examined and
found to be correct. His committee recommended that
the secretary-treasurer be directed to purchase and properly
keep a ledger of income and disbursements, and that a
record be so kept that will show each member's dues are
paid, together with the date of payment. Motion made to
accept the report and the recommendation as presented.
Seconded and carried.
Report of the Secretary-Treasurer: The Secretary read
before the meeting his annual message, the same being a
resume of the year's work and activities and accomplish-
ments of the society.
The Treasurer's report, being an exhibit of the income
and disbursements of the society for the year. Motion
made to accept the reports as presented and file. Seconded
and carried.
The chairman called on the Nominating Committee for
the nominations.
President: Dr. H. S. Clark, Dr. Mark A. Griffin and
Df.G.'Farrar Parker.- Nominations from the floor asked
for. None made. The balloting was then begun, three
ballots were taken before a choice could be made. Dr.
Geo. Farrar Parker won the nomination on the last ballot
and was duly declared elected president for 1936. (Dr.
Parker was not present in the room at the time.)
Vice President: Dr. G. W. Kutscher and Dr. C. C.
Swann. Nominations from the floor asked for. None
made. The balloting was begun and two ballots were nec-
essary for a choice (1st a tie). Dr. G. W. Kutscher was
elected on the 2nd ballot and was declared elected.
Secretary-Treasurer: The incumbent. Nominations from
the floor asked for and none heard. Election by acclama-
titon.
Third Member of Board of Censors: Dr. L. M. Grif-
fith. Motion made to close nominations. Sec. and carried.
Election viva voce.
1936 Delegates to the State Society session. The follow-
ing five delegates and their alternates: Delegates — Drs. R.
R. Ivey, Chas. C. Orr, Chas. A. Hensley, R. C. Scott, W.
C. Lott; Alternates— Drs. R. A. White, A. B. Craddock,
S. L. Whitehead, W. M. Hollyday, C. H. Cocke. Motion
made to accept the nominations as presented and the elec-
tion be by acclamation. Seconded and carried.
The secretary was instructed to convey the society's
greetings to the following physicians unable to attend the
meeting tonight because of illness: Drs. Lynch, Craddock,
L. L. Williams, Scott and J. E. Cocke.
Buncombe County (N. C.) Medical Society, .\sheville,
the evening of January 6th, at the City Hall Building,
President Parker in the chair. 4S members present; visitor.
Miss Margaret Thompson, a teacher of lip reading for the
hard of hearing.
Dr. Kutscher presented a baby, 8 months old. The
history of case outlined, a display of the blood work and
laboratory work done, x-ray films shown and consultant's
report read. Case undiagnosed. Essayist's opinion was
condition a mediastinal tumor, possibly a tumor of thy-
mus.
The president then asked Dr. Kutscher, the vice presi-
dent, to take the chair, and the Presidential Address and
Outline of Policies for the year was delivered. Dr. Ward
moved the address be reviewed by a committee appoint-
ed by the chairman and reported back to the society. Dr.
Grantham, chr., and Drs. Mears and Huston appointed on
this committee.
Miss Thompson was then called on and spoke of the
importance of recognizing the hard of hearing children
early and starting immediate treatment, medical, surgical
or lip reading. She spoke of the work of the Volta Bureau
at Washington, D. C, and the American Society for the
Hard of Hearing. Presentation discussed by Dr. Elias.
Committee reports:
Welcome to Asheville, Inc., Dr. Colby, chr., made a ver-
bal report to the effect that several of our members were
also members of this organization and their advise and
counsel was always available.
Dr. C. C. Orr submitted a written report from the N. C.
State Nurses Assoc, District No. 1, which gives an outline
of the work done for the year 193S. Report accepted as
information and filed.
Dr. G. S. Tennent, chr. of the By-Laws committee for
1935, presented the amendment to the By-Laws up for
adoption on Jan. 20th.
Dr. McCall of the 1935 Banquet Committee reported
that the banquet exhibit came out even as to income and
expenditures. Applause.
The Standing Committees for 1936 were announced by
the president.
(Signed) M. S. Broun, M.D., Sec.
GiTiLFORD County Medical Society', December 5th, King
Cotton Hotel, Greensboro, 6:30 p. m. Dr. W. P. Knight,
the president, presided; invocation by Dr. C. W. Banner.
Paul H. Harrel. Greensboro manager of the Hospital
Care Association, Inc., addressed the society briefly con-
cerning the Association. He stated that the Association
is operating in the larger towns of the State, including
Greensboro. He also explained the plan, rates, etc.
Dr. Chas. E. Moore was elected into full membership of
the society.
Dr. W. T. Tice of High Point was then presented to the
society and read a very interesting paper on Syphilis in
General Practice: discussed by Drs. F. R. Taylor, S. F.
Ravenel, C. C. Hudson, Wesley Taylor, A. D. Ownbey
and W. W. Harvey.
Second paper by Dr. Russell O. Lyday on Surgical
Treatment of Chest Conditions (illustrated) : discussed by
Drs. M. D. Bonner, Harry Brockman, Marion Y. Keith
and F. R. Taylor.
Dr. W. P. Knight, retiring president of the society, ex-
pressed his appreciation for the splendid co-operation he
received throughout his period as president of the society.
Adjourned until the first Thursday in January.
January 1st the following officers (elected in October)
take charge: president. Dr. J. W. Tankersley; vice presi-
dent. Dr. R. 0. Lyday; secretary-. Dr. Norman A. Fox;
treasurer, Dr. H. R. Parker; member board of censors.
Dr. F. R. Taylor; delegates to State Society— Drs. R. O.
Schoonover (3 years). Dr. Houston B. Hiatt (2 years).
Januan-, 1936 SOUTHERN MEDICINE AND SURGERY
Eli Lilly y\ND Company
FOUNDED 18 76
^Makers of !Medicinal Products
Clinical investigations reveal the benefits from
the nasal application of ephedrine in head
colds. Ephedrine Inhalants, Lilly, in the one-
ounce dropper assembly, suggest a convenient
prescription form. For prompt and well-sus-
tained tissue shrinkage with improved respira-
tory ventilation, prescribe:
Inhalant Ephedrine CPlaM, Lilly,
containing ephedrine (in the form of ephed-
rine cinnamic aldehyde and ephedrine ben-
zaldehyde) 1 percent in an aromatized
hydrocarbon oil . . . or
Inhalant Ephedrine Compound, Lilly,
containing ephedrine 1 percent, with men-
thol, camphor, and oil of thyme in a neutral
hydrocarbon oil.
Prompt Attention Qiven to Professional Jncjuiries
PRINCIPAL OFFICES AND LABORATORIES, INDIANAPOLIS, INDIANA, U.S.A.
Please Mention THIS JOURNAL When Writing to Advertisers
52
SOUTHERN MEDICINE AND SURGERY
January, 1Q36
Other officers whose terms have not expired are as follows:
board of sensors— Drs. Fred Patterson, H. L. Cooli; dele-
gates to state society— Drs. W. F. Cole, J. T. Taylor, S. S.
Saunders.
(Signed) D. W. Holt, Acting Secretary.
Regular monthly meeting of Wake County (N. C.)
Medical Society held in the Carolina Hotel, Raleigh, the
evening of December 12th, 1935, at 7:30. The meeting
was called to order by the president. Dr. M. R. Gibson.
Mr. C. A. Douglas, Raleigh attorney, was introduced
by the president, and gave a most interesting talk to the
society on Medical Jurisprudence. At the conclusion of
the address. Dr. H. B. Haywood moved a rising vote of
thanks, seconded, passed and heartily applauded. Dr. C.
C. Carpenter moved that the society ask Mr. Douglas the
permission to have the paper published in Southern Med-
icine and Surgery. This was seconded and passed. Mr.
Douglas gladly granted the request.
The secretary and treasurer then made his annual re-
port.
A letter of transfer for Dr. R. H. Hackler, from the
Buncombe County Medical Society, was read. Dr. J. B.
Wright moved unanimous acceptance, seconded and passed.
Dr. Gibson then gave a resume of the year's programs.
Nominations for the election of officers for 1036 were
then entertained. Dr. J. B. Wright nominated Dr. Ivan
Procter for president, seconded by Dr. Carl Bell. Dr.
J. W. McGee nominated Dr. Henry Turner, seconded by
Dr. L. N. West. Dr. Turner then maDV lt>< request that
his name be withdrawn. Dr. McGee acquiesced. Dr. L.
N. West then moved that the nominations '.e closed, the
rules be suspended, and the secretary be ins rycted to cast
the unanimous vote of the society for Dt. Procter. This
was seconded by Dr. McGee and the motion passed. The
secretary so cast the vote.
Dr. Procter took the chair and nominations for vice
president were entertained. Dr. B. J. Lawrence nomi-
nated Dr. R. L. McGee. Dr. Yarborough seconded and
moved that the nominations be closed, the rules be sus-
pended, and the secretary be instructed to cast the unani-
mous vote of the society for Dr. McGee.
For secretary-treasurer Dr. Hugh Thompson nominated
Dr. N. H. McLeod. Dr, J. W. Ashby moved that the
nominations be closed, that the rules be suspended, and
that the president be instructed to cast the unanimous vote
of the society for Dr. McLeod.
Dr. J. B. Wright moved that Dr. J. M. Judd be re-
elected to the censorship committee for two years. This
was seconded and passed.
(Signed) N. H. McLeod, jr., M.D., Sec.-Treas.
At the last meeting of the Randolph County (N. C.)
Medical Society, Dr. C. S. Tate was elected president, and
Dr. W. L. Lambert, vice president. Dr. J. H. Soady was
re-elected secretary-treasurer.
Dr. C. C. Hubbard was named Councilor.
Those attending the meeting and enjoying the turkey
dinner served were Drs. J. H. Soady, C. C. Hubbard, L. M.
Fox, R. L. Caveness, W. L. Lambert, J. T. Barnes, F. C.
Craven, J. C. Rudd, E. A. Sumner, G. H. Sumner, J. T.
Barnes, H. L. Griffin, J. V. Hunter, J. T. Burrus and R. P.
Sykes.
At the meeting of the Edgecombe-Nash County Medi-
cal Society the following officers were elected for 1936:
Dr. J. H. Cutchin, Whitakers, president; Dr. A. G. Nor-
fieet, Tarboro, vice president ; Dr. W. O. House, second
vice president, and Dr. A. L. Daughtridge, Rocky Mount,
secretary-treasurer. Dr. R. S. Anderson, Rocky Mount,
and Dr. Borden Hooks, Tarboro, were elected delegates to
the State convention with Drs. J. G. Raby and M. W.
DeLoach as alternates. Dr. Thomas H. Royster, Tarboro,
joined the society at this meeting.
The officers of the Wayne County Medical Society
for 1936 are Dr. D. J. Rose, president; Dr. Luby War-
rick, vice president. Dr. Jack Harrell, secretary-treasurer,
all of Goldsboro.
Officers of the Wilson County Medical Society for
the ensuing year are Dr. M. P. Mullen, Wilson, president ;
Dr. R. H. Putney, vice president; Dr. E. T. Clark, secre-
tary-treasurer.
RuTHEREORn CoUNTY Medical SOCIETY at its regular
meeting elected the following officers for 1936: president,
Dr. W. H. Knight, Bostic; vice president. Dr. R. N. Har-
din, Rutherf ordton ; secretary-treasurer. Dr. C. F. Glenn,
Ruthcrfordton.
A BOND ISSUE of $80,000 which will be supplemented by
a like amount from Duke Endowment was voted by a
large majority in Cabarrus County on December 17th.
This bond election was provided for by the last session of
the General Assembly.
The University of North Carolina School of Med-
icine will continue its course in Public Health Adminis-
tration in 1936.
From Dr. A. E. Baker, jr., Charleston
The semi-annual meeting of the First (S. C.) District
Medical Association was held in Walterboro, S. C, Wed-
nesday, November 20th, at 4 p. m. The program was as
follows: The Clinical Use of the Electrocardiogram, by
Dr. G. P. Richards, Charleston — discussion by Drs. W. C.
O'DriscoU and P. G. Jenkins, Charleston; Treatment of
Skin Diseases, Drs. Robert Taft, John van de Erve and
A. E. Baker; Some Common Diseases of the Eye, Dr. P.
G. Jenkins, Charleston, Dr. L. C. Stokes, Walterboro, Dr.
J. T. Townsend, Charleston; Treatment of the Common
Cold, Dr. W. P. Rhett— discussion by Drs. J. F. Town-
send, P. G. Jenkins and A. E. Baker, .\fter this program,
a delightful dinner was served.
Dr. Charles C. Higgins of the Urological Department of
the Cleveland Clinic gave an address to the Columbia Med-
ical Society, November 11th, at the Forest Lake Club, on
Experimental Production and Solution of Urinary Calculi
with Clinical Application and End Results.
Dr. I. R. Wilson was inaugurated for his second term
as Alderman, ward 7, Charleston. He was appointed Mayor
Pro Tem for the year of 1936.
Dr. Josiah Smith, Charleston, was inaugurated for his
first term as Alderman. Both doctors are members of the
Ways and Means Committee, the most powerful committee
on the board.
Darlington went to the polls November 26th in a second
municipal election for mayor between Dr. G. B. Edwards
and J. H. Willcox in perhaps the closest election in the
histor>' of the town, votes cast were: Dr. Edwards, 383,
and Mr. Willcox, 379. Dr. Edwards has been a practicing
physician in Darlington for a number of years. He has
served on the town council and was for two years County
Health Officer.
Dr. James H. Hutchison, prominent Columbia physician,
and Miss Hildegarde Schroder of Lancaster, Pa., and Char-
leston, S. C., were united in marriage Saturday afternoon,
Januan-, 1936 SOUTHERN MEDICINE AND SURGERY
SERENIUM
Aids the natural processes
of recovery
The use of an effective bacteriostatic agent in the treatment of genito-
urinary infections restrains the growth of bacteria, and thus, by hmiting
the irritation, frequently aids the natural processes of recovery.
Serenium (diamino-ethoxy-azobenzene hydrochloride) is an orally ad-
ministered agent which, while bacteriostatically effective, is so free from
toxic effects as to be innocuous. Serenium imparts a reddish orange color
to add urines, a fact which often inspires confidence in the patient that a
cure is being effected. The relief from symptoms which it brings
strengthens the patient's morale and enables the physician to institute
other suitable local treatment.
Serenium is often useful in the treatment of pyelitis and cystitis even
when the condition has become chronic. It has given excellent results in
children. In gonorrhea it has been shown effective in alleviating the
symptoms and in shortening the duration of the infection as much as
30 per cent when used in conjunction with local treatment.
Serenium is supplied exclusively by E. R. Squibb & Sons. It is supplied
in bottles of 25, 50 and 500 chocolate-coated tablets of 0.1 gram each.
The usual dose is one tablet three times a day after meals.
Por literature write the Professional Service
Department, 745 Fifth Aienue, New York
ERrSoinBB SiSONS^NEW^YbRK
MANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858.
SOUTHERN MEDICINE AND SURGERY
January, 1936
November 30th, in St. John's Lutheran Church, Charles-
ton.
Dr. Edward Sinton Cardwell, Columbia, and Miss Lily
Mikell Legare, formerly of Charleston, but now of Colum-
bia, were married November 29th, at the First Presbyterian
Church in Columbia. Doctor Cardwell is a graduate of
the University of S. C. and in 1934, was graduated from
the Medical College of S. C, where he is now assistant
pathologist. He completed a year's interneship at the Co-
lumbia Hospital this past summer. He is a member of
Alpha Kappa Kappa, medical fraternity.
Dr. J. Dougal Bissell, a South Carohnian who for many
years was connected with the Woman's Hospital of New
York, died in the second week of December. Com-
mittal services were held at Magnolia Cemetery, Charles-
ton, on December ISth. Dr. Bissell was one of the famous
surgeons of this country. A few years ago, he was invited
to read an essay on the life of Marion Sims, in London,
England, at which time he was made a Fellow of the Royal
College of Surgeons.
Dr. William C. Austin, head of the Loyala University
School of Medicine, chemistr>' department, in Chicago,
died the last of November of a heart attack. Dr. Austin
was a native of Cross Hill, S. C, the son of Dr. J. D.
Austin. He was a graduate of the Medical College of the
State of South Carolina and had been with Loyola for 12
vears.
Dr. L. Rosa Hirschmann Gantt, wife of Robert J. Gantt,
Spartanburg attorney, and the first woman graduate of
the Medical College of the State of South Carolina, died
November 16th, at a Philadelphia hospital where she was
taken for treatment. Dr. Gantt was a former president of
the Medical Women's National .Association and was one
of the most prominent of the women physicians of the
section. She was also active in social work, having pro-
moted the establishment of the Reform School for Girls at
Columbia. Later she served on the State Welfare Board.
Dr. Gantt was a native of Charleston.
Annual meeting of Pirr Coitnta- Medical Society, No-
vember ISth, Dr. S. M. Crisp elected president, Dr. W.
M. B. Brown, vice president, and Dr. W. K. McDowell,
secretary-treasurer, all of Greenville. Dr. Alban Papineau
of the State Sanatorium staff presented a paper on Tuber-
culosis and Dr. N. Thos. Ennett made his monthly report
as County Health Officer. Drs. Winstead and Wooten of
Pitt Memorial Hospital, Greenville, gave a report of their
attendance at the recent meeting of the College of Sur-
geons in the State of Washington.
The Medical College of Virginia, Richmond, has re-
ceived recently from a donor who does not wish to have
his name given a princely gift of 250 mgms. of radium.
Dr. WiLLLAii R. Hill, native of Statesville, has recently
been given a three-year appointment as assistant resident
physician at the University of Virginia Hospital.
Dr. George Bachisian, director of the Rockefeller School
of Medicine at the University of Puerto Rico, San Juan,
has lately been the guest of Dr. W. B. Porter at his home
in Richmond.
Dr. B. H. M.artix, of Richmond and Westhampton, has
been appointed by the Circuit Judge to membership on
the Board of Supervisors of Henrico County, Virginia.
Dr. a. D. Crec«. who served as Edgecombe County
Health Officer from August until recently, has gone to
Liberty where he will engage in the practice of medicine.
Narna Darrell, a historic novel by Dr. Beverley R.
Tucker, Richmond, will be issued from the press of the
Stratford Company, Boston, about February- 1st. In this
romance Dr. Tucker traces from its earliest origin the in-
flux of Anglo-Saxon civilization into Virginia.
Dr. Mark T. Frizzelle, Ayden, has been elected presi-
dent of the Duke Alumni Association of Pitt County,
N. C.
MARRIED
Dr. Paul D. Camp, of Richmond, and Miss Nellie Cor-
nelia Staves, of Schenectady, New York, at the home of
the bride on December 7th. After January 1st they will
be established in the Tuckaho Apartments in Richmond.
Deaths
Dr. James J. Stewart, 59 (N. C. Med. Col. '04), at his
home at Mt. Holly, Januar>- 1st. Dr. Stewart was a
practicing physician at Mt. Holly for 30 years, having
retired about three years ago. He had been in declining
health for several years, although he was able to walk
about town up to the time of his death.
Dr. Charles W. Gleaves died at his home at Wytheville,
V'irginia, on December 12th, at the age of SO. He was a
graduate of the Medical College of Virginia in the class
of 1S79. For several years he had been president of a bank
in Wvtheville.
Dr. .\rthur Ogburn Spoon, at his home in Greensboro on
December 10th at the age of 54 of post-influenzal pneu-
monia. He was a graduate of the Medical Department of
the University of Maryland.
Dr. James Carlisle Moore, McCoU, S. C, died at a
hospital in Florence, S. C, on December 13th at the age
of 58. He was a graduate of the Medical College of the
State of South Carolina in the class of 1901.
Dr. Parran Jarboe, Greensboro, surgeon of this State,
aged SO years, died from an automobile injury at the
Shelby Hospital, December 29th.
Dr. Wm. R. Goley, aged 59, Southport, a prominent
physician and mayor of Shallotte, died in the Brunswick
Hospital November 12th.
Dr. John Arnold Board, 44 (M. C. V. '13), Altavista,
Va., December 18th, after a long period of ill health.
Dr. A. R. Hodge, aged 35, Severn, died recently of pneu-
monia.
Our Medical Schools
Medical College of Vieginla
A gift of 250 milligrams of radium with the most ap-
proved type of filters, applicators, et cetera, has been an-
nounced.
Work on the foundation of the new clinic and laborator>'
building is well under way. This building will house out-
patient clinics on the first four floors; one floor each will
be given to bacteriology, biochemistry and pathology; one-
half floor each to physical therapy and preventive medicine,
and perhaps the top floor to offices.
Januar>-, 1936
SOUTHERN MEDICINE AND SURGERY
INHALANT
No. 77
An Ephedrine Compound used as an inhalant and
spray, in infections, congested and irritated condi-
tions' of tlie nose and throat. Relieves pain and con-
U'estion, preventing infection, and promotes sinus
ventilation and drainage without irritation.
Description
Inhalant No. 77 contains Ephedrine, Menthol, and
essential oils in a Paraffin oil.
Application
Can be sprayed or dropped into the nose as directed
by the Physician.
Supplied
In 1 ounce, 4 ounce and 16 ounce bottles.
Burwell & Dunn Company
Manufacturing Pharmacists
CHARLOTTE, N. C.
Sample sent to any physician in the U.S. on request
When the clinic and laboratory building is ready the
department of anatomy will be given the full third floor
of McGuire Hall.
Contracts have been let for the new laundry to be con-
structed on Thirteenth street back of the Ruffner School.
This is a PW.'\ project.
Miss Frances H. Zeigler, a member of the National Red
Cross Committee, attended the annual meeting of this
committee on December 10th, in Washington.
Dr. Roshier W. Miller was inducted into the Rho Chi
Honor Pharmacy Society on December 3rd.
BOOK REVIEWS
THE PRACTICAL MEDICINE SERIES OF YEAR
BOOKS: Series 1935. The Year Book Publishers, Inc.,
Chicago, 111.
DERMATOLOGY AND SYPHILOLOGY, edited by
Fred Wise, M.D., Professor of Clinical Dermatology and
Syphilology, New York Post-Graduate Medical School and
Hospital of Columbia University ; Members of the Ameri-
can Dermatological Association, Inc., and Marion B. Sulz-
berger, M.D., Assistant Professor of Clinical Dermatology
and Syphilology, New York Post-Graduate Medical School
and Hospital of Columbia University ; Member of the
American Dermatological Association, Inc. $3.00.
Included in the introduction is a 12-page article
on "Modern Treatment of Eczema: A Guide for
the General Practitioner." This evidence of the
practical nature of the work is substantiated by
the contents as a whole.
FOR
PAIN
The majority of the phy-
sicians in the Carolinaa
are prescribing our new
tablets
^AMDS
751
Analgesic and Sedative ' parts 5 parts I part
Aspirin Phenacetin Caffein
JFe will mail professional samples regularly
with nur compliments if you desire them.
Carolina Pharmaceutiral Co., Clinton, S. C.
MEDICAL TREATMENT OF GALLBL.ADDER DIS-
E.ASE, by M.^RTiN E. Rehfuss, M.D., Clinical Professor of
Medicine at Jefferson Medical College, Philadelphia; and
Guy M. Nelson, M.D., Instructor in Medicine at Jefferson
Medical College, Philadelphia. 465 pages with 113 illustra-
tions. Philadelphia and London. W. B. Saunders Com-
pany, 1935. Cloth, !?5.S0 net.
The subject of gallbladder disease is presented
from a medical viewpoint. In the great majority
of instances medical management is the proper
SOUTHERN MEDICINE AND SURGERY
January, 1936
FERRICIT
Each tablet contains ten grains
Iron and Ammonium Citrate, of
the highest medicinal quality.
ISSUED IN BOTTLES OF 100 TABLETS
INDICATIONS
Secondary (hypochromic) Anemia
Chlorosis
Also in Pernicious Anemia in
conjunction with liver therapy.
mples sent to any Physician in the United Stales on Request
Van Pelt & Brown, Inc.
Richmond, Va.
management, and the authors of this book are
admirably equipped by long experience of the right
sort for giving this instruction on recognition and
management of these commonly encountered condi-
tions.
LAW AND CONTEMPORARY PROBLEMS (Vol, II,
No. 4). Published Quarterly by the Duke University School
of Law, Durham, N. C.
This volume's interest for doctors lies in its be-
ing taken up with the subject, Expert Testimony.
The Development of Expert Testimony is recounted
first, then follow: An Alternative to the Battle of
the Experts, The Briggs Law of Massachusetts,
The Qualification of Psychiatrists as Experts in
Legal Proceedings, ^Medical Testimony in Personal
Injury Cases, and a number of other articles, some
dealing with the testimony of medical experts in
foreign countries.
This volume is full of information of interest and
profit to any doctor liable to have to appear in
court as a witness — and who is not?
Impotence in Man
(O. S. Lowsley, New York, in Sou. Med. Jl,, Dec.)
In man, plication of the bulbocavernosus and ischio-
cavernosus muscles with ribbon gut has been followed by
ability to have erections and satisfactory intercourse, even
in cases in which erections had been impossible over a
period of years. The operation has been performed upon
14 men whose ages were 22 to 66 years. The results were
perfect in 9 cases, all of whom had had no erections, or
entirely unsatisfactory ones for 2 years or over. The 57-
year-old man had had no erections for S years. Since the
operation he has had both erections and intercourse and
is improving all the time. A man 5S years old has had
erections, contemplates matrimony. The 6S-year-old pa-
tient is still in the hospital. The 63-year-old patient had
syphilis 20 years ago and has not had an erection since.
He has received no benefit from the operation. The 66-
year-old man had the operation following a prostatectomy,
with very little benefit.
The operation must be skilfully performed: if the mus-
cles are too tight, a constant painful erection will result;
if not tight enough, satisfactory erections will not be pro-
duced. The success of the operation apparently depends
upon the use of ribbon gut, which does not tear through
the delicate muscles as does ordinary twisted catgut.
Sufficient time has not elapsed since performance of
these operations for us to say how permanent the results
will be.
Congenital Malaria
(Bela Schick and Martin Stein, New York, in Jl, Mt, Sinai
Hosp,, Nov, -Dec.)
A consideration of the literature establishes fairly well
the occurrence of malaria transmitted from the mother to
the fetus either before or at the moment of birth.
A case of malaria is presented which appears to be in'
this group, though wholly on circumstantial evidence.
Despite some evidence to the contrary, it appears that
transplacental migration of the parasites is made possible,
or at least facilitated, by pathological changes in the pla-
centa induced by a severe type of malaria, by syphilis, and
possibly by other factors.
The hardest part in the diagnosis of calcium defi-
ciency (J. W, Boggess, jr,, in Jl. Med. Assn. Ala., Dec.)
is to suspect it ; once it is suspected and determinations
made, it is my opinion that fewer diagnoses of neurosis
will be made.
CHUCKLES
The Mote and the Beati
Disgusted Lady — Does your mother know you smoke?
Small Boy — Does your husband know you speak to
strange men in the street? — Ghost.
Patient — "The size of your bill makes my blood boil."
Doctor — "That will be $20.00 more for sterilizing your
svstem."
Bishop — "Ethel, you are a bright little girl, can you re-
peat a verse from the Scripture?"
Ethel — "I'll say so."
B. — "Well, my dear, do so for me,"
E. — "The Lord is my shepherd; I should worry,"
Old Lady — "Where did those large rocks come from?"
Tired Guide — "The glaciers brought them down, ma'am,'
0. L. — "But where are the glaciers?"
T. G. — "Gone back for more rocks, ma'am."
"What did father say when you told him you were
going to take me away from him?"
"He seemed to feel his loss keenly at first, but I squared
things with a good cigar." — Lincoln County News.
January, 1936
PROFESSIONAL CARDS
GENERAL
THE NALLE
Telephcme—i-2141 (If no
General Surgery
BRODIE C. NALLE, M.D.
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Vol. XCVIII Charlotte, N. C, February, 1936 No. 2
Vertigo — Its Causes and Treatment*
James Asa Shield, M.D., Richmond, Virginia
Associate Professor of Neuropsychiatry, Medical College of Virginia
THE profound distress and the frequency of
patients presenting a symptom-complex of
vertigo and associated complaints has
stimulated my interest in these cases and it seems
timely to discuss their etiology and treatment as
seen today.
The phenomenon of equilibration functions
through the subconscious reflex mechanisms, that
control and coordinate our muscular system. Pa-
tients with disturbances in their equilibrium consult
their doctors with complaints of vertigo, dizziness
or giddiness. The complaint may be continuous
with or without exacerbations, or it may be inter-
mittent; it may occur in such severe attacks as to
cause the patient to grasp something to keep from
falling. Nystagmus, impairment of hearing, tin-
nitus, headache and nausea are often associated
symptoms.
Diseases of the organ of equilibrium can origi-
nate either in the inner ear, in the vestibular nerve
or in the interior of the skull. It may be a primary
or secondary involvement of the vestibular system.
The associated nystagmus and impairment of hear-
ing and the sensory disturbances in the form of
headache, pain in the nape of the neck, behind the
ear, or down the nose are to be expected, due to the
anatomical proximity and connections of the vesti-
bular, cochlear, trigeminal, oculomotor, trochlear,
and abducens nerves.
I shall first speak of the diseases of the inner ear,
then the vestibular nerve and finally the interior
of the skull. One should always think of the possi-
bility of a disease of the inner ear when disturb-
ances of balance appear in combination with dis-
turbance of hearing. This is known as the IMeniere
symptom-complex, because Meniere described
such a case in the year 1862, which showed a
severe hemorrhage in the inner ear at the post-
mortem. The term Meniere's symptom-complex
is used, and not Meniere's disease, because such
clinical pictures may develop with various inner-
,„*Pi'es«'nted hy Invitation to the Eighth (N. C.) District
ear pathology. In the acute attack there are sudden
disturbances of balance, extreme dizziness, nausea,
tinnitus and impairment of hearing.
There is a IMeniere syndrome sometimes spoken
of as position vertigo. It appears suddenly accom-
panied by nystagmus, appearing when the indi-
vidual lies down on the right or left side or when
he turns over or looks up. The nystagmus lasts
ten or twelve seconds and is associated with vertigo.
In every stage of otitis media, acute and chronic,
the inner ear may be damaged, caused by a marginal
labyrinthine hyperemia or a rupture of the infection
in the labyrinth, or one may have meningogenic
labyrinthine inflammation. The involvement can
be recognized by the onset of vertigo, vomiting, im-
pairment of hearing and nystagmus. These cases
may be complicated by meningitis and we had bet-
ter be on the outlook for any stiffness of the neck.
Besides organic causes, (hemorrhage, inflamma-
tion of the inner ear and infections) functional dis-
turbances can, as we know, cause the Meniere
complex of symptoms. The sudden appearance and
disappearance of the attack, as well as the strik-
ingly favorable action of spasmolytic remedies,
justify the assumption that the functional Meniere
can depend on spasms of the internal auditory
artery.
The inner ear is very sensitive to variations in
the blood supply, because its lone supply is the
internal auditory artery. Therefore, conditions
changing the flow in the blood vessel, the capacity
of the blood vessel, or the type of blood, give inner
ear symptoms. It can be assumed almost with cer-
tainty that the increased absorption of toxins occur-
ring from time to time from the infections leads to
spasms of the internal auditory artery and this is
the explanation of the Meniere syndrome that
occurs in infected sinuses, infected teeth, or in-
fected tonsils, which is due to transitory hypertonia
of the internal auditory artery.
Medical Society meeting at Greensboro, September 24th,
VERTIGO— Shield
February, 1936
We see patients who have hypertonia superim-
posed on arteriosclerosis. The cHnical picture in
these cases is not as sudden in onset nor does the
vertigo appear in such severe attacks as in true
hypertonia.
It has been proven that degenerative changes
may occur in the inner ear following slight head
injuries without hemorrhage. A concussion of the
brain can exist without concussion of the inner ear,
but a concussion of the inner ear can not exist
without concussion of the brain. I shall, therefore,
refer to this condition again when discussing the
central vertigos following head injuries. The above
is the result of everyday head injuries. Of course,
with a fracture of the inner ear, the acute symptoms
will be marked vertigo with nausea and vomiting
and falling to the side of the injured ear, nystagmus
to the side of the normal ear and total loss of hear-
ing on the injured side.
In any case with disturbance of equilibrium and
sudden appearance of deafness or hardness of hear-
in, luetic injury to the labyrinth should be thought
of, of which marked diminution of the conduction
of the bones of the head and loss of function of
the vestibular apparatus are characteristic.
I now come to the diseases of the vestibular nerve.
Here the loss of function predominates over the
symptoms of irritation. A vestibular nerve neu-
ritis will give a rapidly progressive picture of dizzi-
ness, nystagmus, tinnitus, difficulty in hearing and
vomiting. You can elicit a history of (1) syphilis,
(2) focal infection, (3) injuries through various
poisons (arsenic, lead, mercury, alcohol and
quinine). In some of these cases probably the de-
structive process develops by way of the meninges.
Lastly, we come to the vertigos that are caused
by disturbances which originate in the interior of
the skull. We have discussed under peripheral
vertigos those of inner ear and vestibular nerve
origin which are characterized by a turning dizzi-
ness and its accompanying nystagmus. The dizzi-
ness is the turning of objects around and around
or turning of the patient, being consistent in one
direction or another. The nystagmus is always
horizontal and rotary. The head movement test,
that is, one takes the patient's head between his
hands and rolls it from side to side four or five
times, will produce a jerky nystagmus of ten to
fifteen seconds duration. If it is a peripheral
vertigo you can not repeatedly get this reaction. If
it is central you can continue to get this nystagmus.
In central vertigo the symptoms progressively in-
crease as a rule beyond the few weeks ordinarily
seen in inner ear disease.
I shall first discuss pathological entities that may
be responsible for vertigos of both the peripheral
and central types. An injury to Deiter's nucleus, the
most important of the nuclei of the vestibularis
found in the medulla oblongata, occurs in head in-
juries. I shall divide them as previously mentioned,
first, concussion of the brain with ear symptoms,
and second, concussion of the brain with concussion
of the inner ear. In this division a concussion of
the brain can e.xist without concussion of the inner
ear, but a concussion of the inner ear cannot exist
without concussion of the brain. Every concussion
of the brain causes changes in the brain that can
be demonstrated a/nd seen histologically if the
patient comes to autopsy. We have observed that
about 45 per cent, of brain concussions involve
the vestibular nuclei. The degenerative changes
are locatfd in the brain and not in the ear. In
these cases we have slight dizziness, appearing in
attacks. It is seen at times when the patient is ex-
cited or has taken alcohol but not often. If such
a patient has had continual dizziness, then very
likely he is a malingerer or he has more than a
concussion of the brain. Second, nystagmus is
similar to the dizziness in degree. Third, hearing
is not impaired. We were taught that the bone
conduction is reduced in these cases, but experience
does not agree.
Concussions of the brain with concussions of the
inner ear are due to the direct relationship between
the brain circulation and the circulation of the inner
ear. The chief artery to the inner ear, the internal
auditory, comes from the brain, a branch of the
posterior inferior cerebral artery, and this is the
reason that dilatation of the cerebral vessels brings
dilatation of the internal auditory artery. This en-
tity has been given the name vasomotor internal
otitis, because it is an internal otitis produced by
vasomotor disturbance. This otitis vasomotorum
is fairly common. In this condition dizziness occurs
in attacks which are slight. There is no tinnitus
and diminished hearing is usually unilaterial; if
bilateral it is always more on one side than the
other.
There is a syndrome due to involvement of Dei-
ter's nucleus and the adjacent structures. Tha
clinical picture of this so-called Bonnier 's syndrom:
is one of nausea, vomiting, vertigo and nystagmus,
with tinnitus and deafness. The inclusion of the
nuclei of the vagus nerve accounts for the anxiety,
tachycardia, nausea, vomiting and pallor.
Vertigo and nystagmus may be caused by foreign
bodies in the fourth ventricle and by tumors in
the occipital fossa, the pressure affecting the re-
gion of the vestibular nuclei. Vestibular or cochlear
symptoms may be the only manifestations of cere-
bral disease for a long time, especially of tumors of
the acousticus and cerebellopontine angle. Acoustic
tumors usually begin with unilateral impairment of
hearing which can not be influenced and which
February, 1936
VERTIGO— Shield
gradually increases to complete deafness. Head-
aches and spontaneous nystagmus, vertical or diag-
onal nystagmus appear from time to time. Finally
choked discs and cerebellar symptoms develop.
The cerebellar abscess causes almost the same
symptoms as a tumor of the cerebellopontine angle;
central nystagmus and choked discs are almost never
absent, but these sometimes appear only tempor-
arily.
Cerebral arteriosclerosis is often accountable for
occipital headaches and severe attacks of dizziness
with some continuous dizziness and tinnitus. Pa-
tients with encephalitis and multiple sclerosis also
complain of vertigo.
There is a vertigo that is often seen after at-
tacks of grippe and in various gastrointestinal dis-
orders. The attacks of dizziness with nausea noted
after grippe usually run for two to three weeks
and are explained on a toxic basis. The attacks
of vertigo with gastrointestinal disturbances are ex-
plained on a reflex basis, there being peripheral in-
volvement of the vagus nerve which in turn in-
volves the triangular nucleus and this in turn the
vestibular nucleus.
Dizziness may be be an aura in epileptic attacks,
accompany migraine headaches and is seen in aller-
gic states. We consider epilepsy and migraine as
idiopathic and allergic states as having an idio-
pathic feature.
In the neuroses we frequently see patients who
complain of dizziness. Characteristic of this com-
plaint is the patients' inability to describe the feel-
ing that they have. They have no turning dizzi-
ness or errors in sensation. It is essentially a
giddiness.
The treatment is the elimination of the cause
and the alleviation of symptoms. However, the
first therapy is to relieve the patient of his fear;
this is done by the assurance that you will be able
to give relief and that his anxiety is not justified.
In the peripheral vertigos or those originating in
the inner ear, local treatment is possible by injec-
tion through the ear drum. Pilocarpine has been
given this way with the idea in view of paralyzing
the parasympathetics. Medications are given by
hypodermic for relief during the acute attacks as
it is difficult to get the patient to take medicine
by mouth, or one may substitute suppositories.
As soon as we can divert ourselves from the prob-
lem of taking care of the immediate attack we
make every effort possible to eliminate the etiologi-
cal factors. In central vertigo there is no local
treatment that we can give other than that to alle-
viate the severity of the attack. We, however,
must treat the underlying cause.
The treatment of the Meniere syndrome is plac-
ing the patient in bed on his back and making
the room dark so that objects moving around will
be less likely to precipitate an attack of dizziness.
For the acute attack Bulbokapnin (Merck) is given
hypodermically. If this is not effective small doses
of adrenalin, 0.2 or 0.3 c.c. of a 1-1000 solution,
may be given hypodermically once or twice a day.
In using adrenalin we must keep in mind that it is
usually not effective until twelve to twenty-four
hours later. If it does not give relief in that length
of time it is useless to repeat it. A suppository
of medinal, pantopon and belladonna may be used
during the attack. If the patient can be gotten
to take a single large dose of sodium bromide, 30-
45 grains, or luminal grains V/z, the attack may
be stopped.
^ In between the attacks we find that a prescrip-
tion of sodium iodide and sodium bromide is of
value. The focal infection, or the toxic condition,
whatever it is, is removed.
The treatment of the vestibular neuritis is the
elimination of the cause, giving small doses of
salicylate and large doses of calcium.
The treatment of the head injuries in regard to
eliminating the dizziness is not extremely satisfac-
tory, but we are able to help these people by giv-
mg them iodine and calcium preparations intra-
venously; or iodine, calcium and atropine prepara-
tions by mouth, but at the time of the head injury
we can be of the most value to the patient by our
advice. That is, it is imperative to keep these
people quiet in bed even with slight head injuries,
neurological studies are essential and if there is
any question about ear involvement one should
have an otologic opinion. This is imperative be-
cause of the residual brain degeneration, with con-
vulsions, that follows head injuries sometimes two
years or even more after the time of injury.
The various vertigos that are caused by the dis-
eases in the medulla and adjacent structures in-
volving the nuclei of the vestibular nerve do not
respond very well to therapy, especially in the later
stages. The tumors can usually be removed; the
syphilis treated. The abscesses are very difficult
to handle and depend entirely on the status of the
patient and are purely a neurological problem.
Arteriosclerosis is treated in the usual manner.
The sodium nitrite compounds are thought to be
of value. Vertigos that are frequently seen in
patients with cardiovascular disease sometimes im-
prove when the intake of sodium is as small as
possible and its accumulation in the body is pre-
vented. The former is attained by means of con-
trolled diet and the latter by use of acid-producing
salts such as ammonium chloride. Recently I have
treated the arteriosclerotic vertigos in patients with
hypertension by the injection of 25-30 c.c. of pa-
tient's own bluod deeply in the gluteal muscles,
VERTIGO— Shield
Februan.', 1936
This injection may be repeated several times with
an interval of three or four days. This treatment
has been very satisfactory in some of the cases,
especially the cases that give a history of a recent
muscular weakness.
Encephalitis is treated by the iodines intraven-
ously; multiple sclerosis is treated by silver salvar-
san and non-specific protein; sodium iodide is given
to treat the dizziness residual from attacks of
grippe and the treatment of gastrointestinal dis-
turbances eliminates the reflex vertigo and accom-
panying nausea. The anemias and leukemias are
specifically treated. In the treatment of the dizzi-
ness of epilepsy, we give phenobarbital and the
diet should be high in proteins with the fluids lim-
ited. Tartrate of ergotamine (Gynergen), grams
0.001, is of value in the treatment of migraine.
The allergic cases are problems for the general
physician's guidance. In the neuroses, by analyti-
cal and re-educational therapy we are able to elim-
inate this sensory disturbance. In some unilateral
vertigos as a last resort we consider resection of
the vestibular nerve.
The anxiety states and debilitation caused by
vertigo demand that we, as physicians, give these
cases serious consideration, so as to alleviate both
the patient's fear and his vertigo.
From the Address by the President of the Medical
Society of Virginta in 1879
(L. S. Joynes, Richmond, Va. Med. Monthly, Jan.. ISSO)
If every physician in this State should bring forward
for the general information even.- significant and instruc-
tive fact, throwing fresh light on the history and nature
of disease, which has fallen under his observation, and
every new and valuable lesson he has learned with regard
to the use of remedies, the record would beyond doubt
fill a volume which all might consult with profit.
Some of the brightest ornaments of our profession, and
most effective workers for its advancement, have been
country practitioners.
The whole medical world knows how much we are in-
debted to the late celebrated Dr. Graves, of Dublin, for
the greater success attained in the treatment of low fevers
by the practice of diligently supporting the powers of
life by the free administration of nourishment — an im-
provement which he himself estimated so highly, that he
once told his friend, Dr. Stokes, that he wished him, when
the time came, to write his epitaph, and that it should be
in three words — "He fed fevers." It is interesting to
learn from Graves himself how the light on this subject
came to him. "An attentive consideration," says he, "has
led me, in the treatment of long fevers, to adopt the advice
of a country physician of great shrewdness, who advised
me never to let my patients die of starvation. If I have
more success than others in the treatment of fever, I think
it is owing in a great degree to the adoption of this ad-
vice." It is truly edifying to observe the unselfish candor
with which this eminent physician and clinical teacher in
one of the great medical centres of Europe, confessed that
he had derived his most valued lesson in practice from a
country doctor!
We have frequent complaints and criticisms, more or
less exaggerated and illiberal, of the uncertainties of med-
icine, and the differences among doctors. The distrust of
many of the critics is more affected than real, and vanishes
when the moment comes to put their faith to the test.
There are many things, not only in medicine, but in
other departments of the wide domain of human knowl-
edge, about which men, equally sincere and well-informed,
and equally competent to weigh the merits of questions
in dispute, will differ honestly in opinion. It is independ-
ence of thought — the tendency of different individuals to
regard things from different points of view and reach dif-
ferent conclusions, that impels them to labor with so much
zeal to clear up the points of controversy and test the
correctness of their several opinions. There was a time —
a very long time — when medical men all professed sub-
stantially the same opinions, because they all acknowledged
the infallible authority of Galen ; and the chief dispute
among them was as to what Galen taught. But these
ages of servility were ages of stagnation; and no real prog-
ress was made until men began to suspect that there might
be things which Galen did not know, and accordingly
ventured to investigate and think for themselves.
Differences of opinion and action of the kind here re-
ferred to are not thought strange, or treated as subjects of
reproach in the other concerns of society ; then why should
they be in medicine? Different statesmen hold the most
opposite views on questions of public principle and policy.
Different political economists are far from agreeing in their
theories of trade and finance. Different agriculturists, even
in the same vicinity, plant the same kind of crop at dif-
ferent times, and manage it in different ways; yet the
crop flourishes and comes to maturity under each system,
and the cultivators are regarded as having only exercised
an allowable independence of judgment in seeking each to
do what was best.
If we turn to the learned professions, how is it with
them? Is there anything in the conflict of medical systems
to be compared to the diversity of systems of theology?
What various and inconsistent doctrines, all professedly
derived from one and the same book, do different theolo-
gians require us to believe! — doctrines too, which are not
mere matters of taste or amusing speculation, but which
concern our eternal welfare. And what strifes have con-
vulsed society — what bloodshed has stained the face of
Europe, because of opposing systems of religious faith and
their struggles for supremacy !
But how with our friends of the legal profession, who
take such keen delight in knocking our heads together on
the witness-stand — in instigating and then turning to profit
our conflicts of testimony — and in holding up our short-
comings in general to public notice? Is the science which
they profess any more "certain" than our own? Or is it
true, as has been said, that "the glorious uncertainty of it
is of more use to the professors than the justice of it?"
This satire, one would say, ought not to be merited; for
various authoritative books set forth the principles and
details of the common law, which one of them declares to
be "the perfection of reason." But if lawyers differ, from
neophytes to gray-haired veterans, can it be so with judges,
who are not engaged to advocate opposing interests, but
have been selected in consideration of their mature intellect,
legal learning and upright character, to declare authorita-
tively amid the clash of legal warfare, what the law is?
Recently to endeavor to ascertain, by actual examination
of reported cases, how far the decisions of different courts
in Virginia have been in accord or otherwise, I studiously
e.xamined 5 volumes of Grattan's Reports of cases decided
in the Supreme Court of ."Appeals, volumes embracing
{Continued to p. 72)
I
February, 1936
SOUTHERN MEDICINE AND SURGERY
Medical Jurisprudence*
Clyde A. Douglass, LL.B., Raleigh, North Carohna
MEDICAL JURISPRUDENCE is "that
science which appHes the principles and
practice of medicine to the elucidation
and settlement of doubtful questions which arise in
Courts of Law." These doubtful questions which
arise in Courts of Law are properly embraced in
five classes:
The first class includes questions arising out of
the relations of sex, as impotence, sterility, rape,
pregnancy, legitimacy, delivery, etc.
The second, injuries inflicted upon the living or-
ganism, as infanticide, wounds, poisons, persons
found dead, etc.
The third, those arising out of disqualifying dis-
eases, as the different forms of mental alienation.
The jourth, those arising out of deceptive prac-
tices, as feigned diseases.
The fijth is made up of miscellaneous questions,
as age, identity, life assurance and medical evi-
dence.
"Like all other sciences, the study of Medical
Jurisprudence, and its application to the affairs of
man, has grown more rapidly since the opening of
the 19th Century than in all previous time. In
the English House of Commons, in 1807, during
a public debate called forth by the appointment
of Dr. Andrew Duncan, jr., as Professor of Med-
ical Jurisprudence in one of the universities, a
member said, "I do not understand what the duties
of such a professor are, or what is meant by the
science which he professes."
In 1867 so great progress had been made that
the "Medico-Legal Society" of the City and State
of New York was organized to carry out the prin-
ciple that a lawyer could not be fully equipped
either for the prosecution or for the defense of
an individual indicted for the crime of homicide,
without some knowledge of anatomy or pathology,
and that no physician or surgeon could give abso-
Kite satisfaction as an expert witness, without some
knowledge of law. This was the first society in
the world organized for this purpose, but there
are now many such societies in this country and
in Europe." {Legal Medicine — Stewart, p. 3.)
Woodrow Wilson once said that there are times
when it is best to put all of your eggs into one
basket and then watch the basket! Following this
homely, but wise, suggestion, I shall not attempt
to cover every phase of medical jurisprudence. In
fact, my subject could properly be designated as
Medical Evidence, or The Physician or Surgeon as
a Witness.
In law, the word Medicine relates to a profes-
sional science, comprehending not only therapeu-
tics, but the art of understanding the nature of
diseases and the causes that produce them, as well
as the art of knowing how to prevent them. The
law regards it as an experimental and not an exact,
science. The word evidence in our legal accepta-
tion, imports the means by which any matter of
fact, the truth of which is submitted to investiga-
tion, may be established or disproved. Hence a
rule of evidence may be defined as "a principle
expressing the mode and manner of proving the
facts and circumstances upon which a party relies
to establish a fact in dispute in judicial proce-
dure." Mr. Justice Blackstone said in his Com-
mentaries (HI, 367), that "Evidence signifies that
which makes clear or ascertains the truth of the
very fact or point in issue, either on the one side
or the other."
The search for truth has engaged the attention
of men in every epoch of the world's history; and
numerous have been the systems evolved for its
ascertainment. As the social fabric has become
more closely woven, the greater have been the
efforts toward new discoveries. In none, perhaps,
of the many objects and purposes of all investi-
gation is society more interested than in those
seeking a just determination of controversies be-
tween persons or bodies of persons. Little prog-
ress seems to have been made toward a peaceful
solution of the differences of nations; but, in re-
spect of the individual, modern systems of judicial
investigation have been accepted in almost every
part of the world. Appertaining to every judicial
system are rules of evidence. {Legal Medicine —
Stewart.)
Medical evidence is testimony given by physi-
cians or surgeons in their professional capacity as
experts, or derived from the statements of writers
of medical or surgical works. (40 Corpus Juris
625.)
The real purpose of a trial is the ascertainment
of the truth. The law, in its effort to ascertain
the truth, and in seeking a just determination of
controversies, recognizes the fact that without the
aid of expert testimony from physicians and sur-
geons, juries would frequently be left (o guess or
grope in the dark.
•An address delivered to the Wake County (N. C.) Medical Society. December 12th,
MEDICAL JURISPRUDENCE— Douglass
Februar>', 1936
We find in the most ancient law books mention
of principles and practices falling distinctly within
the limits of this science. This type of evidence
was first given official recognition by Emperor
Charles V of Germany, and it was incorporated
in the Caroline Code in 1532, wherein it was or-
dained that the opinions of medical men — at first
surgeons only — should be received in cases of death
by violent or unnatural means, where suspicion
existed of criminal agency. The publication of
this code encouraged the members of the medical
profession to renewed activity, tending greatly to
advance their science, and the cause of justice
generally. Many books soon appeared on the sub-
ject of medical jurisprudence and the importance
of medical evidence was more fully understood.
(Elwell, Malpractice & Medical EvidetKe, 285.)
The treatment of the sick is a matter of so
much concern to the State that special rules of
law are made to govern physicians. The founda-
tion of the relation is laid on the theory that a
physician is one experienced and skilled in those
subjects about which the ordinary layman knows
next to nothing.
The physician's position toward his patient is
that of trust and confidence, and there are certain
legal obligations of the physician to his patient.
The nature of a physician's calling necessitates the
disclosing to him of certain private matters, and
it follows that it is the duty of the physician to
preserve his patient's privacy; but the law, under
such circumstances, gives due regard to the fun-
damental, underlying principle that the real pur-
pose of a trial is the ascertainment of the truth.
In recognition of these salient principles, the
Legislature of North Carolina has enacted the fol-
lowing Statute:
"No person, duly authorized to practice physic or sur-
gery, shall be required to disclose any information which
he may have acquired in attending a patient in a profes-
sional character, and which information was necessary
to enable him to prescribe for such patient as a physician,
or to do any act for him as a surgeon: Provided, that
the presiding judge of a superior court may compel such
disclosure, if, in his opinion, the same is necessary to a
proper administration of justice." (C. S., 1798.)
The Supreme Court of North Carolina, in Brew-
er V. Ring & Valk, 177 N. C, 485-6, says:
"It was competent to examine the medical experts upon
questions relating to their particular science. We could
obtain reliable information upon scientific subjects in no
other way, and the jury would be left to guess or grope
in the dark, instead of having trustworthy knowledge as
to these special matters of inquiry, if their opinions were
not admitted for the purpose of enlightening the jury upon
such questions as are peculiarly within their knowledge,
which they have acquired by actual study, experience and
practice. [Precedents quoted.] It was, therefore, compe-
tent to ask the witness whether, in his opinion, upon the
facts stated in the hypothetical questions, if found by the
jury upon the evidence, the diagnosis was made according
to the approved practice and principles of the medical
profession. [Precedents quoted.] It has been held com-
petent to ask whether an autopsy had been properly made,
S. V. Moxley, 102 Mo., 3S6; whether it was necessary to
remove one eye to save the sight of the other, which was
endangered by sympathetic inflammation, Reid v. City of
Madison, 85 Wise, 667; whether a limb of the patient
was or not in as good condition as the average of those
treated by skillful physicians or surgeons in like cases,
Olmstead v. Gore, 100 Pa., St. 127; and there are in the
books other apt illustrations which are almost without
number."
In Pridgen vs. Gibson, 194 N. C, 291-293, the
Court says:
"If a physician, who is duly licensed by the proper
authorities to engage in the general practice of his pro-
fession, says that assuming a hypothetical statement of
facts to be true he can express an opinion satisfactory to
himself as to a question of science pertaining to a partic-
ular branch of medicine, he is not precluded from testify-
ing as an expert simply because he is not a technical
specialist in that particular department. The word 'expert'
has been variously defined: 'A man of science'; 'a person
conversant with the subject matter'; 'a person of skill'; 'a
person possessed of science or skill respecting the subject*
matter'; 'one who has made the subject upon which he
gives his opinion a matter of particular study, practice,
or observation.' The basic theory is that the opinions of
experts are admissible on questions of science, skill, or
trade, or on questions which so far partake of the nature
of a science as to require a course of previous study, not
necessarily technical speciaUzation in any department.
Jones V. Tucker, 41 N. C, 547.
"In his work on Expert Testimony, Q9, 101, Rogers says
the principle is established that physicians and surgeons
of practice and experience are experts in medicine and
surgery, and that their opinions are admissible in evidence
upon questions that are strictly and legitimately embraced
in their profession and practice; also, that it is not neces-
sary that the medical witness should have made a spe-
cialty of the particular disease which is the subject of
inquir>-. Lawson, reaching the same conclusion, observes
that a physician or surgeon need not have made the par-
ticular disease involved in any inquir\' a specialty as pre-
requisite to the admission of his testimony as that of an
expert, but if he has made the subject a specialty, his
opinion may be of more value than it would have been
if he had not. Expert and Opinion Evidence (2nd ed.),
1036, Greenleaf states the result of his research in these
words: 'On matters in which special medical experience
is necessary, the question may arise whether a general
practitioner will suffice, or whether a specialist in the par-
ticular subject is necessary. The courts usually and prop-
erly repudiate the finicial demand for the latter class of
witnesses'."
!Most writers on medical evidence say that the
testimony of the medical witness is strictly that
of an expert, but it may be properly regarded in
two aspects:
First, as ocular evidence — those cases in which
the physician actually sees and examines the pa-
tient, and is called upon to testify as to his condi-
tion.
Februar>', 1936
MEDICAL JURISPRUDENCE— Douglass
Second, evidence based upon a hypothetical
statement of facts propounded to him in the court
room. In either case, the witness should, in fair-
ness to the litigants — as well as to himself — be
thoroughly familiar with the facts and with the
subject about which he is to testify.
A thorough knowledge of any subject, when sup-
ported by honest belief and unquestioned sincer-
ity, will instill confidence and command respect,
and carry with it a conviction that will be of prac-
tical benefit to a jury in the ascertainment of the
truth.
"An honest man will swear to his own hurt and
change not." !Much of the difficulty experienced
by physicians in giving their testimony in Courts
of Law arises from the fact that they do not prop-
erly prepare themselves for the occasion.
John Hunter said that he regretted that he had
not made more experiments and more diligent re-
search on the subject before giving an opinion in a
Court of justice. Thus being vexed at himself, it
was eas}' to get angry with the cross-examining
lawyer.
Another mistake often committed by the medi-
cal witness is, what the jury often feels, an at-
tempt to appear learned.
"It is always best to use ordinary language in giving
your testimony. Call the different parts of the body by
the names they are generally known by: if you wish to
say that you turned back the scalp and exposed the skull,
how much better to say so, rather than to say that you
reflected back the integument and exposed the calvaria;
and speak of diseases in the same way." {Legal Medicine
— Stewart, page 29.)
-Another point in regard to which the witness
must be careful is not to draw conclusions unless
called for, and to always bear in mind the uncer-
tainties of the result of all human accidents and
the utter impossibility of foretelling a sure result
from any known cause.
The manner of a witness goes far to inspire con-
fidence or distrust in his testimony. He should be
calm, open and free and use affirmative terms.
"One of the greatest objections to expert evidence, and
at the same time of the things which tend to throw dis-
credit upon it, is that experts are not only looked upon,
but are actually in many cases partisan counsellors instead
of impartial witnesses, and it seems as if one could obtain
experts to testify in support of any theor>', however ab-
surd." {Legal Medicine — Stewart.)
In giving expert evidence, the expert should be
perfectly impartial, and altogether indifferent as to
the merits or demerits of the case. He should
remember that he has nothing whatever to do
with the consequences to which his opinions may
lead, provided always that they are fully warrant-
ed by the facts, and are the result of sound knowl-
edge and due reflection. His province is distinct
from that of the counsel, the judge or the jury.
The late Dr. Wilbur, of Syracuse, N. Y., well said:
"Expert testimony should be the colorless light of science
brought to bear upon any case where it is summoned. It
should be impartial, unprejudiced — there should be no
half-truth uttered; and suppressing the whole truth is in
the nature of fake testimony."
Careful research and due consideration are of
inestimable value. It has been well said that:
"In most, if not all of our courts, there has apparently
been undue deference paid to personal experience, as if it
was only necessary to enjoy opportunities for improve-
ment, whether improved or not, in order to constitute a
witness an expert ; it is freely admitted that,
other things being equal, the man of experience should be
preferred to the one without it, yet when one is found
who has nothing else to commend him except that he has
seen, his claim to the highest confidence might well be
doubted. Indeed, what has been rightly seen may be im-
perfectly remembered; what is rightly remembered may,
through incapacity or inattention, be misreported, and
what is rightly reported may be misunderstood. In any
of these ways it may turn out that the man of mere ex-
perience is a man of information through the senses only.
It is ver}' possible, therefore, that he may be inferior in
knowledge and intelligence to the diligent student. Medi-
cal opinions must have their original foundations in au-
thority: and if we were to confine a man's real knowledge
to that obtained from personal experience only, or as it
may be formed from observation alone, we should commit
a great absurdity. For what is individual experience at
best, when compared with the collected experience of ages?
A mere drop of water when compared with the great
ocean. Personal experience, unless enlarged, improved, and
corrected by that of others, is frequently of little value."
Medical testimony when of any value is but little else than
a reference to authorities combined with experience, plus
the application of common sense, with due regard to cause
and effect. {Legal Medicine — Stewart, pp. 54-SS.)
But the naked statements of books of science,
not verified by the witness" own experience, are
of no more authority than the books themselves,
and the opinions given in such books are not legal
evidence.
The remedy for many of the evils, even if no
change is made in the present mode of calling ex-
perts, lies with the medical profession; and unless
they do resolve to prepare themselves thoroughly
beforehand, and divest themselves of all partizan-
ship in the trial, they will not be heard when they
complain that they have been treated the same as
ignorant witnesses or paid counsel.
The medical witness should not lose sight of the
fact that medicine is not an exact science. It has
made wonderful progress, particularly during the
past century. It has been but a few years since
the best physician was honestly of the opinion that
the proper way in which a pneumonia patient
should be cared for was to chink every window
and door, and thereby exclude all oxygen from
the room. The treatment no doubt, in many in-
stances, took its ghastly toll. Not many years
MEDICAL JURISPRUDENCE— Douglass
February, 1936
have elapsed since the best physician honestly be-
lieved that malaria was due to the bad air from
swamps — hence its name, mal-aerla. Many of the
ailments to which mankind falls heir were consid-
ered as incurable just a short while ago and are
today considered as easily cared for. The wonder-
ful progress that has been made in modern labora-
tories and excellent hospitals enables the physician
and surgeon of today to render unlimited service
to mankind. But I dare say that medical science
is, in a measure, still in its infancy.
The best that the physician and surgeon can
do, through his study, his knowledge and his ex-
perience, is to give to the world his honest opin-
ion. The layman is sometimes awestricken when
reputable physicians and surgeons so widely differ
in their opinions as to cause and effect.
Some years ago I appeared in a case in which
the evidence developed that the plaintiff, a railroad
conductor, prior to being thrown from one end
of a coach to the other, was strong, active, robust
and a perfect picture of health, a man of 225 lbs.,
who, according to a physician of high repute, was
examined for life insurance about thirty days prior
to the injury, and was then found to be in perfect
physical condition. Shortly after the wreck, he
was examined again by the same physician, and
by others, who testified that he, at that time, had
a typical Argyll Robertson pupil, Romberg symp-
tom, absence of patellar reflex, ataxic gait, the Bab-
insky test was positive, he lost considerable weight
and was weak and nervous, and occasionally he had
sharp, shooting pains in the legs. He had been
injured about the head and lower back. The ques-
tion before the Court was the nature of his con-
dition, as well as its cause. The medical experts
v/ere all agreed that he had the symptoms of tabes
dorsalis. The usual tests were made, including a
spinal puncture, all of which were negative, and
there was no history of syphilis or alcoholism. My
own investigation of what was then generally re-
garded as the best medical works was intensely in-
teresting, and, to a degree, enlightening, but, to an
even more marked degree, confusing! Osier took
the position that traumatic injury would produce
tabes dorsalis. White and Jelliffe took the position
that the only two causes of true tabes dorsalis were
syphilis and alcoholism. The other works were
almost as conflicting with Osier, some stating that
although there were only two producing causes of
luch condition, that traumatic injury might pro-
duce a flare up or precipitate the condition. In the
trial at least one of the medical experts testified
that, in his opinion, the plaintiff did not have
tabes dorsalis, but that he had a condition very
Limilar thereto, and his diagnosis was multiple
sclerosis, which had been produced, or precipitated
by trauma. There was a noted expert in support
of each and every theory that had been advanced on
each side of the case. Each expert who had testi-
fied was, no doubt, absolutely honest in his opinion,
yet the jury was thrown into confusion. The only
position that I could take with any degree of safety
was that, whereas the plaintiff was all right up to
the time of his injury, he had been all wrong ever
since he was injured, and that it did not make an
iota of difference whether we named his condition
locomotor ataxia or something else, or whether
trauma produced it or accentuated it.
I dare say that the physician and surgeon of to-
day is applying more common sense in diagnosis and
treatment than ever before in the history of medical
science. Not many years ago, asthma was regarded
by the best physician as merely a nervous disorder,
yet the physician was confronted with the fact that,
when asthmatic patients were exposed to certain
substances or animals, or when they would par-
take of certain foods, such patients would be
thrown into a paroxysm. Had there been no mem-
bers of the profession who were willing to dig more^
deeply into such subjects in their quest of the truth,
time would have opened into eternity without any
discovery of the real causes of the so-called nervous
disorders.
More than 2,000 years ago the wisest man of
the ages well said: "Where there is no vision the
people perish." Thank God for the fact that there
are physicians and surgeons who are not satisfied
to let good enough alone, but who forge ahead in
the advancement of their science. Endless com-
ment could be made upon the discoveries of the
pathologist, the botanist, the toxicologist, the bac-
teriologist, the chemist, the physician and the sur-
geon within the past decade.
"He most lives who thinks most,
Who feels the noblest.
And who acts the best."
You are marching on, and you are entitled to the
sympathy, the cooperation, the love, the respect
and the appreciation of your fellow man. I wish
you God-speed in your progress!
In 1805 Humboldt and Gay-Lussac (Va. Med. Month-
ly, 1882) were in Paris, engaged in experiments on the
compression of air. The two scientists found themselves
in need of a large number of glass tubes. These were ex-
ceedingly dear in France at the time, and the rate of im-
port was something alarming. Humboldt sent to Germany
for the needed articles, and gave directions that the man-
ufacturer should seal up the tubes at both ends, and put a
label upon each tube with the words Deutsche Luft (Ger-
man air). The air of Germany was an article upon which
there was no duty, and the tubes were passed by the cus-
tom officers without any demand, and arrived free of duty
in the hands of the two experimenters.
February, 1936
SOUTHERN MEDICINE AND SURGERY
A Physician's Theology
Frederick R. Taylor, B.S., M.D., F.A.C.P., High Point, North Carolina
The Startlinc Question
YEARS ago a startling question flashed into
my mind. I have been trying to answer
it ever since. It crystallized out from
what has been the central problem of philosophy
and life since the dawn of human thought; the
problem of the existence of evil and suffering, es-
pecially the disproportionate evil and suffering that
so often beset the innocent. The question has
shocked many to whom I have put it. Others are
unable to comprehend its significance; they call
it foolish, as certain of the ancients, accepting the
dogma that the earth rests on an elephant, which
in turn, stands on a tortoise, called foolish the
obvious question as to what supported the tor-
toise. Fortunately, however, this age is more tol-
erant than that of the ancient questioner, so I have
not yet been destroyed for my heterodoxy. A few
have grasped the meaning of my question and ex-
pressed appreciation of my efforts to answer it.
These efforts were at first rather blind and grop-
ing, but recently they have seemed to develop a
somewhat more definite trend.
The question is this: May not those of us who
believe in God, u<ho assume Him to be at once all-
knowing, all-good, and all-power jul, be guilty of an
unconscious accusation of Him which woidd be
blasphemous if we realized its implications^
No one can discuss such a question without de-
veloping to some degree his idea of God. To me,
atheism — by which I mean a positive assertion of
knowledge that there is no God — seems so utterly
untenable as to border on insanity. From the ma-
terial side alone, it is as illogical to assume a uni-
verse or an atom with its marvelous obedience to
mathematical law to be an accidental occurrence
without a creative mind behind it, as to assume that
a locomotive or a watch comes into being by sheer
chance. From a spiritual side, man's incessant
search for God, plus the amazing effects on human
personality of apparently superhuman spiritual
forces are, to many, convincing evidence of a great
energizing spiritual power. To such persons, this
evidence also disputes agnosticism, a much, more
rational and tenable viewpoint than atheism. Still
more conclusive to some is the fact that they have
had individual experiences of a spiritual power
which has lifted them to new levels of life and
vision, as real as any material experience. Always,
such an uplifting force seems to come from a power
far greater than our own.
Obviously, this discussion can appeal only to
those who, like myself, accept the idea of a Creator
of the material universe, and who also accept the
existence of a mighty spiritualizing Power capable
of raising human personality to a level which trans-
cends the biological. However, most of those who
will go thus far with me will go much farther, where
I can follow but dimly or not at all, for they will
assume that God is at once all-knowing, all-good,
and all-powerful. This assumption, however, may
take us into very deep water. Let us analyze it
and see a few of its implications.
In the first place, the material universe seems to
have no fixed moral values at all. Tornadoes, fam-
ine and pestilence wreak their havoc alike on the
just and the unjust. Lightning strikes saint and
sinner alike. Everywhere in nature is the law of
fang and claw, the law that might makes right, the
pitiless working out of the survival of the physically
and intellectually fittest. Alongside these things
are almost totally opposite manifestations of a spir-
itual nature, in which sacrifice, rather than survival,
at least in the material sense, is the supreme law.
There may even be sacrifice in a spiritual sense,
when one submerges one's hopes, aspirations and
special gifts — in short, one's whole personality — for
the good of another. What is the meaning of such
an antagonistic state of things?
The easy thing is to say that man's mind is finite,
therefore he cannot hope to grasp The Infinite.
This may be the final answer to our question, but
before we accept it, let us go a little farther.
Suppose I am a judge passing sentence for a
crime. I say to the prisoner, you may go free, but
your child must suffer life imprisonment or be de-
livered to the torturers. Would not that outrage
the moral sense of even the most depraved men
of Inquisition days? Yet, assuming that God is
all-powerful, are we not at least accusing Him of
permitting such outrageous injustices in nature,
though He could stop them if He would? Carrying
the thought but a step farther, does not the assump-
tion of omnipotence really make Him particeps
criminis with a great deal of evil in the world? Is
it presumptuous for a finite mind to feel unwilling
to ascribe to the object of its worship actions that
outrage the most fundamental moral sense?
At this point, no doubt, many will advance the
old argument of freedom, and claim that all evil
and suffering result from man's wilful choice of
the wrong. Granting that within certain limits
most wills are free, outside those limits they are
A PHYSICIAN'S THEOLOGY— Taylor
February, 1936
not, and there is no equality of freedom or of the
limits of freedom. The idiot has no freedom at all,
so far as purposive choice goes. This one fact
wipes out freedom as the adequate explanation of
all the evil in the world. Even if one could believe
in the shocking idea of intentionally punishing a
child for the sins of his parents, abundant facts
show that some parents of the highest tj-pe may
have idiot children, whereas the children of some
of the worst criminals are normal. Moreover, while
some pay heavily for their sins, others seem to es-
cape almost scot-free. While we have all suffered
for our misdeeds, most evil and suffering is not of
our own choosing, but results from factors beyond
our control. It is also true that many great bless-
ings are not achievements, but gifts, and those
gifts are very unequally distributed. Merit does
not always get its deserts, any more than crime.
Consider such a catastrophe as the World War.
Those free to choose, who made the war, suffered
least. Those who had no choice suffered most.
If God could have stopped such a colossal crime
(and, if spiritual values are supreme, it was colossal,
even though this planet is but a speck in a ma-
terial universe) — if He could have stopped it, but
would not, is that the natural attitude of an all-
good, all-wise, and all-powerful Spirit? It is beg-
ging the question to go back on the inviolability of
natural law — if that law works havoc, could not
an Almighty Being change it for the better.''
Does it require an infinite mind to see that any
God whom an intelligent being can worship must
have a moral sense above that of the average man?
Two Possible Solutions
There seem to be at least two possible solutions
to our problem. One intrigued me for years, but
never quite satisfied me. That is, a dualistic the-
ology. There might be two Gods, a material Cre-
ator of infinite intelligence who is totally immoral,
and an ethical Being whose great function is to
gradually transform and spiritualize the material
vi'here it rises to a level to make that possible. Re-
cently, however, a friend asked the simple ques-
tion, "Can you really conceive of a Being so in-
telligent as to create this material system of uni-
verses who is at the same time totally devoid of a
moral sense?" Candor compelled me to admit the
difficulty.
Abandoning a dualistic theology, what remains?
Perhaps only this: The idea of a God who is good
and wise and powerful to a degree unapproachable
by man, but who may not be literally omnipotent.
He has started great forces to working that may
not be completely under His control. In such
a case, He may actually have to depend on feeble
human beings to accomplish His spiritual pur-
poses in this world. He may not even be absolutely
sure to win! The wicked do flourish as the green
bay tree, despite His displeasure and the little
children do starve to death despite His love and
care. But, in this event, will not the true man,
recognizing the greatness of God's purposes, say
with Joshua, "As for me and my house, we will
serve the Lord"?
I am not putting forward any thought that I
have at one stroke solved the central problem of
the thought of the ages. I am merely raising
a question that seems to me an important step in
the development of our understanding of that prob-
lem, and trying to face it. Through it all, how-
ever, I am conscious of some passages in the most
sublime exposition of our problem in world litera-
ture, the great epic drama of Job:
"Who is this that darkeneth counsel by words without
knowledge ?
Gird up now thy loins like a man;
For I will demand of thee, and declare thou unto me,
Where wast thou when I laid the foundations of the
earth?
Who laid the cornerstone thereof;
When the morning stars sang together,
And all the sons of God shouted for joy?
Can'st thou bind the cluster of the Pleiades,
Or loose the bands of Orion?
Can'st thou lead forth the signs of the Zodiac in
their season?
Or can'st thou guide the Bear with his train?
Shall he that cavilleth contend with the Almighty?
He that argueth with God, let him answer it."
Yet, a greater personality than the author of
Job, quoting an ancient law-giver, said "Thou
shalt love the Lord thy God with all thy mind"
as well as with heart and soul and strength. Only
by facing problems honestly can we hope to solve
them. Sir Isaac Newton faced some of them as
they had never been faced before, and when he
found the answer, fell to his knees, and with tears
in his eyes exclaimed, "Oh, God, I think thy
thoughts after thee!"
Perhaps the greatest weakness of the Church
today is that in large part she is dodging these
profound issues instead of facing them and mak-
ing an honest effort towards a solution, however
imperfect it may be.
In conclusion, let me say what should be more
or less obvious, which is that my theology makes no
pretence at being either infallible or complete. It
is, indeed, very incomplete, and subject to change
with fuller light. It is only in process of develop-
ment, and may progress, retrace its steps, or turn
in a new direction, as determined by further evi-
dence and a larger experience.
Februar>') 1936
SOUTHERN MEDICINE AND SURGERY
The Surgical Treatment of Peptic Ulcers*
Paul McBee, i\l.D., Marion, North Carolina
PEPSIX probably has nothing to do with the
production of these ulcers, and it might be
more accurate to call them acid ulcers. This
paper, however, will not go into the etiology. Most
peptic ulcers do not require any surgery and can
be encouraged to get well on a regime consisting
of rest in bed, propter diet, and a few well known
medicines.
We operate in the cases — 1) in which the ulcer
threatens to perforate, 2) in which perforation has
occurred, 3) in which the pylorus is obstructed, 4)
in which the lesions may be malignant, 5) in which
medical management does not meet with favorable
response, and 6) in some of the bleeding cases.
This tj^pe of surgery is not a special field, and no
gadgets are required. A well trained general sur-
geon with modern hospital facilities at his disposal
should be able to manage these cases competently.
The role of the family doctor is obvious. It is his
responsibility to see that the patients having peptic
ulcers which require surgical treatment shall go to
a properly qualified surgeon at the right time.
The intelligent treatment of peptic ulcers,
whether medical or surgical, is not possible without
accurate x-ray studies, except in those cases which
are first seen as acute surgical emergencies. A sharp
knife in capable hands will settle minor points of
differlential diagnosis much more promptly and
economically when one is dealing with an obviously
acute condition.
The following nine case reports taken from my
surgery service will illustrate most of the problems
in this branch of surgery.
Case I. — A mechanic, 33, was referred by Dr. C. A. Pet-
erson on March 17th, 1934, with a diagnosis of a perfor-
ated peptic ulcer of less than two-hours duration. He was
operated upon immediately under spinal anesthesia, and
a small perforation was found an inch on the gastric side
of the pylorus. This opening was closed by plication, and
since there was hardly any spill of stomach contents, the
appendix was removed. The incision was closed in layers,
and the patient made an uneventful recovery. I under-
stand that he pitched and won several baseball games
last summer.
Case II. — A sawmill operator, 46, was referred by Dr.
I. W. Bradshaw on May 4th, 1934, with a diagnosis of
perforated ulcer of six-hours duration. He was operated
upon immediately under ether anesthesia, and a perforation
the size of a half dollar was found at and including the
pyloric sphincter. The wall around this perforation was
excised, and a pyloroplasty of the Horsley type was done.
There had been a great spill of stomach contents. This was
mopped out, and a drain was put down near but not
against the suture line. The incision was closed in layers
around the drain. This patient made a very stormy re-
covery complicated by a subhepatic abscess which required
a second operation. The patient finally recovered and
has remained well. I feel that I did entirely too much
surgery in this case.
Case III. — A farmer, i2, came to see me of his own
accord on September ISth, 1934, seven hours after he had
been struck down by a sudden, terrific pain in his epigas-
trium. He was operated upon immediately under spinal
anesthesia, and a small perforation was found in the an-
terior wall of the duodenal cap. The perforation was
closed by plication, and the abdominal incision was closed
in layers. The patient made an uneventful recovery, and
has remained well to date.
Case IV. — A feldspar miner, 37, was referred by Dr. C.
A. Peterson on September 30th, 1934, with a diagnosis of
perforated peptic ulcer of only one-hour duration. He was
operated upon immediately under spinal anesthesia, and
a small perforation was found in the anterior wall of the
duodenum. This was closed by plication, and the appen-
dix was removed. The abdominal incision was closed in
layers. This patient made an uneventful recovery, and
has remained well to date.
Case V. — A sawmill operator, 35, was referred by Dr.
A. E. Gouge on September 20th, 193S, with a diagnosis
of perforated peptic ulcer of five-hours duration. He was
operated upon immediately under spinal anesthesia, and
a perforation the size of a dime was found in the duo-
denum right against the pyloric sphincter. Plication of
this perforation caused such a narrowing of the pylorus
that a posterior gastro-jejunostomy was done to provide
a gastric outlet. The abdominal incision was closed in
layers. The patient made a perfectly uneventful recovery.
Case VI. — A mica miner, 38, referred by Dr. C. A.
Peterson, came in on May 31st, 1934, with a diagnosis
of chronic pyloric obstruction due to a series of healed pep-
tic ulcers. He was operated upon the next morning, and
a benign pyloric obstruction was found. A posterior gastro-
jejunostomy was done, and the abdominal incision was
closed in layers. This patient made an uneventful re-
covery, and has remained well to date.
Case VII.— A widow, 57, was referred by Dr. C. A.
Peterson on July 1st, 1935 with a diagnosis of a lump in
the belly. She had suffered from a chronic pyloric ob-
struction for six years. At operation, four days later, under
ether anesthesia, the lump proved to be a benign inflam-
matory swelling around a duodenal ulcer of the posterior
wall which had penetrated into the head of the pancreas.
The first portion of the duodenum and the pyloric one-
third of the stomach were resected and the intestinal con-
tinuity restored by a retrocolic gastro-jejunostomy of the
Polya type. This patient made an uneventful recovery,
and was out digging potatoes at the last report.
Case VIII.— .^ farmer, 36, was referred by Dr. W. S.
Masters on November 19th, 1934, with a diagnosis of a
bleeding peptic ulcer. The patient was still bleeding when
I saw him. He was put immediately to bed and given
nothing by mouth. He was given plenty of morphine, and
fluids were supplied very slowly in the form of 5 per cent.
•Prese.:ted to the Tenth District (N. C.) Medical Society, meeting at Tryon, X. c;., Oet. Kith, 1935.
72
SURGICAL TREATMENT OF PEYTIC ULCERS—McBee
Februarj-, 1936
dextrose in norma! saline intravenously. After the bleed-
ing was stopped, the patient was put on an ulcer diet. He
made a complete recover>', and has remained well.
Case IX. — A farmer, 19, was referred by Dr. A. E.
Gouge on February 21st, 1935, with a diagnosis of pene-
trating peptic ulcer. He was operated upon immediately
under ether anesthesia, and an ulcer was found in the an-
terior wall of the duodenum. It had penetrated through
the muscular coat of the bowel and the peritoneum was
beginning to break down, but as yet there was no leak.
The ulcer was excised, and a pyloroplasty of the Horsley
type was done. The appendix was removed and the ab-
dominal incision closed in layers. This patient has made
an uneventful recovery to date.
Summary
In this paper I have reported nine peptic-ulcer
cases with eight operations and no deaths. I feel
that the decision not to operate upon the bleeding
case was just as important as the operations upon
the others.
The results in this series of cases constitute a
great tribute to the diagnostic ability, intelligence
and character of my friends, a mighty fine group
of family doctors. One could hardly expect a like
group of specialists to do so well.
Medicine — Theology — Law
{From p. 64)
periods separated by intervals of several years, in which
the constitution of the court was more or less varied by
the introduction of new judges in places of those who had
died or resigned. The whole number of cases decided was
215; of these, the judgment of the court below was af-
firmed in 90; reversed in 102; partly affirmed and partly
reversed in 23. So that the judgment on which the appeal
was taken was completely affirmed in only about 42% of
the cases, and reversed, wholly or in part, in 5S%. More-
over, in 34 of these cases — say l/6th of the whole — one
or more of the judges dissented from the judgment of the
court.
One of the most remarkable illustrations of the conflict
of judicial opinion in the highest courts, and consequently
of the uncertamties of the law, is presented in the follow-
ing notice: "One ver>' grave question remains in a state
of singular uncertainty; it is: What is necessary to con-
stitute a complete and valid marriage?, or rather, are the
ceremonies and forms or any of them, which are indicated
by law, or are customarily used, for the solemnization of
marriage, indispensable, or is the mere consent of the par-
ties sufficient? Recently, this precise question has passed
through the English courts. It came first before the court
of Queen's Bench in Ireland, upon a trial of bigamy. The
defendant was found guilty, and then, the first of the
marriages not having been solemnized according to the
direction, if not the requirement of law, the question
arose whether it was so complete and perfect as to make
the crime of bigamy possible. There were 4 judges, and
they were equally divided. The chief-justice then (against
his opinion) joined pro joma with the two who thought
the marriage valid, for the purpose of having a decision
by a majority, from which an appeal could be made to
the House of Lords in England. On appeal, the question
of the validity of the marriage by mere consent was fully
argued by the ablest counsel in England before the Lords,
and the 6 law-peers gave their opinions severally, each
at great length; and they were equally divided — Lords
Brougham, Denman and Campbell being in favor of the
validity of the marriage at common law, and Lords Lynd-
hurst, Cottenham and Abinger against it. This equal
division affirmed the judgment, and the defendant was
sentenced. Almost at the same time, by an odd coinci-
dence, the same question came before the Supreme Court
of the United States, and Chief Justice Taney, in deciding
the case (on other grounds), said: 'Upon this point, the
court is equally divided, and no opinion can be given.' "
Here we have the singular spectacle of the highest tri-
bunal in Ireland, the highest tribunal in England, and the
highest tribunal in the United States, all equally divided
upon a fundamental legal question relating to the institu-
tion of marriage. Certainly, no consultation of doctors
possessing different systems, and neutralizing each other's
counsel with equal opposing forces, could be more dis-
cordant and more barren of results.
Some New Factors in the Diagnosis of Acute
Appendicitis
(0. N. Cooper, Waterloo, in Jl. Iowa State Med. Soc,
Dec.)
Broadly, when one encounters a child with moderate
abdominal pain and tenderness, and little or no rigidity
manifested in the right lower quadrant with digestive symp-
toms, loss of energy and moderate rise in t. and pmns.
one should consider a possible mesenteric lymphadenitis
particularly if the symptoms have persisted 2 or 3 days
and are associated with frequent colics.
In rupture of a graafian follicle, corpus luteum and
small cysts, operation could be avoided in the majority of
cases because the bleeding ceases spontaneously. The pain
of appendicitis is usually gradual in onset and of crampy
nature at first ; whereas in rupture of the ovary, whether
mild or severe, pain is almost always very sudden, often
stabbing in character. Over 60% occur approximately 2
weeks after the menstrual period. No cases reported have
had abnormal vaginal bleeding, which is of some aid in
differentiating ectopic pregnancy. There is tenderness and
often spasm of the lower abdomen. Rectal tenderness
may be present on the right or left and often pain is elicited
on moving the uterus. No mass is made out. Consider-
ing the amount of pain and discomfort, the t., p. and
w. c. are little affected. Operation is not indicated except
in rare cases of massive hemorrhage.
All agree on the necessity of a thorough chest examina-
tion particularly in children and young adults. Pneumonia
is usually ushered in with a chill and high fever. The
leukocytes early are higher. Abdominal tenderness is dif-
fuse and rigidity is less. Physical examination, particu-
larly in smaller children and in adults with deep consoli-
dation, may be inconclusive. The chest examination should
include the heart and pericardium, particularly when
a possibility of rheumatic fever exists.
An uncommon differentiation from appendicitis which,
with the increased incidence of fungus growth on the feet,
and secondary infection, is acute iliac lymphadenitis in-
volving those nodes along the iliac vessels, these being on
the right side in close relation with the appendix.
Acute seminal vesiculitis from appendicitis: in the usual
case there is dysuria, pain in the lower back and a his-
tory of recent infection. Usually a coexisting epididymitis
clarifies. Pugh reports in 1930, IS patients with acute
seminal vesiculitis, erroneously subjected to appendectomy.
The 4th annual George W.\shington University Post-
Gr.u)uate Clinic will be held this year on Saturday, Feb-
ruary 29th, at the University Hospital from 9 a. m. until
4:30 p. m. All physicians who are interested are cordially
invited to attend the meetings.
Februan", 1936
SOUTHERN MEDICINE AND SURGERY
The Treatment of Congenital Syphilis With Acetarsone
Jay M. Arena, M.D., and Charles H. Gay, AI.D., Durham, North Carolina
from the Department of Pediatrics, Duke University School of Medicine and Duke Hospital
FOR the past fourteen years in Europe and
the last six in this country, the oral use of
acetarsone (stovarsol, spirocid) in the
treatment of congenital syphilis has gained wide-
spread popularity. 1 Acetarsone is a pentavalent
arsenical compound containing 27.4 per cent, ar-
senic (arsphenamine and neoarsphenamine have 32
and 20 per cent, respectively). Our treatment was
patterned after that recommended by Bratusck-
Marrian -, which is as follows: 0.005 grams (5
mgms.) of acetarsone per kilo of the patient's body
weight was given daily in capsules, tablets or in
milk for the first week, followed by 0.010 grams
(10 mgms.) per kilo daily for the second week,
0.015 grams (15 mgms.) per kilo daily for the
third week, and 0.020 grams (20 mgms.) per kilo
daily for the ne.xt six weeks. This was followed
by six weekly intramuscular injections of 0.1 or 0.2
gms. of a 10 per cent bismuth preparation. Some
of our earlier patients were given the maximal dos-
age (0.020 gms. (20 mgms.) per kilo) as long as
tolerated or as long as the patients continued to re-
turn for treatment. However, from recent reports
in the literature 3, the addition of bismuth, espe-
cially for older children, has given better serologi-
cal results.
Table 1. Results of Acetarsone Therapy
Length of
Wassermann
Acetarsone
Number of
Reaction
Clinical
Treatment
Patients
Reversed
Improvement
1-2 weeks
7
3
2-8 weeks
9
2
6
3-6 months
7
3
7
6-12 months
S
2
5
1-2 years
4
1
4
Our series includes 32 children from birth to
eleven years of age. Sixteen patients had inade-
quate treatment, i. e., less than eight weeks. Table
1 shows the varying amounts of treatment and
periods of observation in these children. Acetarsone
seems to be more efficacious in infants under one
year of age (Table 2). Of 15 infants in this
group, only eight received adequate treatment. Of
this number, six had reversal of the Wasserman
reaction. They were treated from 2 to 18 months.
The clinical improvement obtained was remark-
able, especially in gain in weight and in the dis-
appearance of such lesions as: skin manifestations,
rhinitis, periostitis, condylomata and other mucous
membrane lesions, epiphysitis, interstitial keratitis
and Glutton's joint (syphilitic synovitis). The
skin lesions unless secondarily infected were well
healed or markedly improved within two weeks.
Rhinitis responded more slowly though some im-
provement was noticeable after two weeks of
therapy. Three children with condylomata showed
complete healing of the lesion within three weeks.
Four children with epiphysitis and pseudoparalysis
responded rapidly, and in two to three weeks' time
there was normal function of the involved extremi-
ties. Bone x-rays were not taken routinely, but
in those who were followed roentgenologically the
healing of the pathological lesion was rapid. Two
children with interstitial keratitis showed marked
improvement with a nine-weeks' course of acetar-
sone, but complete healing was not obtained until
treatment had been carried out for six months. An-
other child with interstitial keratitis was prac-
tically blind when treatment was instituted and,
although vision improved after three weeks, it did
not become normal with continued therapy. Two
of the three children with interstitial keratitis also
had syphilitic synovitis involving the knees, a fre-
quent combination as recently demonstrated by
Klauder and Robertson *. The synovitis was
promptly ameliorated in both of these patients, but
another child with syphilitic synovitis required
three weeks of therapy.
Table 2. — Relation of Age to Efficacy of Acetarsone
Therapy
Wassermann Clinical
No. of Reversed Improvement
Age Patients No. % No. %
Under 1 year *15 6 40 12 80
1-5 years 8 2 25 7 88
6-12 years 9 6 66
♦Only 8 of these patients were treated longer than 3
weeks; 6 or 75% had reversal of the Wassermann reac-
tion.
Following ingestion, acetarsone is rapidly ex-
creted in the urine ''. Although individuals vary in
their susceptibility to the drug, we have had very
few reactions; one eleven-year-old boy was given
0.8 gm. daily for approximately six months and
showed no ill effects. Practically all of the toxic
reactions were seen in the group of infants under
one year of age. Vomiting and diarrhea occurred
four times, but subsided within a few days after
cessation of treatment and did not recur when
therapy, using the minimal dose, was again started
shortly afterwards, .•\rsenical dermatitis occurred
twice, but the lesions disappeared seven to twelve
days after the drug was discontinued and did not
reappear when treatment was again instituted. One
child developed a mild hemorrhagic nephritis with-
AC ET ARSON E IN CONGENITL SYPHILIS— Arem and Gay
Februar>', 1936
out edema. The urine cleared within two weeks
and remained clear with further treatment. Al-
though very few severe reactions to the drug were
seen, it should be strongly emphasized that pa-
tients undergoing treatment with acetarsone should
be kept under close and careful observation. Parents
should be warned that at the first sign of fever, vom-
iting, diarrhea or appearance of a rash, the medi-
cation should be immediately discontinued. When
therapy is again instituted, the course should start
at the beginning with the minimal dosage regard-
less of the dose at which the drug was discontinued.
Conclusions
Acetarsone is an effective and convenient drug
for the oral treatment of congenital syphilis in the
infant and of great value in the older child. The
clinical response is excellent and the influence of
the drug on the serologic condition of the ade-
quately treated patients is satisfactory.
The medication is easily administered and con-
trolled and has many advantages over the previous
therapy of congenital syphilis, which required
weekly intravenous or intramuscular injections over
a period of tv/o years.
The acetarsone (Stovarsol) used was provided through
the Courtesy of Merck & Company.
References
1. Maxwell, C. H., jr., and Glaser, J.: Treatment of
Congenital Syphilis with acetarsone (stovarsol) given
by mouth. Am. Jl. Dis. Child., 43:1461, June, 1932.
2. Bratxjsch-Marr.un, a.; Wert and Durchfuhrung der
Spirocidbehandlung der Syphilis im Kindersalter. Arch,
j. Kinderh., 92:26, Nov. 2Sth, 1Q30.
3. Tr/USMAN, a. S.: Further Observations on the use of
Acetarsone in the Treatment of Congenital Syphilis.
Jl. Pediat., 7:495, Oct., 1935.
4. Klauder, J. v., and Robertson, H. F.: Symmetrical
Serous Synovitis. /. A. M. A., 103:236, July 28th,
1934.
5. Chen, M. Y., Anderson, H. H., and Leake, C. D.:
Rate of Urinary Arsenic Excretion after Giving Acetar-
sone and "Carbarsone" by Mouth. Proc. Soc. Exper.
Biol. & Med., 28:145, Nov., 1930.
The Age of Choice for Non-Emergency Operations in
Infancy and Childhood
(J. W. Duckett, Dallas, in Texas State Jl. of Med., Jan.)
Some deformities, such as imperforate anus, must be
operated upon within a short time after discovery. Cor-
rection of other defects is not an immediately urgent mat-
ter and the best interests of the patient may be served by
postponement.
Clejt Lip and Palate. — In the pre-alveolar cleft group
repair may be done preferably before 3 months of age. In
the post-alveolar cleft group, the palate alone is involved,
and operation should be delayed to allow the soft tissues
on either side of the cleft to develop a maximum strength
for use as sliding flaps; most prefer the age of 16 to 22
months.
Spina Bifida. — No operation for correction when there is
more than the mildest paralysis of the lower extremities
or of the sphincters, or when a definitely developing hydro-
cephalus is present; in the absence of these conditions.
early operations — even in the first few days of life — may
be necessary when the covering membrane is torn or so
thin that spinal fluid is leaking or rupture seems inevitable.
Early operation is indicated only to prevent meningitis,
in a child which has a good chance to live and develop
normally without paralysis or hydrocephalus. Careful
protection of the sac is imperative.
Birth Palsies. — Mechanical treatment must be begun
early and persisted in. If at the end of 3 months no
recovery of function, approximation of severed nerve ends
can be done, and sometimes all that is necessary is a
removal of excessive scar tissue surrounding the damaged
nerve trunks.
Exstrophy of the Bladder, Epispadias and Hypospadias. —
Correction of these anomalies should be deferred until the
child is several years old, but completed before school age.
Webbed Fingers and Supernumerary Digits. — Sterile pre-
cautions, thin webs, loosely connecting fingers or toes may
be clipped; with more solid webbing digits have bony con-
nections operations are best deferred until the age of 2
years.
Strabismus. — In young infants this may be usually more
apparent than real. If definite and persistent a competent
ophthalmologist should give corrective exercise for the
weak eye muscles very early, with lenses later, may effect
a complete cure. Operation, if necessan,-, may be done
after 5 years of age.
Clubbed-Feet and Poliomyelitis Deformities. — Each an .
individual problem.
Hernia. — Small umbilical often cure with no treatment
whatsoever. Better — wide strip of adhesive almost encir-
cling the abdomen, and tight enough to invert the umbilicus
between two longitudinal folds of skin for a few weeks:
may require months or a year. When operation is neces-
sary, it should be delayed until the age of 2 years.
Inguinal hernia in the infant is often corrected spon-
taneously, with control of constipation and phimosis. A
very effective truss of ordinary skein of woolen yarn.
The hernia reduced, the skein is applied about the infant's
waist one end looped through the other in front and
drawn snugly tight, so that the point of crossing of the
loops lies directly over the external inguinal ring. The
free end of the skein is then carried back between the
child's legs, and tied behind. This type of truss will
usually hold the hernia, and it can be changed when soiled,
with little more trouble than the diaper is changed. In
some cases, an adult type of spring truss, carefully padded,
may be more satisfactory. If trussing is unsuccessful after
the age of 18 months, operation will be necessary. When
a hernia does not occur, or is not recognized, until after
the age of 2 years, a truss may be tried for 3 to 6 months.
If no improvement results, operation should be advised.
Hydrocele. — Even a large hydrocele in a child is likely
to disappear permanently after 1 or more aspirations.
Undescended Testicle. — Many cases are wrongly diag-
nosed, and repeated observation will show the testes both
in the scrotum at one time, though drawn up into the
inguinal canal or higher at other times. In some instances,
one or both testicles never enter the scrotum until the
child is several years old, but will descend finally into
normal position. Recent reports indicate that descent of
the testis may be brought about in some cases by the
injection of the anterior pituitary hormone. Operation
should not be done before the age of 5 years. Many prefer
to wait 10 years, or just before puberty. The objections
to long postponement of operation are the questionable
susceptibility of such testicle to occurrence of malignant
disease, and atrophy of the abdominal testis. Atrophy
probably does not occur until after puberty.
Februarj-, 1936
SOUTHERN MEDICINE AND SURGERY
Institutional Treatment of the Negro With Special Reference
to Collapse Therapy*
J-
Donnelly, M.D., Huntersville, North Carolina
Mecklenburg Sanatorium
TUBERCULOSIS in the Negro still remains
a matter of great importance, not only
from a humanitarian viewpoint, but also
because of the increased demands for public funds
to care for those handicapped by the disease. Since
the greater proportion of the unskilled laborers and
practically all of the house-servants throughout the
Southern States are recruited from the Negro pop-
ulation, the effort to save the lives and increase the
working capacity of the members of this race re-
solves itself largely into an economic problem.
Consequently, the mortality caused by tuberculosis
among Negroes is a matter of gravest import be-
cause of the great loss of productive power in this
very necessary class of laborers.
To illustrate, I quote some figures from the rec-
ords of my own institution, which was opened in
1926. Of the Negro patients admitted since that
date 14.5^ have been cooks, 21.55% common
laborers, and 7.439r farmers. A total of 43.48%
of any number of individuals prevented for a con-
siderable period of time from working at their var-
ious occupations indicates a very considerable eco-
nom'c loss to a community. The high percentage
of cooks in this series also is an item of extreme
importance. From the nature of their occupation
they must necessarily have been a menace to the
various households in which they have worked,
and particularly so to the children in these house-
hold i. Consequently, it is evident that a reduc-
tion of the incidence of tuberculosis among Negroes
and the institutional care of the open cases among
them is of vital importance to the health of both
races. Laborers and farmers are a most necessary
part of the physical equipment of a community,
and any procedure which will tend to reduce the
death rate and prolong the working time of these
two classes of workers will certainly add greatly
to the public wealth.
.Although the Negro death rate from tuberculosis
is still three to four times as high as the white race,
it has been considerably reduced in the last few
years, e.xcept probably in the large centers of pop-
ulation. During the period of slavery their death
rate from this disease was approximately equal to
that of the whites, but, after attaining their free-
dom, the rate rose rapidly reaching more than 600
per 100,000 in 1885. This was unquestionably
•Read liefnrp the Medical Section at the
Sept. 16th, 1935.
largely due to poor environmental conditions and
lack of lucrative employment, with the consequent
lack of the food necessary to preserve their physical
resistance to disease.
The cause of the prevalence and high mortality
of tuberculosis among Negroes is probably a combi-
nation of several factors. The greater proportion
of adult Negroes, in addition to being practically
uneducated, have no particular desire to better
their economic situation. Furthermore, their re-
action to the effects of a disease of any type is rad-
ically different from that which obtains in the white
race. As a rule the Negro pays no attention to the
initial symptoms of disease, making no effort to
seek medical advice until the disease is well ad-
vanced. For that reason tuberculosis is frequently
far advanced in the Negro before he is willing to
admit that he feels ill, because in this disease pros-
tration is not often extreme. Also it seems a diffi-
cult matter to impress on many members of the
race that each individual case of adult disease is a
serious menace to all contacts. A very difficult
and discouraging procedure is an attempt to teach
the basic principles of sanitation and health to the
average uneducated adult Negro.
Environmental facto)rs enter largely into the
maintenance of the high death rate from the disease
among Negroes. The greater number of them are
fitted only for occupations in which the wages,
as a rule, are low. Because of this, the food supply
of the family is invariably limited; and cheap,
more-or-less insanitary living quarters are the rule.
However, in the Southern States the living quarters
of Negroes are usually not so congested as is the
case in the larger Northern centers of population,
which may account for the much lower death rate.
The Negro has a much better chance to escape
death from tuberculosis if he remains in his South-
ern home. Just a few months ago I was told by
a physician interested in tuberculosis work in one
of the largest cities in the LTnited States that he had
never seen a Negro obtain an arrest of his tuber-
culous process. Several other factors have their
effect in increasing the incidence of the disease, viz:
the prevalence of venereal disease, disregard of
fatigue whatever the cause, addiction to alcohol and
drugs, and carelessness about exposure to the dis-
comfort and rigors of severely cold and damp
annual meeting of the Southern Tuljerculo.sis Conference, Hou.ston, Tex.,
COLLAPSE THERAPY— Donnelly
February, 1936
weather. Sensitiveness to discomfort of any type
is far less acute in the Negro race than in the white.
All of the elements mentioned have an effect, nec-
essarily, on the incidence of tuberculosis in the
Negro.
It has been the opinion of many authors more
or less familiar with disease conditions among
Negroes that they are lacking in physical resist-
ance to infection by the tubercle bacillus. This
opinion has no doubt been based on the fact that,
in previous years, the greater proportion of cases
of the disease have been far advanced when first
seen by the physician. It is very difficult in many
cases to obtain an authentic history as to the length
of time the individual has been ill from the disease,
since seldom is medical attention sought until the
patient is unable to work. It is susceptible to proof
that even repeated infections in the Negro child are
handled quite as successfully as in the white child.
Many cases of childhood type tuberculosis in the
Negro become completely healed without removal
of the child from its old environment. Furthermore,
many of the far-advanced cases when under ob-
servation in an institution show a remarkable re-
sistance to extreme toxemia over long periods of
time. Frequently one observes maximum tempera-
tures of 103 to 105^ with daily variations of 6 to
7° continuing over periods of weeks, or even
months. Evidence of such severe toxemia over
such long periods is not usually seen in tuberculosis
in the white race. With the proper care and effort,
in even the far-advanced cases, life may be pro-
longed considerably.
In- spite of numerous difficulties which interfere
with the institutional treatment of the tuberculous
Negro, many excellent results therefrom indicate
that it is well worth while. However, many more
sanatorium beds are necessary. There are, I be-
lieve, approximately 700 beds for the care of
Negroes in the institutions of the South. There
should be 7,000. Statistics indicate that although
Negroes comprise only li'yc of the population of
the South, among them occur 53% of the deaths
from tuberculosis. Many times Negroes afflicted
with the disease refuse to remain in a sanatorium
where their activities are limited, and where they
might at least receive sufficient benefit to prolong
their lives. In my own experience, however, cases
leaving the institution against medical advice are
not nearly so numerous as they were even three
years ago. It is also my experience that benefits
derived from institutional treatment are far more
appreciated among Negro patients, as a rule, than
among some classes of whites with whom we have
to deal.
The oft-repeated statement that institutional
treatment of the adult tuberculous Negro is a hope-
less effort to my mind is a statement which is not
supported by the facts. Although many cases are
discouraging, excellent results are sufficiently num-
erous to offset such disappointments. The addi-
tion of collapse therapy to the treatment by bed-
rest frequently eventuates in surprisingly good re-
sults. Since many cases of tuberculosis among
Negroes are well advanced when first seen, it is
frequently impossible to obtain results by means
of pneumothorax because of adherent pleurae, but
this difficulty is probably found no more frequently
among Negroes than among the whites who are
afflicted by the same degree of disease. Collapse
therapy is certainly of inestimable value in the re-
duction of infection by rendering the sputum
negative.
To illustrate results which may be obtained in
institutional treatment I wish to offer the short
case histories and x-ray reports of several cases. The
first two cases have shown remarkable improvement
on bed-rest alone, without the addition of any
form of collapse therapy. The others have had
collapse therapy in addition.
Case I. — Negro man, 29, entered sanatorium for treat-
ment Nov. 29th, 1926. History indicated that he had been
ill for about two years. He had worked in an automobile
tire manufacturing plant before becoming ill. He had had
several pulmonary hemorrhages, had lost weight and had
considerable cough. He weighed 154 pounds, and his
sputum was positive for tubercle bacilli. His temperature
did not exceed 100.5° for several days before entering the
sanatorium. There was no family history of tuberculosis.
The physical e.xamination and x-ray indicated a bilateral
tuberculous involvement considerably more extensive in
the right lung.
On continuous bed-rest the patient began to show grad-
ual improvement. During the first year he had several
small hemoptyses, but apparently was not damaged by
them. On discharge as a quiescent case on Aug. 10th,
1029, 32 months after entering the sanatorium, he weighed
184 lbs., having gained 30 lbs. He has remained in ex-
cellent physical condition since discharge and is still work-
ing every day. Bed-rest alone, and no form of collapse
therapy, was used in this case.
Case II. — Negro man, 28, common laborer, entered the
sanatorium for treatment June 20th, 1934, complaining of
feeling ill since the fall of 1933, loss of weight, weakness
and a hacking cough. He said he had lost about 20
pounds in weight, his weight on admission being 132 lbs.
His sputum was positive for tubercle baciUi. There was
no family histop.' of tuberculosis. The physical examina-
tipn and x-ray films indicated an extensive bilateral
tuberculosis, which was apparently of a more or less
acute type. The prognosis did not appear at all good,
although the patient appeared to be willing to co-operate
in any way possible.
He was put on continuous bed-rest immediately. Within
three months he began to show marked improvement, not
only in his general physical condition, but also in the
clearing up of the chest condition. His cough became
considerably reduced, his appetite remained good, and he
continued to gain in weight. He is still under treatment
in the sanatorium. He rarely coughs and his expectoration
is slight, his sputum is continuously negative, his tempera-
Februan-, 1936
COLLAPSE THERAPY— Donnelly
77
ture and pulse rate remain normal, and he weighs 1795^2
lbs., a gain of 47}2 lbs. in weight in fourteen months. The
x-ray film taken May 1st, 1935, compared to the ones
taken June 15th and July 20th, 1934, indicates that this
Negro man has made remarkable improvement on bed-
rest alone.
C.«E III. — Xe.sro woman. 2Q, entered the sanatorium
for treatment July 24th, 1033. Her occupation was given
as "cook." She stated she had been ill about seven
months, her complaints being fever, productive cough,
gradual loss of weight, poor appetite and slight dyspnea.
She said she had recently had an attack of "influenza." She
had lost 2S pounds in seven months, and her symptoms,
she stated, had gradually become more marked. The
maximum daily temperature at the time of entering the
sanatorium was from 100.5 to 101°. Her mother had died
from pulmonary tuberculosis.
The physical examination and x-ray films indicated an
extensive bilateral tuberculous involvement, apparently of
a more or less acute type, with a cavity in the right upper
lobe.
Patient was put on continuous bed-rest, and began to
show gradual improvement, gain in weight, reduction in
temperature and some reduction in cough. When she had
been in the sanatorium for one year her general condition
had become surprisingly good. She had gained 39 lbs.
in weight, her temperature remained practically normal,
and her cough was considerably better. The activity in
the left lung had cleared considerably, and we decided
to do a phrenic interruption on the right. This was done,
resulting in a considerable reduction in the size of the right
upper lobe cavity and a further improvement sympto-
matically. Several months later this patient left the sana-
torium against medical advice. Her sputum had been
much reduced in quantity, but was occasionally positive for
tubercle bacilli. Although I have not seen her lately, I
understand her general condition still remains good. The
x-ray films show a marked improvement in the lung con-
dition, in spite of the well advanced bilateral involvement.
Case IV. — Negro man, 37. This patient entered the
sanatorium Oct. 31st, 1933. His occupation was common
laborer. His complaints were loss of weight, cough and
general malaise. He had been feeling ill since April, 1933,
but continued to work until .\ugust, 1933. He had a
moderate pulmonar,- hemorrhage on Oct. 15th, 1933, and
had lost 24 pounds in weight in about 8 months. His sputum
was positive for tubercle bacilli. His weight on admission
was 1395/2 lbs., and the daily temperature range was 98°
to 102°. The family history was negative for tuberculosis.
The physical examination and x-ray films indicated a bi-
lateral tuberculous involvement, which was considerably
more extensive on the right. The x-ray film showed a fair-
.=izcd cavity in the right lower just above the diaphragm.
A phrenic evulsion was decided upon and this was done
Nov 9th, 1933. After this time the improvement was con-
tinuous. There was a steady gain in weight and the cough
L'radually entirely disappeared. Later x-ray films showed
the right basal cavity completely closed, and the sputum
became continuously negative. This patient was discharged
-■Vpril Sth, 1935, in excellent condition, weight 202 lbs., a
gain of 6254 lbs. since admission, no cough or expectora-
tion, and pulse rate and temperature within normal limits.
This man still remains in fine physical condition.
Case V. — Negro man, 27, entered sanatorium for treat-
ment Jan. 3rd, 1933. He said he had been ill about two
months, his complaints being loss of weight, lassitude,
dyspnea and cough. He had had no hemoptysis, but had
suffered from night sweats, and had afternoon rise of
temperature. He had lost about fifteen pounds in weight
in two months, his weight at this time being 135 pounds.
He was a hotel bellboy by occupation. The family history
was negative for tuberculosis. The sputum was positive
for tubercle bacilli.
The physical examination and x-ray films showed ex-
tensive bilateral tuberculous involvement with, apparently,
cavitation in the right apex. The afternoon temperature
record approximated 101°.
This patient was immediately put on complete bed-rest,
which was continued for about 20 months. At the end of
this time he had improved considerably. His temperature
and pulse rate had remained practically normal for some
time, weight had increased to 217 lbs., a gain of 82 lbs.
since admission, and the chest condition had cleared, par-
ticularly on the left side. The cough had decreased con-
siderably.
.At this time it was considered advisable to do a phrenic
interruption on the right to attempt if possible to close
the cavity in the right apex which still remained open. A
phrenicectomy was done in September, 1934, with fairly
satisfactory results. The cavity at this time is not com-
pletely closed, but is much smaller. The last few sputum
examinations have been negative for tubercle bacilli. The
man's temperature continues practically normal, and the
cough is slight. His general condition is quite good, and
he weighs 214 lbs. He is still under sanatorium treatment.
C.«E VI. — Negro man, 24, entered sanatorium for treat-
ment May 26th, 1933, with a history of having been
ill about two months. His complaints were loss of about
ten pounds in weight, and a productive cough. His gen-
era! health previous to his present illness had been good.
His afternoon temperature had been for several days from
100 to 101°, and his symptoms were gradually becoming
more marked. He had worked as a janitor, and had con-
tinued to work until Feb. 1933, when he was forced to
quit because of physical weakness. Two brothers had
died from tuberculosis. His sputum was positive for
tubercle bacilh.
His physical examination and x-ray films indicated an
extensive involvement in the right lung, with the prob-
ability of a slight amount of activity in the left apex. After
slightly less than thirty days bed-rest, artificial pneumotho-
rax was instituted. Eventually a fairly satisfactory col-
lapse was obtained, as indicated by the film taken April 6th,
1934. This patient was discharged from the sanatorium
Dec. 9th, 1934, as a quiescent case. He was symptom-free
having had a negative sputum for some time, and had
gained 19i/^ lbs. in weight. The collapse was maintained
until June, 1935, at which time the patient left the
county, and I have not seen him since. I hear, however,
that he still remains in excellent physical condition.
Although the institutional treatment of the adult
tuberculous Kegro is at times discouraging, it seems
to me that these few cases indicate that such treat-
ment is far from a hopeless effort. To those who
adhere to the idea that the Negro is racially sus-
ceptible to tuberculous disease, I should like to add
that, with one e.xception, all of these patients are
pure blacks. Consequently, it cannot be argued
that their strong resistance to the disease is due to
an admixture of white blood. To my mind collapse
therapy in its different forms is most valuable in
the treatment of adult tvpe tuberculosis in the
Negro. The results obtained are very frequently
COLLAPSE THERAPY— Donnelly
February, 1936
most gratifying, and the procedure offers great
hope not only in returning many of these patients
to some form of productive work, but also in mate-
rially reducing the sources of infection to contacts.
The Practicai, Management of Cardiovascular
Emergencies
(E. F. Horine, Louisville. Ky., in Jl. Indiana State Med.
Assn., Dec.)
In a person who has fainted if the cardiac sounds are
clear, or with a murmur, if the rhythm is alternate slowing
and quickening with apparent relationship to respiration,
the condition is harmless vasovagal syncope. If it occurred
upon the assumption of an upright position and if the
heart is slow and regular with low and variable b. p. the
cause is a postural hypotension. Profuse sweating is an
almost constant accompaniment of the former whereas
anhidrosis is the rule in the latter.
The history of illness with anemia or of hemorrhage
will clarify fainting from these causes. With vestibular
involvement there is a typical sense of rotation. Fainting
due to intracranial lesions will require study and laboratory
and instrumental aid. First-aid treatment of syncope due
to extracardiac factors consists in supine position, seeing
that the rela.xed tongue does not obstruct breathing and
losening about the neck and waist, lifting the lower jaw,
turning the head to one side and inserting some type of
airway. Atropine 1/50 gr. subcutaneously to reUeve sweat-
ing and increase the heart rate. The intramuscular injec-
tions of 10 m. of a 1-1000 epinephrm is of value.
In heart block differentiation requires electrocardiographic
observations which are seldom possible. Ventricular fibril-
lation may be suspected when rapid heart action precedes
the syncope. Slowing of the already slow ventricular rate
in complete block possibly precedes a syncopal attack due
to ventricular standstill. Epinephrin solution into the
heart might be of value in ventricular standstill but it
would probably maintain a ventricular fibrillation and
cause death. Hence a patient with an Adams-Stokes seizure
must not be given epinephrin unless one is reasonably
certain of the exact mechanism present. In the prevention
of Adams-Stokes seizures barium chloride, 1/3 gr. three
times daily, will often abolish the attacks. Ephedrine,
gr. 1,3, has been reported to be effective.
Paroxysmal tachycardia, multiple premature contractions
and a bigeminal rhythm only occasionally produce faint-
ing. Very firm pressure for 20 seconds over either carotid
artery below the angle of the jaw will frequently terminate
an attack of paroxysmal tachycardia.
In the loss of consciousness of ventricular fibrillation,
death is inevitable if the ventricles fail to contract within
6 or 7 min. There is no known preventive nor has any
type of treatment proved of any value. Epinephrin is apt
to kill and quinidin is contraindicated. Some patients have
hundreds of attacks while for others a single attack may
prove fatal.
Syncope and even sudden death may occasionally occur
in patients with aortic stenosis.
The common basis for paroxysmal dyspnea in its varied
forms is acute left ventricular failure ("defeat") of greater
or lesser degree. Morphine sulphate in full dosage in
consideration of the weight, strength, age, sex and severity
of the attack should be given intramuscularly. In the
more severe attacks, when marked relief has not been
obtained within 45 minutes, half the primary dose should
be given intravenously. Should pulmonary edema be man-
ifest, at least 1/50 gr. atropine sulphate should be admin-
istered with the first dose of morphine. Venesection may
prove a life-saving measure. If the patient is plethoric
and has hypertension, from 300 to 600 c.c. of blood should
be withdrawn. Patients of this type are usually receiving
digitalis and it should be continued in a maintenance dos-
age. When attacks of parox>-smal dyspnea recur frequently,
the daily administration intravenously of 100 c.c. of a 50%
glucose solution may prove beneficial, also a mercury
compound and theophylline, even though congestive failure
is not manifest. A high-protein diet, no added sodium
chloride. The attacks may be, at times, prevented by ab-
solutely prohibiting the ingestion of liquid from noon until
the following morning. Epinephrin is contraindicated.
Patients with moderate to severe grades of heart failure
occasionally manifest delirium and become difficult to
manage. Hypnotics in large doses will not entirely con-
trol the condition. Ammonium chloride, daily oral dosage
60 to 90 grs., and 2 c.c. of mercupurin given intravenously
each day will often control the psychotic state.
An excellent rule to follow is that any type of discom-
fort, whether oppressive, burning, tingling, severely painful
or only enough to barely register itself, radiating or not,
anywhere above the umbilicus up to the upper jaw, in
the arms or hands, and which is uniformly provoked by
exercise but relieved by rest or the administration of the
nitrites is angina pectoris. Instruct upon the onset of the
symptoms to cease any exercise, sit or lie down, dissolve
under the tongue a hypodermic tablet of nitroglycerine,
gr. 1/100. A 2nd tablet is to be taken in 10 minutes and
if relief is not secured after this one, a physician is to be
called, inasmuch as there is now to be considered the ■•
possibility of a coronary thrombosis. Amyl nitrite may be
used instead of nitroglycerine, though the latter is more
easily and satisfactorily employed.
In preventing attacks sedatives, the xanthine derivatives,
alcohol and bromides may be of value. Frequent attacks
with slight effort or at rest and despite the medication
indicate a coronary thrombosis is imminent. Placed at
absolute rest in bed for 4 weeks, often not only is the
threatened coronary thrombosis averted but the anginal
syndrome is temporarily abolished. Patients with diabetes
mellitus who are receiving insulin experience an anginal
syndrome when the blood sugar is lowered below or even,
at times, to a normal level.
Of pains suffered by human beings that of coronary
thrombosis is the most excruciating. Yet cases of coronary
thrombosis occur without pain. Embolic phenomena in-
volving arteries of the systemic circulation in a person
who does not have rheumatic heart disease or an active
endocarditis strongly suggests a coronarj' thrombosis. More
or less shock, a fall in b. p., fever, leukocytosis, a pericar-
dial friction rub, hematuria and certain electrocardio-
graphic signs round out the perfect picture. Morphine
sulphate in adequate dosage intravenously, if necessary, is
the emergency remedy for the painful type. Shock or
embarrassment of respiration will be benefited by an oxy-
gen tent or chamber. The presence of coronary thrombosis
necessitates the 9 to 15 grs. daily of quinidine sulphate
to prevent frequent premature contractions or auricular
fibrillation. Digitalis is not used unless congestive heart
failure is present and then only a maintenance dose. Co-
deine, a carbamides or paraldehyde, but barbiturics are
contraindicated. If vomiting occurs the intravenous use of
50 to 100 c.c. of a 50% glucose solution once or twice daily
is quite effective. Patients with coronary thrombosis should
be kept absolutely at rest in bed for a minimum period of
4 weeks, dating from the last attack of pain. A relatively
low-calorie diet is indicated.
I believe that in influenza the combination of codein and
pyramidon is almost specific. — T. E. Zerfoss, in Jl.-Lancet,
Dec. ISth.
February, 1936
SOUTHERN MEDICINE AND SURGERY
79
Surgical Observations
A Column Conducted by
The Staff of the Davis Hospital
Statesville, N. C.
The Treatment of Laryngeal Obstruction in
Diphtheria
In the treatment of diphtheria with or without
complications, a large initial dose of the antitoxin
and general supportive and symptomatic measures
are necessary. Proper means for protection of oth-
ers and prevention of the spread of the disease are
also very important.
In the air passages of the child who is develop-
ing obstruction due to the disease, we usually have
a highly inflamed condition, especially of the larynx
and upper trachea. In addition to the inflamma-
tion and swelling there may be a membranous for-
mation which in itself is often sufficient to cause
partial or complete obstruction. Much obstruc-
tion, however, is caused by thick, tenacious mucus,
the removal of which will give relief, at least for
the time being.
In the treatment of obstruction, the first measure
should be an examination of the larynx with a
laryngoscojje and aspiration of this area and the
upper trachea to remove this mucus and any mem-
brane which may be loose. Repeated aspirations
may keep the air passages clear and prevent the
necessity of intubation or tracheotomy.
Where aspiration does not relieve the obstruc-
tion, intubation should be done promptly. In in-
tubation one of the most important points is to
select a tube of the proper size and to intubate
without trauma.
Usually after intubation the patient will cough
and expel a considerable amount of mucus. By
holding the child with the head downward and
getting the aid of gravity, the escape of mucus
from the upper air passages will be facilitated, the
child made much more comfortable; the necessity
for removing the tube for cleaning it may be ob-
viated by this simple procedure.
During the period of intubation the child should
be fed very carefully. Those children who can not
swallow well when held with the head inclined
downward, should be given their food by means of a
small nasal tube. This is probably the most satis-
factory means of giving liquid food, laxatives and
other medicines, as it involves no risk of any
aspiration of these things into the air passages.
The removal of the intubation tube may be done
on the fourth or fifth day; in some cases it is pos-
sible to remove the tube earlier and in others it is
necessary to leave in position for a longer period.
Whenever a tube is removed, the child should
be under observation for some time, and if any
symptoms of serious obstruction develop, the tube
can be replaced and left in for a day or two more.
Rarely tracheotomy is necessary. It is indicated
more often in cases where there is an extensive
membrane formation in the upper trachea and
where pieces of membrane come loose and obstruct
the tube, or where the mucus forms so rapidly
and is so thick and tenacious that intubation is
unsatisfactory.
Tracheotomy should never be done except where
absolutely necessary, as it greatly increases the
liability to bronchopneumonia, which is perhaps
the most frequent serious complication of diphthe-
ria unless it be the degeneration of the heart muscle
due to the action of the diphtheria toxin.
The medical treatment of the patient should be
constantly kept in mind and every precaution used
to protect the patient's heart from unusual strain.
Feeding is extremely important and aids greatly
in enabling the child to overcome the infection and
to combat the toxemia. Considerable quantities of
liquid food may be given through a nasal catheter
and without any great difficulty. A careful check
should be kept upon the amount of food given.
The child should receive the proper nourishment,
especially during the period of obstruction when
swallowing is difficult or almost impossible.
The importance of suction in treatment in laryn-
geal obstruction is not generally properly appreci-
ated. It will remove much of the obstructing ma-
terial and, in many instances, prove an entirely
satisfactory substitute for the more heroic meas-
ure of intubation or tracheotomy.
An early diagnosis of diphtheria with the prompt
administration of a sufficient amount of antitoxin
usually controls the disease, but sometimes patients
are not seen by a doctor until obstruction has de-
veloped. When a child is found to have obstruc-
tion with difficult respiration, retraction of the
suprasternal space and cyanosis, only prompt ac-
tion will save its life, and there should be no delay
in instituting proper treatment. With the aid of
the laryngoscope, view the obstructed portion of
the air passage and insert a suction tube removing
all loose material from this air passage, protecting
yourself with a Negus face shield to prevent the
child coughing infectious material into your face.
A large, circular sheet of plate glass held in front
of the face by a head band and rotated as
certain areas become covered with moisture enables
the operator to work close to the child's face with-
out any particular danger to himself. Everyone
who treats diphtheria should use this little device,
besides it is a great protection to the doctor in
examining the throats of patients who are inclined
to cough unexpectedly.
SOUTHERN MEDICINE AND SURGERY
February, 1936
Bronchopneumonia and otitis media are com-
mon serious complications following diphthe-
ria, and I believe frequent aspirations have done
much and will do more to lessen the frequency of
pneumonia and, consequently, the mortality. In
large hospitals for contagious diseases the mortality
from diphtheria is gradually being reduced and
intubations are less frequently done. Repeated
aspiration, where there is any obstruction at all, is a
routine treatment and is most satisfactory.
The Tongue
(J. Milner Fothergill, Va. Med. Monthly, Mar., (1SS2)
Tell the patient to put out his tongue fully, so that the
circumvallate papillae can be clearly seen; it is no use to
study the tip. If the patient is an infant. Sir William
Jenner's plan of placing a drop of syrup upon the chin is
well worth following.
Tremulousness of the tongue indicates alcoholism, or,
less frequently, lead or mercurial poisoning, muscular weak-
ness. When seen in the early stages of typhus, or typhoid
fever, it indicates a grave condition of bad prognostic
omen. In advanced stages, the tongue is protruded slowly
and with difficulty. In hemiplegia, the protruded tongue
turns its apex to the paralyzed side, from loss of power
in the genio-hyoglossus muscles of the affected side. In
glossolabial paralysis the capacity to protrude the tongue
is impaired or lost. In facial paralysis, without hemiplegia,
the loss of power to protrude the tongue tells that the
mischief is within the skull.
Dryness of the tongue is found in pyrexia, in diabetes
and other conditions of polyuria, and in some of the
functional disorders of digestion. It is marked by the
teeth in conditions of debility, from menorrhagia, chronic
diarrhea or acute prostration, however mduced. The
tongue is furred constantly with some individuals who are
well and strong; and especially in the morning, is common
with heavy smokers. Usually, a furred tongue denotes dis-
turbance of the digestive organs, or the oncome of acute
disease. When found with shivering fits, this condition of
the tongue tells of coming trouble. When the coating has
a distinctly yellow or brownish hue, there is usually a bad
taste in the mouth in the morning. Repeated free purga-
tion without a mercurial, often leaves the tongue as thickly
coated as before, and a few grains of calomel produce a
clean tongue in a few hours. Clearing up of the tongue
tells of uninterrupted convalescence. In scarlet fever, the
tongue assumes a strawberry appearance — sometimes the
red papillae stand out on a red surface, like a ripe straw-
berry; at other times, the red papillae stand out upon a
coat of fur like the seeds of an unripe strawberry. In
almost every case of indigestion with furred tongue, con-
stipation is present, and a continuous course of laxatives
must be considered in therapeutic plan. Mechanical
means of cleaning the tongue, as scraping it or rubbing it
with lemon-juice or vinegar, are well enough for the local
sense of cleanliness or comfort.
The tongue may be furred along one sive only, or may
be raw and irritated, or even ulcerated by a jagged tooth.
At other times the epithelium of the tongue is stained, as
by drinking elder wine, sucking a piece of licorice, or
chewing tobacco; or it may be discolored by some prepara-
tion of iron.
The raw tongue has not received a tithe of the attention
it deserves. So long as this condition remains, tonics are
useless and are not digested. Give bland food, with seda-
tives to the gastro-intestinal tract. In phthisis it is of all
semeia the one I personally dislike most. It is not usually
complete over the whole tongue, but lies as a large patch
in the middle, the irregular edge usually extending further
on one side of the mesial line than on the other. We have
even.- reason for supposing that this condition of the tongue
is significant of the state of the unseen portion of the
gastro-intestinal canal; and the absence of epithelium
interferes with assimilation. This it is which excites one's
apprehension in all wasting diseases.
It is easy to get rid of the layer of dead epithelium cells
of the coated tongue; but it often taxes all our resources
to restore the epithelial coat where the tongue is raw.
Here our best efforts are futile and unproductive of good
result !
There is a peculiar silvery sheen of the epithelial cover-
ing of the tongue in many cases of menorrhagia ; especially
when the tongue looks swollen and shows the indentation
of the teeth.
In relapsing fevers, there is often a small triangle on
the tip of the tongue, much cleaner or rawer than the
rest of it.
Deep rugour fissures are very suggestive of syphilis.
Chancre must be discriminated from cancer by the history,
the age, and the condition of the glands of the neck. When
inspecting the tongue, other evidences of syphilis may be
furnished by the state of the phar\-nx or soft palate. Cica-
trices are observed in persons subject to epilepsy, as the
result of wounds inflicted by the teeth during the parox-
ysms. These may be useful in determining that paroxysms
which a patient has experienced were epileptic. Coldness
of the tongue belongs to the moribund condition.
iTEur From Report on Advances in Surgery to Medicax
Society of Virginia 1881
(M. C. Kemper, Goshen, in Va. Med. Monthly, Jan.. 1SS2)
Girdner, of New York, says, in Medical Record, July
30th, ISSl: A patient comatose for several hours from
lightning stroke. Skin came off his left arm and scapula,
leaving a large, raw surface; treated by different means for
some weeks, until a healthy granulating surface was ob-
tained. .\bout this time, a healthy young German, who
had attempted suicide by cutting his throat, was brought
to the hospital, and died within a few hours. Six hours
after his death, I removed a portion of skin from the
inner side of the thigh, cut this piece of skin into a great
many small pieces and applied them, and dressed the sur-
face.
After 4 days the dressings were removed. One-fourth of
the grafts had failed to take, and were washed off when
the wound was cleansed. The remainder have attached
themselves to the ulcer, and the lower and central portions
of the ulcer on the arm are already covered with a thin,
delicate skin, as a result of fusing together of the islands
of skin.
{Dr. Kemper concluded his report with this admirable
statement. — J. M. N.)
It has become a custom for the chairman of the various
committees of this Society to apologize for the length of
their reports, and to plead as excuses, for whatever de-
fects they may contain, want of leisure and facilities for
familiarizing themselves with the literature of their sub-
jects. While no one can be more keenly alive to the
defects of this report than myself, and while it has been
spun out far beyond the usual length of such reports, I
propose to honor this custom by deliberately breaking it.
This is the result of an honest effort to comply with the
duties imposed by my position, and as such I respectfully
submit this report,
February, 1936
SOUTHERN MEDICINE AND SURGERY
•I***'*******J»*'I**I*'5**I*'5«»J«*5«»J»»J»^»«J»^^J» "j
President's Page
Tri-State Medical Association of the Carolinas and Virginia
"In lazy apathy let stoics boast. Their virtue fixed;
'Tis fixed as in a frost: contracted all, retiring to the
breast; But strength of mind is exercise, not rest."
It is said that the passions are the springs of
most of our actions, and that apathy has come to
signify a sort of moral, mental or physical inertia,
the absence of all activity or energy.
If we are not alert we may find ourselves in that
state of apathy where every glow of enthusiasm is
paralyzed. Apathy means indifference, an absence
of any special interest toward anything, due to
lack of the proper moral, physical or mental exer-
cise. In every man's career there are certain im-
portant things about which he dare not be indiffer-
ent and this applies especially to the members of
the medical profession — a profession ever laboring
to prevent diseases among his fellowmen and to
bring amelioration and cure to the suffering and
siclc.
General Robert E. Lee is quoted as saying that
duty is the noblest word in the English language.
It is our duty to keep physically fit, morally right
and mentally alert. Every physician should look
to his own physical welfare. Yet how often are
physicians in their busy lives indifferent to their
own physical needs. They are forgetful of the
much-needed vacation, regular hours and the cul-
tivation of a hobby outside of their routine duties,
all which would add much to their wellbeing, until
finally they find themselves gradually and uncon-
sciously slipping into that category of ills so com-
mon to our profession, namely, cardiorenal disturb-
ance, hypertension, or nervous breakdown. Give
some thought to your own physical fitness; culti-
vate a hobby; take a vacation and thus prove
yourself better able to serve your practice longer
and better.
As to moral indifference perhaps few are guilty,
for the success of any physician in his community
and among his fellow practitioners depends much
on his conduct as to distinction between right and
wrong, and in his ethical attitude in all things per-
taining to the practice of medicine. Let us look
at ourselves through our fellow-practitioners, for
by knowing each other better we receive a stimulus
to right conduct. There is some of good in the
worst of us, much of bad in the best.
.\s to mental apathy perhaps most of us are
culpable to a certain degree. We need our books
and our journals. So many changes are taking
place and there is so much about which we know
so little. However, there is no better way to ex-
ercise the mind and to familiarize ourselves with
a subject than to write a paper. It is said that
a nationally known physician of enviable reputation
and a member of a widely known clinic once made
the remark that when he came across a subject of
which he knew little or nothing, he wrote a paper
on that subject and so informed himself about it.
If we all used this means of selecting a subject
there would be little difficulty in finding a title for
a paper. I am certain I would be writing papers
the rest of my days. However, it is a plan well
worth consideration and adoption. On the other
hand, the physician who has learned well, observed
and gathered much knowledge from that great
teacher, experience, may also present papers worthy
of the careful attention of any audience. There
is no one who acquires more from experience than
the general practitioner who is usually the family
physician, and the doctor from the smaller com-
munities who does not have at his beck and call
the expert laboratory technician or the specialist.
As a stimulus to physical, moral and mental ex-
ercise there is nothing better than regular attend-
ance on the meetings of a good medical society.
Osier was a regular attendant on medical meetings
and he emphasized to his fellow practitioners the
importance of this habit; he insisted that thereby
harmony and goodfellowship were promoted. He
emphasized that physicians are inclined to live
apart too much. They need friction. The daily
round of the busy doctor tends to develop an
egotism to which there is no antidote. The few
setbacks he gets are soon forgotten. Mistakes are
buried and then after a few years of successful
practice he tends to become touchy, dogmatic and
self-centered. To this mental attitude the medical
meeting is the best corrective.
This brings me to the very important point in
my message to you, fellow members and friends
of the Tri-State Medical Association — the urgent
request that you now make your preparation to
attend the Thirty-eighth Annual Meeting to be
held February 17th and 18th, at Columbia, S. C.
There are invited guests from well known clinics,
which to hear will be well worth the trip. It will
be a two-day program full of interesting papers and
discussions. We know a cordial welcome from
the physicians of Columbia awaits us. Let us go
early and stay late.
CHARLES C. ORH
SOUTHERN MEDICINE AND SURGERY
February, 1936
DEPARTMENTS
HUMAN BEHAVIOR
James K. Haxl, M.D., Editor, Richmond, Va.
.•\bout Mr. Polydoron
I shall call my friend Mr. Polydoron, a man of
many gifts, although he is experiencing difficulty
in making helpful use of them. Even though he
appears before us only through the medium of his
own words and mine, you can easily see that his
physical appearance does not suggest that he lacks
four years only of being sixty. There is no graying
even about his temples; he is somewhat overweight;
his color is good; and you feel that his physical
structure may be sound. He is large of body and
his mental capacity is spacious. Before he had
reached the age of twenty he had obtained a college
degree. Innately studious, he has continued to
add to his store of knowledge. His memory is
tenacious, and what he learns he retains. He is a
member of one of the learned professions, and in
that profession he lives in the upper stratum.
Throughout the years his acquisitions have steadily
increased. But his losses have been heavy and
continuous. Let him speak to you as he spoke to
me, for only he knows that immaterial structure
which constitutes himself. His vocabulary is large;
he uses words with careful discrimination; he
knows himself. He will present that invisible, that
impalpable, that real self known only to himself:
"Doctor, I proffer my apology to you for calling
you back to your office at night. But I thought it
best to speak to you, for you have known me long
and intimately, and you may know me more inti-
mately than even I know myself.
"Several years ago I came to you a wreck —
physical, emotional, spiritual, and perhaps mental.
For no man could drink as much whiskey as I
had then been consuming for a long time and re-
main normal. You will recall that I had a persist-
ent bronchitis, attended by an annoying cough that
kept sleep from me at night and wracked me
throughout the days. My kidneys were in poor
condition, and I had to guard my diet to prevent
the development of diabetes. For a long time I
had relied upon alcohol to propel me during the
day, and I had depended upon hypnotics to soothe
me during the night. Before it had been possible
for you to finish the treatment you had prescribed
for me I was unavoidably called back to my home.
But, for a while, I restrained myself and my health
continued to improve. Eventually, however, my
former mode of life reasserted itself, and I lived
as imprudently as I had formerly done.
* Presented to the Neuropsychiatric Society of Virginia
at its first meeting, Richmond, January 24th.
"I speak not in defense of myself, but there were
distressing factors. Many years ago my wife died.
I devoted my life to my two children. The older,
a splendid, brilliant boy, became my professional
associate. A short attack of pneumonia took him
from me. The other son measured up to me, un-
fortunately, rather than to my expectations of him,
and now he is in a remote corner of the world. A
little more than a year ago, when I had been with
you, for the second time, only a little while, I was
unexpectedly called to the grave of my brother
who had come to a tragic death. I know and you
know that the man who sits in your office tonight
is many times more than a year older than that
same man who talked to you twelve months ago,
for many things are more ageing than the mere
passing of the years.
"I am bowed down by grief and by deprivations
and by my own self-reproaches. Disease and dissi-
pation have left their permanent imprints upon
my structures — material and immaterial. I have
eaten immoderately: I have imbibed alcohol long
and excessively; I have sought surcease in sedative
and hypnotic drugs. At last morphine has em-"
braced me, and I cannot free myself from its ten-
tacles. I doubt not that I have made use of pain,
physical pain, real and imaginary; and mental and
emotional pain, to justify this morbid indulgence.
My sinuses have been infected; some of them have
been operated upon, and they have had much sub-
sequent attention.
"But I know myself well enough to know that
I am not always and, perhaps, not ever, wholly
honest with myself. I know that I am unwilling,
perhaps I am unable, to face the world of reality;
to stand up and be the man I once was. In spite
of the self-depreciation and the self-reproaches that
I bring upon myself by my morbid self-indulgences,
I live more comfortably in that world of unreality
and phantasy, created by the physiological and the
psychological effects of opium, than in that world
of reality made possible only by self-discipline,
self-denial, and rigid self-control. I know that
only to him that hath shall be given. Now I am
giving myself morphine daily no less than five or
six grains, and at night I induce sleep by heavy
phenobarbital medication. I know that this mode
of life cannot continue. I shall be obliged to give
up these indulgences, to face life as it is, or to give
up life itself.
"And before my life reaches its termination I
may become a mental wreck. I am already hallu-
cinated. I hear voices speaking to me almost con-
stantly. Yes, I know what hallucinations are. I
read much. I think even more. I know that those
around me do not hear the voices that I hear. I
know the voices are unreal, but they are terribly
February, 1936
SOUTHERN MEDICINE AND SURGERY
real and vivid to me. But so far the voices have
not begotten delusions. They remain pure hallu-
cinations. I do not believe, except most momen-
tarily, what the voices say. Occasionally I step to
the window to see the man who is talking about
me, but I stop myself, for I know that the experi-
ence is altogether internal. I think I understand
that the voices merely project into the outer world
and into those around me those things that I am
thinking about myself. The voices serve the pur-
pose of making my subjective self objective to my-
self. They reveal my inner self to me, but in
defense of myself I try to attribute the voices to
others. For no one has the inclination nor the
courage, perhaps, to speak even in corrective con-
demnation of himself. I am a professional man,
well educated, and competent in my profession. I
know that I should occupy a pedestal in my com-
munity. Every professional man should live an
ideal life. Every professional man must respect
his own character if he is to expect others to have
respect for him. I have come to feel inferior; to
be without adequate respect for myself. When I
see two or three men talking together it is easy
for me to imagine that they may be talking about
me — and in derogation of me. Eventually, 1
imagine I actually hear them talking about me.
Generally, but not always, they speak in adverse
criticism of me. Sometimes, rarely, to be sure, a
voice speaks a word in approval and in commenda-
tion of me. Perhaps that merely represents the
dialogue that I often have with myself about my-
self. Well, here I am, doctor. Take me, and see
what you and the other doctors and I can do with
and for myself. But I fear there is no balm in
Gilead. I fear that my state is that of despair —
and that word means without hope. I know that
I am running away from life, and that alcohol and
drugs merely serve as avenues of escape for me.
And I know that the denouncing voices represent
such conscience as I still have left and that it is
speaking in reproof of my waywardness in an effort
to save me from myself."
A mere generation or so ago the examination of
the physical body was made mostly by observation
limited to its surface. But that day is gone. Even
so recently as when I was a medical student psych-
iatric investigation reached scarcely beyond a de-
scription of the individual's behavior. The de-
pressed were inert; the excited were overactive.
But we have come to know that the immaterial
domain — the instincts, the emotions, the world of
ideas and of thoughts — is inconceivably larger and
infinitely more complex than the interior of the
physical body; and that the content of this world
of the unconscious may be explored and analyzed
and understood and, if in disorder, may sometimes
be corrected. And we know, too, that out of this
buried world come all hallucinations and delusions.
Every individual represents an energy system. En-
ergy insists upon being liberated. It resents and
resists restraint and incarceration. Toxic sub-
stances, whether they be drugs or disease products,
may liberate repressed emotions and ideas, but they
cannot create them. But within us at all times at
least two antagonistic forces are at work. We are
instinctively inclined to express ourselves freely — •
our feelings, our thoughts, our yearnings, our fears,
our hopes, our hates, and our loves. Such behavior
is nistinctive, natural — in such manner, perhaps,
the lower animals live. But, for many reasons,
chiefly because of the demands of religion and
law and order and respect for public opinion and
devotion to that fabrication we miscall civilization
we cannot live in that simple, natural and whole-
some manner. We dare not allow many of our
impulses to express themselves — we must repress
them — push them clear out of daily consciousness
down into the unconscious and hold them down
there. And that unceasing effort calls for the
constant use of energy. And sometimes we be-
come tired holding things down. This repressive
mechanism we speak of as inhibition. When we
are made perhaps our more complete, natural
selves by a toxic disease, by alcoholic ingestion, by
drug addiction, by an attack of mental sickness,
or by any other factor which releases the hand
from the inhibitory lever, then our real, natural,
repressed selves are liberated. And then our neigh-
bors may talk in whispers about us, because they
have made a discovery that was shocking to them.
And the individual, whether he be sick or well,
insists upon and succeeds ultimately in dsclaring
himself. We are all many-faceted. When in one
state we exhibit one facet; when in another state,
another facet. But the individual is always him-
self, and not another. Perhaps we cannot reveal
ourselves in our entirety until we have been well,
and also unwell — from disease, from drugs, and
from what we may call mental abnormality.
The Role of Psychotherapy in General Medicine
Psychotherapy is the attempt to find the psychic origin
of functional symptoms and either to remove their causes
or enable the patient to overcome or tolerate his symptoms.
This paper is to give scientific facts devoid of humbug
concerning psychotherapy.
In analyzing the histories of psychoneurotic individuals I
have found that the majority have received illogical, un-
necessary examinations and treatments which have fre-
quently further discouraged the patient and increased his
neuroticism. About 20% of my patients have been sub-
jected to needless surgical procedures.
All neuroses are over-reactions in suggestible, sensitive
types; faulty responses to difficulties or problems not met
frankly by the individual. A running away from the hard
84
SOUTHERN MEDICINE AND SURGERY
February, 1936
realities of life produces a neurosis to compensate or pro-
tect the individual.
Psychoneuroses are: 1. Hysterical reactions. 2. Anxiety
states. 3. Neurastiienic reactions. 4. Obsessive compulsive
states.
Anxiety states include the largest number of psychoneu-
rotic patients. Here morbid fear motivates the conduct:
dread produces physical symptoms through the vegetative
nervous system.
Neurasthenic reactions are rare and limited to irritable
exhaustive states with hypotensive phenomena.
The obsessive compulsive states are also rare types; they
fear disease and contamination, are guilt conscious, and set
up defensive symbolic rituals to escape from their un-
conscious conflicts.
Establishment of emotional rapport usually obtained by
the physician's warm personal interest in the patient, is
the first objective. Care in the taking of the history con-
vinces of the physician's thoroughness. Encourage the pa-
tient to talk out everything. After the physical study to
exclude organic disease, the examination consists in getting
a detailed record of the patient's previous life: the study
of his background, of factors leading up to the current con-
flicts.
The constant question in the physician's mind being,
"What is the genesis?", if the problem is psychogenic one
must determine whether simple suggestive therapy, super-
ficial re-educative therapy or detailed psychoanalysis is
indicated.
For the majority of mildly neurotic individuals of average
intelligence, re-educative therapy is the best method. The
goal is to get the patient to stand upon his own judgments,
and is reached through a mutual understanding relation-
ship, sometimes reinforced by persuasion or suggestion.
The next step is desensitization, wherein, by intimate dis-
cussion of the conflict material as elicited, the patient is re-
quired repeatedly to face the situation or to make con-
tinued adjustments until the symptoms in that situation
no longer occur or can be tolerated or ignored. Encourage-
ment, patience with setbacks, and positive reassurances are
essential. Gradually one will be rewarded by a rebirth of
emotional control and a grateful patient.
Suggestive therapeutics must first develop in the patient
the belief that he can get well, since he is cured on the
day he believes himself cured. Stick to scientific sugges-
tive measures. After one is certain of the patient's power
to get well, he should reiterate the positive statement
pointing out all improvements, however slight. Asking the
patient to measure his own improvement is an indirect sug-
gestion. At times patients benefit from reading such books
as "Outwitting Our Nerves," "Re-educating Ourselves," and
certain books on sex. Avoid setting time limits for re-
covery, teach the patient endurance and tolerance — the
doctor practicing the same perseverence and never display-
ing by word or deed any lack of confidence in the patient's
recovery.
Some patients need a temporary change of environment,
hospitalization or even psychiatric treatment if there are
harmful eounter influences from family or friends. Rela-
tives often have to be taught insight into the patient's
neurotic mechanisms. By suggestion the patient is also
taught sensible ideas about digestive functions, constipa-
tion, anorexia, cardiac action, etc. He is taught to ignore
cr overcome many distressing sensations. He must learn
to use whatever normal recreation and social assets he may
have; at times the therapist must supply him with new
ones.
All these measures may or may not be reinforced by
drug therapy. Some patients are helped by sedative drugs,
but these should be dropped gradually and the importance
of self-control and independence should be stressed. With
certain resistant symptoms, hypnotic therapy is valuable in
overcoming insomnia, aphonia, amnesias, impotency, and
vaginismus or in probing for unconscious material in an-
alysis; but it is of temporary value only. The lasting cure
must be a change in the total personality reaction with the
development of a new objective stronger than the old
neurotic desire to yield to inferiorities.
In certain cases where ordinary superficial psychotherapy
fails, psychoanalysis is successful. It is superior to other
psychotherapy in only a very small group of patients.
UROLOGY
For this issue, P. A. Yoder, M.D., Winston-Salem, N. C.
Medical Treatment of Genito-Urinary
Tuberculosis *
Until comparatively recent years a paper on
this subject would have been almost as important as
a drink of water to a drowning man. The little
attention that was directed to the subject was very
aptly designated either palliative or expectant
treatment — palliative in that it was reserved for
use in trying to palliate suffering in the hopeless
case, expectant in that some measures were though!
to be of slight value in preparing the patient for
the expected operation. Today we all agree that
in certain cases medical treatment has an import-
ant place in tuberculosis of the urogenital tract. In
fact, some genito-urinary surgeons, as well as many
internists, have begun to insist on a clinical trial
of general rest and sanatorium care in practically
all of these cases before resorting to surgery.
There is surely no question as to the importance
of genito-urinary tuberculosis itself, as available
statistics show that from 3 to 8 per cent, of all
pulmonary tuberculosis cases have associated uro-
genital lesions, and that 50 to 60 per cent, of all
extra-pulmonary tuberculous lesions are genito-
urinary. It therefore behooves the general prac-
titioner who is treating tuberculous patients, as well
as tuberculosis workers, to be ever on the alert
for indications of these frequent complications. As
is true of uncomplicated pulmonary cases, this
watchfulness is all that is needed for diagnosis;
for with present modern technique of examinations,
and with so many excellently trained and compe-
tent specialists, the suspected case is essentially a
diagnosed case.
It is the duty of the genito-urinary man, also,
to be on the lookout for pulmonary complications
in his cases, since 60 to 70 per cent, of all genito-
urinary tuberculosis is accompanied by pulmonary
tuberculosis. Of course, many of these present
pulmonary involvement of little consequence, many
being a primary focus (or Ghon tubercle) with its
associated regional lymph mode; but many of
'Presented to the North Carolina Urologieal Society,
eeting at Salisbury, October, 1935.
February, 1936
SOUTHERN MEDICINE AND SURGERY
them have a lung involvement of clinical import-
ance requiring careful weighing before surgical
procedures are undertaken. Here, probably, is the
most important place for medical treatment of
these cases. Many lives have been lost that could
have been saved by preliminary efforts directed
toward building up the patient's general condition.
As in tuberculosis of other organs, the most im-
portant single element in medical treatment of
genito-urinary tuberculosis is rest — physical rest
in bed, on an open porch if possible, but in any
event where there is an abundant supply of fresh
air and as much sunlight as it is possible to obtain;
mental rest so far as possible, preferably in a good
sanatorium — with a full diet of simple, easily di-
gested foods of high caloric value; and plenty of
water.
Under such a regimen a certain percentage of
these cases will go on to recovery, as is proved by
calcified areas shown in x-ray films and in speci-
mens removed at operation. A still larger per-
centage will be so generally improved that later
surgery can be performed with a greatly increased
chance of ultimate cure.
In addition to rest and diet, attention must be
directed toward control of symptoms. A majority
of these cases are of kidney involvement, with
secondary cystitis, and in practically all of these
there is dysuria. One teaspoonful every three hours
of a mixture of one part potassium citrate, one
part tincture hyoscyamus, and three parts water,
in a full glass of water, will help to relieve the dis-
comfort and tenesmus nearly always complained of.
In certain cases heliotherapy is of value. Natural
sunlight is best, but artificial light containing the
whole solar spectrum is an acceptable substitute.
Caution must be exercised here, however, as un-
favorable reactions occur. For highly toxic and
febrile patients, with acutely active pulmonary
complications, sun baths are definitely contraindi-
cated.
As in pulmonary tuberculosis, climate and alti-
tude are generally accepted now to have little or
no direct effect on any tuberculous process, but
indirectly, as they affect the patient's comfort and
thereby contribute to relaxation and rest.
While of great value in diagnosis, after years of
thorough trial in various forms of tuberculosis,
tuberculin has been abandoned as a therapeutic
agent, it having failed to show any demonstrable
beneficial results, except, possibly, in some indolent
eye conditions, such as tuberculous keratitis. It
surely has no place in genito-urinary tuberculous
conditions and is mentioned here only to be con-
demned.
An important and often little considered field
for medical treatment, in these cases, is the postop-
erative care of the surgically treated patient. Very
often the final outcome will be found to depend as
much on after-care as on the surgical manipulations.
Several months of postoperative routine sanatorium
treatment is surely little enough to advise for all
patients in this group.
In conclusion let me say a word for teamwork.
The word has been used so frequently by our pro-
fession lately that it is becoming very trite; but I
know of no place where genuine teamwork is more
vitally necessary to efficient medical practice than
in the handling of these cases. The urologist, the
internist, the radiologist and the clinical patholo-
gist must work hand in hand in arriving at a cor-
rect estimate of the situation; in deciding what
procedures to adopt and when to apply each; in
preparing the patient for operation, in giving him
the best chance to get the best results possible from
his surgery, and last, but not least, in correctly
evaluating the results that have been obtained.
Routine Treatment of Gonorrhea in Females
(Bernard Notes, in Amer. Jl. Obs. & Gyn., July, via
International Med. Dig., Nov.)
Positive diagnosis was based on smears with gram-
negative intracellular diplococci having the morphology of
the gonococcus, plus objective clinical signs. While not
taken as diagnostic, e.xtracellular gram-negative diplococci
were considered as suspicious. In order to discharge a
patient as cured, 4 consecutive smears negative for both
intracellular and e.xtracellular gram-negative diplococci ob-
tained at intervals of 2 weeks absence of objective clinical
signs were required. Thus each patient was observed 2
months for recurrences.
The basis of treatment in the beginning was drainage
and antisepsis. Results in 1931: discharged as cured, 1%;
in 1932, 3.4%; in 1933, S.7%. In August, 1933, treatment
on the bases of creation of local reaction and drainage
with the omission of antiseptics was begun as follows;
(a) all crevices with glands functioning were cauterized
one or more times with the electrocautery at intervals
of 2 or more months in order to cause local reaction and
to give better drainage; (b) urethral meatus and cervix
were treated weekly with applicators saturated with 25%
silver nitrate (considered a local irritant in this strength),
in order to cause local reaction and to favor better
drainage; (c) 5% sodium-bicarbonate douches were taken
by the patient at home twice daily, by fountain syringe
until the cervix healed and by pressure syringe (bulb type)
after the cervix healed; (d) nightly instillations of 1 dram
of 1% lactic acid jelly were made by nozzle to the vaginal
vault in order to promote the normal bacterial flora and
to get rid of secondary invaders which cause desquamative
vaginitis. During the first 6 months of this period but 12
patients were discharged; however, improvment and in-
crease in negative smears were marked. Beginning with
February, 1934, sustained results began to be obtained,
and of 677 cases admitted during the followmg 12-month
period, 131 were discharged, 19.3%.
Ages of patients ranged from a few weeks to 60 years,
the average being 19 years. Approximately one-half had
syphilis which was under active treatment. The largest
number of cauterizations upon a single patient was 5, the
smallest 1, the average 2. Some cases which had resisted
treatment by antiseptics for as long as 4 years were cured
S6
SOUTHERN MEDICINE AND SURGERY
February, 1936
within 1 year by creation of local reaction and drainage.
No patient who co-operated failed of cure.
Complications such as pelvic peritonitis and hemorrhage
were at times severe but at no time dangerous, and these
did not develop often. Patients were prepared for these
reactions by a thorough explanation of what was being
done, why, and what was to be expected. Occasional in-
complete stenosis of the cervLx developed as was expected
but no cases of hematometra.
It is concluded that antiseptics should be abandoned in
the treatment of gonorrhea in females.
CARDIOLOGY
For this issue, Samuel F. Ravenel, M.D., Greensboro, N. C,
Rheumatic Fever: Complications
Generalizations. — (1) Chorea, involvement of
the pericardium, myocardium or endocardium,
rheumatic pneumonia, etc., are sometimes spoken
of as complications of rheumatism. As a matter
of fact they are part and parcel of that disease just
as chancre, gumma, aortitis, paresis all are syph-
ilis, the specific infectious agent remaining con-
stantly present within the body, its attack upon
various organs being conditioned by such factors
as time, functional strain, intercurrent infection.
(2) There is a unanimity of authoritative opin-
ion in regard to rheumatism in a few respects only,
such as (a) involvement of all the body tissues,
(b) duration of infection, (c) predilection for
youth, cold damp climates and the mitral valve,
(d) specific nature of the pathologic lesion, (e)
the necessity for prolonged rest in its treatment.
Almost all else is controversial.
(3) It is necessary constantly to remember with
reference to involvement of the heart that the en-
tire organ is affected in rheumatic carditis; that
no matter whether pericardial effusion, myocardial
failure or valvulitis give rise to the principal
symptoms, all three structures invariably are in-
vaded.
Chorea is regarded by many as a rheumatic en-
cephalitis, the immediate precipitating factors be-
ing upper respiratory infection, emotional and
physical strain. The diagnosis ordinarily is so
obvious are not to be missed. It is necessary,
however to recall that one may encounter forms
so mild they may be confused with tics or "nerv-
ousness," so severe as to simulate grave disease of
the central nervous system or so limited as to
effect only half the body (hemichorea). Import-
ant features in treatment are mental and physical
lest until the mind and body are normal, as evi-
denced by (a) loss of nervousness, (b) cessation
cf abnormal muscular movements, (c) return of
pulse, temperature and leucocyte count to their
customary levels. Isolation, bed rest, bromides
and phenobarbital usually suffice. Recent studies
suggest that intravenous tj-phoid vaccine fever ther-
apy shortens the course of the disease dramatically
and safely.
Pericarditis and pericardial effusion are often
missed or confused with other diseases — the former
with appendicitis or pleurisy, the latter with car-
diac dilatation or left-sided pneumonia. These
mistakes may be obviated by thinking of it in
any unexplained acute fever (pericarditis is rare
but probably not more so than typhoid in most
cities) and by loking for it in children who pre-
sent a history or any manifestation of rheumatism.
It may be helpful to remember that: (1) the fric-
tion rub may be audible only over the sternum,
(2) the pulse usually is very rapid, (3) in the
case of large effusions orthopnea is often present,
the neck veins are engorged, the apex impulse is
diffuse, signs of solidification of the lung may ap-
pear in the left interscapular space, the respirations
are rapid but not sharply limited on one side as
in the case of pneumonia. .Accepted therapeutic
measures are bed, back rest, ice bag or dry heat and
opiates for pain, sedatives. In case severe dyspnea,
cyanosis, falling systolic pressure herald fatal tam-
ponade of the heart, decompression by aspiration
of the effusion may be life saving. After care in-
cludes bed rest until all signs of rheumatic activity
have disappeared — whether that requires weeks,
months or years.
The classical signs of rheumatic heart disease
are those referable to the mitral valve. It is nec-
essary to recall that weeks or months may elapse
after the initial febrile attack before signs of mitral
disease are manifest. Prior to that tachycardia
may be the only suggestion that the heart is in-
volved. An accelerated pulse following acute up-
per respiratory infections should act as a fire alarm
to the physician. If practitioners insisted upon
bed rest for all children suft'ering acute infections
until pulse and rectal temperature returned to nor-
mal and then examined these patients carefully in
the office 2 weeks later, an incalculable amount of
cardiac damage would be prevented. JNIitral sten-
osis is inherently a lesion implying chronicity — it
requires j'ears to develop. One may hear a mitral
diastolic murmur early in the course of rheumatic
fever but this is due to mitral "roughening." Le-
sions of the aortic valves are usually found in severe
cases only: almost always mitral disease is also
present: very rarely a pure rheumatic aortic valv-
ulitis may be encountered. In rheumatic heart dis-
ease the activity of infection and the efficiency of
the muscle are vastly more important than the
character and location of the murmurs. Digitalis
is of value only in children with congestive failure
and then must be prescribed in adequate dosage.
One practical method of administration in such
cases is to give 3 grains of the powdered leaf by
February, 1936
SOUTHERN MEDICINE AND SURGERY
87
mouth each 6 hours until nausea or marked slowing
of the pulse supervenes, and thereafter V/, grains
twice daily as a maintenance dose. The subjects
of rheumatic valvular disease obviously must be
kept in bed until rectal temperature, pulse rate,
leucocyte count, heart size are restored to normal
levels.
Finally it is necessary to realize that every tissue
in the body may be invaded by the virus (?) of
this disease to such an extent that clinical symp-
toms may be produced. .Accordingly we may en-
counter in its course pleurisy, pneumonia, periton-
itis, erythema nodosum, subcutaneous nodules, etc.
— all due to rheumatic fever.
—371 N. Elm Street.
Editor's Note: This is the 3rd in a series of articles on
Rheumatic Fever. The Early Diagnosis and Early Treat-
ment have been discussed in previous articles. Next month
Late Sequelae will be discussed by Dr. Elias Faison, of
Charlotte.
Poisonous ANiMAts and Their Poisons, With Speclax
Reference to Snakes, Spiders and Insects
(H. E. Essex, Rochester, Minn., in Jl. -Lancet, Xng- 1st)
In spite of the fact that investigators have repeatedly re-
ported the finding that potassium permanganate is of less
value than no treatment at all in cases of snake bite, text-
books still recommend it.
The best method of treating a person who has been bit-
ten by a rattlesnake or moccasin: If of one of the ex-
tremities, a tourniquet should be tied between the wound
and the body, this released 1 min. in every 10. If antivenin
can be obtained, the contents of 1 ampule, 10 c.c, every
1 or 2 hrs. until symptoms are relieved. In severe cases
intramuscularly or intravenously. If antivenin is not avail-
able, only one method of treatment has been found of
value: an incision J-2 in. long, J4 in- deep over each fang
mark, and another cut should be made at right angles
to the first. Suction should be applied either by mouth
or by mechanical means for 20 min. out of each hr., for
15 hrs. The victim should not consume alcoholic bever-
ages or apply kerosene, gunpowder, bile, or potassium
permanganate.
Centipedes are commonly held in much dread. The
venom of these animals has not been found to be danger-
ous to man. The appUcation of antiseptics should follow
the bite.
The scorpions are close relatives of the spiders. The
sting of the larger species is capable of causing severe
symptoms even in an adult; in a child alarming symptoms
have been known to follow the sting of even the smaller
species. Treatment is principally symptomatic. According
to some relief has followed spinal puncture. Antiseptics
aid in the prevention of local infection. As a rule the
sting of a scorpion causes only a temporary inconvenience.
The bite of the tarantula has been found to be incapable
of causing serious danger to human hfe. I injected intra-
venously into a small dog all the venom obtained from
both poison glands of one tarantula. A very slight de-
pression in blood pressure resulted.
The female honeybee, bumblebee, wasp and hornest pos-
sess a sting which is in reality a slightly modified ovipositor,
consists of a sheath that encloses a pair of barbed stylets,
which move backward and forward, penetrate the skin,
and the venom is so carried into the puncture. It is not
generally known that the action of the venom of the
honeybee resembles ver\- closely that of the rattlesnake.
The venom from 6 bees when given intravenously to a
dog weighing 4.5 Kg. was sufficient to cause the death of
the animal. The best method of treatment is cold appli-
cations. Should alarming symptoms result, they should
be treated symptomatically. Epinephrine has been shown
to be of benefit in restoring the blood pressure.
GENERAL PRACTICE
WiNCATE M. Johnson, M.D., Editor, Winston-Salem, N.C.
An Open Letter to the American Foundation
Doubtless many readers of this Journal re-
ceived letters from Miss Esther Lape, member in
charge of The American Foundation Studies in
Government. Apparently this letter was sent to
private practitioners of medicine, with the object
of finding the prevailing sentiment of these men as
to the future of medicine. For the benefit of
readers of this department, I am publishing my
own reply for what it is worth.
Dear Miss Lape:
Your letter of December sixth impresses me most
favorably, for a number of reasons. It is pleasing
to know that The American Foundation has noth-
ing to advocate, that it has no preconceived ob-
jective, and is not yet convinced that any essential
change in the present system is indicated. So far
as I know — and I have done my best to keep in-
formed on all matters concerning the medical pro-
fession — it is the first "foundation" that has done
the private practitioner of medicine the courtesy
of asking his opinion about the future of his own
profession. Perhaps we private practitioners de-
serve to be thus snubbed, since, as H. L. Mecken
has said, "The men of no other profession are so
facilely operated on by specialists in other peoples'
duties." It is true that the traditions of our profes-
sion have made us ready to give our services too
freely, perhaps, for our own good. Certainly our
idealistic tendencies have caused the social service
workers and professional propagandists who favor
socialized medicine to discount our ability to man-
age our own affairs.
In 1883 W. G, Sumner wrote: "The type and
formula of most schemes of philanthropy of hu-
manitarianism is this: .\ and B put their heads
together to decide what C shall be made to do for
D. The radical vice of all these schemes is that
C is not allowed a voice in the matter. ... I call
C the forgotten man." In all the schemes yet ad-
vanced for revolutionizing medical practice, the
most important factor — the doctor himself — is cer-
tainly playing the role of C. .As one of that group,
I thank you for at least remembering our existence.
With this rather lengthy preface, I will try to
answer your questions, as far as possible, in order.
SOUTHERN MEDICINE AND SURGERY
Februar>-, 1936
At the risk of deserving my friend T. Swann
Harding's characterization of me as "an outspoken
reactionary," I feel that we do not need any
essential change in the present organization of med-
ical service, except the apparently backward step
of restoring the family doctor to the central place
in medicine; of debunking much of the current
literature dealing with the exhaustive medical re-
search needed to diagnose a case of measles or of
the itch; and of discouraging the hospitalization of
the simplest maladies. These views I set forth at
some length in an article published in the Atlantic
Monthly in 1931, a copy of which I am enclosing.
As to voluntary health insurance I can not see
any reasonable objection, provided there is no re-
striction in the choice of doctor. Insurance com-
panies have been selling such insurance for years,
but my observation is that in too many instances it
is a question of whether the company or the patient
profiteers the most. The best insurance against
sickness I know of is a savings account, and if the
average citizen would put into the bank the sums
he pays for health insurance, and use it only for
sickness, he would be far better off at the end of
ten years — if the bank did not fail.
Hospital care can be provided for in many states
by comparatively small insurance payments. If
this be kept strictly separate from the medical bill,
and not allowed to be the entering wedge for social-
izing medical service, it may prove a good thing.
It should help to make the emergency operation
or serious illness less terrifying to the family wage
earner.
I certainly do not think either the public or the
medical profession would be benefitted by any form
of socialized medicine, call it what you will — state
medicine, compulsory health insurance, or a com-
munity health center. On the other hand, both
the public and the profession would have much
to lose; the profession, in losing the incentive of
competition and in the deadening effect of bureau-
cratic control; the public, in giving up the time-
honored sacred relationship between patient and
doctor, in exchange for the indifferent attitude of
a public employee. I am well aware that some
lay advocates of socialized medicine claim that this
relationship between patient and doctor would be
preserved; but doctors know better. In the
American Mercury for September, 1934, "an emi-
nent New York physician," under the pen name
of George W. Aspinwall, offers "A Plea for Social-
ized Medicine." Although strongly in its favor,
he admits that "Except for those desirous of pay-
ing the doctor directly, free choice of doctor will
be lost. . . . Calls for attendants upon the sick at
home are to be received at these centers, such calls
to be assigned to physicians assigned to cover spe-
cific local territories."
I can not refrain from another direct quotation
from Dr. Aspinwall's article: "Politics will no
doubt play a considerable role in the organization
of state medicine. ... It is common knowledge that
our law-makers will not encourage the enactment of
a project for which large sums of money will be ex-
pended unless they can control the disbursements."
Comment is unnecessary.
I hope you will not think me immodest if I re-
fer you to "The Case Against State Medicine" in
the Forum for November, 1933, for my further
views on this subject. In addition I would like to
call your attention to a few other facts. First, that
it would cost from two to three billions a year to
insure the workers of the United States, and to in-
clude the unemployed would increase the cost to
four billions. Second, that in Germany there are
2,000 more lay workers than there are physicians
in the Krankenkassen. Third, that in Great Bri-
tain the time lost on account of sickness (real or
alleged) has doubled in twenty years of compulsory
insurance; in Germany it has increased threefold"
in fifty years. And, finally, that the latest avail-
able statistics of the League of Nations (for 1933)
show that the United States has a lower general
death rate, a lower infant mortality, and a lower
mortality and morbidity from diphtheria and tuber-
culosis than has any other first-class power for
which data are available.
In view of these facts, Miss Lape, I can not see
where we have anything to gain by any experiment
in socialized medicine. Your final question, "If
you consider it desirable or imperative that the
medical profession through the medical societies
should control standards, public health appoint-
ments, etc., how do you think that this end could be
best achieved?", is not a hard one. Let local ap-
pointments and problems that concern the local
profession be referred to the local society or ap-
propriate committee, such as the executive or pub-
lic relations committee. Let state appointments and
problems be referred to the state societies and na-
tional ones to the American Medical .^Association.
Certainly the members of these respective medical
organizations are at least as intellectual, as public
spirited, and as capable of dealing with medical
problems, as are our aldermen, our legislators, and
our representatives in Congress.
I appreciate your assurance that my views will
he kept in confidence, but this letter expresses my
sincere convictions, and you are at liberty to make
any use of it you see fit. I shall await with in-
terest the result of your investigation.
Sincerely,
—WING ATE JOHNSON.
February, 1936
SOUTHERN MEDICINE AND SURGERY
89
The Doctor May Do Much For Man's Happiness
{G. C. Robinson, Peiping, in Chinese Med. Jl., Sept.)
Many people who have no disease are yet far from well.
Here lie the problems of the future. An improvement
in human happiness should be the next great objective to
which the best minds of medicine may be applied. The
human mind must be better understood, and must be the
subject of more serious study and research from the medi-
cal view point. It is known vaguely how largely the
mental state may be responsible not only for generat-
ing discomfort and suffering, but also for the actual pro-
duction of organic disease. The time has come to convert
these beliefs or surmises into scientific facts. Some progress
has already been made in America and elsewhere.
Such problems as the relation of population to the
number of people a district or province can adequately
support is a field of co-operation for doctor and sociolo-
gist. Birth control must come to be recognized as a
scientific approach to human happiness, and it must be
recognized that over-population leads to want and disease,
to social unrest and to war.
The doctor may do much to improve the happiness of
man not only by taking part in carrying out broad projects
of social adjustment but also by developing a deeper know-
ledge and understanding of the human emotions, mental
problems and social difficulties of each individual to whom
he renders service. Let the medicine of the future carry
along all that is essential and valuable that has been
learned by those who have lived in past generations, let
medicine do all it can to prevent disease and improve the
state of hygiene, but let it not stop here. The doctors of
the future should have at their disposal more knowledge
for the increase of human happiness, and may the gen-
eration now coming on and those to follow give to this
problem their best minds in the same spirit of unselfish
toil that distinguishes the leaders of medical progress in
the past.
The Treattmcent of Tuberctjeosis in the Home
(R. B. Homan, El Pasu, in Texas State Jl. of Med., Oct.)
The vast majority of these cases must be treated in the
home. At the beginning of the treatment, even in the
incipient case, bed rest with bathroom privileges only
should be instituted ; this may necessarily be prolonged
over a period of months. As the symptoms and physical
signs improve concessions are made slowly. The patient is
allowed to sit up in a comfortable chair for IS minutes
once or twice daily, the time to be gradually increased to 1
hour before the patient is allowed to walk about the house
or venture off the porch.
Walking is the most strenuous e.xercise allowed for many
months, and it must be very gradually increased, the pa-
tient being very careful not to tire himself at any time.
The p., t. and general reactions must be closely watched
during these periods of graduated exercise, and any un-
toward symptom should be the signal to go backward
rather than forward.
The Major Lmforta.nxe of Minor Infections
(P. A. Caulfield, Washington, in Med. Annals D. C, Oct.)
Every accidental wound should be considered as a po-
tential reservoir of infection. The greatest danger of in-
fection in wounds is from the hands and instruments of
the doctor treating them, since these are more likely to
be contaminated with virulent organisms. The mechanical
force producing the wound enters it but once, whereas
the hands and instruments enter it many times. This
entrance usually takes place after the f\ow of blood has
stopped, and infection is harbored better in clotted, than
in freely flowing, blood. Before an attempt is made to
repair any wound, all instruments to be used should be
carefully sterilized and the hands carefully washed, the
same as in any major surgical procedure. All bleeding
should be stopped, the wound flushed with soapy water
and its edges washed and shaved, all loose and devitalized
tissue and foreign bodies removed, all cavities and recesses
opened and obliterated and the wound flushed with 95%
alcohol; and if badly contaminated, it should be first
cauterized with pure phenol. AW accidental wounds should
be drained, the drain to remain in place no longer than
is necessary to remove serum or liquefied fat. If infection
occurs drain until all pus has been removed.
All sutures should be interrupted. It is best to let the
wound remain open without a dressing unless such a pro-
cedure is impractical. Dressings do not prevent infection.
.\ wound uncovered can be washed and bathed with soap
and water, and the possibility of infection being rubbed
into the wound by a contaminated dressing is removed.
GYNECOLOGY
For this issue, William Francis Martin, M.D.
Charlotte, N. C.
The Charlotte Tumor Clinic
A Summary of the Diagnosis and Treatment
OF Cancer of the Cervix
Twenty-five years ago when pelvic examina-
tions were less common than they are today the
diagnosis of cancer of the cervix was usually made
at a very late stage in the disease. Even in many
new textbooks the most frequent symptoms given
are cachexia and loss of weight. These, of course,
are terminal symptoms of cancer and when a pa-
tient has reached this stage little is to be offered.
In late years, however, pelvic examination is a
routine procedure with most doctors in doing a
physical examination; and, so many cancers are
being discovered in their incipiency, when the
prospect of cure by proper measures is good.
The signs of cancer of the cervix should be
more emphasized, as any symptom the patient is
capable of discovering usually occurs late in the
disease. In the probable sequence of development,
they are: (1) slight odorless leucorrhea, (2) an
odoriferous purulent discharge with hemorrhagic
spotting, (3) bleeding. Usually the first bleeding
that is noted is a slight spotting after intercourse.
Frequently there is a prolongation of the menses;
this may go unnoticed and attention first be at-
tracted by bleeding between the periods, which
may be an acute hemorrhage or a slow bleeding
over a period of days. This is nearly always due
to rupture of a blood vessel in the ulcerating le-
sions.
Early in its course, carcinoma of the cervix is
usually symptomless. There may or may not be
pain during intercourse, or pains in the back and
resultant weakness. Late symptoms are a foul
serosanguinous discharge, loss of weight, cachexia
and edema of the vulva: a palpable mass is nearly
SOUTHERN MEDICINE AND SURGERY
February, 1936
always diagnostic of a so-called frozen pelvis, in
which case the tumor has invaded the parametria
and become iixed to the pelvic walls.
Although a number of tests have been designed
to facilitate the making of a diagnosis of carci-
noma of the cervix by the general practitioner,
the most valuable point in all of these tests is the
fact that before the test is made the examiner
must look at the cervix.
It is our opinion that the trained observer can
discover a malignant lesion more accurately by
vision than by any chemical test. It is also our
opinion that any erosion or ulceration of the cervix
demands a biopsy and histological examination by
a trained pathologist. There are, however, cases
of cancer which originate in the cervical mucosa
and extend upward or downward and spread under
the mucosa lining the portio vaginalis and hence
produce no ulceration.
Many of these lesions are pedunculated cauli-
flower-like growths and then, to obtain a biopsy, it
is only necessary to snip off a piece of the tissue
with scissors or biopsy forceps. While in the re-
gressive type of lesions an ample F-shaped section
the entire thickness of the wall should be removed
from the cervix. In some cases it may be neces-
sary to dilate the cervix and obtain currettings
from the cervical canal. The specimen should be
preserved in a 5-per cent, formalin solution — not
in alcohol which cooks the tissue, nor in water
which causes it to become edematous. This pro-
cedure can be performed easily in any well equip-
ped office.
The degree of advancement of any cancer of the
cervix may for the sake of easy classification be
divided into three grades. In grade I the cancer
is limited to the portio vaginalis of the cervix. In
grade II one or both parametria are involved. In
grade III the cancer has invaded the pelvic wall
with or without distant metastasis. This grading
is less complicated than that which was promul-
gated by the International Cancer Congress.
In view of the excellent results obtained by
competent x-ray and radium therapists it takes a
brave surgeon indeed to institute any radical sur-
gical procedure. Certainly, in even the earliest
cases in which any hope for a cure can be offered,
the radical abdominal operation of Wertheim, or
the radical vaginal Schauta operation — each, in
the hands of the best surgeons, has a primary
operative mortality of 20 per cent. This, it seems,
would argue for placing cancer of the cervix in
the hands of the radiologist.
The treatment pursued in this clinic may be di-
vided into three periods. First is the period of
deep x-ray therapy, adminstered through six ports
over a period of three weeks for a total of 8,000
to 10,000 roentgens, using a 200-KV machine.
After a two-weeks rest period the patient is either
clinically free of disease or the tumor has regressed
to that size which will give free access to the va-
ginal vault and the external os so that radium may
easily be applied. The second period is that of
the application of radium. A modification of the
Regaud technique is used, the length of applica-
tion being over a period of six days with a dose of
approximately 60 millicuries destroyed. The filtra-
tion used is 2 mm. of brass. The third period is
the remainder of the patient's life, throughout which
she could be closely followed. An examination
should be made every two months in the first
year, and at least every six months for the first five
years.
Summary. — Investigate all vaginal discharge and
bleeding. Take specimens for biopsy from all ul-
cerations of the cervix and if positive for cancer
have it treated by a competent radiologist. Ob-
serve the patient frequently for carcinoma recur-
rence for at least five years.
Claude Tardi, Early Advocate of Direct Transfusion
OF Human Blood
This kind of transfusion should be done promptly and
by two able surgeons in this manner:
Cut lengthwise on the same side, right or left, the skin
of the arm of the two people on whom you are going
to operate; cut it over the vena basilica or median with-
out wounding it. Expose and tie with a noose each of
the veins in two places, separate the nooses one from the
other a good inch. Open the veins between the ligatures,
then introduce a bend-pipe in the end of the vein nearer
the heart, which is to receive the blood, and tie it with a
noose. The other end of this same vein ought to remain
tied as before, if bleeding is not expedient. If bleeding is
necessary one can unty it, in due time and place, and
draw the patient's blood, as much as he has received,
more or less. Let the blood flow over the arm, without
making him undergo the pain of a new ligature or of a
pipe.
The cut end of the vein of the healthy man which is
nearer the heart does not need so tight a ligature, as it
happens always to exhaust itself by its own attraction;
but it is very necessary on the cut end of the vein nearer
the hand. One ought to introduce there a bend-pipe simi-
lar to that used on the patient and tie it strongly above,
for it is through the other end of it that all the blood
passes. One ought also to tie the arm above the elbow,
as one does in bleeding. There are then only two liga-
tures and two pipes which are absolutely necessary; one
of the pipes fits into the hollow of the vein which is
nearer the hand of the healthy man; the other fits into
that which is nearer the heart of the patient.
Make both men sit down opposite each other, so that
their left legs touch. Lift their hands and apply them
reciprocally on their shoulders. Introduce then the pipe
of the healthy man into that of the sick, without pulling
it, because the vein shrinks and is weakened by lengthening
it. Join exactly the two pipes, as well as you can; warm
them, and put over them a small cloth, dampened with
warm mucilage or dipped m spirits of wine.
Februan', 1936
SOUTHERN MEDICINE AND SURGERY
Tie gently the two arms of the two men together, in
two places, four fingers above and four fingers below the
openings. Loosen then the ligature of the end of the vein
which is nearer the hand of the healthy man; apply the
cloth without ceasing, as much on the outside as on the
inside up to the pipes.
Bathe also the arm of the patient, up to the arm-pit
and the shoulder . . , continually with aponges and with
clothes dampened and moistened with hot water, or with
an emollient decoction; and .... the blood will flow
from one to the other in abundance. Make the blood of
the healthy man flow as much as the force will permit:
let him eat and rest, he will be able to furnish blood a
second time on the same day, by the same opening, tying
and loosening the ligature of the vein. If the superfluous
blood of one man does not suffice, one can receive that
of two, of three and even of more, choosing always the
most suitable.
Lacking a capable [assisting] surgeon, I can myself per-
form the transfusion alone, having practiced all my life,
not only at operations on the dead, but also on living
bodies.
SURGERY
Geo. H. Bunch, M.D., Editor, Columbia, S. C.
The Care of the Surgeon's Hands
No apology need be made for an editorial on
this commonplace subject. Although the head and
the heart should at all times control the surgeon's
work the work itself must be done by the hand.
The skilled hand is more important than any elab-
orate armamentarium. Without it, expensive in-
struments are useless. By palpation, by the sense
of feel, by the educated finger the surgeon often
gets information that he can get in no other way.
It is an inspiration to watch a skilled surgeon
explore the abdomen with the gloved hand for an
obscure lesion. Each organ has a normal size and
a normal resistance with which he is familiar. Any
abncrmality in size, contour or consistency is de-
tected. In an orderly way he explores the unseen
viscera with an accuracy of finding that is some-
times uncanny. When a tumor is found he learns
its location, its size and extent, its consistency, its
fixation, its operability. He examines for seconda-
ries — for metastases in the liver, and for involve-
ment of the lymph glands. From this information
the surgical procedure best suited for the patient
is determined. Whether this be simple closure for
inoperable cancer or extensive resection, the tissues
in trained hands are handled gently with mini-
mum trauma which reduces postoperative reaction
to the minimum.
Modern surgery is based upon aseptic technique.
Neither diagnostic ability nor operative dexterity
avails if infection follows an operation and the pa-
tient dies of peritonitis. An absolute essential in
insuring aseptic technique is the cleanliness of the
surgeon's hands. We are indebted to Halstead
for the introduction of rubber gloves that may be
sterilized by boiling before being worn by the
surgeon at operation. Although the surgeon is
often called upon to operate upon infected cases,
by the use of gloves he should keep his hands un-
contaminated.
-Although it is impossible to sterilize the deeper
layers of the human skin, if the skin is healthy
and smooth most organisms may be removed from
it mechanically by scrubbing with soap and run-
ning water. If the hands are smooth, scrubbing
with soap and water followed by rinsing in a mild
non-irritating antiseptic solution, preferably 70 per
cent, alcohol, is ideal preparation before operation.
The inability to mechanically cleanse rough fissured
hands, to make them aseptic, by any method, is
known to every one.
The surgeon's hands have to be scrubbed many
times a day. Any method of preparation which
irritates will in time destroy the smooth texture of
the skin and make the hands unsafe for operative
work. There is no place for strong antiseptics in
the preparation of the hands. No antiseptic can
do more than cleanse the skin surface. Organisms
in the hair follicles and sweat glands are not reach-
ed by any antiseptic. In preparing the hands for
surgical or obstetrical work more stress should be
put on thorough mechanical cleansing, scrubbing
with soap and water, and less on antiseptics. This
fundamental fact is recognized by most of the
younger men of the profession. The writer has
seen one of the most noted surgeons in America
immerse his hands for five minutes day after day,
operation after operation in one to one thousand
bichloride of mercury solution. As a result they
were fissured almost to the quick. They were
unclean and uncleanable, an unsightly menace to
his patients that showed their illustrious owner to
be ignorant of a fundamental principle of asepsis.
Now that winter is here, when every skin tends
to chap if exposed to the weather, it behooves the
surgeon to take good care of his hands, to keep
them out of irritating solutions, to grease them at
night before retiring, to cherish and to keep them
for the wonderful asset they really are to him.
BorLs AND Carbxincxes
(J. R. Chappeir, Orlando, in Jl. Fla. Med. Assn., Dec.)
The carbuncle occurs where the skin is closely attached
to the fascia, particularly on the back of the neck; thus
infection, instead of producing the conical swelling cus-
tomary in boils, makes the connective tisiiue taut, and
forces the infection laterally, producing widespread necrosis
under a plateau-like elevation.
The chief danger oj jur uncles of the upper face is cav-
ernous sinus thrombosis, an infection by way of the facial
vein. Trying to open and squeezing the infection should
be warned against, and a plan of treatment outlined which
places the part as nearly as possible at physiologic rest, by
prohibiting speaking and mastication of solid foods. ' In
cases in which the infection travels through the
SOUTHERN MEDICINE AND SURGERY
February, 1936
ophthalmic vein which can be recognized by a red round
swelling up to the grooves of the nose, ligation of the vein
just below the inner canthus should be done. Should the
infection follow the anterior facial vein on its way to the
internal jugular, which may also be recognized, then this
vein should be ligated at the angle of the jaw.
DeKeyser recommends the oxygen treatment for boils
and carbuncles. He introduces a needle into the opening
of a furuncle. When the opening is delayed, he hastens
it by hot compresses which have been wrung out in oxy-
genated water or solution of hydrogen peroxide. He
states that the furuncle is cured in from 3 to 4 days; that
a carbuncle is slower to cure, but easily in about IS days.
Many approve vaccine therapy; others foreign-protein
therapy. Many recommend x-ray.
Pfahler found that his series of boils usually followed
a heavy carbohydrate meal, and he reduces carbohydrate
food to a minimum, as long as there is any tendency to
boils; removing all source of focal infection; local appli-
cations of tincture of iodine to the initial lesion, allowing
iodine to dry between applications, and massaging the
area around the lesion thoroughly from 5 to 10 minutes,
3 to 4 times a day. He does not recommend incision.
Bieber states that 2 units of insulin, daily, for 2 days
will cause the furuncle to disappear.
Winckler advocates the use of a Paquelin cautery, the
pcH!*b-bT«3fb4Tto.a..wi«te- beat, introduced easily and rap-
idly, perpendicularly exactly in the center, in order to de-
stroy the necrotic core. To do this, he recommends using
a metal disk, perforated in the center by a small hole,
placed on the furuncle with slight pressure so that the apex
bulges into the opening.
Bruce withdraws 5 c.c. blood from the median basilic
vein, and immediately injects it into the gluteal muscles.
He states that this causes boils to dry up within 24 hours
and prevents further formation of boils. In only one case
was a second inoculation found necessary.
prophylaxis: Shaving w-ith a dull razor should be
avoided. In diabetics, careful dietary precautions. Strict
body cleanliness aids in the prevention of boils, particu-
larly, in. those., people, who perform manual labor. Athletes
are peculiarly susceptible to boils and carbuncles which,
I think, is due largely to body massage before taking a
shower. A good sun tan aids in the prevention of skin
infection.
.fiDIATRICS
G. W. KuTSCHER, M.D., F.A.A.P., Editor, .\sheville, N. C.
I Believe
Tomorrow may be another day. but today, /
believe that, —
Codliver oil is not needed by the average child
after the third birthday.
The common cold is not prevented by the ad-
ministration of vitamins. The best treatment for
a head cold is absolute bed rest. It shortens the
duration and tends to reduce complications. When
mothers agree with you on this point, you have
received your reward for patient and persistent
inculcation of sense.
Nose drops never cured a cold I They open the
nasal airways, tend to protect the ears and give the
mother something to do. I prefer aqueous to oily
preparations. Too long continued, the nose drops
themselves create a discharge. We must not forget
that argyria results from persistent use of the silver
salts in nasal instillations.
I had heard of it, but now I have seen it — acute
suppurative otitis media without pain at any time.
This is a fairly common experience in practice on
babies, but uncommon in 7-year-old children.
October, January and February are the peak
months for respiratory infections.
Constipation developing during the first six
months of life is usually man-made. If mothers
and doctors would leave the baby to its own de-
vices, constipation would correct itself. Instead
we meddle and the result is bigger and better con-
stipation.
A slight nasal discharge in young babies is not
necessarily a head cold or snuffles. It is best treat-
ed by watchful neglect.
The obstetrician who advised the young primi-
para not to buy a clinical thermometer as part of
the nursery equipment deserves a big hurrah. In
many instances baby scales are about as bad.
If cold hands and feet caused the colic, there
wouldn't be enough paregoric available to keep ba'-
bies quiet.
There ought to be a law against a doctor giving
advice for a baby over the telephone. My most re-
cent dereliction was treating the baby for indiges-
tion that turned out to be earache when I saw it
the next day. If mother can diagnose so well why
does she request us to treat? To her, diagnosis
carries no responsibility, but treatment is all im-
portant. The physician says, Any fool can look
up the treatment, but it requires a wise man to
make the diagnosis.
In most instances, making a charge for swabbing
tonsils is receiving money under false pretenses.
Even if it did some good the fear element that
enters the pictures far outweighs any possible bene-
fit. Gargling probably is about as useless. Yet
both supply the patient, the mother or the doctor
with something to do while the patient recovers.
Irrigations of the throat are beneficial but must be
done by someone who has been trained to adminis-
ter them.
Smallpox, whooping cough, typhoid fever and
diphtheria are diseases we should never see. They
can all be prevented. We can convey this idea to
every parent (with rare exceptions), but we must
let them know the facts. If we don't protect
against these diseases someone else will.
What do you believe?
H.A.BiTr.Ai CoxSTrp.^TioN As a Sign of Infaktiie
Pre-beriberi
(Soji Takai. Tohoku, Japan, in Tohoku Jl. of Exp. Med..
Dec.)
The pharmacological action of orypan (extract of rice
polishings) upon intestinal movements is similar to that
Februan', 1936
SOUTHERN MEDICINE AND SURGERY
of pilocarpine. Various vitamin-B preparations adminis-
tered in small amounts cause moderate peristalsis of the
intestines; large amounts, after a momentarj- stoppage,
cause a very marked peristalsis, and still larger amounts
cause a complete stoppage of the peristalsis, though this
effect is still observed after the destruction of the vitamin
(Bj and Bo) in the preparations by exposure to a high
temperature (1/5° C.) under a high pressure (100 lbs.) for
4 hours. In consideration of these views and our cases,
we can with good reason conclude that in the case of
infantile pre-beriberi, which is an early state of infantile
B-avitaminosis, constipation is a natural symptom which
may occur frequently. This should prompt us to think of
infantile pre-beriberi in the case of an apparently healthy
infant who complains of constipation.
HOSPITALS
R. B. Davis, M.D., M.S., F.A.C.S., fdf/or, Greensboro,N. C.
Hospital Waste
XoT infrequently hospital owners and operators
seek advice from many sources on how to prevent
waste. If the author had only one word to use in
ansv.'er to an inquiry concerning this matter it
would be, Watch.
It seems almost as natural for some people to
v.'sate as it is for them to breathe. It is not always
true that this type of person is an unprofitable em-
ploye in general. This type of individual may be
found in any position from cook to chief-of-staff.
This being true there must be economical supervis-
ion directly over every department.
If one tries to analyze as to wastefulness, he will
usually find that the surgical department is the
chief offender. This accusation will be resented by
a good many surgeons, but I dare say those who
have actually operated hospitals will agree readily
with the writer.
Let us take for instance the matter of linen used
in a simple appendectomy. The surgeon and his
assistant put on clean, two-piece suits, caps and
masks — eight pieces of clean, fresh linen — and pro-
ceed to scrub up. Many surgeons require in every
major operation two sterile nurses. In the case of
a clean appendectomy where the surgeon has an as-
sistant only one is necessary. The four pieces of
linen necessary to properly prepare one for her duty
at the operating table can be saved, also her time.
In draping a patient almost every surgeon is waste-
ful. Four towels and a regular operating cover
sheet should be enough for any simple appendec-
tomy. Instead most surgeons use six or eight
towels.
When a surgeon scrubs up he usually wastes as
much tincture of green soap as he uses by dipping
the brush down in the green soap dish and imme-
diately taking it out, allowing much soap to run
off in the basin before the brush gets to his hand.
A pause of one or two seconds and a slight shake
of the brush over the dish will save enormouslv
in the soap bill. With gauze the average assistant
is very free and after mopping a few drops of blood
he discards the sponge. Six small sponges should
be ample for this type of operation. No large tapes
are needed.
The antiseptic material used to paint the field
of operation is usually more than is necessary be-
cause the sponges are nearly always too large and
soak up twice as much solution as is needed.
Sutures are perhaps at the top of the list for
waste. Many clever surgeons are as clumsy in ty-
ing sutures as a farm laborer would be in tying up
a sack of feed. The length of the average, com-
plete suture is seldom more than three-fourths of
an inch. Many surgeons cut and throw away off
the ends from two to four inches. If a hemostat
were used to tie these sutures the waste would be
cut at least two-thirds.
The dressing applied to the wound is invariably
more than is needed, and usually subsequent dress-
ings are equally as wasteful. Two small pieces of
gauze are all that are necessary to put over a clean,
two-inch incision. There is no need of a large pad.
Wide, instead of narrow, strips of adhesive are
often used. The only time large amounts of ad-
hesive are needed is at the time of the first dress-
ing. This is necessary because the abdomen needs
splinting in case of postoperative vomiting. After
this period only enough adhesive is necessary to
hold the dressing in place.
In a similar manner each department's activities
could be analyzed, step-by-step, noting a number
of wasteful habits which in no way contribute to
efficient service. The only way to prevent hospital
waste is for the head of each department to watch
closely the use of all equipment and material com-
ing under his or her supervision. Every one con-
nected with the hospital's operation should gladly
accept suggestions of economy from whatever
source, and no department should feel that it is so
efficient that advice would not be helpful at all
times.
Enemas ajto Colon Irrigations
<H. W Soper. St. Loui.«. in Clin. Med. & Surg., Jan.)
Ihe chiel current crimes against the colon are: (1) The
cathartic habit; (2) the habitual employment of water
enemas; and (3) colon irrigations.
Purgative drugs should never be given in cases of spas-
tic constipation. The atonic colon often needs a gentle
stimulus, such as small graduated doses of cascara, the
lapactic pill, or any similar; avoid to.xic drugs, of which
phenolphthalein is the most popular. It is a dangerous
drug and is never indicated therapeutically.
The habitual use of the enema for chronic constipation
is not to be recommended. Injury to the mucosa will occur,
infectious material is likely to be introduced and the
water or saline solutions are readily absorbed by the colo-
nic mucous membrane. A toxic solution of fecal matter
is thus produced. The patient is deprived of the use of
any rational method for the restoration of colonic function.
SOUTHERN MEDICINE AND SURGERY
February, 1936
In cases of severe atony and dilation of the lower colon,
the daily use of an evacuant enema may be imperative.
Then the solution should not consist of absorbable ma-
terial. The colonic mucosa is impermeable to the passage
of sulphates, while chlorides and some other salts quickly
pass through the wall of the colon into the blood stream.
Use a 3-5% solution of sodium sulphate to incite con-
traction of the gut; solutions of magnesium sulphate to
produce dilation. In emergencies and in post-operative
conditions, when we know that a spasmodic tendency is
present in the lower colon, the magnesium sulphate enema
(107b solution) is useful.
In cases of strong contraction or spasm of the recto-
sigmoid region, with the patient in the knee-chest posture,
the sigmoidoscope is introduced and direct applications of
a 50% solution of magnesium sulphate are made by means
of a long cotton applicator. Relaxation can be demon-
strated in a few minutes.
Spasmodic contractures of the iliac colon can be diag-
nosed by palpation of the abdomen, with the patient re-
laxed. The normal colon can be induced to contract by
manipulation of the palpating hand, but it will agam relax.
In cases of extreme atony, no such contraction can be
elicited. In spasmodic contractures of the iUac colon, it
can be felt as a firm, hard cord, which never relaxes. Pal-
pation usually elicits painful sensations. Treatment by
means of magnesium sulphate solutions is ver>' efficacious.
The technic is essentially the same as described except that
a soft-rubber, 24-F. catheter is introduced through the
sigmoidoscope and the solution injected by means of a
piston syringe. The patient lies on his back immediately
after the injection and retains the solution as long as
possible. Usually a series of 8 or 10 such treatments,
every second day, suffices to overcome the spasm. At the
same time a smooth diet is employed and all laxative drugs
avoided.
The majority of physicians have ceased to use the so-
called colonic irrigations, but the "mtemal bath" is still
employed by the commercial irrigation specialist. My
experience is: the more one irrigates, the more mucus
one gets.
Abdominal or colonic massage is absurd and dangerous.
The colon is readily lavaged. All the apparatus that is
necessary is a large glass funnel, to which it attached a
large-caliber stomach tube.
The oil retention enema 6-8 ozs., introduced through a
2S-F. catheter, to which is attached a large rubber valve
bulb— a simple apparatus which the patient can easily use
at bedtime, with instructions to retain it all night. The
oil quickly reaches the cecum. We employ mmeral oil
as it is not absorbed and it inhibits the growth of bacteria.
It is of great value m recurring attacks of subacute ulcer-
ative colitis, spastic contractures of the lower colon, mucous
colitis and colonic diverticulosis. A series of oil retention
enemas is the best preparation for the patient who is to be
ooerated upon for carcinoma and other lesions of the colon.
The use of chemical solutions, formerly much in vogue
in the treatment of dysentery, ulcerative colitis, etc, should
be abandoned.
The insufflation of dry powder is a very useful pro-
cedure i'l inflammatory and ulcerative conditions in the
rectum and lower colon. When the pathologic process is
limited to the ampulla recti, the patient is placed in^ the
knee-chest posture and the sigmoidoscope (small caliber,
Ys\.\\ to ^ in) is introduced, the obturator withdrawn and
the powder blown directly into the bowel by means of a
special powder-blower equipped with a long tube. My
final choice in such conditions is a powder consisting of
equal parts of bismuth subcarbonate and calomel. This
powder has the advantage of adhering tenaciously to the
mucosa; and it is strongly antiseptic and non-irritating. It
is best to avoid the sigmoidoscope after the diagnosis has
been made in such cases, and employ the 24-F soft-rubber
catheter, introduced directly into the rectum, insufflating
the powder through the catheter. This is also the method
of choice in the treatment of lesions higher up in the
colon, where daily insufflations are necessary. One thus
avoids the trauma occasioned by the daily passage of the
instrument.
Bismuth subgallate is the best powder for higher in-
sufflations, because of its lightness and more astringent
qualities. I have demonstrated deposits of this powder
as high as the splenic flexure. Care must be taken not
to overdistend the gut: the powder-blower is detached
from the catheter from time to time and the excess
air allowed to escape.
In old, chronic, ulcerative lesions in the rectume, direct
application of 25% solution of silver nitrate, under guid-
ance of the eye, are often very useful. Dry the tube well
before withdrawing it to prevent any of the solution
touching the anal canal. Polypoid growths are best de-
stroyed by diathermy.
A 10% aqueous solution of mercurochrome is of great
value in the treatment of proctitis involving the anal
canal. A f^-in. caliber scope is introduced and the
cotton applicator wet with the solution is passed through
the scope, which is withdrawn. Now the wet applicator
is withdrawn through the contracted anal canal, Uterally
squeezing its contents into the crypts and folds of mem-
brane.
The introduction of the ordinary foodstuffs per rectum
has been practically abandoned, because of the failure of
the colon to absorb and utilize them. Water, weak solu-
tions of alcohol, physiologic saline solution, and a 3%
solution of dextrose are readily absorbed and utilized. The
Murphy drip method is to be preferred, but in some pa-
tients with sensitive anal canal reflexes it is better to intro-
duce slowly about 4 ozs. of the fluid every 2 or 3 hours.
ORTHOPEDIC SURGERY
0, L. Miller, MD., Editor, Charlotte, N. C.
CoLLEs' Fracture
CoLLEs' fracture is of comparatively common
occurrence in the routine practice of medicine.
The principles apph'ing to treatment of this injury
are well recorded in the periodicals and textbooks
on surgery, yet it is not amiss to reemphasize them
from time to time in the interest of improving our
end-results. There is some tendency to treat this
fracture lightly, at times with dire consequence to
the future use of a hand.
The incidence of Colles' fracture is somewhat
greater in elderly people than in younger adults
and this fracture in elderly patients should be
treated somewhat differently as compared with
similar fractures in younger patients. There is
greater hazard to obtaining a good anatmoical and
functional result in the elderly patient.
Haggart, of Boston, told the Bone and Joint
Section of the A .iNI. A. at Atlantic City that,
owing to the relative brittleness and avascularity
of the bones of elderly individuals, comminution
of fragments is more frequently observed at the
Februan-, 1936
SOUTHERN MEDICINE AND SURGERY
time of reduction. Such comminution may not be
evident in a preoperative x-ray picture.
Bony union in these patients is delayed as com-
pared with the same fracture in younger adults.
In some elderly patients complete bone repair may
not occur even though the fracture is perfectly re-
duced. This is due, apparently, to disintegration
of bone cells at the end of each fragment with
consequent loss of bone substance. Delay in heal-
ing is particularly prone to occur at the dorsal
fracture line in the radius, where the distal dorsal
end of the proximal radial fragment tends to ab-
sorb. Hence, bone repair is often so far from
complete that, following the usual two- to three-
weeks splintage, a partial to complete recurrence
of the deformity takes place on resumption of the
use of the hand, notably the act of dorsiffexion.
It is often necessary to hold the hand in palmar
flexion and ulnar deviation in order to prevent dis-
placement of the comminuted radial fragments.
Fluoroscopic vision or x-ray photographing of the
fracture will determine whether this position is
indicated.
These fractures are most satisfactorily reduced
under a general anesthetic. Impaction of the radial
fragments is first broken up by manipulation and
then, with traction maintained, the fragments are
molded into alignment by firm pressure of the oper-
ator's thumb passing distally over the dorsum of
the patient's wrist. This maneuver brings the pa-
tient's hand into volar flexion, thus fixing the re-
duced radial fragments in position. If necessary,
the fragments are aligned by ulnar deviation of the
hard.
The plaster splint or cast is one of the simplest,
yet most efficient, appliances that can be utilized
in fractures of the forearm. The length of the
splint is determined by the distance from the
knuckles up the dorsum of the forearm, around the
elbow and down the volar surface of the forearm
to the base of the fingers. It is particularly im-
portant to note that the respective ends of the
plaster terminate at the knuckles on the dorsum
and just proximal to the base of the fingers on
the volar surface of the hand. When properly
applied, this splint permits the patient complete
normal range of flexion-extension in all the inter-
phalangeal and metacarpophalangeal joints. In
addition to antero-posterior immobilization of the
radius and ulna, by passing around the elbow the
splint or cast should also prevent pronation and
supination — an especially important stabilization
when dealing with a comminuted Colles' fracture.
Care must be exercised to prevent circulatory dis-
turbance and ischemia.
After x-ray examination confirms a satisfactory
position of the fragments and shows the restoration
of normal radiocarpal and distal radioulnar joint
relationship, the patient is instructed, first, to use
the fingers constantly: not only to move the joints
actively through their maximum range fifty times
daily but at all times to employ the fingers as
nearly as possible as in normal daily use: secondly,
to abduct the entire arm over the head a minimum
of six to eight times a day. The latter exercise
prevents loss of shoulder joint function, which is
so prone to occur if the arm is held constantly at
the side of the body. Impairment of shoulder joint
motion is particularly apt to follow Colles' frac-
ture, since falls on the outstretched hand frequently
injure the tendon of the supraspinatus muscle and
the subacromial bursa.
Because of the tendency to recurrence of the
deformity of the distal end of the radius in these
elderly patients owing to delayed bone repair, it is
believed that the extremity should be continuously
immobilized for a minimum of from five to seven
weeks.
Free finger-joint motion is necessary, a range of
motion allowed by careful application of the splint.
Daily complete arm abduction is of advantage in
preventing limitation of shoulder joint motion. With
this procedure, followed by intensive massage, heat
and active exercise, a good anatomic and a good
functional result should be obtained.
Leucocytosis Following Inhalation Anesthesia.
(I. B. Taylor & R. M. Waters, Madison, Wise, in Anes
& Analg., Nov. -Dec.)
A review of the literature indicates that administration
of all the commoner anesthetic agents by inhalation is fol-
lowed by a marked leucocytosis. Observations on 8S clin-
ical cases and 5 dogs support a similar conclusion.
Increases in the total leucocyte count amounting to 2J^
times the normal in long serious cases and V/z times the
normal in minor cases are the rule. Three to S days are
required for a complete return to normal white blood count
following inhalation anesthesia.
Sudden Death
(J. H. Dible, Liverpool, in Liveroool Medico-Chiruraical
Jl., Pt. 3. 1035)
The form of cerebral hemorrhage which produces the
most rapid extinction of life, and which usually occurs
in young subjects, is that due to aneur>-sm of the large basal
vessels. The aneurysms are of unknown etiology. They are
neither syphilitic nor atheromatous. The rupture of such
aneurysms produces the sudden onset of coma which, if it
occurs prior to the degenerative period of life and is ac-
companied by the presence of recent blood in the cere-
brospinal fluid, is almost pathognomonic of this condition.
Dr. /oynes'* contributions to medical literature (I'a
Med. Monthly, Jan., 1882) were numerous and valuable.
No article of his ever went to press without thorough
preparation in study of the subject of which he was treat-
ing and exactness in manuscript.
^^'':i'^• ^'^y'". •'^- -Isynes, long Professor of Physiology and
Medical Jurisprudence in the Medical College of Virgina.
SOUTHERN MEDICINE AND SURGERY
Februarj', 1936
RADIOLOGY
Wright Clarkson, M.D., and Allen Barker, M.D.,
Editors, Petersburg, Va.
Roentgen Diagnosis of Heart Disease
Holmes,! Kohler,- Assmann^ and Levene have
contributed much to our present knowledge of
roentgen cardiology, and the heart measurements
established by Vaquez and Bordef* have proven of
great assistance to radiologists in the differential
diagnosis of heart diseases. The size of each of
the four chambers of the heart and the thickness
of the left ventricular myocardium can now be
quite accurately determined.
Von Zwaluwenburg and Warren^ have shown
the value of studying the relationship between the
size of the auricles and the size of the ventricles.
If the length of the auricles is divided by the length
of the ventricles, the auriculoventricular ratio is
established. This ratio is definitely increased, or
that is to say, the auricles are proportionally larger,
in cases of mitral stenosis, and in mitral stenosis
complicated by mitral insufficiency. The ventricles
show relatively more enlargement, causing a de-
crease in the auriculoventricular ratio, in cases of
functional mitral insufficiency, in aortic stenosis,
and in aortic insufficiency.
Levene and his co-workers have shown that
roentgenoscopic examination of the heart is equally
as valuable as examination of the cardiac roent-
genograms. Levene and Reid" say: "With in-
creasing experience we learn to obtain from roent-
genoscopic examination important information re-
garding the functional status of the heart; the film
was more useful in portraying gross, structural
changes of the various chambers."
By combining the roentgenoscopic and film ex-
aminations, the roentgenologist is able to differen-
tiate the various organic diseases of the heart with
accuracy and in some cases the diagnosis can be
recognized by roentgen examination before symp-
toms appear, and before the diagnosis can be estab-
lished clinically. For instance, mitral stenosis may
be recognized roentgenographically at a very early
stage, because in this condition the left auricle be-
gins to dilate before there are clinical signs of
impaired cardiac function.
In mitral insufficiency the radiologist can dif-
ferentiate between the functional and the organic
forms. A functional insufficiency of the mitral
valve may be caused by any condition requiring
the left ventricle to do more work, and, following
the hypertrophy and gradual enlargement of the
ventricle, the valve flaps fail to completely close
the mitral opening. The transverse diameter of the
heart is increased and the apex becomes rounded
from myocardial hypertrophy.
Levene believes that mitral stenosis always pre-
cedes the organic form of mitral insufficiency and
therefore in this condition the cardiac changes are
superimposed upon those produced by mitral steno-
sis. In the latter, the left ventricle is small and
the apex is pointed and therefore when the mitral
valve begins to leak, we get a combination of roent-
gen signs. The left ventricle dilates, but the apex
remains pointed and the auricles of the heart con-
tinue to show relatively more enlargement than
the ventricles. These changes can be clearly dem-
onstrated roentgenographically and this fact makes
repeated roentgen examinations of the heart of
great value in following the course of organic mitral
disease.
Aortic stenosis under the roentgenoscope reveals
a hypertrophied left ventricle with practically no
enlargement of the right heart, and the slow force-
ful contractions so typical of the condition can be
readily recognized. In like manner, all the other
valvular lesions produce distinctive changes which
can be readily recognized by a careful roentgen
examination.
A very instructive scientific exhibit on the roent-
genoscopic appearance of the heart was given by
Levene at the last annual meeting of the American
Roentgen Ray Society, and again before the an-
nual meeting of the Radiological Society of North
America meeting in Detroit. The characteristic
roentgenoscopic appearance of sinus arrhythmia,
extrasystoles, auricular fibrillation, thyrotoxicosis,
coronary disease and heart block were particularly
striking.
It is really hard to explain why radiologists in
the past have paid relatively little attention to
cardiac examinations, since by the proper use of
the roentgenoscope it is comparatively easy to
watch the action of each chamber of the heart.
For instance, in heart block, due to interference
with the conduction of impulses from the auricle
to the ventricle, the auricle beats faster than the
ventricle, and counting the number of beats made
by each chamber per minute by means of a stop
watch is a simple procedure. For example, if the
ratio in a case happens to be two to one and the
ventricular rate is slow (about forty per minute),
the diagnosis of heart block is established.
Myocardial impairment may be accurately de-
termined by roentgen examination. The dimin-
ished amplitude of the cardiac contractions varies
in direct proportion to the amount of myocardial
damage. In cases of coronary thrombosis the con-
tractions are often barely perceptible upon the flu-
oroscopic screen. The left border of the heart is
straight or concave instead of being well rounded
as seen in hearts with thick healthy myocardium.
Care must be taken in these cases to exclude thy-
February, 1936
SOUTHERN MEDICINE AND SURGERY
97
rotoxicosis, which also produces a straight or con-
cave left cardiac border, but in the latter condition
the amplitude of the contractions is forceful and
not at all like the feeble impulses of myocardial
impairment.
Sosman and Wosika" have succeeded in demon-
strating calcified coronary arteries and calcified
deposits in the valves of the heart. The fact that
the three patients reported by them suffered with
angina pectoris is quite significant.
From the foregoing facts, it can be seen that the
value of roentgen examinations of the heart is well
established. Everyone attempting this work, how-
ever, should realize that the successful roentgen
diagnosis of cardiac conditions is dependent upon
the possession of a broad knowledge of cardiology,
and unless the roentgenologist is well acquainted
with all the various cardiopathies his attempts will
be unsuccessful. It is likewise true that roentgen
examinations of the heart should always be corre-
lated with the various clinical and laboratory ex-
aminations now in general use. In this w^ay roent-
genology will add materially to our knowledge of
cardiac conditions and it will be particularly help-
ful in permitting clinicians to follow the course of
their heart cases under treatment.
Bibliography
1. Holmes, G. W.: The Use of the X-ray in the Exam-
ination of the Heart and .\orta. Boston M. and S.
Jl., 191S, 179, 478.
2. KoHixR, Alban: Roentgenology. Wm. Wood and
Co., New York, 1929.
3. AssMANX, H.: Die klinische Roentgendiagnostik der
inneren Erkrankungen. F. C. W. Vogel, Leipzig, 1924.
4. V'AQtJEz, H., and Bordet, E.: The Heart and the Aorta,
Translated by James A. Honeij and J. Macy. Yale
University Press, New Haven, 1920.
5. Vox ZwALU\VENBURC, J. G., and Warren, L. F.: The
Diagnostic Value of the Orthodiagram in Heart Dis-
ease. Arch. Int. Med., 7:137-152, Feb., 1911.
6. Levexe, George, and Reid, William: The Differential
Diagnosis of Organic Heart Disease by the Roentgen-
ray. Am. Jl. of Roenl. and Rad. Th., 1932, Vol. 28,
No. 4.
7. Sosman, M. C, and Wosika, P. H.: The Roentgen
Demonstration of Calcified Coronary Arteries in Liv-
ing Subjects. /. A. M. A., Feb. 24th, 1934, 102, 591.
Complete axd Uxiversal .Alopecia Following Fright
(E. Wigglesworth. Boston Med. & Surg. Jl., Ort. 21,
ISMi. \ia Va. Med. Monthly, .Jan., l.Ssl)
.\ healthy Italian blonde, 17, lymphatic, with exception-
ally profuse hair, was sewing at a window. Suddenly the
floor fell in, leaving her only time to catch hold of the
window frame, where she hung until taken down by means
of a ladder. No subsequent loss of consciousness nor nerv-
ousness excitement ensued through the day. At night, she
had headache, chills and bad dreams; in the morning,
nervous excitement, weakness at the knees, spasms in the
fingers and itching of the scalp. The following day she
felt better, only the itching of the scalp remaining; but
on arranging her hair, whole tufts came out by the roots.
In 3 days, not a hair was left on the scalp. The eyebrows
and eyelids were lost, and in 5 days the axillae and gen-
itals were devoid of hair. General health good; no func-
tional disturbance of any kind. K month after the fall of
hair began, Fredet was consulted. The fallen hair, which
had been made into a wig, was fine, silky, very rich and
long. Not a hair could be found on the body, though a
lens was used in the search. Two years later, after con-
stant treatment, no return of hair.
Hyperpyrexia Produced by the Hot Bath in the
Treatment of Syphilis
(C. C. Dennle, Morris Polsky & A. N. Lemoine, Kansas
Cit.v, Mo., in Jl. Mo. State Med. Assn., Jan.)
Efficient temperatures can be produced in syphilitic pa-
tients by the use of the hot bath in the ordinary tub.
The best time is just before retiring, 2 or 3 hours after
eating.
We believe that in some way the defense mechanism of
the body is raised and the virility of the organism lowered
simultaneously by the use of hyperpyrexia. It seems that
temperatures of 104 F. and above set the defense mechan-
ism in motion. With the exception of early seronegative
syphilis, inadequately treated syphilis with recurrent mani-
festations and eariy malignant syphilis, heat should not be
used in the early types of syphilis. By the application of
heat alone it has been shown that syphilitic manifestations
disappear temporarily; if subsequent treatment with heavy
metals is employed they disappear permanently. Heat is
an efficient therapeutic agent in recurrent neurosyphilis
where malaria has already been used.
Malaria still remains supreme as the treatment of neuro-
syphilis.
Heat as a therapeutic agent is probably the equal of
malaria when used in other than neurosyphilis.
The work presented here is experimental, and is not pre-
sented with the idea that all the statements herein made
are absolutely proved.
Report on Advances in Hygiene and Public Health
(S. K. Jackson, Norfolk, in Va. Med. Monthly, Jan.. 1880)
Among the parasites recently discovered, the trichina
spiralis is of great importance. It exists in the hog in the
developed stage as well as in the encysted form, but it is
introduced into the human system, generally, if not always,
in the latter stage, as in this stage it is more likely to
escape destruction by the process of cooking. The worms'
favorite habitat is the voluntary muscles which they reach
by piercing the mucous membrane soon after being hatched.
Body-Snatching in Richmond
(Edi. in Va. Med. Monthly, Jan.. 18S0)
Body-snatching in Richmond has been the subject, for
the past few weeks, of much ventilation through the daily
papers of this city and other places.
The acts of incorporation of the two medical colleges in
Virginia which are State institutions and under State con-
trol provide that there shall be in each a practical anat-
omical course. .Anatomical and dissecting rooms have been
built and fitted up at State e.xpense and under State law;
but, unfortunately, there is no "dissection act" as yet
adopted by the State. In regard to the subjects selected
for resurrection, so far as we have any occasion to believe,
the utmost circumspection has been used in selecting those
bodies whose dissection cannot give grief to the living.
Scorpion Deadlier Than Black Widow Spider
(Col. Med., Jan.)
.\r'uon3. State Board of Health records disclose 35 deaths
from poisonous insects and reptiles in the past 6J/2 wears,
of which 25 were caused by the sting of the scorpion.
SOUTHERN MEDICINE AND SURGERY
February, 1936
Southern Medicine and Surgery
Official Organ of
Tri-State Medical Association of the
Carolinas and Virginia
Medical Society of the State of
North Carolina
James M. Northington, M.D., Editor
Department Editors
Human Behavior
James K. Hall, M.D Richmond, Va.
Dentistry
W. M. RoBEY, D.D.S.- - - Charlotte, N.C
Eye, Ear, Note and Throat
Eye, Ear and Throat Hospital Group Charlotte, N. C.
Orthopedic Surgery
0. L. Miller, M.D ) ...Charlotte, N. C.
John Stuart Gaul, M.D.)
Urology
Hamilton W. McKay, M.D i Charlotte, N. C.
Robert W. McKay, M.D j
Internal Medicine
W. Bernard Kinlaw, M.D --- Rocky Mount, N. C.
Surgery
Geo. H. Bunch, M.D Columbia, S. C.
Therapeutic*
Frederick R. Taylor, M.D. High Point, N. C.
Obitetrlct
Henry J. Langston, M.D. - ^..Danville, Va.
Gynecology
Chas. R. Robins, M.D Richmond, Va.
Pediatrics
G. W. Kutscher, jr., M.D
.Asheville, N. C.
General Practice
WiNGATE M. Johnson, M.D Winaton-Salem, N. C.
Clinical Chemistry and Microscopy
C. C. Carpenter, M.D. ...Wake Forest, N. C.
Hospitals
R. B. Davis, M.D Greensboro, N. C.
Pharmacy
W. L. Moose, Ph. G .....Albemarle, N. C.
Cardiology
Clyde M. Gilmore, A.B., M.D Greensboro, N. C.
Public Health
N. Thos. Ennett, M.D ...Greenville, N. C.
Radiology
Allen Bahker, M.D I Petersburg, Va.
Wright Clarkson, M.D.J
Offerings for the pages of this Journal are requested
and given careful consideration in each case. Manu-
scripts not found suitable for our use will not be returned
unless author encloses postage.
This Journal having no Department of Engraving, all
costs of cuts, etc., for illustrating an article must be
borne by the author.
The Columbia Tri-State Meeting
In a few days the Fellows of the Tri-State Med-
ical Association of the Carolinas and Virginia wil'
gather at Columbia for the annual meeting.
For this meeting a program has been arranged
with a view to broad usefulness. Whether you b:
a doctor whose day's work may include everything
contemplated by those who made your diploma
declare you to be "very noble and most learned, '
or a doctor in "practice limited," — and no matter
how limited — much of daily helpfulness is offered,
and in an attractive way.
Study your program. See the subjects which
will be presented and the names of the essayists
and those who open the free discussions; and accept
our assurance that the main idea will be to put out
things of solid worth in diagnosis, in cure and in
comfort.
Come prepared to stay through, till v/e have
done the work of the session and said a word in
commendation of those whose seats will be vacant.
Bring along your medical neighbor. Write friendi
inside and outside the Association to meet you^
there. Readers of this journal who are not in the
Association are extended a cordial invitation to
meet and mingle with us. Don't wait for som?
one to ask you in person.
No doctor leaves a Tri-State meeting but he
feels it was well that he had been there.
Write this journal for a program if you do not
have one.
The Public's Obligation to Doctors
Anyone not stone deaf hears a deal about the
obligations of doctors to the public: who has ears
keen enough to hear anything said about the obli-
gation of the public to doctors? Albeit many
who sit in seats once occupied by educators set
little store by the classics and have only a tolerant
smile for those who speak up for the Latin and
the Greek, these studies — if studied — have their
uses.
Ligo means bind; obligo, bind about: and it is
plain that one can not be bound to another, with-
out the other being bound to the one.
It has always been held that, by adopting a
profession, one assumes a special obligation to his
fellows; and for just as long has it been held that
society at large has a reciprocal obligation to the
professions. It would seem that, of late, thos?
who profess to speak for the public have neglected
half the postulate.
This journal has, many times, challenged thos2
who demand radical changes in medical practice
to point out a specific instance in which a man,
woman or child has, because of poverty, been
denied the services of a physician; and all of the
February, 1936
SOUTHERN MEDICINE AND SURGERY
99
meager evidence offered has been as little convinc-
ing as tales of "seein' hants" and of having conver-
sations with the dead.
The obligations of the public to doctors are
many and important, much more important to the
public than to the doctors.
A good many otherwise sensible grown persons
appear to think the practice of medicine consists
of the laying on of hands, incantations and giving
the command ''Take up thy bed and walk." They
ignore the fact that, in the great majority of cases
of illness among those who can not pay for doc-
tor's services, the indispensables for recovery are
proper food, clothing and shelter right now, and
the mental relief which only assurance of the con-
tinuation of these supplies would afford. Could
anything be more ironically stupid than to assume
that a doctor's visit would accomplish any good in
a case of pellagra, when there is no money to buy
proper food for the patient or other members of
the family?
For my part — and doctors generally will back
up the offer — I would gladly contract to supply
medical services gratis to every person unable to
pay, the blatant philanthropists to supply at their
expense the needed food, clothing, coal, shelter,
medicines, furniture, school-books and other neces-
sities.
Food, clothing and shelter are every-day essen-
tials. Medical care is rarely needed for more than
a few days in the year. Why not have first things
first, and provide "through taxation or insurance''
for properly feeding, clothing and sheltering every-
body? Prevention is better than cure. The plan
suggested would keep folks from starving or freez-
ing, suddenly or by slow degrees; it would prevent
more than half the cases of tuberculosis and pel-
lagra; it would greatly reduce the incidence, the
time in bed and the death-rate in most acute dis-
eases; it would prevent or delay heart and kidney
disease; it would keep a whole lot of persons from
having peptic ulcers, and a lot of others from losing
their minds.
Other obligations to doctors that come to mind
right now is the obligation which should, but does
not, bind newspapers to refuse to lend or hire their
pages for the dissemination of plainly fraudulent
claims as to the value of wonderful medicines and
methods; the obligation which should put a heavy
hand on fortune-telling, mental telepathy and
every other form of superstition; the obligation to
accept and support the teachings and the leadership
of the regular medical profession as to inoculations,
autopsies, worthless and dangerous drugs, and in
all health matters. Medicine has done its work well
and still is doing it far better than any other group
is doing its job. But for the hindrances from poli-
ticians and other lawyers, newspapers and maga-
zines and radios, and certain brands of so-called
religion, it would do a whole lot more.
What a pity it is that everyone does not realize
the deep significance of, — Lord protect us from our
friends; against our enemies we can defend our-
selves.
What's a Plain Doctor of Medicine For?
This question must come into the mind of every
individual at some time and, as time goes on, it
seems to press more and more for answer.
The only conclusion in the report of the late and
unlamented Committee on the Costs of Medical
Care with which this journal agreed was the one
which said 80 to 85 per cent, of medical care
should be rendered by family doctors. One could
wish the Committee had gone into particulars.
Learned and dignified Faculties accept certain
young men and women as promising, and, after
many years of arduous application, the few surviv-
ors are certified to be Doctors of Medicine, worthy
to be recommended to the general public as capa-
ble physicians and surgeons, but, strangly contra-
dictory, a good many of the members of those
Faculties immediately join in with others who
have limited their practice to a special field in
saying, in effect, You are capable physicians and
surgeons in every field but mine.
All this is confusing. How is the confused young
doctor to know what he should attempt? How is
a head of a family to know the proper procedure
for providing proper health care for those depend-
ent on him and for himself?
Should practice be divided according to organs,
according to regions, according to special diseases,
according to sex, according to age, according to
station in life, according to therapeutic methods, or
according to means of making a livelihood?
If according to organs should one man do the
medicine and the surgery of, say, the stomach?; or
should there be two or more?
When there is something wrong with an eyelid
should the patient be in the hands of a skin spe-
cialist or an eye specialist?, or maybe a cosmetic
surgeon, or a radiologist or a cancer specialist?
If the person with the diseased eyelid happen to
be a child under seven, or a pregnant woman,
would either of these factors have a determining
influence?
Up to a few weeks ago we had blandly assumed
that one disease condition had been properly as-
signed — and that there was no dissent to this as-
signment. Now it seems that even that is contro-
versial.
In our issue for January is published an article'
from which we quote:
SOUTHERN MEDICINE AND SURGERY
February, 1936
"There is no single renal pathological entity that
should not be under the supervision of the urologist
rather than the internist." Who would have an-
ticipated that organ specialism would have attempt-
ed to go that far?
All of us are appreciative of the manipulative
dexterity and of the great usefulness of the urolo-
gists. Every doctor looks upon urology as among
the most valuable of the specialties. However,
whenever urologists attempt to label Bright's dis-
ease as theirs, or to supersede the medical men as
the proper ministers to those suffering this chronic
constitutional condition, with manifestations in the
heart, the blood, the brain, the eyes, the lungs, the
bloodvessels, the liver — indeed in all the tissues of
the body — it is time to call a halt.
It is not our belief that the opinion of this one
urologist is generally held by urologists. We do
not believe that there was ever a time when Dr.
Hugh Young would have said that a patient with
chronic Bright's disease would be better off under
his care than under the care of Dr. Barker or Dr.
Thayer.
If the medical man is not the one to be in su-
preme command in the management of what are
commonly called the medical diseases of the kid-
neys, then he should undertake no more in his
profession than to act as a traffic director, advising
which specialist should be consulted, until that
early day when all patients would choose their own
specialist, and the species plain doctor perish from
the earth.
1. Nephritis a Medical or a Urological Problem, Elmer
Hess, M.D., Erie, Penn.
bill. Some doctors enter in a casual way, apparently un-
conscious of the patient's presence, and talk about the
weather or the fire, while the patient longs for succor. The
egotistic kind first must tell how busy they are and how
little sleep they snatch between the rings of the telephone,
how fast they have to drive to reach the outposts of dis-
ease, and how extraordinary are the cures they make; these
give comfort to some, but mostly to themselves. There is
the stumbling lout, whose bag upsets the vase of flowers,
and who sets his bulky hulk upon the bed; the patient
forgives much in the hope that the doctor is mighty also
in healing power. The business-man phj'sician whose man-
ners smack of the marts of trade, smart, abrupt and dap-
per, impresses the patient that he is attending a board
meeting and wants the minutes read at once; the patient
wishes he were more sympathetic. And then comes the
doctor of mystery, all quiet and sedate, with soft voice,
and furtive words, and sanctimonious manner; the patient,
if of the susceptible type, thinks of wonders and of mira-
cles.
When the patients do well under their administrations,
which in nine cases out of ten they do, each of these
peculiarities becomes glorified into a healing virtue, and
the doctor goes on cultivating his idiosyncrasy.
The vast number of highly qualified physicians come
under none of these classifications. Most physicians are
just plain doctors. They may be tinctured with some of
these traits, but not enough to matter. They exemplify
good bedside manners. They possess urbanity; it is ob-
vious that they are gentlemen; they do and say the thing
that is fitting ; they do about their business with dignity,
directness, and dispatch; it is clear that they have the
matter in hand ; and then, when they have finished, they
say the few words that indicate sympathy and understand-
ing, and quietly take their leave.
Doctors, Doctors and Doctors
(Editorial Bui. St. Louis Med. Soc, Nov.)
Some doctors come plunging into the chamber of the
sick like a fireman about to extinguish a conflagration;
they alarm the patient. Some come Like a detective looking
for a criminal, and give the patient cold creeps. Others
enter stealthily like a cat stalking a bird, and are beside
the patient and pounce upon the pulse before any one is
aware; they fill the patient with a weird sense of the
chase. There is a class that come like purring doves, as
though they would make love; they are thought nice by
sentimental ladies. There are the doctors with the doleful
faces, Hke the hired mourners who follow the catafalque:
if the patient is bad they make him worse; if he is not
they cause him to smile. A common lot enter like the
monologue artist on the vaudeville stage and start a bar-
rage of wise-cracks that entertain the nurse and amuse
themselves, while the patient waits for business to begin.
Then there is the radiant doctor who has studied how to
impress himself upon others and fill the room with the
effulgent aura of his personality ; he impresses only the
weak-minded. There is the pompous doctor of the school
of hope, who comes with a strong expression and eyes
beaming with glad tidings; he scares the demon of disease,
and makes the patient fearful of the size of the doctor's
The Practical Bearing of Recent Advances in Cerebral
Localization and General Thermometry
We have, I think, in cerebral thermometry a means of
determining the situation of lesions of the greatest value.
In a letter recently received a friend mentions a recent
case of middle ear trouble, followed by coma and death,
in which the rise of temperature above the diseased ear
was very marked.
You will observe in the diagram that the left side of
the head at all points shows a rather higher temperature
than the right.
There can scarcely be a reasonable doubt, I think, that
over a localized collection of pus or an inflamed spot there
would be a very marked rise of temperature, and, indeed,
the cases to which we have already referred place this fact
beyond all question.
Hydrobromate of Quinine Hypodermically
(G. Wm. Semple, Hampton, in Va. IVIed. Monthly, Jan.,
1SS2)
.•\ continued experience of the effects of a solution of
the hydrobromate of quinine increases my confidence in
the remedy for hypodermic injection. Twenty minims of
the solution, containing grs. iv of the salt, administered
by hypodermic injection 2 hrs. before the expected chill,
is much more certain to prevent the paroxysm than 20
grs. of the sulphate administered in the course of 8 pre-
ceding hours. It does not produce cinchonism or any of
the other unpleasant effects so often the result of the sul-
phate. Those subject to urticaria from the sulphate can
take it with impunity.
February, 1936
SOUTHERN MEDICINE AND SURGERY
Eli Lilly 4ND Company
FOUNDED 18 76
!Makers of ^Medicinal Products
Widespread clinical application has demon-
strated the effectiveness of Merthiolate as
a first-aid antiseptic. It is admirably suited
for use in many surgical fields, f Merthiolate
(sodium ethyl mercuri thiosalicylate, Lilly)
is an organic mercurial compound. For
special application in medicine and surgery,
Merthiolate is incorporated in a colored
alcohol - acetone - aqueous tincture, in an
ointment base, in a water-soluble jelly, and in
a modified greaseless cream. Salient points:
i High germicidal activity 2 Rapidity of disin-
fection 3. Sustained action. 4 Jissue comjHilibilily
Prompt Attention Qiven to Professional Jncfuiries
PRINCIPAL OFFICES AND LABORATORIES, INDIANAPOLIS, INDIANA, U.S.A.
Please Mention THIS JOURNAL When Writing to Advertisers
SOUTHERN MEDICINE AND SURGERY
February, 1936
NEWS ITEMS
The Southeastern Surgical Conrgess New Orleans
Assembly
The following doctors to appear on the program with
papers and clinics;
Arthur W. Allen, Boston; Roger Anderson, Seattle;
W. T. Black, Memphis; 0. P. Board, Birmingham; Charles
O. Bates, Greenville, S. C; Guy Caldwell, Shreveport;
Thomas E. Carmody, Denver; Virgil S. Counseller, Roch-
ester, Minn.; George W. Crile, Cleveland; Roger G.
Doughty, Columbia; John F. Erdman, New York; Edgar
Fincher, jr., Atlanta; Paul G. Flothow, Seattle; Emmerich
von Haam, New Orleans; W. D. Haggard, Nashville;
Arthur Hertzler, Halstead, Kan.; Gerry Holden, Jackson-
ville; C. C. Howard, Glasgow, Ky.; Chevalier Jackson,
Philadelphia; Kerry H. Kerr, Washington; Joseph E. King,
New York; Francis E. Lejeune, New Orleans; Jennings
Litzenberg, Minneapolis; James S. McLester, Birmingham;
Julian A. Moore, Asheville; Fred Rankin, Lexington, Ky.;
J. U. Reaves, Mobile; Curtice Rosser, Dallas; Alfred A.
Strauss, Chicago; A. Street, Vicksburg, Miss.; J. W. Tank-
ersley, Greensboro, N. C; Alan C. Woods, Baltimore.
// you do not receive a program by the first oj March
write for one to Dr. B. T. Beasley, Atlanta, Ga.
The first meeting of the Neuropsychiatric Society of
Virginia was held at the Memorial Hospital in Richmond
on January 24th. The officers of the organization are:
Dr. David C. Wilson, University, president; Dr. R. Finley
Gayle, Richmond, vice president ; Dr. Frank H. Redwood,
Norfolk, secretary-treasurer.
Dr. Henry G. Turner was elected president. Dr.
Ch.^vrles p. Eldridge, secretary. Dr. E. C. Judd, treasurer;
and Drs. J. W. McGee, Hubert B. Haywood and Z. M.
CANfENESS were placed on the board of censors, at the 66th
annual meeting of the Raleigh Aa'U>EMY of Medicine
Feb. 1st.
The Academy elected Dr. Carl V. Reynolds, State
Health Officer, as a member. Dr. Reynolds came to Ralei^^h
from Asheville more than a year ago to succeed the late
Dr. James M. Parrot as State Health Officer.
Dr. Hubert Royster discussed briefly the histor\- of the
.Academy, founded in February, 1870, and the oldest medi-
cal organization in the State in point of continuous and
active existence.
At the annual meeting of the board of trustees of Baker
Sanatorium, Luraberton, held there January 16th, K. M.
Biggs was elected president of the board and R. H. Liver-
more vice president.
Dr. H. M. Baker, who has been at the head of the in-
stitution since it was founded 14 years ago, was re-elected
v.'ith the title of administrator, secretary and treasurer.
His report showed the hospital to be in excellent condition,
with a nice profit for the year, exclusive of an addition
costing about $14,000 which increases the capacity from 65
to 81 beds.
The scientific meeting of the staff of the McGuire Clinic
en evening of January 21st, in the Library of the Clinic
Building. Program: My Most Humorous Case, Dr. John
B. Williams; My Most Mortifying Case, Dr. Stuart Mc-
Guire; Addison's Disease with Report of Case, Dr. CHfford
Beach; Treatment Fibromyoma Uterus with X-ray, Dr. J.
L. Tabb.
Mecklenburg County Medical Society, first regular
meeting for the year, evening of January 7th, Medical
Librar>', Charlotte, President McKay in the chair.
Dr. H. C. Neblett gave an instructive case report of an
infection of Tenon's capsule; discussed by Dr. H. L. Sloan.
Dr. H. L. Sloan gave a paper, Ocular Tendon Transplan-
tations for Paralytic Squint, with lantern slides; discussed
by Dr. H. C. Neblett.
The meeting then was given over to business.
Dr. Andrew Blair, Chm. Com. on Hospital Savings As-
sociation, reported:
" This committee feels that the Hospital
Savings Association plan contains many desirable features
and we are desirous to co-operate in every way consistent
with the high ideals of the medical profession. When the
plan was first presented to the Medical Society, the mem-
bers of the committee understood that it was to cover
hospital board, room and care, and not medical services.
We firmly believe that the practice of medicine is indi-
vidual, personal ser\-ice and should not be contracted for
or sold by any organization, except one organized and
operated by the doctors involved. We also understood
that the privileges of the Hospital Savings Plan were to
have been extended only to those whose incomes came
within the lower brackets. We believe that this principle
should be adhered to as closely as possible.
"A. X-ray: The roentgenologist is and should be a
highly specialized doctor of medicine and as such he should
be recognized and his ser\'ices may not be sold to anyone
except by the doctor himself.
"B. Anesthesia: In Charlotte the doctors give nearly'
all anesthetics and wc see no reason why their services
should be drafted.
"C. Pathology: .... Pathologists should be and are
(as it is in this city) specialists in a certain branch of
medicine and have the responsibility of the selection of
all laboratory methods, standardizations, interpretations,
clinical applications and pathological diagnoses. Their pro-
fessional services may not be sold to anyone except by
themselves
"In a joint meeting of representatives of the staffs of all
the hospitals in Charlotte and this committee .... it was
the unanimous opinion that:
"1. No contract should be entered into by any of these
hospitals without a reasonable assurance that the contract
was workable and could be maintained for more than 30
days.
"2. The hospitals will not assume the responsibility ol
carrying out the contract of the Hospital Savings Associa-
tion with their members unless all hospital charges are
paid for by their association.
"3. Professional medical services should not be con-
tracted for or sold by any organization except one organ-
ized and operated by the doctors involved.
"4. The hospitals will not give any reduction on the
bill for time spent in the hospital beyond the 21 -day limit
of the contract.
"It was agreed by both committees that the hospitals
of Charlotte would and could furnish for $4.00 a day
the following: bed in ward, board, floor nursing, use of
delivery and operating room, dressings, simple and routine
medication, routine urinalyses and blood counts and one
blood chemistry determination.
".\nyone wishing to occupy another room at any time
other than the one in the ward, will be given a credit of
S4.00 per day for the number of days specified in his
contract, this period of time being paid for by the Hospital
Savings Association.
"The committee sees in no way how the contract fur-
nished to the patient helps lift the load from the hospital.
The committee feels that the individual whose income falls
within the lower level is the one who should be helped.
February, 1936
SOUTHERN MEDICINE AND SURGERY
10?
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i^ncxu/^ct fr
jp^ ^ ^ § Compound
Theobromine grs. 2.27 Calcium gr. 0.38 Salicylates grs. 4.35 Phcnobarbital gr. 0.25
DIURETIC, CORONARY VASODILATOR,
MYOCARDIAL STIMULANT AND
NEURO-CIRCULATORY SEDATIVE
May be administered over long periods without gastric irritation
One to three tablets - three times a day after meals
Wm. p. Poythress & Company, inc., Richmond, Virginia
Manufacturers of fine Pharmaceutical Specialities
Please Mention THIS JOURNAL When Writing to Advertisers
104
SOUTHERN MEDICINE AND SURGERY
February, 1936
We suggest that the governmental units (municipal, town-
ship, county, etc.) should provide for their indigent sick.
The committee finds in the plan no solution of the prob-
lem of the contagious case needing hospitalization. It is
the experience in Charlotte that the emergency contagious
case is found largely among those least able to pay and
the committee feels that cognizance should be taken of this
fact and a solution worked out whereby the other patients
in the hospital can be safeguarded while the immediate
needs of the contagious patient are taken care of ade-
quately.
"The committee of this society feels that the present
contract as issued by the Hospital Savings Association has
departed from the original idea as presented to the North
Carohna Medical Society and the Mecklenburg County
Medical Society and, inasmuch as the House of Delegates
of the North Carolina Medical Society has not passed
upon the present contract, the latter should be referred
through the proper channels to this representative body
of the State Medical Society. We request that the other
county societies of the State assist by similar action."
Dr. McKay expressed his regrets that Dr. I. H. Manning
found it inconvenient to attend the meeting. He then
called on Dr. Paul H. Ringer, president of the N. C.
State Medical Society and a member of the Board of
Trustees of the Hospital Savings Association, Inc., in
N. C.
In substance Dr. Ringer stated that the question of x-ray
had been threshed out with a com. from the Roentgenol-
ogical Society, and it was definitely agreed that this was
a medical instead of a hospital service; therefore, x-ray
service is not listed in the contracts sold to the individuals
buying the policy. Dr. Blair's committee felt the plan of
the H. S. A. would have to undergo certain modifications.
Dr. Ringer agreed that the conditions are not the same in
all cities and towns, but he cannot see how one type of
contract can be sold in Charlotte, another in Gastonia,
and others in other towns. The H. S. A. is aiming to
include the "low-bracket" income group. Anesthesia is to
be furnished "if administered by a salaried employe of
the hospital." In Asheville the Hospital Care Association
is paying $9 per anesthesia. The anesthetist under the
H. S. A. plan might reasonably e.xpect $7 or $8, and it
might be that this could be worked out on this basis. It
was Dr. Ringer's feeUng that pathological tissue examina-
tions are a part of medical service; however, practically
ail laboratory work including bacteriology is done by
trained technicians and salaried officials of the hospital.
He, therefore, feels that this should be included as a
hospital service. He was unaware of the clause in the
contract indicating a reduction of l/3rd of rates at the
conclusion of 21 days hospital service offered. He con-
cluded by expressing a feeling that conditions in this State
vary greatly and it will take some sacrifice to serve all the
State.
Questions;
Dr. Leinbach wished to know whether the contracts
have been accepted in other hospitals and medical societies
of other counties — in part or in whole.
Dr. J. S. Gaul raised the question of the care of indigent
patients who would not subscribe to the plan under insur-
ance or any other method to defray their hospital expenses,
also attempting to sell a "block policy" to municipal
governments to defray the expenses of its indigent sick on
the present rate basis or a cheaper rate.
Dr. Northington: In the earlj- stages of the formation
nf this movement, did not its promoters say it would be
limited to those of low'-income group?
Dr. Ringer's answers: I know of no objections to the
contract as applied in other cities.
Dr. Gaul's question of caring for indigent patients is
fine if it can be accepted without becoming mixed with
political groups. He questions its being acceptable in a
city like Asheville.
Nothing has been decided in the meetings to hmit the
sale of the contract to a group with a stated income level;
however, it is decidedly favorable to solicit the lower level
groups. It is his feeling that where a mill superintendent
is solicited to take a policy might not be objectionable
when used as a means for selling it to workers under him.
Dr. Northington asked what success the Hospital Care
Association had made.
Dr. Ringer: Hospital Care .Association has been in
operation for IS months. It is well received. It is apparent
that the hospitals are satisfied with arrangement, and he
is of the opinion that the anesthetists and radiologists are
also satisfied.
Dr. Leinbach pointed out that in Charlotte no hospital
has enough work to require the services of a full-time
physician in x-ray, pathology, or anesthesia; that practi-
cally all x-ray, laboratory and other equipment has been
brought into Charlotte, not by hospitals, but by individual
physicians. He is of the opinion that the Hospital Asso-
ciation plan is in part good, but maintains that x-ray,
laboratory and such services should not be thrown in
and included in the contract for hospital service. This,
he believes, will be detrimental not only to the doctor's
pocketbook, but also to the services offered.
Dr. McKay asked that the status of the Hospital Sav-
ings .Association with respect to the State Medical Society
be discussed by Dr. McBrayer.
Dr. McBrayer: Hospital associations are being organ-
ized throughout the State and the medical profession has
nothing to do with them. In view of this fact, it occurred
to Dr. Manning, when president of the State Medical So-
ciety, that if the doctors and Medical Society of
North Carolina did not take action, hospitalization was
going to be taken over by commercial organizations. The
present Hospital Association plan was referred to the ex-
ecutive committee with instructions to proceed with or-
ganization ; however, the House of Delegates has the au-
thority to adopt, amend, or reject the plan. He expressed
the hope that the Mecklenburg County Medical Society
would look upon the hospital plan from a State-wide view-
point. He stated that a committee of the Roentgenological
Society met in Charlotte with a committee from the H.
S. .A. and formulated final resolutions with respect to
x-ray service. This committee decided that x-ray is to
be included or excluded as optional. Superior Court has
ruled that anesthesia constitutes the Practice of Medicine
and anyone administering it is violating the law of prac-
ticing medicine without a license. It is his feeling that
the same rule governs x-ray and laboratory procedures.
The H. S. A. makes arrangement with the hospitals for
x-ray services and the hospitals should make arrangements
with their roentgenologists.
Dr. Leinbach: What do you think the duty of the
Mecklenburg Society is if they are viewing the thing from
a State-wide view?
Dr. McBrayer stated that he would not attempt to
answer this question, but stated that Dr. W. S. Rankin
had expressed the view that unless the matter was entirely
satisfactory to the Medical Society as a whole, he would
not recommend that the Duke Foundation grant a loan
of §25,000.
Dr. Blair considered the inclusion of x-ray service, path-
ology and anesthesia with hospital service not apphcable.
Dr. Scruggs raised the question as to how under this
contract will anesthesia be paid for.
Dr. EUiott raised the question "How can we accept the
Februan,', 1936
SOUTHERN MEDICINE AND SURGERY
KIRK
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Complete line of intra-
venous and intramuscular
ampoules of highest qual-
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Bacterial vaccines — Kirk
are of high antigenic po-
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30 cc. and 100 c.c. Glass Stoppered Bottles
AMPOULE MEDICATION and BACTERIAL VACCINES
C. F. KIRK COMPANY
Pharmaceutical and Biological Laboratories
Bloomfield, New Jersey
Distributors for Carolinas
Winchester Surgical Company Charlotte, N. C. — Greensboro, N. C.
contract when our cost per day is $1 more than the con-
tract calls for when x-ray is excluded?"
Dr. Ringer requested that he be excused and left the
meeting.
Dr. Davis stated that the committee that went to Lon-
don to seek additional information was not in unanimity
since one member of the committee felt that a federation
of Hospital .•\ssociations should be effected rather than a
State- wide plan. He also pointed out flaws in the contract
as follows:
1. That x-ray service should have been optionally indi-
cated in the contract as was the final agreement of the
committee above referred to.
2. That the clause with respect to anesthesia was
omitted and should be included "when administered by
an employe of the hospital."
3. The reduction of l/3rd after 21 days apparently was
tacked on.
Dr. Hart moved that first the committee on the Hospital
Savings Association be continued; second, that its report
be accepted as information, and, third, that action on the
question be deferred.
This motion was seconded and passed unanimously.
Dr. Gaul requested that this contract be altered or
thrown back into the House of Delegates for further
threshing out.
Dr. McBrayer will undertake to get meeting of directors
and can get those ideas included.
Dr. Leinbach made a motion that a letter of thanks be
sent to Dr. McBrayer and Dr. Ringer for coming to
Charlotte for meeting.
There being no further business the meeting adjourned.
Mecklenburg County Medical Society, January 21st,
Medical Library, Charlotte.
Dr. L. C. Todd under voluntary case reports presented
two interesting dermatological lesions, and illustrated them
with cultures and microscopic slides which were projected
on the screen. One was a case referred to him by Dr. O. L.
Miller which occurred as an ulcer on the knee in a man
35 years of age. The biopsy showed the lesion to be
actinomycosis. The second case was a lesion on the arm
SOUTHERN MEDICINE AND SURGERY
February, 1936
orf a girl 7 years of age. Dr. Elliott had made a clinical
diagnosis which Dr. Todd was able to confirm by smears
from a culture. The diagnosis was sporotrichosis and the
organism was showed in slides of sporotrichum shenchii.
The first case report was given by Dr. Elias Faison,
Subacute Bacterial Endocarditis. Atopsy specimens showed
the vegetation on the heart valves and an infarct in the
spleen. Microscopic views were also shown with aid of
the projectoscope. Liberal discussion followed with the
following taking part: Drs. T. J. Holton, R. F. Leinbach,
William Allan, L. C. Todd, W. Z. Bradford and S. W.
Davis.
Dr. O. L. Miller, Preliminary Report on Experience With
Internal Fixation in Fracture of the Hip. Dr. Miller pre-
sented a patient who had received this treatment, and she
was able to walk and had fair motion of the affected ex-
tremity with very little shortening.
Dr. Sylvia Allen discussed the child guidance clinic. She
pointed out the history of th development of this work
and stated that here in Charlotte, it was her opinion that
124 cases could be considered saved during the past year.
In analyzing the work of the group here, she feels that
real adjustment had been accomplished in 33 per cent.,
partial adjustment in 2 per cent., still under observation
and treatment 44 per cent., and failures 3 per cent. She
also brought to the attention of the society the fact that
the work of the clinic here had received national recogni-
tion along with clinics in other large metropolitan centers.
Her paper was discussed by Dr. Wm. Allan, Dr. S. W.
Davis and Dr. Green Ray.
Dr. S. W. Davis read a letter from Dr. Paul H. Ringer.
Dr. J. A. Elliott as chairman of the auditing committee
reported that Dr. J. D. McGregor's books for the fiscal
year 1935 had been audited and were found to be in
order.
Dr. J. A. Elliott as chairman of the executive committee
made the following recommendations:
1. That all paprs given by members of the society be
limited to 20 minutes and discussions to 5 minutes.
2. Recommends that a Public Relations Committee be
r.ppointed by the president of the society.
Dr. John Q. Myers moved that the above recommenda-
tions be adopted. This motion was seconded and it was
passed unanimously.
Dr. R. B. McKnight as chairman of the program com-
mittee requested that those who have papers to present
please notify him so that they can be scheduled, and he
further stated that he hoped to have Dr. Cahcart of Char-
leston for the next meeting.
Adjourned at 10:30 p. m.
Mecklenburg County Medicai. Society, Tuesday even-
ing, Feb. 4th, Medical Library, Charlotte, the president,
Dr. Hamilton W. McKav, presiding.
Drs. S. W. Davis, T. C. Bost, L. C. Todd and L. D.
Walker gave a composite report of case of Ulcerative
Aortitis, discussed by Dr. William Allan.
Dr. J. P. Kennedy reported a case of Congenital Urethral
Valve, and presented autopsy specimens, discussed by Drs.
Raymond Thompson, Robert McKay, H. L. Newton and
R. A. Moore.
The address entitled What is Public Health? was given
by Dr. William Allan; discussed by Drs. J. Q. Myers and
S. W. Davis. Dr. Davis made the following motion:
"Whereas, the health authorities in controlling infec-
tious diseases have reduced sickness and death to the extent
that today the leading causes of death are chronic heart
disease, Bright's disease, apoplexy and mental disease, be
it resolved the Mecklenburg County Medical Society rec-
ommend the establishment of a Family Records Office (or
Genetics Laboratory) in the Mecklenburg County Health
Office and the State Health Department to study hereditary
diseases and to apply such control measures as are feasible
at the present; seconded and unanimously passed.
Dr. R. B. McKnight made a report on the Physicians'
Credit Exchange and the Charlotte Medical Library, stat-
ing that a Library has been established at Winston-
Salem, and one at Asheville, and that it is possible that
others will be established at Greensboro and Rocky Mount,
and at Spartanburg, S. C.
On recommendations of the secretary to purchase a mul-
tigraph machine for getting out letters. The machine cost
$42.50. This was passed by the society, and the bill was
ordered paid in view of the fact that the secretary had the
equipment on approval.
The president announced the following committee as a
result of the resolution passed at the last meeting recom-
mending a Public Health Relations Committee. Dr. McKay
appointed the following committee: Dr. J. S. Gaul, chair-
man ; Dr. C. N. Peeler, vice chairman ; Drs. Lucius Gage,
T. C. Bost, H. L. Newton, J. H. Tucker and S. W. Davis.
Dr. R. L. Gibbon was appointed to represent the Meck-
lenburg County Medical Society in the Charlotte Co-oper-
ative Nurses' Association.
On motion of Dr. V. K. Hart that no meeting be held
February ISth, as this date conflicts with the meeting of
the Tri-State Meeting of the Carolinas and Virginia wh;ch
will be held at Columbia, S. C, the motion was passed.
Dr. R. B. McKnight reported as chairman of the Pro-
gram that Dr. Cathcart of Charleston would speak at the
first meeting in March.
The meeting adjourned at 9:45 p. m.
(Signed) Stephen W. Davis, M.D.,
Sec.-Treas.
(Signed) Hamilton W. McKay, M.D.
Pres.
Buncombe County Medical Society, Asheville, regular
meeting evening of January 20th, at the City Hall Build-
ing, Pres. Parker in the chair, 42 members present.
Committee on Presidential .'Vddress, Dr. J. W. Huston,
Chr., made a written report, adopted.
Committee on Arrangements for the 1936 State Meeting,
Dr. J. L. Ward, Chr., reported progress.
Address Dr. Geo. W. Kutscher on Prolonged Obscure
Fever of Childhood; discussion Drs. Ward, Freeman, Har-
rison, Elias, Huffines and essayist.
Dr. Greene spoke of the recent coming into State of
Dr. Milton J. Rosenau of Harvard University to organize
the new Dept. of Hygiene and Public Health at the Uni-
versity of N. C. He read a resolution in this regard and
moved its adoption, carried unanimously. Dr. Greene spoke
of a recent meeting of the State Med. Soc. Committee
with the N. C. Industrial Commission. He announced that
in a great many instances the professional fees for indus-
trial illnesses and injuries had been increased. A new fee
schedule would be announced shortly.
The secretary brought to attention proposed changes in
our By-Laws in regard to the dues. Dr. Greene moved
the adoption of the amendment as read. Sec. by Edwards
and carried unanimously.
The application for membership of Dr. Wm. C. McGuffin
was read by the secretary and referred to the Board of
Censors for consideration.
The president announced the resignations from our so-
ciety of Drs. Alfred Blumberg, J. C. George, G. C. Godwin
and Geo. H. B. Terry, all of the Oteen Med. Staff. The
secretary announced the resignation of Dr. Edward King.
Buncombe County Medical Society, Asheville, Feb.
3rd, 34 members present; visitors, Dr. Costin of the Mission
February. 1936
SOUTHERN MEDICINE AND SURGERY
^%>!2
For the relief of pain in cancer, Dilaudid, in doses of
l/48 to 1/16 grain, given about every 3 hours for a con-
tinuous effect, tends less than morphine to cause loss
of appetite, nausea, constipation or marked drowsiness.
Dose: About \/5 that of morphine - - 1/20 gr. Dilaudid
will usually take the place of 1/4 gr. morphine.
*DI LAU D I D (dihydromorphinone hydrochloride) Council AcCSpied
Hypodermic and oral tablets, rectal suppositories, and as a soluble powder
• Dilaudid comes within the scope of the Federal Narcotic Regulations.
No prescription containing Dilaudid, regardless of quantity, is refillable.
Bl LH U BE Rfc KNOLL CORR i5aogden?ave. jersey citM'nJj:
Hosp. Staff and Mr. Clippard.
Dr. J. T. Saunders: Injuries to the Knee Joint (patient
presented). Discussion opened by Dr. Geo. Mears who
showed several x-ray films. Dr. Suggett continued the dis-
cussion. Closed by the essayist.
The application for membership of Dr. Wm. R. Mc-
Guffin, approved by our Board of Censors, was presented
and unanimously approved.
The application of Dr. Russell D. Holt for Associate
Membership in our society was presented by the secretary
and referred to the Board of Censors.
Dr. Johnson, that 63 journals were now coming to the
Medical Library regularly and urged more general support
from our membership.
(Signed) M. S. Broun. M.D., Sec.
From Dr. A. E. Baker, jr., Charleston
Dr. Keith F. Sanders was honored December 28th with
a dinner party by the staff of the Kelley Sanatorium,
Kingftree, where he had served as house physician for the
last five years. Doctor Sanders is leaving to open an
office for private practice in Kingstree. The delightful
affair was given in the dining room of the hospital; covers
were laid for 30 guests. Dr. W. Gordon Rodgers was
master of ceremonies, and impromptu speeches were heard
from several of the guests, who included, besides the hos-
pital staff, several of the physicians of the town and their
wives and other close friendsof Doctor and Mrs. Sanders.
Miss Martha Thurmond, Edgefield, and Dr. Walter
Grady Bishop, Greenwood, were married Jan. 18th at the
Edgefield Baptist Church. The ceremony was performed
by the Rev. B. \V. Thomason in the presence of an assem-
blage of more than 500 persons. The bride is a graduate
of Winthrop College and has until recently taught in
F-OR
The majority of the phy-
sicians in the Carolinas
are prescribing our new
tablets
/^ANDg
751
Analg«sle and Sedative 7 parts 5 parts I part
Aspirin Phenacetin Caffein
We will mail projessional samples regularly
with our compliments if you desire them.
Carolina Pharmaceutical Co., Clinton, S. C.
Orangeburg High School. She is a daughter of Mrs. Ger-
trude Strom Thurmond and the late J. William Turmond.
Doctor Bishop is a son of Mr. and Mrs. W. W. Bishop,
Inman, and is one of the most successful young physicians
of the State. He received his medical training from the
South Carolina Medical College in Charleston and was
afterwards on the staff of Roper Hospital before going
to Greenwood.
F'uncral services for Dr. Joseph Walker Eargle, 88, of
Chapin, who died January 4th, were conducted in the
108
SOUTHERN MEDICINE AND SURGERY
February, 1936
afternoon of the 5th from Mount Olivet Lutheran Church
at Spring Hill. Doctor Eargle was a pioneer physician in
the Dutch Fork section, where he practiced for 61 years.
He was born in the Dutch Fork, July 14th, 1847, and
attended school in Lexington County. He received a lit-
erary degree from Mount Pleasant Collegiate Institute in
North Carolina and was graduated from the South Caro-
lina Medical College in Charleston. He took post-graduate
work at Columbia University and served his intemeship
at Bellevue Hospital in New York and at Roper Hospital
in Charleston.
BOOK REVIEWS
Dr. J. F. Foster, prominent physician and a leading
physician and a leading citizen of Sanford, N. C, has been
selected as Lee County's Man of the Year for 1933, in the
recent contest sponsored by the Sanford Herald, and has
been awarded a silver loving cup.
Dr. T. Stanley Meade announces the opening of offices
at 913 Floyd Avenue, Richmond, Virginia. Practice lim-
ited to Care of Infants and Children.
Dr. Tom Sasser, Charlotte, announces the removal of
his office to the First National Bank Building.
Miss Edna Elizabeth Keily of Bristol, Tenn., and Dr.
Bernard Showalter of Kenbridge, Va., on Dec. 19th.
Dr. Hubert A. Royster, jr., of Philadelphia and Miss
Elizabeth Rutan of Bryn Mawr were married at the home
of the bridge on January 17th, 1936.
Dr. Charles Walton Purcell of Charlottesville and Miss
Cleo Virginia Ashby of Raleigh.
Deaths
Dri-Ghades-P.-Smithj 7S, prominent physician and well
known in political circles, died Jan. 17th at his home at
Martinsville, Va.
Dr. Frank Vaughan Fowlkes, retired, of Richmond, Jan-
uary 20th, following a paralytic stroke suffered the day
before.
Dr. Thomas W. Edmunds, 50, Danville, Va., for many
years an eye, ear, nose and throat specialist, died Feb. 1st
of puneumonia in a hospital at Clearwater, Fla., where he
went two weeks ago because of a cold.
Dr. Clarence Linden Lewis, 65, retired, January 17th, at
Bilo.xi, Miss.
Dr. Lewis established his residence in Richmond about
ten years ago, moving to this city from Nashville, after
retiring from the active practice of his profession.
Dr. .-Mfred Alfred W. Howell, 7S, died at his home at
Cherryville, N. C, Jan. 18th, after months of failing
health. Dr. Howell was born in Cherokee County, Ga.,
and had been engaged in the general practice of medicine
in Cherryville for 52 years. He was active and kept up his
practice until about two months ago. Among the surviv-
ors are two doctor sons: Dr. John H. Howell, Anderson,
S. C, and Dr. Wayne Howell, Gaffney, S. C.
I had an ambition for surgery — general surgery — and
performed all sorts of beautiful and brilliant operations. —
From The Story of My Life, by J. Marion Sims.
SOCIAL SECURITY, by Edward H. Ochsner, M.D.,
Chicago. Social Security Press, 538 S. Wells St., Chicago,
Cloth bound, 231 pages, 50c, postpage prepaid in U. S.
Woodrow Wilson is quoted: "It will be a bad
day for society when sentimentalists are encouraged
to suggest all the measures that shall be taken for
the betterment of the race."
Dr. Ochsner has had experience with German
Medicine institutions. He was for four years presi-
dent of the Illinois State Charity Commission. His
experience with the practical operation of the va-
rious forms of social security insurance and large
charities both in Europe and in this country qualify
him to speak.
The book discusses old age pensions, unemploy-
ment insurance, compulsory health insurance, and
widows' and orphans' pensions. He would arouse
the professions and the general public to an impend-
ing danger and dispel a number of quite generally
held false opinions.
Under social insurance in other countries the
number of days lost by the German worker from
sickness has more than doubled, and the mortality
rate is higher in Germany today than in this coun-
try. The quality of medical services has deteriorat-
ed under compulsory health insurance and the costs
of hospital and medical care are increasing year
by year.
Dr. Ochsner's book is not burdened with vol-
uminous statistics. Many first hand experiences
are recited and the facts are forcibly stated. The
work attracts by what it says and by the method
of saying.
THE 1935 YE.\R BOOK OF GENERAL SURGERY,
edited by Ev.\rts A. Grah.«i, A.B., M.D., Professor of
Medicine, Washington niversity school of Medicine, St.
Louis. The Year Book Publishers, Inc., 304 S. Dearborn
St., Chicago. 3.00 postpaid.
Peripheral vascular disease has much said about
it, likewise thoracic surgery and acute pancreatic
diseases. New features in preparing patients for
operation are brought forward. Certain of the
newer anesthetics have much said for them. Im-
provements in operative technique are described.
Wound healing and improved bone surgery are fea-
tured, Dr. A. G. Brenizer on Cancer of the Thyroid
is given a long abstract, Ulcer of the Stomach is
given much space. Splenectomy seems to be re-
gaining its popularity, but to be used with great
discrimination. The editor's comments are pithy
and pertinent.
"As the calorimeter tells the activity of the patient's met-
abolism, so may you determine the plus or minus activity
of the local profession in any district by the condition of
its library." — Harvey Cushing.
February. 1036
SOUTHERN MEDICINE AND SURGERY
AS AC
ELIXIR ASPIRIN COMPOUND
ANTI-RIIEl'M Vnc MItJUAIMi:
Indications
All conditions in which any of the Salicylates
liave proven of value for the relief of Rheumatism.
Neuralgia, Tonsillitis, Headache; also pre and post
minor operative cases, especially removal of the
tonsils.
Description
ASAC contains five grains of Aspirin, two and
line-half g'rains Sodium Bromide, and one-half grain
( 'afFeine Hydrobromide to the teaspoonf ul in stable
Elixir.
Dosage
The usual dose, subject to modification by the phy-
sician, ranges from two to four teaspoonfuls in one
to three ounces of water.
How Supplied
In Pints, Five-Pints and Gallons to Physicians and
Druggists only; thus eliminating the self medication
now so prevalent with Aspirin in tablet form.
Burwell & Dunn Company
Manujactiiring Plianiiaciils
CHARLOTTE, N. C.
Sample sent to any physician in the U.S. on request
The Doctor Looks at the Cults
(C. L. Farrell, Pawtucket. in R. I. Med. Jl., Jan.)
The medical profession's attitude has been more or less
indifference toward them. When any group begins to leg-
islate itself into the same standing as the medical pro-
fession, it is time that something was done.
/ believe that it is the solemn duty of the medical pro-
Jession to protect the people from charlatans and quack-
ery and that the education of the people in the matters
of heahh must be undertaken by us.
A few years ago many neurotic persons had "adjust-
ments" apparently without any harm resulting and the
medical doctor recognized that the cult was supplying a
mental peace to the inferior minds that needed a placebo.
I questioned their committee at the State House last Jan-
uar>- as to why they wanted to administer drugs when
the osteopathic principles were against it. To my amaze-
ment, they refused to be bound by this principle. They
had no answer when I informed them it was the word
of their founder, A. T. Still. Further conversation with
these osteopaths, elicited the belief that osteopathy was
but one therapeutic measure in their armamentarium and
it was no longer regarded as a separate theory of disease.
Because of the indifference of organized medicine regard-
ing osteopathy they have gathered unto themselves dignity
and privileges to which they are not entitled; there is a
determined attempt on the part of the osteopaths to legis-
late themselves into the same standing as regular prac-
titioners. They desire to be school physicians and health
officers. They desire to write prescriptions — and this in
spite of the fact that the most recent pronouncements of
their authorized schools reiterate their belief in osteopathy
as originally defined, the frank substitution of osteopathic
therapeutics and osteopathic medicine in place of materia
medica and practice of medicine. The basic science law
will check these individuals in a fair and impartial manner.
It is the practitioner's privilege to treat the patient any
way he so desires especially so if it satisfies the patient, but
we want to be sure that he first recognizes the condition
he is treating and has been exposed to at least a safe min-
imum of general training. We in the medical society hope
to put through a basic science law. So far we have not
succeeded, but we have made definite progress. You have
no realization of the outrageous and extravagant claims
made before legislative bodies by the irregular practitioners,
and we are always put in the position of being afraid
of the irregulars and jealous of our hold on the people
"as a medical trust."
The fault hes wholly at the door of the medical pro-
fession because each and every individual in these other
cuUs strives together for the good of the cults, while the
doctors are too prone to concern themselves with scien-
tific assemblies and neglect their professional responsibility
in public health.
I hope in the future, as each medical student takes
his internship, he will begin to pick up that spirit of re-
sponsibility, shouldering his part of the burdens and re-
sponsibilities that go with being a doctor. The old policy
to ignore the irregulars and let the poor fools who will
patronize them, must be discarded, and a sense of civic
duty and responsibility recognized wherein we assume the
role, guardians of the public health in all its phases.
In December, 1802, Lettsom sent to the College of Phy-
sicians of Philadelphia a supply of vaccine virus. He was
elected an .'\ssociate Fellow. But Jenner, proposed by
Plunket Glentworth, failed of election.
In 1787 the College of Physicians of Philadelphia ap-
pointed a committee to submit plans for establishing cold
and hot baths and a botanical garden for the city.
SOUTHERN MEDICINE AND SURGERY
February, 1936
The Safest Anesthesia vs. Safest Anesthetic
(Jos. Galasso, New York City, in Anes. & Anal..
Jan. -Feb.)
The odor of cyclopropane is not unpleasant, it is rapidly
absorbed, very rapidly eliminated, and is non-toxic, and
non-irritating to the respiratory tract. As far as we know,
it does not chemically combine with any fluid or tissue in
the body, is not detoxified in any organ or tissue, does not
affect metabolism or blood pressure, and does not cause
any structural or functional change in any organ or tissue.
There is absolutely no contraindication to its use. Dia-
betes, tuberculosis, heart disease, nephritis, hypertension, or
any of the other usual contraindications to the use of the
ordinary inhalation anesthetic agents present no barrier.
Not one death or aggravation of existing functional or
structural disease has been encountered. For intra-abdom-
inal surgery it shows its superiority over ether in the
quiet relaxed belly simulating that of spinal anesthesia.
Vomiting is almost an unheard-of complication when cyclo-
propane is administered properly — and this is certainly a
blessing for patients who have had intra-abdominal sur-
gery and especially of the stomach. Recovery is shortened.
Fluid and food intake can be instituted much sooner than
after ether. \ patient who has undergone previous opera-
tion under ether anesthesia will not only notice the great
change but will invariably mention the fact that this one
has been the best anesthetic he has ever taken.
All anesthetic agents are poisons. The safest avenue of
administration is that which is most controllable — the in-
halation route. The best technique of administration is
the one which insures an atmosphere of at least 20% o.xy-
gen and carbon dioxide reduced to a minimum. The safest
anesthetic agent — the one which presents all the good quali-
ties and none of the objectionable side effects of the agents
we have on hand is cyclopropane.
Hiccough
(E. L. Kellog & Wm. Meyer, New York, in Med. Rec,
Nov. 20th)
Dr. Gibson quotes the following passage from Plato's
Dialogues: "when Pausanias came to a pause Aristodemus
said that the turn of Aristophanes was next, but that he
had the hiccough, and was obliged to change with Eryxi-
machus, the physician, who was reclining on the couch be-
low him. ■En.'ximachus' he said, 'you ought either to stop
my hiccough or to speak in my turn until I am better.'
" 'I will do both,' said Eryximachus, 'I will speak in
your turn and do you speak in mine ; and while I am
speaking, let me recommend that you hold your breath,
and if this fails, gargle with a little water; and, if the
hiccough still continues, tickle your nose with something
and sneeze, and if you sneeze once or twice, even the
most violent hiccough is sure to go. In the meantime I will
take your turn and you shall take mine'."
Among unusual measures are intubating the esophagus
leaving the tube in situ, digital compression of the phrenic
nerve, lifting up the hyoid bone and compressing it with-
out checking respiration, grasping the left carotid sheath
with the thumb and forefinger at the anterior border of
the middle portion of the sternomastoid muscle and com-
pressing it tightly for one minute, hypodermic injections
of apomorphine (J^th gr.), hypnotism, an emetic dose of
ipecac, hypodermic injections of ether and inhalations of
carbon dio.xide and oxygen. Lumbar puncture has relieved
a case of 15 months' duration.
Thyroid extr.^ct accelerates the transition of salt and
water from the tissue. It is best used in chronic nephrosis,
3 to 15 gr. daily, with a high-protein diet. — Harold W.
Jones.
Should you be disappointed in quinine by mouth
(0. F. Manson, Richmond, in Va. Med. Monthly, Jan.,
1882), you may give it by the rectum, and should this
be expelled, we have, thanks to a recent discovery, an
invaluable resource in the hypodermic method. Dissolve
the dose in a half drachm of distilled water, by the addi-
tion of 1 drop of dilute sulphuric acid to the grain of the
sulphate, and inject it. There are objections to its use,
in this way — the principal one being the excitement of
local inflammation, and the production of troublesome
abscesses. Usually, by persistence in its use, enough quinine
will be absorbed by the buccal and gastric mucous mem-
brane to bring the patient under its influence.
The Electrocardiogram (L. H. Signer, in Med. Times
&■ L. I. Med. JL, Jan.) must be correlated with chnical
findings if significance is to be attached to it. As a lab-
oratory method, a full understanding of possible techni-
cal errors and a proper interpretation of the findings are
imperative in order that we be not misled rather than
aided in our diagnosis.
The sexton had been laying the new carpet on the pulpit
platform, and had left a number of tacks scattered on the
floor. «
"See here, James," said the parson, "what do you suppose
would happen if I stepped on one of those tacks right in
the middle of my sermon?"
"Well, sir," replied the sexton, "I reckon there'd be one
point you wouldn't linger on." — Waichii'Drd.
Couldn't Remember One Off-hand
Ed — "I guess you've been out with worse looking fellows
than I am, haven't you?"
Ed — "I say, I guess you've been out with worse looking
fellows than I am, haven't you?"
Cod-ed — "I heard you the first time. I was just tr>'ing
to think."
No answer.
Somebody pulled the bell rope. The engineer put on the
brakes too quickly, and one of the cars went off the rails.
"We'll be tied up about four hours," announced the con-
ductor.
"Four hours!" exclaimed a passenger. "But I'm to be
married today!"
"See here," the conductor demanded, "you aren't the guy
who pulled the bell rope, are you?"
.^n old lady who could not see eye to eye with the taxi-
driver on the question of fare, finally remarked: "Don't
you try to tell me anything, my good man. I haven't
been riding in taxis for five years for nothing."
"No," replied the driver, "but I know you made a
faithful try!"
I
"Your Honor," said the prisoner, "will I be tried by a
jury of women?"
"Be quiet," whispered his counsel.
"I can't be quiet ! Your Honor, I can't even deceive my
own wife, let alone 12 women."
"This tonic is no good."
"What's the matter?"
".\11 the directions it gives are for adults, and I never
had them."
February. 1Q36
PROFESSIONAL CARDS
GENERAL
Nalle Clinic Building
THE NALLE
Telephone— i-2\-i\ (If no
General Surgery
BRODIE C. NALLE, M.D.
Gynecology & Obstetrics
EDWARD R. HIPP, M.D.
Traumatic Surgery
PRESTON NOWLIN, M.D.
Proctology & Urology
CLINIC
answer, call 3-2621)
General Medicine
412 North Church Street
Consulting Staff
DOCTORS LAFFERTY & PHILLIPS
Radiology
HARVEY P. BARRET, M.D.
Pathology
LUCIUS G. GAGE, M.D.
Diagnosis
G. D. McGregor, m.d.
Neurology
LUTHER W. KELLY, M.D.
Cardio-Respiratory Diseases
J. R. AD.'\MS, M.D.
Diseases of Infants & Children
W. B. MAYER, M.D.
Dermatology & Syphllology
BURRUS MEMORIAL HOSPITAL, INC.
(Miss Gilbert Muse, R.N., Supt.)
General Surgery, Internal Medicine, Proctology, Ophthalmology, et
High Point, N. C.
Diagnosis, Vro
Pediatrics, X-Ray and Radium, Physiotherapy, Clinical Laboratories
STAFF
John T. Burrus, M.D., F.A.C.S., Chief Everett F. Long, M.D.
Harry L. Brockmann, M.D., F.A.C.S.
Phillip W. Flagge, M.D., F.A.C.P.
O. B. Bonner, M.D., F.A.C.S.
S. S. Saunders, B.S., M.D.
E. A. Sumner, B.S., M.D.
WILSON CLINIC, INC.
AND
WOODARD-HERRING HOSPITAL, INC.
SUCCESSORS TO
The Moore-Herring Hospital
WILSON, N. C.
Surgery
C. A. WOODARD, A.B., M.D., F.A.C.S.
Pediatrics and Obstetrics
G. E. BELL, B.S., M.D.
X-Ray and Traumatic Surgery
M. A. PITTMAN, B.S., M.D.
General Medicine
R. L. FIKE, A.B., M.D.
Miss Leona D. Boswell, R. N.
SUPERINTENDENT OP
The Training School For Nurses
L. C. TODD, M.D.
Clinical Pathology and Allergy
Office Hours:
9:00 A. M. to 1:00 P. M.
2:00 P. M. to 5:00 P. M.
and
by appointments, except Thursday afternoon
724 to 729 Seventh Floor Professional Bldg.
Charlotte, N. C.
Phone 4392
WADE CLINIC
Wade Building
Hot Springs National Park, Arkansas
H. King Wade, M.D. Urologist
Charles S. Moss, M.D. Surgeon
J. 0. Boydstone, M.D. Internal Medicine
Jack Ellis, M.D. Internal Medicine
N. B. BuRcn, M.D.
Eye, Ear, Nose & Throat
Raymond C. Turk, D.D.S. Dentist
A. W. ScHEER X-ray Technician
Miss Etta Wade Clinical Pathologist
Please Mention THIS JOURNAL When Writing to Advertisers
PROFESSIONAL CARDS
February, 1936
INTERNAL MEDICINE
JAMIE W. DICKIE, B.S., M.D.
INTERNAL MEDICINE
DISEASES OF THE CHEST
Pine Crest Manor, Southern Pines, N. C.
STEPHEN W. DAVIS, M.D.
Diagnosis
Internal Medicine
Passive Vascular Exercises
Oxygen Therapy Service
Medical Arts Bldg. Charlotte, N. C.
JAMES M. NORTHINGTON, M.D.
Diagnosis and Treatment
in
INTERNAL MEDICINE
Professional Building Charlotte
ORTHOPEDICS
J. S. GAUL, M.D.
ALONZO MYERS, M.D.
ORTHOPEDIC SURGERY and
ORTHOPEDIC SURGERY and
FRACTURES
FRACTURES
Professional Buildinff Charlotte
Professional Building Charlotte
HERBERT F. MUNT. M.D.
FRACTURES
ACCIDENT SURGERY and ORTHOPEDICS
Nissen Building
Winston-Salem, M. C.
EYE, EAR, NOSE AND THROAT
AMZI J. ELLINGTON, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
PHONES:
Burlington
Office 992— Residence 761
North Carolina
J. SIDNEY HOOD, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
PHONES: Office 1060— Residence 1230-J
3rd National Bank Bldg., Gastonia, N. C.
H. C. NEBLETT, M.D.
OCULIST
Phone 3-5852
Professional Building Charlotte
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Februan', 1036
PROFESSIONAL CARDS
OBSTETRICS and GYNECOLOGY
C. H. C. MILLS, M.D.
OBSTETRICS
Consultation by Appoint
1st Nat'L Bank Building Charlotte
NEUROLOGY and PSYCHIATRY
W. C. ASHWORTH, M.D.
W. CARDWELL, M.D.
yERVOUS AND MILD MENTAL
DISEASES
ALCOHOL AND DRUG ADDICTIONS
Glenwood Park Sanitarium. Greensboro
\Vm. Ray Griffin, M.D.
Appalachian Hall
M. A. Griffin, M.D.
DOCTORS GRIFFIN and GRIFFIN
NERVOUS and MENTAL DISEASES,
and ADDICTIONS
UROLOGY, DERMATOLOGY and PROCTOLOGY
THE CROWELL CLINIC OF UROLOGY, DERMATOLOGY AND PROCTOLOGY
Suite 700-717 Professional Building Charlotte, N. C.
Hours— Nine to Five Telephones— 3-7101— 3-7102
STAFF
Andrew J. Crowell, M.D. Claude B. Squires, M.D.
Raymond Thompson, M.D. Theodore M. Davis, M.D.
Dr. Hamilton McKay Dr. Robert McKay
DOCTORS McKAY and McKAY
Practice Limited to UROLOGY and GENITO-URINARY SURGERY
Hours by Appointment
Occupying 2nd Floor Medical Arts Bldg. Charlotte
WYETT F. SIMPSON, M.D.
GEXITO-URJNARY DISEASES
Phone 1234
Hot Springs National Park Arkansas
C. C. MASSEY, M.D.
Diseases of the Rectum &■ Coloh
Professional Bldg. Charlotte
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PROFESSIONAL CARDS
February, 1936
SURGERY
G. CARLYLE COOKE, M.D.
GEO. W. HOLMES, M.D.
Diagnosis, General Surgery and X-Ray
Nissen Bldg. Winston-Salem, N. C.
R. B. Mcknight, m.d.
General Surgery
Professional Bldg. Charlotte
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 will be rendered on terms comparing favorably with those
charged generally in other Sections of the Country — taking into consideration the
prices paid for cotton and tobacco.
SOUTHERN MEDICINE & SURGERY.
Please Mention THIS JOURNAL When Writing to Advertisers
Journal
of
SOUTHERN MEDICINE ^ SURGERY
Vol. XCVIII
Charlotte, N. C, March, 1936
No. 3
Art of Practice and Healing
C. C. Orr, jNI.D., Asheville, North Carolina
IX choosing a subject for the address which
it is my privilege to make at this time, I was
mindful of the fact that my audience is com-
posed of general practitioners and sf>ecialists in all
the different branches of healing and that many sub-
jects that would interest one class would be wholly
uninteresting to others. After careful considera-
tion I have decided to speak to you on the Art of
Practice and Healing, a subject which if carefully
studied and understood will add much to the suc-
cess of general practitioners and specialists alike.
By art of practice and healing we mean skill or
proficiency in doing it. Art, in general, is but
the employment of the powers of nature for an end.
It uses system and traditional methods for facilitat-
ing the performance of certain actions. The art
of practice and healing is closely allied with the
science of medicine and the one is more or less de-
pendent upon the other. Yet, the object of science
is knowledge and truth — the object of art is work.
Both may be said to be investigations of truth; but
science inquires for the sake of knowledge, art for
the sake of production; hence they differ some-
what in that with which they are concerned.
Science is analytical and critical while art is syn-
thetical and constructive. Art involves skill in the
use of knowledge which may have been furnished
by the corresponding science. It may be viewed
as arranging or systematizing knowledge and form-
ing rules which are the lessons of experience and
which are designed to facilitate work and give it
superior e.xcellence. The more complete the scien-
tific basis the more perfect the art. Healing as an
art is the work of the skilled physician: healing as
a science is the work of the informed and analytical
brain seeking truth. The relationship of the two
has been paraphrased thus: ".Art consists in doing,
science consists in knowing."
It is difficult to say just when medicine assumed
a definite status in human affairs, but its origin may
be traced to the primal sympathy of man with
man. Sympathy is one of the most effectual of the
emotions and like all emotions it is the antecedent
of desire. The emotion of sympathy and pity in-
spired man with a desire to relieve human suffering
and pain. In primitive man these emotions were
concerned more or less with self-preservation and,
having little or no knowledge of the phenomena of
nature with which he was surrounded, man sought
an e.xplanation in the supernatural. This led to
the setting aside of men who had access to the
invisible spirits and these men became priests and
priest and physician were often one. Deification
became popular. Later medicine and religion sep-
arated. Those who followed medicine devoted
themselves to the relief of human suffering with
no knowledge of the fundamental sciences and the
resources of the physician were practically limited
to the art of magic, sorcery and incantations. Fear
and superstition predominated in the minds of the
physicians, priests and people. For a period there
was a belief in astrology. Then came the Greek
philosophers who often were physicians as well.
Medicine became still further separated from re-
ligion and closely associated with philosophy. The
great impression that Greece made on medicine
was due to the philosopher-physician. There was
developed a philosophical reasoning and vivid
imagination that led to constructive thinking. The
physician, Empedocles, introduced the theory of
the four elements — fire, air, earth and water —
composing all bodies. The disturbance of any one,
or all, would produce disease. .Although erroneous
it was a step forward. The Greeks were the first
to transcend mysticism, superstition and ritualism
and grasp the conception of medicine as an art.
Greek medicine as expounded by Hippocrates and
•Presented to the Tri-State Medical Associatinn of the Carolinas and Virginia, meeting at Columbia, South Caro-
lina, February 17th and 18th.
PRESIDENT'S ADDRESS— Orr
March, 1936
later by Galen ruled the art of practice and healing
for hundreds of years; but during this time, for
lack of knowledge of the fundamental sciences on
which the art must rest, little progress was made.
After the fall of Rome there was the period of
the Dark Ages lasting 1,000 years during which
little progress was made in medicine either as an
art or science. The land was overrun by quacks
and charlatans who played upon the credulity and
ignorance of the people.
In the 13th and 14th centuries the little know-
ledge of medicine had survived the Dark Ages began
to take form in Southern Italy and soon there
arose a medical school that became famous. There
was an increase in the knowledge of anatomy, phy-
siology and chemistry, but medicine made slow
progress. The real cause of disease remained a
mystery until the great scientific discoveries of Pas-
teur, Lister, Koch and others were given to the
world. From this time on medicine assumed th;
dignity of a science and made rapid strides.
Previous to this the art of practice and healing
may ha.ve made certain attainments, but more
often resulted in failure than success for it had no
scientific knowledge of truth as a basis. With the
knowledge of anatomy, physiology, chemistry,
pathology and bacteriology there was constructed
a solid scientific base for the development of the
art of practice and healing. Every physician should
be familiar with the fundamental and allied sciences
to attain success in the practice of medicine, yet
with this foundation he may be a failure if he has
not that intuition, personality, individualism or,
using a more comprehensive clause, if he has not
the art of bringing relief, hope and healing into
the life of suffering humanity.
There are few in this audience who do not re-
member some classmates who were good students
and who could turn in excellent examination papers
or answer most any scientific or technical question,
but who when they assumed a practice somehow or
other failed to achieve that success which was ex-
pected of them. Perhaps, also, you remember some
who did not do so well, barely passed the State
Board and yet who are successful practitioners. It
is true that some of these did not wake up or find
themselves until brought in actual contact with
the patient, and while they knew somethin'; o.'
the science of medicine and surgery they were quick
to adapt themselves to the needs and environment
of their patients and to learn much in that greates
of all schools, experience. They may not have been
specialists, but they were experts in the art of prac-
tice and healing.
A clear definition of the art of healing is d ffi-
cult. Some call it a knack to deal with the pa-
tient in such a way as to gain his confidence, his re-
spect and his liking; to remove all emotional diffi-
culties; to adjust the prescribed treatment to his
peculiar idiosyncracies of mind and body and to
get his coop)eration in carrying out treatment.
How is this art to be learned? Can it be taught?
Our medical schools are of the highest standard.
They are well equipped for study in all of the
scientific branches. The requirements for entrance
to these schools are very strict and are becoming
more so. Most students in working for their col-
lege degree direct their studies along scientific lines
as a preparation for entrance into a medical school.
The scientific preparation of our students and grad-
uates from medical school is perhaps better than
it has ever been. Graduates have a thorough
knowledge of disease and its treatment, they are
familiar with the fundamental sciences; and yet
we wonder if they are more proficient in the art of
practice and healing than the older practitioners
who have had fewer advantages. This art depends
much on the student's original endowment of brain
and heart, on his ability to like people, to get along
with them, to understand them, to sympathize with
them and to make people like him and to have coit-
fidence in him. Perhaps in no other profession is
there such need for good judgment, for good sense,
for the poise, culture and charity of a philosopher.
Is it possible for the student to learn something
of this art while pursuing his scientific studies?
Some of the heads of the leading schools in the
country are now beginning to see the need of
giving this subject more attention and, wisely, they
are turning to the successful practitioners for help;
asking them to give lectures or act as preceptors so
that the student may know something about the art
of healing as it is carried on outside of the hos-
pital and college. One of our large universities
(Wisconsin) has had all fourth-year students work
under the supervision of competent practicing phy-
sicians and are sent for part of that year into
adjacent large cities and smaller cities under the
supervision of competent clinicians. In this way
they are brought in direct contact with the prob-
lems of medicine.
No one is or should be better trained in the art
of practice and healing than the general practitioner
who usually is called upon to assume the position
of family adviser. It is claimed he is rapidly dis-
appearing. He is still a necessity with us and ever
will be. He has discarded his high silk hat, his
long frock coat and gold-headed cane and comes
forth with new modern equipment, a diploma show-
ing he is familiar with the basic sciences, equipped!
v»fith laboratory, technicians, hospital and every!
means for making a diagnosis and with competent!
specialists at his service, he is better qualified than 1
ever before to assume the envied position of family
March, 1936
PRESIDENT'S ADDRESS— On
physician or medical adviser. The importance of
the family physician is recognized and will be more
so in the future. The public should be taught that
the family physician is essential to its welfare no
matter what the problem is or may be, and that
no one is better versed in the art of practice and
healing than he.
Perhaps the time when the art of healing was
at its height was the period of the Revolutionary
War and the years following. Men's minds were
turned to serious matters. Devotion to a principle
was taken seriously. There were such men as
Shippen, INIorgan and Rush, later came our beloved
Osier. These men made an art of practice and
healing. They were great physicians. Rush loved
medicine. He believed in it with a patriotic fervor.
He was a product of his time, a time when medical
men were called upon to face adversity and when
adversity was a stimulus to thought and action.
Osier, himself, was a wellnigh perfect example
of the union of science and the humanities. He was
imbued with the art of medicine as well as the
sciences and he advanced and enriched both. He
was the friend of all he met. He know the work-
ing of the human heart, metaphorically as well as
physically. He achieved many honors but none
greater than his power to bring hope and courage
as he stood by the bedside of the sick. To him
no mercenary thought or cold scientific fact ever
overshadowed that warmth of sympathy that makes
for trust and confidence between patient and phy-
sician. He was a great physician and equally as
great in the art of practice and healing.
It is not my purpose to speak disparagingly of
scientific training; it is essential. We are un-
justly accused sometimes of becoming ultra-
scientific. The urine, the blood, the spinal fluid or
bit of tissue can be taken to the laboratory and
should be, but we should not be forgetful of the
personality of the patient, a dual personality, a
physical and spiritual, each reacting on the other —
to a personality which cannot be carried to the lab-
oratory. To be able to correlate all symptoms,
physical and spiritual along with laboratory find-
ings and to give them their true evaluation, and
to tune the eye and ear and the touch to the dis-
cords of nature — this is an art developed by the
true clinician only.
Our medical education has changed and scien-
tific study has become paramount. Specialists are
being developed more rapidly than ever before.
Preventive medicine has grown and is being empha-
sized by State and Federal government. Group
practice, large and small clinics, and various guilds
have sprung up over the country. The probability
or possibility of state medicine or socialistic medi-
cine stares us in the face. These changes are prob-
lems for organized medicine. Whether these
changes come or not they should not cause the phy-
sician to lose that personal touch with the patient.
They should not make his practice become one of
routine duty and a mechanical procedure with fixed
compensations and rewards, destroying all enthusi-
asm for the development of the art of healing and
all stimulation and initiative for investigation and
research. Under whatever scheme or change that
may come, may the art of practice and healing be
not forgotten. The art may sometimes be glorified
unduly, and there is such a thing as emphasizing
overmuch the science; the true physician is the one
who combines both.
It has been a very great and pleasant privilege
for me to serve as your president during the
past year. Conscious of the responsibilities of the
office, I have felt my inability fully to measure up
to the high standard set by the distinguished men
who from year to year have preceded me. They
were the leaders who with the faithful and untiring
help of capable secretaries and other officers, and
the cooperation of members, have developed our
Association into what it is today — an Association
of doctors of which we all feel justly proud.
May I close with the words of Robert Louis
Stevenson who knew the physician so well: "Gen-
erosity he has such as is possible to those who prac-
tice an art, never to those who drive a trade; dis-
cretion tested by a hundred secrets, tact tried in a
thousand embarrassments, and what are more im-
portant Herculean cheerfulness and coura'^e. So
it is that he brings art and cheer into the sick room
and often enough, though not as often as he
wishes, brings healing."
vi^-^m"^;::::/
SOUTHERN MEDICINE AND SURGERY
March, 1936
The Upper Respiratory Infections*
Improved Management through the Family Doctor
Page Northington, M.D., New York City
IT is believed that the public would not con-
sider the common upper respiratory infections
as trivial disorders if it were generally known
that often they are the beginning of an infectious
process that causes disabling illnesses of long dura-
tion and that sometimes results in death. The lay-
man believes that he is competent to diagnose and
treat the usual infections of the upper respiratory
tract, and he is encouraged in his belief by the pat-
ent medicine vendors who are permitted to assure
the public that self medication with their own par-
ticular nose drop, gargle or rub is efficacious. It
is true that the mild types of infections cause only
slight impairment of general wellbeing and the
sufferer recovers his health in a short time regard-
less of the treatment. It is impossible, however, to
foretell whether or not a patient with upper respira-
tory infection will develop a sinus or ear disease
that in turn may cause an orbital cellulitis, mas-
toiditis, septicemia, meningitis, or brain abscess;
or will develop a disease of the lungs, heart, kidneys
or joints. To those patients who consult us, even
those with a slight complaint, our duties are to
make a systematic examination of the ear, nose,
throat and larynx in order that a precise diag-
nosis may be made, as otherwise treatment is spec-
ulative. There is nothing new of proven value in
the prevention, diagnosis or treatment of these in-
fections or their complications; but there is much
of the old, that, generally applied, would be for
many comforting and curative, for some life saving.
Progress in medical practice here, as in many other
fields, is more likely to come through a greater
use of the accepted clinical principles and formulae
than it is from new discoveries. The hopeful phase
of our problem is that, although at present a satis-
factory examination of the ear, nose, throat and
lar5mx is not commonly made, a systematic ex-
amination is so simple and may reveal so much
that it is gradually being adopted as a part of the
general examination procedure by all doctors who
treat these diseases. When such examinations are
regularly made the diagnosis, upper respiratory
injection, in a patient with a running nose becomes
as unacceptable as the diagnosis, lower respiratory
injection, is now in a patient with a cough. Ap-
proximately, twenty-five per cent, of the patients
referred to the otolarynologist have no disease of
the ear, nose, throat or larynx, or have disorders
•Presented by Invitation to the Tri-tSate Medical Assoc
South Carolina, February 17th and ISth.
SO mild as not to require a specialist's care. An-
other twenty-five per cent, have such severe diseases
that frequently treatment is not life-saving. The
family doctor represents the main line of defense
here, as everywhere in medicine. He has the privi-
lege as well as the responsibility of seeing most of
the sick as the first consultant. The specialist has
only to know more and more about less and less;
the family doctor must know more and more
about more and more.
The following outline for the examination of
the ear, nose, throat and larynx is recommended
to those who do not already carry out some such
satisfactory procedure. It can be used at the bed-
side as well as in the office and requires only about
ten minutes of time.
1. As complete a view as possible is obtained of
the nares by using a nasal speculum and light re"-
flected by a head mirror. Then, the nose is sprayed
with a 2 % cocaine solution. After a few moments
a 10% cocaine solution on a cotton-tipped appli-
cator is applied to the mucous membrane along
the floor of the nose carrying it to the nasopharynx
and then upward to include the surfaces of the
middle meatus.
2. The frontal and maxillary sinuses are transil-
luminated. The frontal sinuses are not fully de-
veloped until about the thirteenth year and are
equal in size in no more than half of the adults.
Patients wearing upper dental plates should re-
move them for this part of the examination.
3. The ears are examined with a speculum and
reflected light or an electric otoscope. Cerumen that
prevents a satisfactory view of the drum membrane
should be removed, by irrigation with a sodium bi-
carbonate solution. It may be necessary to use a
syringe that ejects with considerable force. The
area of the mastoid is examined by inspection and
also by digital pressure.
4. The mouth and throat are examined with a
reflected light. The tongue is depressed when the
throat is examined. Palpation is used when any
circumscribed swelling is present. The lower part
of the pharynx and the larynx are examined indi-
rectly using a mirror while the tongue is drawn
forward. It may be necessary to spray the throat
with a 2% cocaine solution to diminish gagging.
5. The mucous membrane of the nose by this
time is sufficiently anesthetized to use the naso-
pharyngoscope. This is passed along the floor of
:iation of the Carolinas and Virginia, meeting at Columbia,
UPPER RESPIRATORY INFECTIONS— Northington
the nose to its posterior limits where a view of the
nasopharnyx, the orifices of the eustachian tubes,
and the posterior ethmoid and sphenoid regions is
obtained. By slightly elevating the distal end of
this instrument and bringing it forward, the middle
turbinate and middle meatus are inspected.
(Through the interest of Dr. ]\Iikell patients
are available for carrying out this examination
procedure by all who care to do so.)
Notes on Diagnosis and Treatment
At the onset of the common infection, the find-
ings are usually a red, congested mucous membrane
of the entire upper respiratory tract and a variable
amount of thin mucoid secretion. The diagnosis
of rhinitis, pharyngitis, tonsillitis or laryngitis sig-
nifies the part of the greatest involvement. In
some patients the sinuses will transilluminate un-
equally, secretion will be seen coming from the
orifice of one or more sinuses, or an ear drum
membrane will be seen to be reddened; but an in-
fection of either the sinuses or the ears is some-
what rare in the early stage of an infection.
Pain, contrary to the popular belief, is not always
present even in acute sinus infections, although it
is an early symptom in otitis. When a sinus
disease causes considerable pain usually it is either
just above the eyes from a frontal sinusitis, or in
the occipital region from a sphenoid infection. In
ethmoiditis and maxillary sinusitis pain is seldom
present, and the most acute infection rarely causes
more than slight discomfort in the region of the
sinus or about the eye. Pain in a maxillary sinus
region is more frequently due to an infection in a
tooth than to a sinus disease. Pain occurs almost
invariably very early in a middle-ear infection, when
an examination may show only slight inflammatory
changes in the drum membrane.
It should be kept in mind that the very young
cannot voice their complaints. Although the sinuses
are rudimentary at birth, the middle ear is of al-
most adult size, and the antrum leading into the
mastoid is larger than later in life. The ossicles and
drum membrane are likewise well developed at
birth. Experience indicates that these are factors
worth reckoning in the diagnosis of middle-ear
disease in the young. The appearance of the drum
membrane as a sign of middle-ear infection is not
so dependable in a child as it is in an adult. It
is not uncommon for mastoiditis in the young to
be diagnosed by a subperiosteal abscess over the
mastoid or by roentgenray evidences, there being
neither discharge from the ear, nor inflammatory
changes in the drum membrane. The youngest in
whom I have seen such an infection was three
months of age. When the general condition of a
young patient warrants the assumption of some in-
fective focus and the location is obscure, the middle
ear should not be excluded without making a roent-
genray examination of the mastoids or incising the
drum membrane, even when the membrane shows
only slight pathological changes, as a pasty appear-
ance with some loss in the details of its landmarks.
The early stage of an ear infection frequently
gives considerable constitutional symptoms which
alarm the patient, as he thinks that his symptoms
are due to a mastoiditis. In most cases these gen-
eral symptoms abate within a few days and within
ten days to two weeks the infection in the ears and
nasopharynx is subsiding. When the fever, the
mastoid tenderness or only an ear drainage con-
tinues for two weeks, a roentgenray examination
of the mastoids is indicated. Distressing pain in
the ear is frequently due to an infection of the
external ear canal wall, a comparatively innocent
condition, to be looked for when movement of the
auricle increases the discomfort. Also, at times
pain in the ear is due to some focus of infection in
the sinuses, throat or teeth. In an uncomplicated
chronic infection of a sinus or ear, pain is not so
usual as one or more of the following complaints:
frequent head colds, expectoration due to dropping
of secretion into the throat, irritation in the throat,
recurrent hoarseness, coughing, or, in an ear in-
fection, a recurrent discharge without discomfort.
It is unfortunate that infections in the air spaces
of the skull which are potential dangers to life so
frequently exist without causing local or consti-
tutional symptoms severe enough to prompt the
sufferer to consult a doctor. Infection of the men-
inges, brain or blood stream may come from a sinus
or ear focus which has caused the patient no more
previous trouble than a chronic head catarrh or
recurrent, painless ear discharge over many years.
Such grave complications usually occur in chronic
sinus infections and about equally in acute and
chronic ear infections.
Although a diagnosis can usually be made by a
painstaking examination of the sinuses and ears,
roentgenray examination is indispensable in dis-
closing obscure diseases of the sinuses and the
mastoid. It is frequently of inestimable value in
disclosing the extent of the disease in the mastoid
during an ear infection of ten days to two weeks
duration in which the patient has slight general
symptoms of an infection and locally only a dis-
charging ear. .'\ poor roentgenray picture may bs
misleading and cause grave errors in diagnosis. To
cite a personal observation: A woman became to-
tally blind in one eye over a period of three weeks.
There was no demonstrable disease of the eye. The
roentgenray examination was reported as showing
erosion of the corresponding greater wing of the
sphenoid. The diagnosis of tumor of the orbit was
UPPER RESPIRATORY INFECTIONS— Northington
March, 1936
made. The blindness was due to retrobulbar neuritis
resulting from chronic purulent sinusitis, as indi-
cated by recovery of vision and good health for
the past five years under treatment directed to this
condition. Less than one-half of one per cent, of
cases of retrobulbar neuritis are due to sinus
disease.
Hoarseness is frequently an early sign either of
a new growth or tuberculosis of the larynx, or of
paralysis of a vocal cord due to some serious disease.
Many lives could be saved if an inspection of the
larynx were made of all patients with hoarseness on
their first visit to the doctor.
The subjective symptoms of recurrent head colds
are frequently allergic manifestations or evidences
of an exacerbation of a chronic sinusitis.
An inflammatory swelling about an eye may be
the first evidence of a sinusitis that causes the
sufferer to consult a doctor.
Lesions of one side of the throat are not the
ordinary tonsillitis or pharyngitis. Peritonsillar
abscess is the most frequent cause of unilateral
swellings. It is not always easy to differentiate be-
tween a peritonsillar or pharyngeal abscess and a
new growth as shown by occasionally seeing a new
growth that has been lanced to open a supposed
abscess.
Palpation is useful in determining the nature of
swellings in the floor of the mouth, the tongue and
the pharynx.
A thorough examination of the sinuses should
be made in every case of lung infection.
Bacteriological studies are helpful mainly in
identifying membranous and ulcerative lesions as
the diagnosis by inspection is not dependable. A
culture should be made at the time of incising a
drum membrane to determine the nature of the
organism, particularly, whether or not the middle
ear infection is caused by the pneumococcus
type 3.
Biopsy of new growths is essential for a correct
diagnosis.
Blood studies show the general reaction to the
ordinary infections, and also disclose evidence of
blood dyscrasias, agranulocytosis, infective mon-
onucleosis and trichinosis.
Urinalyses are especially indicated in the course
of upi>er respiratory infections because nephritis so
frequently results from a streptococcus infection.
Treatment does not permit of rigid standardiza-
tion because of the variable course and of the lack
of a specific therapeutic agent. My remarks there-
fore, will be on the local therapeutic measures of
greatest usefulness in the ordinary infections of
the upper respiratory tract, and some comments
on the care of sinusitis and otitis. Whether the
patient has acute rhinitis, pharyngitis, tonsillitis or
laryngitis, treatment is usually necessary for the
entire upper respiratory tract with special attention
to the part of greatest involvement. The treat-
ment should be of a soothing and comforting sort
and that which will help maintain the normal aera-
tion of the sinuses and ears. After spraying the
nose with a 2% cocaine solution to relieve the con-
gestion and give a slight anesthetic effect, irri-
gate with a warm salt and soda solution, — one
dram of table salt and one-half a dram of sodium
bicarbonate in a pint of water. A syringe is used
for the irrigating, while the patient's head is straight
forward and the face slightly tilted downward and
he is breathing only through his mouth. This pre-
vents the solution from entering the pharynx and
exciting a fit of gagging or coughing that may ex-
tend the infection to the ears. Patients can be
taught to take this treatment at home, using a foun-
tain syringe for the solution suspended two feet
above the head. Blowing of the nose should be
done with both nostrils open. During an acute
nasal infection, it is preferable to snuff the secretion
into the throat and expectorate it than to clear the
nose by blowing it. Irrigation of the throat with
a 2% warm soda solution is useful when the
throat is acutely inflamed. One-per cent, ephedrine
in oil for the nose and silver protein solutions for
the nose and throat are useful between irrigations.
In acute follicular tonsillitis 3% silver nitrate solu-
tion applied in the crypts frequently is followed
within a few hours by a considerable drop in tem-
perature. In simple laryngitis voice rest is usually
the only care needed. Use of the inflamed vocal
cords may result in a permanent change of voice.
Examination will show that many patients have
a sinusitis from the early stage of the acute upper
respiratory infection, although there are no sub-
jective symptoms to suggest it other than a thick
mucopurulent nasal discharge. Many such infec-
tions will not require any additional treatment,
the infection of the sinus subsiding along with that
of the mucous membrane of the nose and throat.
However, in some patients, the sinus infection will
persist with no more discomfort than nasal drain-
age and perhaps a cough. Such patients cannot
be discharged from medical care if the cases of
chronic sinusitis and their complications are going
to be lessened. Treatment by irrigations of the in-
fected sinus with the salt and soda solution is us-
ually curative.
In a small percentage of the cases of acute upper
respiratory infections, the course is not so benign.
From the onset the symptoms may be of a fulmin-
ating nature or there may be slowly developing local
and constitutional symptoms of a virulent infection
of the sinuses or ears. A sinus infection requires
satisfactory drainage. This can be accomplished in
March, 1936
UPPER RESPIRATORY INFECTIONS— Nortliinglon
some cases by shrinking the mucosa about the ori-
fice of the sinus with cocaine and adrenahn solu-
tion. If relief is not obtained by this treatment the
safest and most effective measure is irrigation of
the sinus. In some patients the maxillary, sphenoid
and frontal sinuses can be flushed out by entering
their normal openings with a small cannula, whereas
in others it is necessary to puncture the maxillary
sinus or remove the obstruction to the normal
opening of the frontal or sphenoid sinus in order
to do this.
I am aware of the sentiment among the laymen
and a few doctors against sinus irrigations. It is
not infrequent to have a patient, before an exam-
ination is made, say in effect: I don't want my
sinuses irrigated because someone has told me that
if once a sinus is irrigated this treatment will have
to be continued throughout life. It is not reason-
able to believe that irrigating a mucous membrane
cavity, infected or not, with a sterile bland solu-
tion is going to have any harmful effect. The irri-
gations are purposeful in that they are done to re-
move from the cavity infection products that na-
ture has failed to remove and, most likely, can-
not remove.
The late Doctor C. G. Coakley, to whom I was
an assistant for several years, was a firm believer
in employing conservative measures in the care of
sinus diseases. In his latter days he depended more
and more on simple irrigations of the sinuses, and
resorted less and less to operations, in the care of
sinus infections that needed special treatment. Oper-
ations on the sinuses cannot be entirely avoided;
however, they may be lessened by the cooperation
of all concerned in encouraging a general accept-
ance of the fundamentally sound principle that
evacuation of pus retained in an air space in the
skull is helpful to the patient.
The use of suction in the treatment of sinus in-
fections by placing a tip firmly in the anterior part
of one naris and applying negative pressure while
the patient alternately closes and opens the naso-
pharynx by saying K-K-K is mentioned, only in
order that it may be condemned. The fluid ma-
terial in the sinus, having no air beneath it, can-
not be aspirated by this method, also the suction
causes congestion of the mucosa about the orifices
of the sinuses and thus interferes with the drainage.
1 am of the opinion that the sinusitis was made
worse by suction in this patient. A woman who
had a doctor sister and a doctor brother was found
to have an acute suppurative sinusitis of both
frontal and both maxillary sinuses. She had been
ill for going on four weeks, having severe head
pains, vomiting and a daily rise of temperature to
103. Suction had been used since the onset of her
illness. The nasal mucosa was so congested that
there was scarcely any drainage from the infected
sinuses. Irrigations of the frontal and maxillary
sinuses were begun at once as it was thought that
there was imminent danger of a bloodstream or
intracranial infection. Considerable relief was ob-
tained in spite of the irrigations being infrequently
done on account of opposition in the family. At
the end of three months this patient developed an
osteomyelitis of the frontal bone that required an
extensive operation.
I have never seen a patient with sinusitis have
grave complications when the infection was treated
early with irrigations. I don't want to leave the
impression that it is my opinion that all infected
sinuses should be irrigated, but with more reason
that it is the most conservative and effective treat-
ment to use when the infection does not subside
under simpler care.
In middle-ear infections a red, bulging drum
membrane should be opened. In a few cases, local
or constitutional symptoms will require incision of
the membrane without such considerable inflam-
matory signs. In those cases in which the infection
does not seem to warrant a membrane incision, a
treatment, honored by time only, is that of phenol
and glycerine drops. This produces very slight
analgesia; also, it is destructive to the epithelium,
which is harmful in itself, and it obscures the true
picture of the drum membrane. Pain may be re-
lieved by acetyl salicylic acid, codeine, or morphine.
The use of barbituric acid preparations is to be dis-
couraged. They are not dependable analgesics and
also may cause a giddiness that may not be dis-
tinguishable from a vertigo caused by the infection.
Vertigo is a very important symptom if arising in
the course of an ear infection, therefore nothing
should be taken that might make it confusing.
This local infection is not comparable to an
abscess in which time is allowed for a walling-off
process. The objective in the treatment of early
middle-ear infections is to drain the infected cavity
before extension takes place to the mastoid, to the
petrous pyramid or to intracranial structures. The
membrane should be incised, therefore, without
waiting for the infection to extend through and
cause its spontaneous rupture. If culture shows the
pneumococcus type 3, a special watch should be
maintained to detect the first signs of complications
that are so frequent and so insidious. When the
middle ear is discharging, drainage is improved bj'
keeping the external canal free of the accumula-
tions. This may require frequent treatments. Irri-
gations with boric acid solution are resorted to be-
cause no one but a doctor will satisfactorily clean
the canal with a dry cotton-tipped applicator. Anti-
septics that stain the tissues are to be condemned
as ear drops because they fail to reach the middle
UPPER RESPIRATORY INFECTIONS— Northington
ear, the seat of the infection, and make it im-
possible to see the changes in the membrane from
day to day. It is advisable to keep it in mind that
a middle-ear infection comes about by extension
through a eustachian tube from the nasopharynx.
Treatment therefore of the nasopharynx is of great
importance. If the nasopharyngitis is dependent
upon a sinusitis the best treatment for the ear in-
fection is that directed to the cure of the sinusitis.
In spite of pain, fever, mastoid tenderness, pro-
fusely discharging ear and the roentgenray examin-
ation showing cloudy mastoid cells being frequent
in the early stage of an ear infection, a simple mas-
toidectomy is very rarely indicated in less time
than ten days to two weeks. On the other hand, if
all of these symptoms subside except a discharging
ear and there is roentgenray evidence of the break-
ing down of the mastoid septa, a simple mastoidec-
tomy is indicated. This is a common experience: A
patient is referred by the family doctor with the
opinion that he has a mastoiditis. The patient
has fever, pain in the ear, mastoid tenderness,
cloudiness of the mastoid cells on roentgenray ex-
amination and a discharging ear for three or four
days. The diagnosis, mastoiditis, as commonly used
means that there is sufficient disease present to re-
quire a mastoidectomy. A cloudy mastoid always
may be seen in an acute middle-ear infection. The
patient and the family doctor are relieved to know
that an operation is not immediately indicated. The
symptoms in a little while subside excepting a dis-
charging ear and roentgenray evidence of pus in
the mastoid. Then, neither the patient nor the
family doctor is convinced of the necessity of a
mastoidectomy. This treatment is indicated in
such cases because of the grave complications that
may arise from the infection, either during the acute
stage or later from the resulting chronic middle-ear
and mastoid infection.
Chronic suppurative middle-ear disease is always
a manifestation of either chronic mastoiditis or
petrositis and is a menace to life. Cleaning of
the canal with dry cotton swabs and using alcohol
and boric acid drops are helpful in some cases.
Granulations should be removed so as to improve
the drainage. Aqueous solutions should not be
used for irrigating the ear. Also, patients who have
recurrent ear discharge should be advised to avoid
getting water in the ear. When pain which is
usually diffuse on one side of the head, or vertigo,
appears as a result of a chronic middle-ear infec-
tion, a radical mastoidectomy is indicated, because
these signs frequently appear just before extension
of the infection to the intracranial structures. Also,
a mastoidectomy and clearing the lateral sinus of an
infected thrombus is a curative procedure in many
that develop a blood-stream infection from the
ear and mastoid disease. A sinus thrombosis should
be considered the diagnosis in the presence of chills
and fever and a running ear, even when the ear
infection appears innocent, unless there is some
other obvious cause. No one dies of a mastoiditis
or a sinusitis: many die of their complications.
Opinion
A thorough examination of the ear, nose, throat
and larynx is within the capacity of all competent
medical practitioners. Vast improvement in the
care of upper respiratory infections and their com-
plications can be easily brought about by the gen-
eral use of a systematic examination, because such
examination leads to an accurate diagnosis that
makes possible the most beneficial treatment.
Trichinosis No Rare Occtjrkence
(H. T. Brooks, New York, in Med. Rec, Feb. 19th)
Februan- 7th, a woman, 22, ate of pork tenderloin. On
February 9th, pain in the eyes, conjunctival congestion
and puffing of the lids ; muscular pain, swelling of the lip:-
and face, pruritus, exhaustion and depression; no diarrhei
or vomiting. On February 13th the fever was 103° F., at
which time she entered Bellevue. On February 20th she ^
left the hospital, but continued to visit the clinic. On
February 26th, 12 bluish maculae, each 4 inches in diameter
and painful on pressure, upon the inner surfaces of the
thighs. Recurrent sharp pains and conjunctival congestion
persisted until March 1st. Wasserman reaction was nega-
tive. February 15th, 53% eosinophilia. A second exam-
ination, 40% eosinophilia. The portion of the lateral
aspect of the biceps near the tendinous insertion revealed
encysted trichinae.
In muscle trichinae retain their viability in the encysted
state even in calcified capsules up to 31 years. Heat of
proper cooking kills them.
Trichinous invasion in man and animals attacks especially
the vigorously active and richly vascular diaphragm, laryn-
geal musculature (particularly the glottis dilators), ocular,
lingual, intercostal, abdominal, lumbar and other muscles,
particularly in the neighborhood of the osseous and ten-
dinous attachments; usually in lesser degree the muscles
of the extremities. That the parasites do not settle in the
heart muscle is said by Hertwig to be due to the extreme
delicacy of the sarcolemma of the cardiac muscle fibers.
The duration of the disease in severe cases is from 4
to 6 weeks. The mortality is sometimes very high. (Don't
eat, or allow your patients to eat, any hog meat that is not
thoroughly cooked. — Ed.)
I AM OF THAT MIND (C. O. Stallybrass, in Pres. Address
99th Session Liverpool Med. Ins., Liverpool Med. Chir. Jl.,
Pt. 3, 1935.) that I believe that learning to think aright
will be of as great service to mankind as all the preven-
tion of physical ills that the Medical Profession has be-
stowed upon a not very grateful world. We have a long
way to go before we attain the ideal of me}is sana in cor-
pore Sana, but I believe that the medical profession has
yet a large part to play in teaching mankind — and doctor
means teacher — how to think aright.
P.ATIENTS SENSITIVE TO HORSE SERUM (F. A. SimOn, Louis-
ville, in Ky. Med. Jl., Jan.) are sometimes sensitive to the
sera of other animals also. If serum other than that of
the horse is to be given, skin tests must be made with
the serum of that particular species.
March, 1936
SOUTHERN MEDICINE AND SURGERY
The Diagnosis and Treatment of Acute Appendicitis*
Hugh H. Trout, M.D., Roanoke, Virginia
IHA\'E personally operated on patients for acute
appendicitis when they had one of the fol-
lowing conditions, and the appendix was the
innocent victim of an unnecessary attack.
1 . Pneumonia
2. Pleurisy
3. Pneumococcus peritonitis
4. Acute spontaneous pneumothorax with
tuberculosis
5. Acute hemorrhagic pancreatitis
6. Strangulated hernia through foramen of
Winslow
7. Gallstones — acute cholecystitis
8. Perforated "peptic" ulcers
9. Ureteral calculi
10. Ureteral stricture
11. Renal calculi
12. Tuberculosis of kidney
13. Infected cyst of kidney
14. P\'elitis
15. Bladder calculi
16. Bladder diverticuli
17. Intussusception
18. Intestinal polypi
19. ^Mesenteric thrombosis
20. Intestinal parasites of various kinds
21. Seminal vesiculitis
22. Acute epididymitis
23. Tuberculosis peritonitis
24. Typhoid perforation
25. Regional ileitis
20. Acute ^leckel's diverticulitis
27. Tabes mesentericus in children
28. Acute enteritis in children
29. Strangulated hernia, reduced
30. Postoperative inguinal hernia case which
developed acute appendicitis while in
bed
31. Rupture of graafian follicle
32. Twisted pedicle with small ovarian cysts
33. Necrotic fibroids following irradiation
treatment
34. Ectopic pregnancy
35. Acute pelvic inflammatory disease.
Having had this experience in making the in-
correct diagnosis of appendicitis so many times is
perhaps the reason for my having been invited
to discuss this subject with you. While this list
looks long and is long, still the correct diagnosis
of acute appendicitis was made in over ninety-
five per cent, of the cases operated on, and this
is a far higher percentage of accuracy than we
have been able to obtain in any other disease. In
fact, in the vast majority of cases the diagnosis
has been made by the family physician before any-
one connected with the hospital staff saw the pa-
tients, and for this reason, we certainly cannot claim
any of the credit. The ease with which such a
high percentage of correct diagnoses is obtained
indicates that there must be some sort of standard
attack of acute appendicitis.
The truth of the situation is that such a large
proportion of the attacks are almost identical with
the symptoms and signs given in our textbooks
that perhaps we become careless and jump to the
conclusion that every right-sided pain is due to
appendicitis. Such attitude is possibly the ex-
planation of numerous mistakes in diagnosis. In
other words, we are often afraid of consuming time
that is valuable to the patient in taking a more
careful history and in making helpful laboratory
examinations.
If one will consult any textbook one will find
that the standard attack of acute appendicitis is
about as follows: The patient is taken, or as the
Negroes express it in our part of the world, "hit",
with a rather sudden pain all over the abdomen.
This pain usually localizes in the right lower quad-
rant of the abdomen. The time required for the
pain to localize varies greatly, but, in my exper-
ience, the younger the patient the more rapid is
this localization. We have operated in three cases
of acute appendicitis with the pain localizing in
the left lower quadrant, but in these cases there
was a transposition of viscera with the ascending
colon on the left. We have seen acute appendi-
citis more frequently in boys than in girls, and in
young people than in those over fifty • years of
age. However, age does not give immunity for we
have operated on a fairly large number of persons
over seventy-five with very acutely inflamed
appendices.
I presume we all have had families in which,
apparently, acute appendicitis was either hereditary
or like an epidemic. These instances might be due
to an inherited development anomaly of the an-
atomy of the appendix. One experience was with
an educational institution from which we received
an unusual number of cases of acute appendicitis
one fall. An exhaustive study by an epidemiologist
•Presented before the Postgraduate Meeting Duke University, Durham. North Carohna, October 31st-November
1st and 2nd, 1935.
ACUTE APPENDICITIS— Trout
did not disclose any definite etiological factor, but
such a study did produce many interesting theories
from various members of the faculty — one, a new
type of enamel pan for the baking of rolls — and
in spite of the fact that no enamel was found in
any of the appendices removed. A new commandant
was blamed, this officer being held responsible for
an earlier drill period, which, in the opinion of one
of the faculty did not give the students sufficient
time to attend to their daily duty, and the conse-
quent constipation, in this instructor's opinion, was
the real cause of the series of cases.
The vast majority of our patients are not only
nauseated but vomit. One should be very careful
to inquire concerning the taking of purgatives. Oc-
casionally one finds that the vomiting is due to
the misapplied medication, but much more fre-
quently a careful history will reveal that the pa-
tient vomited before the taking of the purgative.
Fever is usually present, but this is not a true
index of the trouble. Fever apparently has a close
relationship to the degree of resistance of the pa-
tient — the more resistance the patient possesses
the higher the fever is apt to be. The type of
causative organism has a large influence on the
degree of fever. In our experience, those cases in
which there is sudden rise of temperature which
goes very high but is sustained for a few hours
only, at operation, smears of the peritoneum will
show a streptococcus more often than the colon
bacillus. The cases in which the peritoneum show
the colon bacillus on smears and cultures usually
have a more gradual elevation of temperature,
which is maintained at a relatively high degree for
a much longer period. In other words, apparently,
the streptococcus permeates the walls of the ap-
pendix more quickly. In our experience if clinical
peritonitis has existed longer than twelve hours
a mixed bacterial invasion of the peritoneum is
disclosed at operation.
The pulse usually rises commensurate with the
fever. However, in some of the worst cases of
appendicitis I have seen temperature and pulse
normal.
Gentle examination of the entire abdomen with
the finger-tips usually reveals the right rectus
muscle to be firmer than the left, especially in the
lower abdomen. A deeper pressure elicits more
firmness of the right rectus and frequently a sharp
sudden pressure will be met with a muscle spasm
almost as definite as a knee reflex. Frequently sud-
den release of pressure which has been made in
(.he lower left fossa will produce marked pain in
the appendix region.
We have not found rectal examination of much
aid unless there was a palpable appendix abscess
or a swollen appendix lying in the pelvis.
The leucocyte count is usually of definite aid
in confirming an already established diagnosis, but
I think we should be careful not to place too much
dependence on laboratory tests. Sometimes I feel
that those of us who have been "raised"' in hos-
pitals are failing to use fully our special senses and
taking the easier course of attaching too much
importance to laboratory methods. Sondern's
curves and Schilling's modification of the Arneth
method of shifts of the immature cells are interest-
ing, and usually more helpful concerning the prog-
nosis and assisting in the direction of postoperative
care than they are of diagnostic aid before oper-
ation.
It might be interesting to you, and it certainly
has been helpful to us, to make a hasty review of
the mistakes in diagnosis which we have made.
1. Pneumonia and 2. Pleurisy. — I recall four
of these mistakes. In three cases the lung involve-
ment was in the lower right base, but in one case
the disease was limited to the left base. In none
of these cases was any condition found in the re-
moved appendix to explain the preoperative paia
in the region of McBurney's point. Of course, a
more careful examination of the chest before op-
eration would probably have revealed the true
condition.
3. Pneumococciis peritonitis. — Here the appen-
dix is involved and injected along with the rest of
the peritoneal cavity. Even if the history of a fairly
recent attack of pneumonia is elicited from the
patient I doubt if a surgeon would be justified in
not opening an abdomen presenting signs and symp-
toms of such marked peritoneal involvement.
4. Acute spontaneous pneumothorax associated
with pulmonary tuberculosis, but with nausea and
vomiting and patient having pain tenderness and
spasms localizing in right lower iliac region. This
patient also had an increase in both the total leu-
cocyte and polymorphonuclear counts. We had
an accurate preoperative estimate of the true pul-
monary condition, but the abdominal signs and
symptoms were so suggestive of an associated acute
appendicitis, that we deemed it a safer policy to
explore the abdomen with the use of a local
anesthetic. This exploration revealed a normal
postcecal appendix, which was removed and, for
some unexplained reason, this apparently relieved
the pain. I believe the pain in this case would
have disappeared in several days without the ap-
pendectomy, for I have since seen two other such
cases in which the abdominal symptoms did sub-
side in a very short time, and without surgical inter-
ference. However, in all fairness to phthisiologists
who were associated with us in these cases, in the
case on which we operated the abdominal symp-
toms were very much more marked than in those
March, 1936
ACUTE APPENDICITIS— Trout
two cases not subjected to appendectomy. Of
course, there is the possibiHty that having had this
experience with the first case made us more con-
servative in estimating the symptoms and signs in
the other two patients. Anyhow, this experience
of ours might at some time be of assistance to
some one of you. Permit me to add that the ap-
pendectomy apparently did not interfere with the
progress of the patient, and she actually thought
the operation relieved her abdominal pain. Such
is within the realms of possibilities and if I could
bring myself to share her conviction it would be
of a lot of comfort in mitigating the pangs of an
unpleasant memory.
5. Acute hemorrhagic pancreatitis. — As a rule,
in these cases the extreme signs of shock with the
usual cold clammy skin should give a hint that
the abdominal pain might not be due to acute ap-
pendicitis with peritonitis. However, as surgical
assistance is indicated with either diagnosis the
practical indication s a right rectus diagnostic in-
cision. Incidentally, it is worthy of note that the
operative mortality in acute hemorrhagic pan-
creatitis has been greatly improved since the ap-
plication of the rule to drain the gallbladder as
well as the site of the pancreatic explosion in
such cases.
6. Strangulated hernia through the foramen oj
Winslow. — In our series of mistaken diagnoses was
the only case we have had of this condition. In
this case a resection of about three feet of gan-
grenous small intestine was necessary. In spite
of the intestine being strangulated in the lesser
peritoneal cavity the whole mass had gravitated
to the lower right flank and our preoperative
diagnosis was appendiceal abscess.
7. Acute cholecystitis. — ^We all, I feel quite
certain, have mistaken acute gallbladder disease
for acute appendicitis, and acute appendicitis for
acute gallbladder disease. I am sure it is important
to realize that both conditions may exist at the
same time. I recall quite a number of cases in
which an acutely diseased gallbladder has been
exposed through a right rectus incision, and then
an examination of the right iliac region disclosed
an acutely inflamed appendix, which required re-
moval before giving further attention to the condi-
tion of the gallbladder. And of course, we have all
had the experience of having seen an acutely in-
flamed appendix removed through a McBurney in-
cision, and the pain continue until the removal of an
acutely inflamed gallbladder. In other words, we
should remember that the appendix and the gall-
bladder can be acutely inflamed at the same time,
and that in cases presenting such a possibility a
right rectus incision should be employed in spite of
all the many advantages and comforts of a Mc-
Burney incision in acute appendicitis.
In one of our cases we removed an acutely in-
flamed gallbladder with calculi but failed to ex-
amine the appendix region. The patient's tem-
perature continued elevated and we drained a sub-
phrenic abscess through a lumbar incision without
relieving the condition. Before the patient finally
recovered we removed a post-cecal gangrenous ap-
pendix. It is more than probable that, had we
examined the appendix region at the time of the
first operation, the patient might not have de-
veloped the subphrenic abscess.
In spite of all the differential diagnostic symp-
toms and signs described in journals and textbooks,
I believe it to be impossible to be certain of a
preoperative diagnosis in those cases in which a
post-cecal appendix and a low gallbladder are close
together.
8. Perjorated "peptic" ulcers. — A carefully
taken and logically considered history of previous
ulcer symptoms will usually give the clue to the
peritoneal involvement associated with perforations
of these ulcers. Then, too, the patients having
such perforations do not have a fever for a few
hours after the pain begins, while with appendi-
citis the pain and fever usually run concurrently.
However, fever is dependent on so many different
factors that too great reliance should not be placed
on this reaction to bodily insult.
Also, as a general rule, an increase in the leu-
cocyte count does not always appear early with
"peptic" ulcer perforations. The generally ac-
cepted reason for this is that at first the peri-
toneal reaction is a response to a chemical invasion
by gastric and duodenal contents which contain
few (if any) bacteria that have not been killed or
made dormant by the hydrochloric acid, etc.
9, 10, 11, 12, 13, 14, 15 and 16. Urinary diseases.
— As a rule, involvement of the urinary tract does
not produce symptoms as quickly as does acute ap-
pendicitis, and a surgeon therefore feels he can
take the time for examinations necessary in mak-
ing a differential diagnosis. A flat x-ray plate
takes only a very few minutes, and will often pre-
vent an unnecessary appendectomy. It is also
helpful not to forget that the intravenous injection
of the dye, followed by x-ray examination of the
urinary tract, gives considerable information with-
out subjecting the patient to the pain of a cysto-
scopic examination.
In the case of renal tuberculosis in which we
operated for acute appendicitis the ureter was
acutely inflamed, and I think this explained the
similarity of symptoms.
Pyelitis, especially in children, is very difficult
if not impossible to differentiate from acute appen-
ACUTE APPENDICITIS— Trout
March, 1936
dicitis. Pus and bacteria are often found in ca-
theter specimens of urine in patients with acute
appendicitis, and who probably have pyelitis sec-
ondary to the primary infection of the appendLx.
Whether this is an accurate surmise I do not know,
but I do know we have had a number of cases in
which the pus (or white blood) cells and bacteria
never reappeared in the urine after the removal
of an acutely inflamed appendix.
As a general rule, in patients with uncomplicated
pyelitis both the temperature and the blood findings
are more quickly and more markedly elevated. The
pain associated with pyelitis is more apt to be
more localized toward the back and nausea is very
much less frequent than with acute appendicitis.
17 and 18. Intussusception and intestinal polpyi.
— In intussusception and in obstruction of the
small intestine due to a polypus, usually an ab-
dominal mass can be palpated, the temperature and
blood counts are not elevated until very late if
ever, and the pain is rhythmical. A rectal exam-
ination will often be of great assistance. If the
symptoms of intestinal obstruction have persisted
for as long as forty-eight hours, the blood will be
altered chemically— increase of the non-protein
nitrogen, diminution of the plasma chlorides and
an increase of the combining power of the blood
for carbon dioxide.
19. Mesenteric thrombosis. — There is no ab-
dominal condition with which I am familiar that
gives such profound shock and complete collapse
of the patient as that produced by mesenteric
thrombosis. The pain is more agonizing and really
"hits" the patient so quickly that someone has
described the suddeness of the pain to that of a
bullet wound of the abdomen. In my experience
the pain "hits" very much harder and very much
more quickly than any bullet wound I have ever
seen.
20. Intestinal parasites. — In spite of the fact
that I live in a State, and am now talking in a
State, in which intestinal parasites flourish, I have
been caught off guard and removed appendices
which should not have been removed, but the pa-
tients should have had their parasites removed by
proper treatment. As a rule, an increase in the
eosinophiles of the blood with a careful history
will indicate the necessity for a stool examination.
However, it is wise to recall that acute appendi-
citis can exist with (if not actually be caused by)
intestinal parasites. A patient was sent to us with
the diagnosis of acute appendicitis by one of the
most competent doctors I know. We found hook-
worm in his stools and returned him to his family
physician for treatment; but, fortunately for the
patient, his doctor sent him to another hospital
where an acutely inflamed appendix was removed
the next day and the patient's life probably saved.
Had his doctor followed our instructions, the pa-
tient would have had some purgative, which would
not have added to his chances of recovery from the
involvement of the appendix.
On one occasion we operated on a little patient
with a preoperative diagnosis of appendiceal ab-
scess, and found the terminal ileum completely
blocked with dead round worms. The boy had
taken treatment for the parasites three days before
I saw him.
21. Seminal vesiculitis. — Had we made a rectal
examination and found a swollen, hard and pain-
ful right seminal vesicle, we might not have re-
moved an unoffending appendix in one case. In
such instances a history of gonorrhea can frequent-
ly be obtained
22. Acute epididymitis. — It should not be for-
gotten that acute epididymitis will sometimes pro-
duce pain in the right iliac region, w'ith fever, usual-
ly a very high leucocyte count and sometimes nausea
and vomiting. Frequently in the examination of
the inflamed epididymis the pain will be either in-*
creased or reproduced in the appendix region, and
such palpation will not infrequently produce nausea
and vomiting. Our failure to evaluate this obser-
vation properly caused us to remove a normal ap-
pendix in one case.
23. Tuberculosis peritonitis. — As a general rule
with tuberculosis peritonitis there is to be found
pulmonary involvement. However, frequently the
tuberculous invasion of the intestine is somewhat
localized and permits a resection with increased
chances of an arrest of the tuberculosis.
24. Typhoid perforation. — In the vast majority
of cases a history of typhoid, a positive Widal, etc.,
will prevent confusion in the diagnosis between ty-
phoid perforation and acute appendicitis. In one
case our medical associate made the diagnosis of
typhoid perforation based on a pxjsitive Widal, low
leucocyte count, and a somewhat indefinite history
of typhoid fever about six months previously from
which the patiently apparently had not fully re-
covered. I was equally as certain of my diagnosis
of acute appendicitis, based on the evident peri-
tonitis, generalized abdominal pain, localizing some-
what to the right iliac fossa, nausea and some vom-
iting. After some hours of discussion, an incision
was made, and a generalized tuberculosis peritonitis
found.
25. Regional ileitis. — About four years ago the
attention of the medical profession was called to
what is apparently a new and unexplained patho-
logical entity, namely regional ileitis, the lesion be-
ing most frequently found in the terminal ileum.
Had we taken the time to have made an x-ray
ACUTE APPENDICITIS— Trout
Study of the intestinal tract we would have found
the string-like occlusion these cases present, and
such as we have found in all such cases admitted to
the hospital. As a rule, the symptoms of this con-
dition are not acute, but progressive over a period
of weeks or months, but, with the case in which
we made the wrong diagnosis of acute appendicitis,
the patient, a non-complaining type of individual,
did not complain of his symptoms until the con-
dition had produced an almost complete intestinal
obstruction.
26. Acute Meckel's diverticulitis. — In each of
seven cases, after removal of a normal appendix,
we were able to bring into the field of operation,
through a McBurney incision, an acutely inflamed
^Meckel's diverticulum which had given the picture
of a case of acute appendicitis. I know of no ac-
curate method to differentiate these two conditions.
We make it a practice to always examine the last
several feet of the ileum in every case unless the
appendix is too acutely inflamed. If such an ex-
amination is made routinely one will be surprised
to find the frequency with which a Meckel's diverti-
culum is found, and many of them inflamed almost
as badly as the appendix. In one of our cases both
the appendix and the diverticulum were gangrenous.
2 7 and 28. Tabes mesentericus and acute en-
teritis in children. — These conditions will, in my
opinion, always present unsurmountable difficulty
in some cases; but the history of chronicity in the
former and of dietary indiscretions in the latter
should give a clue in the vast majority of cases.
However, in these cases there will always be found
children that have cried "wolf" so frequently that
unless we are careful we will be fooled into disre-
garding the chronic symptoms of tabes mesentericus.
.■\bount dietary indiscretions, otherwise truthful
children often lie most earnestly, in many instances
from fear of parental punishment.
29. Strangulated hernia, reduced. — You can
imagine my surprise when one day I was operating
on what I took to be an appendix abscess when I
discovered a strangulated hernia, which the pa-
tient had reduced with the sac and all into the
abdomen. Xaturally, examination of the inguinal
I ring before operation showed a closed but tender
I opening. The patient manfully kept the history
I of hernia from the intern who took his history,
I for fear of the wrath of his family physician who
I for years had told him to have this hernial open-
I ing repaired, and to stop reducing it.
! 30. Postoperative hernia case which developed
i acute appendicitis while in bed. — Very occasionally
some intern will become rather critical of doctors
who send patients to the hospital with ruptured
appendices and which cases they had watched for
a few days before admission. Whenever an intern
is so inclined these days, I take great pleasure in
reminding him of a former intern (who is now a
well, and favorably, known surgeon) who gave the
usual purgatives to an uncomplicated postoperative
hernia patient complaining of pain, etc., in his right
side, and after watching this patient for a few
days, we removed a ruptured appendix.
31. Rupture oj graafian jollicle. — This will oc-
casionally produce pain nausea so simulating acute
appendicitis that a differential diagnosis is almost
impossible.
?>2. Twisted pedicle with small ovarian cysts. —
If a pelvic or a rectal examination is made before
every operation a small ovarian cyst with a twisted
pedicle will sometimes be found and the ad-
vantage of a right-rectus incision gained.
ii. Necrotic fibroids following irradiation treat-
ment. — In one case we removed a necrotic peduncu-
lated fibroid with the preoperative diagnosis of
appendix abscess. We failed to obtain before
operation the history that several months before
admission, the patient had been given radium to
cause her fibroids to disappear. It is interesting to
note that the hemorrhage, which was due to the
also-present intramural fibroids, had ceased —
probably the result of the radium.
34. Ectopic pregnancy. — As a rule, a ruptured
tubal pregnancy does not present much difficulty
in differentiation from acute appendicitis. The
history of missed periods, pallor associated with
pain, and pallor continuing and increasing after
the rupture (and therefore relief of pain), lower
than normal leucocyte count, no fever and often
subnormal temperature, presents a very definite
suggestion of the true condition. In only one case
do I recall having seen the so-called Cullen's
sign of blueness in the umbilicus — and this in spite
of the fact that I have been looking for it many
years.
35. Acute pelvic inflammatory disease — Acute
pelvic inflammation of the right tube can and often
does present many difficulties in diagnosis, but in
the vast majority of cases it can be differentiated
by a pjelvic examination. Often the appendix is in-
volved in this pelvic inflammatory invasion, and
it is in such cases that careful surgical judgment is
necessary.
An unusually high leucocyte count, with a posi-
tive blood sedimentation test, high fever, compara-
tively little nausea, often burning and frequency of
urination and sometimes a history of exposure, cer-
tainly demand a pelvic examination even in an un-
married patient.
If one comes to the conclusion that the appendix
is involved in the infection, I believe it should be
ACUTE APPENDICITIS— Trout
removed through a McBurney incision, and the
cure of the acute pelvic condition carried out by
complete rest in bed, injections of foreign protein,
hot douches, etc. Immediate removal of acutely
inflamed pus tubes carries with it a far higher mor-
tality than delay until the infection is somewhat
quieter and in many cases the tubes apparently
return to normal. The temptation to remove
acutely inflamed tubes is greater if they are ex-
posed through a right rectus incision than if seen
through the opening afforded by a INIcBurney
incision.
Having made the diagnosis of acute appendicitis
the immediate removal of the appendix is indicated
in the vast majority of cases. In my opinion, it is
not as much a question of time since the beginning
of the attack as it is of a proper estimation of
the condition of the patient when first seen. If we
operate or do not operate according to some time
schedule, we are certainly doing an injustice to
ourselves and to our patients. It is our rule to
operate on every case just as soon as the diagnosis
is made, provided there is not found some very
definite contraindication.
Perhaps it would be wise for us to consider some
of these contraindications which delay or prevent
immediate operation.
Chest conditions: If the patient has definite
pneumonia, which is not secondary to peritonitis,
we usually delay surgical interference. If the pa-
tient has a secondary pulmonary infection following
a history of appendicitis with peritonitis, we try
to determine if the abdominal symptoms and signs
indicate definite localization; if so we delay oper-
ation. On the other hand, if the patient is pro-
gressively becoming worse with no indication of
localization of the peritoneal invasion, we make
a McBurney incision with either local or spinal
anesthesia and remove the appendix if it can be
located without disturbing any protective adhesions
that might be forming. If the appendix is not
readily located, several drains — one to the pelvis,
and one to the flank — are very gently inserted. It
should be recalled that the blood pressure in these
desperately ill patients is very low, and, for that
reason, spinal anesthesia can be safely employed
only in a limited number of cases. If the surgeon
feels that he must hurry through with such a pro-
cedure, then I feel that the patient stands a better
chance of recovery by pursuing the policy of
watchful waiting. I do not believe that anyone can
be dogmatic about if or when an operation should
be done in this type of case; there are so many
factors to be considered, and these factors differ
so markedly in different cases that each individual
case should be separately considered at the time
and no attempt be made to follow any preconceived
fixed general rule.
With the use of insulin a diabetic patient can be
and should be rapidly conditioned for an early
operation.
If the case is complicated by active pulmonary
tuberculosis the chances are that the patient's blood
pressure is too low to safely employ spinal anes-
thesia. However, ethylene can be given safely to
such patients without the cyanosis that so frequent-
ly accompanies the administration of nitrous oxide.
Ethylene does not produce the pulmonary irrita-
tion which usually follows the employment of ether
in tuberculosis cases.
The postoperative care of the peritonitis cases
will be considered by the other men on the pro-
gram. However, we have found continuous
suction through a nasal tube of so much comfort
to these patients that I cannot refrain from men-
tioning it. As each year goes by we find we are
more frequently employing the continuous in-
travenous drip with increasing satisfaction to both
the patient and to us. With these two aids or\e
can be more liberal in the employment of morphine
to make postoperative convalescence more com-
fortable.
The above is my confession of my shortcomings,
and I hope it has been as helpful to you as it has
been a relief to me to unburden my guilty con-
science.
The Complementary Sex and Its Important FtmcTioN
(A. L. Soresi, New York, in Med. Rec, Jan. 15th)
It is common knowledge that primarily the organism is
bisexual and that, in the great majority, later on one of the
sexes becomes predominant, while the other atrophies. No
man or woman is 100% male or female, respectively; both
are a blending of the 2 sexes, with a varied predominance
of one sex over the other.
Rejuvenation of an old, worn-out organism even if it
could be accomplished, would do more harm than good.
If any one function, like the sexual, should be predominant
the comparatively weaker organs presiding over the func-
tions would be unable to stand the strain put on them by
the more powerful, more exacting sexual organs. Thus the
whole organism, instead of being improved, would go
rapidly to pieces.
I firmly believe that in the complementary sex hor-
mones we have a means by which all the parts of the
organism can be co-ordinately and proportionally re-
activated.
The complementary sex hormones are a general stimu-
lant, not a sexual rejuvenator.
When dealing with males we are able to administer a
good preparation of their complementary sex hormones
and the results are most satisfactory. When dealing with
females we have not been able to administer a good prep-
aration of their complementary sex hormones and the
results were greatly inferior to the results obtained in the
males.
The commonest cause of intraperitoneal hemorrhage,
other than traumatic, is ectopic pregnancy.
1
March, 1936
SOUTHERN MEDICINE AND SURGERY
Chemical Antisepsis*
SouTHGATE Leigh, M.D., Norfolk, Virginia
IT \i OS at the request of our very active secre-
tary that I am imposing on you with this
paper. I was also emboldened by the very
cordial reception accorded my simple effort at the
last meeting in discussing the Family Physician.
Xo one is more heartily in favor than I of the
adoption of every advance in medicine and sur-
gery of proven helpfulness, but I believe that
many of our younger men, in their anxiety to be
up-to-date, are rather inclined to undervalue some
of the older, tried and true remed,i€S and
methods.
Take, for instance, Sims' splendid teachings and
instruments. The practical discarding of them
both by the profession and by the medical schools
has been a grievous hurt to the practice of gyne-
cology, and is probably one of the causes of our
failure to control the prevalence of dancer in
women.
In a way, this same unfortunate tendency has
affected surgical cleanliness. In the early days it
required a tremendous fight on the part of the
doctors and nurses to get clean results. It was
at that time rightly considered the most vital mat-
ter in operative surgery. Vigorous and continued
effort was necessary to put it over, but with such
effort clean results were obtained, notwithstanding
the almost insurmountable obstacles in the way,
and the results were even better than those reported
from many sections today. Of course no one has
ever thought of giving up antiseptic methods: they
are fundamental; but many are underestimating
their vital necessity, are taking surgical cleanliness
for granted, and often are leaving it to others,
with frequent disastrous results.
As I have often said, the vital necessity of strict
attention to details is as pressing today as it was
in Lister's time. Hospitals are still hotbeds of
infection. Serious and dangerous infection can
come upon us at any time if we are careless. We
must all admit that in these modern times, with
modern arrangements and facilities, it is nothing
short of a crime to infect a clean operative case.
.And yet it is frequently done.
In the first two years of the World War, the mor-
tality from infection was frightful, and the pro-
fession seemed helpless to combat it. The situa-
tion appeared so hopeless that it brought from
the great English surgeon, Godlee, an article in
the public press, entitled "Back to Listerism,"
•Pre.sented by Title to the Tri-State Medical Association
faouth Carjima, February 17th and 18th.
showing that the profession had gradually gotten
away from the use of chemical antiseptics and was
depending almost entirely on sK-called apepsis.
Heat, the main agent for asepsis, could not, of
course, be used on deeply infected tissues with-
out injury to the patient. At that stage, Carrell and
Dakin, recognizing the urgency of the situation,
developed the splendid Dakin's solution, through
which with its e.xact method of preparation and use,
and with its general employment, the mortality
was immediately and largely reduced.
The wounds caused by deeply penetrating frag-
ments, bursting shells, many of these neglected
of necessity for hours and even days, could
not be successfully handled by bathing with salt
solution! Dakin's solution saved many a valuable
life in the latter half of the war and is still doing
fine work in accident surgery. Unfortunately,
many surgeons fail to observe the strict rules of
preparation and use laid down by Carrell in his
excellent little book. It is also of great aid in
other suppurating wounds, and especially in ap-
pendiceal sinuses.
Chemical antiseptics, especially bichloride and
carbolic, still have a useful and vital place in sur-
gery, notwithstanding the frequent warning from
theoretical writers to the effect that their use will
interfere with healing.
Those of us who, in the early days of antisepsis,
washed all wounds with chemical antiseptics, can
testify that such fears are unfounded in fact. We
know that such wounds healed just as promptly as
the wounds of today and that the average result
was even better than those in many sections now.
Has anyone ever seen any interference with healing
caused by the surgeon using bichloride solution for
bathing his gloved hands during the operation? Yet
we know that such a practice is a safeguard for
cleanliness.
Practically everyone sterilizes the stump of the
amputated appendix before inverting it, and yet
many fail to use bichloride solution in bathing off
a gastroenterostomy. Many a brilliant operation
about the intestinal tract is spoiled by infection
simply because chemical antisepsis has not been
judiciously used.
All accident wounds are infected, many of them
badly infected. Killing the infection by chemical
means will convert a dirty wound into a clean one.
In small wounds it insures quick healing. In a
compound fracture it means success as against
or the Carolinas and Virginia, meeting at Columbia,
CHEMICAL ANTISEPSIS— Leigh
March, 1936
failure. Here a constrictor is applied (where feas-
ible) and the wound not only cleaned out by de-
bridement but scrubbed out vigorously with a
strong antiseptic, such as 1-500 bichloride followed
by salt solution, bones brought together, fastened
if' necessary, blood vessels carefully ligated, wound
sutured very loosely without drains, large com-
pressing dressings applied with splints and then
the constrictor removed.
If operated on early, primary healing is obtained,
the dressing not being changed even for a month.
Without chemical antisepsis the situation is de-
plorable and the job an endless one.
Chemical antiseptics are also essential in the
dressing of both clean and dirty wounds— for the
former to keep them clean, and the latter to lessen
the severity of the infection.
Of late there have been several new preparations
reported and used to some extent. It is a good
sign and I hope means that the profession is be-
coming interested. They, all of them, no doubt,
will be of use. However, we can hardly get away
from carbolic and bichloride which were used by
Lister, and have continued to be of great aid in
surgery ever since that time.
It is not in the province of this brief paper to
discuss more than the principles involved.
I say then that it is a serious mistake to get
away from the use of chemical antiseptics, which
were the foundation stone of Lister's revolutionary
work, and which today have their place in careful
and safe conservative surgery.
Judiciously used, I have never seen any mtev-
ferenee witli-'prmnpt' healing, and even if such
interference existed, it would not be as harmful as
that from sepsis.
For the Comtort of the Cancer Patient
(T G. Miller, Philadelphia, in Jl. Okla. State Med. Asso.,
Jan.)
Every patient with cancer should be actively treated,
given attention for minor ailments and treatment directed
toward an improvement of their general physical condition.
Few, if any, cancer patients are not suffering from some
secondary or associated disturbance: weight loss, anemia,
general weakness, cough, dyspnea, anorexia, intestinal
indigestion. It is almost invariably helpful to prescribe a
specific hygenic program, including periods of rest, of mild
exercises and of entertainment, and carefully to supervise
the diet. On such a regimen alone many patients promptly
will improve and cooperate more completely in the spe-
cific therapeutic procedures.
When specific measures cannot be considered or have
been employed to the limit, it is all the more necessary
to outline a routine of life conducive to physical and
mental wellbemg. This may involve an entire change of
environment, a return to noutine work or even the de-
velopment of new hobbies and life activities.
Anemia deserves special mention, for it is frequently
looked upon as an essential part of the malignant process
and given insufficient attention. It should be treated
actively: by iron, liver extract, sometimes by transfusion.
as well as by hygienic measures and an adequate and varied
diet. The restoration of a normal blood picture often
brings about decided improvement in the general physical
condition of the patient and in his morale. Thus it con-
tributes, even if not to a prolongation of his life, to hb
comfort and peace of mind.
Particularly important is it that the patient secure regular
periods of sleep: this may necessitate use of the bromides,
the barbiturates or even the opiates; sometimes it may be
secured in a warm bath or a hot drink at bedtime. Under
all circumstances, however, it is as important as the relief
of pain, and it justifies the use of any effective remedy.
When tlie prognosis is hopeless, nothing is to be gaiyied
by sparing such drugs a^ are required to give the patient
comfort and to relieve his fears: habit formation doesf
not have to be considered. When the case is not far ad-
vanced, severe pain is unusual or of brief duration, and,
ordinarily, can be controlled by some of the specific forms
of therapy or by the temporary exhibition of sedatives.
Under no circumstances, however, should the patient be
allowed to suffer needlessly. Often this can be prevented
by the use of the bromides, chloral or the salicylates, but
when such drugs are not effective, codeine, mor-
phine or pantopon should not be withheld. If the opiates
are used discriminatingly, only when needed and in the
smallest doses that will be effective, the total amount is
usually small. Dilaudid, of the newer opium preparations,
seems very promising in that it less frequently than mor-
phine has untoward side actions, acts quickly when given
subcutaneously or by mouth, and for slower and more
prolonged action can be administered per rectum. In
the inoperable cases it seems that small doses of morphine,
pantopon or dilaudid frequently repeated, are more effec-
tive than larger doses less frequently administered. For
terminal cases in which partial narcosis is desirable, I have
found sodium amytal, and especially dial, most helpful.
Whether a trained nurse, a practical nurse or some mem-
ber of the family is immediately in charge of the patient,
she should be acquainted with the nature of the case
in order to thoroughly cooperate with the physician. Only
too often the medical attendant relies upon the nurse's
judgment to handle such situations, without carefully in-
structing her as to his viewpoint about the case and the
methods by which she can assist him. Many patients
have been carried through the most difficult of their
problems by a cheerful, intelligent, tactful nurse, who
perhaps never gives any real information but satisfies the
patient's enquiries by clever evasion, reference to the
doctor, or prompt attention to some minor ailment.
Large Doses op Iron Required
<Edi. in Col. Med., Feb.)
Most of the ordinary doses of iron which we prescribe
are wholly inadequate. Reduced iron, containing 90%
iron, has a daily optimum dose of 1^ grams; iron and
ammonium citrate not more than 17% iron, daily dose 6
grams; ferrous carbonate, in the form of Blaud's pills, re-
quires 17 pills as an optimum dose. Hydrochloric acid
favors iron absorption, and is indicated where hypochlo-
hydria exists. A physician who has decided that iron is
indicated in any given case must direct the use of enough
of it to equal approximately 1 to 1^ grams daily of me-
tallic iron — if results are to be consistent with our war-
ranted anticipations.
Early and careful examination of all patients who are
hoarse (M. a. Lischkoff, in //. Fla. Med. Asso., Dec.)
will reveal many unsuspected cases of incipient laryngeal
carcinoma that will respond to proper care.
SOUTHERN MEDICINE AND SURGERY
Rupture of Ovarian Cysts With Hemorrhage
Report of Cases
A. DE T. Valk, M.D., F.A.C.S., Winston-Salem, North Carolina
THE occurrence of rupture of ovarian cysts
necessitating operation, is relatively rare,
as compared with the frequency of their
existence, though, unquestionably, many such cysts
rupture without serious results. This is particularly
true in rupture of graffian-follicle or small corpus-
luteum cysts. In such cases the fluid or slight
bleeding associated therewith is readily absorbed.
Such evidence is frequently found at a subsequent
operation where an ovary is found rather adherent
to the posterior aspect of the broad ligament or
pelvic floor, without any suggestion of tubal in-
fection. On the whole it is rather surprising that
more trouble does not arise from rupture of ovar-
ian cysts, when the thinness of the cyst wall is
considered as well as the sudden variations of intra-
abdominal pressure that take place especially in
young girls who are athletically inclined.
Trauma is to be considered at all times as a
causative factor in producing rupture of ovarian
cysts and it is here that may be noted the danger
of being too vigorous in making pelvic examina-
tions, especially when the existence of an ovarian
cyst is suspected.
The clinical picture of ruptured cysts with hem-
orrhage sufficient to produce symptoms is quite con-
stant, it varying in degree with the acuteness and
amount of bleeding. The picture is very similar
to that of rupture of ectopic pregnancy with no
real means of differentiation, except, possibly, the
menstrual history. As a rule there is no previous
history of pelvic or menstrual disturbances, the
patient having been quite well until the onset of the
immediate illness. We have the initial sudden,
severe unilateral pain in the lower abdomen, soon
becoming more or less general. Nausea and vom-
iting is variable and may not appear until later in
the course of the disturbance. With severe hem-
orrhage there may be initial shock with moderate
collapse.
The temperature is usually subnormal during the
first few hours with a gradual subsequent rise, while
the pulse varies with the amount of hemorrhage.
There may be only moderate rigidity, but tender-
ness over the lower abdomen is quite definite and,
with the exception of tenderness in the region of
the broad ligaments, there is little to be made out
on vaginal examinations that is helpful. As a
rule, no mass is found, as in ectopic pregnancy.
The leucocyte count is high with a marked in-
crease in neutrophiles. This varies somewhat with
the amount of blood in the peritoneal cavity. A
red blood count and hemoglobin determination
should be made in all suspected cases when first
seen and repeated from time to time, as this may
give very definite and valuable evidence as to the
extent and progress of the hemorrhage.
In most all cases in which there is much free
blood in the peritoneal cavity, the patient will
complain of pain under the costal margin on deep
inspiration and at times pain in the region of the
left shoulder is mentioned. This has been re-
peatedly described in bleeding from ectopic preg-
nancy and is of course present in ruptured ovarian
cysts with hemorrhage when the blood reaches the
diaghragm.
If the hemorrhage is copious, the patient's condi-
tion may become immediately so grave as to call
for a transfusion before operative intervention can
be considered.
The diagnosis of rupture of ovarian cysts is more
often made at operation than before, and not in-
frequently the condition is confused with acute
appendicitis or mild pelvic inflammatory disease.
As a rule, however, the pain is more acute and
severe than in appendicitis. The differentiation
from ruptured ectopic pregnancy is quite difficult
though the menstrual history may be helpful.
In all cases where there is a possibility of the ex-
istence of a pelvic lesion a midline incision is de-
sirable. Whether the ovary is removed or resected
is a matter of judgment, though conservation of
ovarian tissue in such cases is desirable and can
usually be accomplished.
In two of our cases no particular causative factor
could be ascribed ; in the other two there was a dis-
tinct history of trauma.
Case Reports
(1) A white woman, a^cd .J.i yrs., niarrifd 15 months,
referred by Dr. W. M, J., was first seen Jan. I4th, 1916.
The chief complaints were painful menstruation and in-
digestion. There was nothing of importance in the family
or past history. The present illness consists of painful
scant menses lasting four to five days for past three years.
Last period was three vvcel<s ago. Bearing-down pain is
felt when on feet. There is gastric disturbance with
some epigastric pain and eructations and the patient is
very constipated. There have been no pregnancy, no Icu-
corrhea, nor urinary disturbances.
Examination revealed a fair development and good color;
eyes, ears and throat clear; heart and lungs normal; ab-
domen natural-lookinc, no masses seen or felt, i^igmoid
palpable, slight lendcrness in right lower quaflrant, no
rigidity; vaginal outlet marital, cervix conical and well
up in the vault, fundus in anterior position and freely
132
RUPTURE OF OVARIAN CYSTS—Valk
March, 1936
movable, adnexa not felt as patient held abdomen rather
rigid. Gastric analysis showed slight hyperacidity.
A diagnosis was made of chronic appendicitis with dys-
menorrhea, and on January 17th (3 days later), vaginal
examination under ether anesthesia a small cyst of the
left ovary was felt which seemed to immediately disap-
pear. Dilatation and curettage was done, very little en-
dometrium being recovered. At this time the anesthetist
noted that the patient had become slightly pale and her
pulse had suddenly gone to 120 and lost in volume.
A midline incision was made and on opening the peri-
toneum much bright red blood was found. Further exam-
ination revealed a ruptured ovarian cyst with active bleed-
ing: apparently this occurred on bimanual examination,
though very little force was exerted. The left ovary was
removed, also the appendix, this organ showing definite
chronic inflammatory changes.
The postoperative course was uneventful and the patient
was discharged on 18th day.
(2) A white married woman, aged 38 yrs., was ad-
mitted to the hospital July 31st, 1932, referred by Dr.
W. M. J., complaining of severe pain in lower abdomen.
The family and past history were rather unimportant.
No disturbance of menstrual periods, the last one about
two weeks ago. The present illness began 14 hours be-
fore admission, with a rather acute and quite severe pain
during sexual intercourse. This pain was low down in
pelvis and gradually became more severe. Dr. J. saw
this patient two hours after onset and pain was sufficient
to require a quarter-grain of morphine. She slept very
little during the night and in the mornmg, on attempting
to get out of bed, she fainted. At this time the pain and
soreness in the lower abdomen were very marked.
On admission, temperature was 97°, p. 120, r. 20, w. b. c.
15,200— pmn. 86%; r. b. c. 3,100,000; hgbn. 55%. The
patient was quite well nourished though somewhat pale,
heart and lungs negative, urine clear; the abdomen natural-
looking with rather marked tenderness over lower half
with slight rigidity in this region. Vaginal examination
revealed nothing other than cul-de-sac tenderness; no
bleeding. Complaint was made of definite pain under cos-
tal margin on deep inspiration.
The preoperative diagnosis was ectopic pregnancy or
ruptured ovarian cyst.
On July 31st, under ether anesthesia, a midline incision
was made and the abdomen found to be filled with red
blood, and a right ovarian cyst ruptured with active bleed-
ing. The ovary was hastily resected as the patient's condi-
tion was not at all good. The free blood was aspirated
from the abdominal cavity and hasty closure made. An
uneventful recovery ensued with discharge 15 days after
operation.
The next two cases are rather interesting as they
spontaneously ruptured apparently without trauma.
(3) White single woman, aged 20 yrs., referred by Dr.
W. M. J., and admitted to the hospital June 1st, 1933,
complaining of severe pain in lower abdomen, on right
side.
Family and past history unimportant. Patient has never
been robust but apparently well. No menstrual disturb-
ances with last period 15 years ago.
The present illness began 12 hours ago when patient
turned in bed and had a sudden severe pain in right low
abdominal quadrant. This gradually became more severe
with coHcky pains up under costal margin on deep inspira-
tion. There was slight nausea but no vomiting. Some feehng
of bladder pressure with painful urination was experienced.
On admission, t. was 99.4°; p. 100; r. 20, w. b. c. 12,600 —
pmn. 80% ; urine and stool negative.
A slender girl, shghtly anemic, throat injected (recently
had tonsillitis), thyroid palpable, no general glandular en-
largement, heart and lungs clear; abdomen somewhat sca-
phoid, no masses palpable, tenderness in lower half, more
on right with some rigidity; inguinal region negative. Va-
ginal examination not made as hymen would not admit
tip of index finger. A rectal examination revealed some
pelvic tenderness.
The preoperative diagnosis was acute appendicitis.
On June 1st, vaginal examination under ethylene anesthe-
sia was negative other than a suggestive small mass in right
side of pelvis. A midline incision was made and the ab-
domen found to be filled with bright red blood from a
ruptured right ovarian cyst, which was still bleeding ac-
tively. Resection was done and a chronically diseased
appendix removed. The postoperative course was un-
eventful and patient was discharged on 18th day.
(4) A white single girl, aged 19 yrs., was referred by
Dr. C. H., was admitted to hospital July 15th, 1934, com-
plaining of abdominal pain of 24 hours duration. Family
and past history were essentially negative. Last period 14
days ago.
This illness began 24 hours ago with sharp pain more
or less general over lower half of the abdomen; gradually
the whole abdomen became sore and the patient remained
in bed. On attempting to get up she became faint an(J
blind.
This pain and sense of fullness in lower abdomen soon
became aggravated with a sense of pulling on attempting
to stand. Nausea and vomiting ensued. When admitted
the patient was in rather severe shock, very pale and
restless.
The urine was negative, r. b. c. less than 1,000,000,
hgbn. 35%, w. b. c. 18,000— pmn. 8S%, p. 130, t. 99.4°,
r. 28, heart and lungs clear. The abdomen was distended,
very tender generally with dullness in flanks, and some-
what rigid over the lower half. The characteristic pain
under costal margin was present. No vaginal examination
was made as the hymen was virginal.
It was quite evident that the patient was suffering from
an acute intra-abdominal hemorrhage and a tentative diag-
nosis of rupture of ovarian cyst was made.
On the day of admission, the patient was given 500
c.c. of blood and, under ethylene anesthesia, a mid-
line incision was made and the abdomen found to be full of
blood, which was removed by aspiration. A large ruptured
cyst of the left ovary was found, still in active bleeding,
and the greater portion of the ovary resected. A hasty
closure of incision was made. The patient reacted quite
well, and the postoperative course was uneventful, being
discharged 17 days after operation.
While of infrequent occurance, rupture of ovar-
ian cysts should be borne in mind at all times in
dealing with all acute pelvic lesions.
How frequently patients are told to take "a little soda
with the aspirin." One is alkali and the other an acid.
The incompatibilty is worse than one of ordinary neutrali-
zation, for the acetylsalicylic acid is decomposed by the
alkali into acetic and salicylic acids. — Edi. in Mol. Med.,
Jan.
C.4LLF0RXIA has a tick (Ornithodorus coriaceits, com
monly called pajaroello) which is greatly dreaded because
its bite is very painful, slow to heal and leaves an ugly,
permanent scar.
i
SOUTHERN MEDICINE AND SURGERY
Management of Kidney Tuberculosis*
A. J. Ceowell, M.D., Charlotte, North Carolina
TO discuss intelligently the management of
tuberculosis of the kidney, it is first neces-
sary to know the type of infection, whether
human or bovine, the extent of kidney destruction,
whether the infection is primary, or secondary to
extranephritic lesions; if secondary, the location
and extent of the primary infection, whether pul-
monary, glandular or osseous.
It is generally recognized that tuberculosis of the
kidney is hematogenous in origin and that primary
unilateral tuberculosis is rare. The infection is
carried through the blood stream in equal quan-
tities to the two kidneys. The healthy kidney does
not excrete tubercle bacilli. According to David
Band, J. M. Alston and E. F. Griffith, W. P.
Munro, Leiberthal and Von Huth, Medlar, Helm-
holz, Allen and Montgomery (Mayos), R. I. Harris,
and other investigators, infection of the kidney
must occure before the bacilli can pass through and
appear in the urine. Why one kidney should be-
come infected through the blood stream and the
other escape can be explained only by one kidney
having less resistance than the other to such in-
fection. Chronic interference with the elimination
of its secretion may act as a predisposing cause to
such infection. Trauma by blow over such a kid-
ney, in cases of extrarenal tuberculosis, would be an
exciting cause to renal infection.
There is a tendency for the disease to spread
to certain adjacent organs; for instance, the seminal
vesicles and prostate are likely to become involved
from a tuberculous epdidymitis, and tuberculous
meningitis is occasionally seen following nephrec-
tomy for tuberculosis of the kidney. We have had
one such case within the last eighteen months.
Painful and frequent urination, with blood and
pus in the urine, are the most frequent symptoms
and signs of renal tuberculosis: and when these per-
sist, despite the use of measures suitable for cases
of simple cystitis, the condition should be consid-
ered tuberculous until proven of other nature. I
will go further and say that every case of pyuria,
without residual urine, with more or less blood in
the urine should be investigated repeatedly for tu-
berculosis of the kidney, even though there be no
clinical symptoms of the disease.
In the terminal stages of pulmonary tuberculosis,
tubercles are frequently found in the liver, spleen
and kidneys. In these cases there are no bladder
lesions, no destruction of the calyces, no lesions in
•Presented to the Tri -State Medical Association of tlic
lina. February 17th and 18th.
the parenchyma adjacent to the calyces or pelvis.
This type of renal infection is rarely manifested by
urinary symptoms, and it cannot be demonstrated
radiographically.
We believe it has been definitely established by
various investigators, clinically and at autopsy, that
some small tuberculous lesions in the parenchyma,
which produce no symptoms, do heal spontaneously,
but more go on to kidney destruction and the death
of the patient, certainly when there is active infec-
tion elsewhere in the body. In such cases, with no
indication of the disease other than the constant
presence of tubercle bacilli in the urine, nephrec-
tomy is not justified, even if the bacilli are demon-
strated to come from one kidney only.
Renal tuberculosis usually develops slowly,
making it unnecessary to rush into surgery. It is
better to have two tuberculous kidneys than only
one and it tuberculous. Such patients should be
hospitalized and cared for as you would a victim
of pulmonary tuberculosis. Tuberculous lesions
heal in other tissues of the body, and I see no reason
why the bacilli should behave differently in the
kidney. In fact, it is more reasonable to believe
that spontaneous healing would take place in an
organ so richly supplied with blood, certainly but
for the fact that the kidney cannot be put at rest.
We think we are justified in saying that clinically
established renal tuberculosis does not heal.
Renal tuberculosis is quite prevalent in patients
who have tuberculous lesions elsewhere in the body.
Harris found it in 37% in a series of 143 cases in
adults and in 13.8% of 67 cases in children exam-
ined. Other investigators find it in about the same
proportion.
Ureteral stricture is a fairly common occurrence
in renal tuberculosis, and complete occlusion results
in autonephrectomy. It is easily diagnosed by
means of the ureteral catheter, intravenous indigo-
carmine and intravenous pyelography.
About two-thirds of the cases of renal tubercu-
losis have bladder symptoms only. If ureteral oc-
clusion has persisted long enough for the bladder
lesions to heal, autonephrectomy can easily be over-
looked, and in some cases this is a fortunate event.
Two types of autonephrectomy occur: in one the
kidney atrophies and the other it enlarges and be-
comes caseous or cystic; the former occurs if ure-
teral occlusion is of long standing, and the latter
when it is of recent occurrence.
Carolina.s and Virginia, meeting at Columbia, South Caro-
KIDNEY TUBERCULOSIS— Crowell
March, 1936
Here careful study and good judgment are very
necessary to ascertain whether surgical nephrectomy
is advisable. Generally speaking, it is advisable
in the acute occlusion and especially in the presence
of definite bladder symptoms with a mixed in-
fection. In cases of occulsion of long standing, in
the absence of bladder ulceration and bladder
symptoms, the patient can be left undisturbed but
kept under close observation. In such cases the
infection is walled off and frequently sterile. Gibson
is of the opinion that surgical nephrectomy is un-
necessary in such cases, or at least the risk of
leaving the kidney in situ is no greater than sur-
gical nephrectomy. In some of these cases the kid-
ney becomes calcified and this process goes on to
the point that the pathologic process is rendered
innocuous. Crenshaw found, in a study of 1817
cases of renal tuberculosis at the INIayo Clinic,
that 131 (7.17f ) showed calcification. In Caulk's
series 20% showed calcification. Braasch found
that more or less calcification had occurred in 30%
of these cases. This condition seems to be much
more prevalent in cases of renal tuberculosis with
occlusion than in renal tuberculosis without occlu-
sion. It seems from the reports of various urolo-
gists of large experience that calcification in renal
tuberculosis is neither a favorable nor unfavorable
prognostic sign.
Before deciding upon a definite plan of treatment,
an accurate diagnosis should be made of the nature
and extent of the lesion, whether unilateral or bi-
lateral, type of infection, functional capacity of
each kidney, and whether there be active extrarenal
lesions, as well as the general physical condition of
the patient. In other words, a decision must be
made as to whether the case is to be handled medi-
cally only, or medically and surgically. Of course
all cases must have careful medical supervision.
David Band finds that in extrarenal lesions in-
fection with the bovine type of bacillus is much
more deadly than infection with the human tv-pe;
but when the lesion is limited to the kidney, the
reverse is true. He found the bovine type prevalent
in 33.3% of the cases. W. T. Munro finds it in
about 30% of renal tuberculosis in Scotland. He
agrees with Band that the mortality is much higher
in the bovine type of infection, with extrarenal
lesions. This makes it quite important that we
know the type of infection as well as its limita-
tion, whether intrarenal only or both intra- and
extrarenal. This knowledge is necessary to treat
properly renal tuberculosis. We acknowledge we
have not stressed these diagnostic points sufficiently
and I suspect this is true of most of us.
It is difficult to determine, in many cases, just
where surgical interference should succeed medical
care. All agree that surgery is contraindicated in
acute miliary tuberculosis and acute toxic nephritis.
Best surgical results are obtained in the preclinical
cases of unilateral renal tuberculosis, if definitely
known to be unilateral. Nephrectomy before the
disease spreads to the ureter, bladder or genital
tract is advisable. The lesions which can be
demonstrated pyelographically produce definite
clinical symptoms and do not heal. In such cases
ulcers can be found usually in the ureter and blad-
der and abscesses in the kidney. Nephrectomy is
here indicated. Chronic bilateral renal tuberculosis
is not a condition for surgery.
Great gentleness should be exercised in removing
a tuberculous kidney to avoid infecting the
wound with tubercle bacilli or forcing them into the
circulation and so to the meninges or other tissues
of the body. The pedicle should be freed by gent-
lest manipulation possible and the blood vessels
ligated first. The ureter should be freed as low
down as possible, the wound carefully protected by
means of gauze, the ureter severed between two
ligatures by means of the electric cautery and the
distal end of the ureter further cauterized with car-
bolic acid or the electric cautery. Cigarette
drainage should be established and the wound
closed in the usual way.
Discussion
Dr. M.^ion H. Wym.an, Columbia:
Gentlemen, Dr. Crowell has been very fair about this
subject. We do not have so much tuberculosis in South
Carolina. Dr. Ballenger, of .Atlanta, has only occasionally
a case of tuberculosis of the bladder or kidney. I was em-
barrassed for a while; I thought I could not find it. I was
in Bordeaux for four months after the war and worked
with an eminent specialist for several months. We found
a great deal of urinary-tract tuberculosis over there. He
was kind enough to let me work out a good many of
them. We took out several tuberculous kidneys a week.
But in my twenty-two years in Columbia I have seen
very few. Up to a few years ago, when a diagnosis was
made of unilateral renal tuberculosis, the accepted treat-
ment, I think, was to remove any such kidney.
We have had a few tuberculous cases in the Veterans'
Hospital. We have veterans in this State From Florida,
a few from North Carolina, and a few from Georgia.
Most of them are from South Carolina. A great many
Northern boys stayed in Columbia after the war; they
were here in camp and stayed here.
My conclusion is that we do not have so much tuber-
culosis of the kidney. Of course, you want to make the
diagnosis, but you want to be conservative. The condi-
tion, the pathology in the kidney, whether it is functioning
or not, and the condition of the other kidney, must be
considered.
I enjoyed the paper very much. Dr. Crowell.
Dr. Hugh Wymax, Columbia:
I believe we are indebted to Dr. Crowell for bringing
this subject before us. It is very important, to my mind.
In my somewhat limited experience, it is the most trying
urological diagnosis I have ever made. I get discouraged
in trying to make the diagnosis of renal tuberculosis, par-
ticularly in the early stages. Now, if you have constantly
March, 1936
KIDNEY TUBERCULOSIS— Crowell
135
blood cells and a few pus cells in the urine that are un-
explained by any other infection, if you will persist in
looking for tubercle bacilli and make a guinea-pig inocu-
lation you will get a positive result, if you are persistent.
It is my experience that the bacilli come down in showers.
You will get a number of negatives, then finally one
positive. So persistence is ver>' important.
As Dr. Crowell mentioned, and in my experience, stric-
tures of the ureter are very, very common. In any stric-
ture, tuberculosis of the kidney should be ruled out very
definitely. I want to emphasize that where you have ad-
vanced tuberculosis of the kidney, with stricture of the
ureter, those strictures should be dilated at frequent
intervals so as to establish drainage.
Dr. Malcolm Hosteller, Columbia:
I should like to ask a question for information. For
seven years I have been doing roentgenology here, in con-
nection with the hospitals, and I have continuously looked
for cases of tuberculosis. On two or three occasions I
have been almost sure that I had a case of tuberculosis
from the roentgenological standpoint, but later those cases
did not prove to be tuberculosis. For some reason, we
have not been able to find any cases of tuberculosis in this
vicinity, and I wanted to ask Dr. Crowell if it is true that
tuberculosis of a kidney occurs more frequently in some
vicinities than in others.
Dr. Crowell, closing:
Dr. Wyman speaks of the importance and the difficulty
of making the diagnosis of tuberculosis of the kidney. It
is rather tedious, and it takes time. But we can un-
doubtedly make a diagnosis in a resonably short time by
means of culture and the guinea-pig inoculation if we can
not find the tubercle bacilli by smear.
I think that in any locality that has a greater percentage
of tub'irculosis — pulmonary, glandular or osseous — we shall
have tuberculosis of the kidney more prevalent. Investi-
gators have shown very definitely that tuberculosis of the
kidney is a quite common accompaniment of tuberculosis
elsewhere in the body.
I was in hopes that some of the medical men would dis-
cuss this problem, more especially the men who are in-
terested in tuberculosis generally, on account of the ten-
dency now to be a little more conservative, from the sur-
gical standpoint, than formerly.
Extraperito.veal Pathology With lNTRAPERiTO>rEAX
Symptoms
(J. B. Haskins, Chattanooga, in Jl. Tenn. State Med.
Asso., Feb.)
In one, an emotional insult will produce a visceral reac-
tion, either unnoticed or soon forgotten, whereas the same
stimulus to another individual will produce a distressing
response. With such idea in mind, the correct interpreta-
tion of the symptom of abdominal pain is not always simple
or easy of explanation.
A young person who has always been in good health is
seen for the first time complaining of acute diffuse ab-
dominal pain, vomiting, increased pulse rate and slight
or no fever, or the pain may be so that he twists, turns, and
groans. There is general abdominal tenderness with mus-
cular rigidity, more marked toward the lower right quad-
rant, the leucocyte count is elevated with an increase
in pmns. — a classical picture of acute appendicitis and
such a diagnosis most frequently is correct. This picture
may be simulated by other conditions, as — poisoning from
the bite of the black widow spider, abdominal crises in mi-
graine, pneumonia, diaphragmatic pleurisy, pericarditis,
herpes zoster and tonsillitis; with the onset of some of
the acute infectious diseases — scarlet fever, measles, mumps,
rheumatic fever, influenza and typhus fever. Chronic
poisoning with lead, arsenic and mercury' may give re-
ferred pain. The referred pain of Pott's disease and the
abdominal crises in tabes dorsalis, Henoch's purpura, an-
gioneurotic edema, urticaria, allergic reactions, arterios-
clerosis, atheromatosis, thromboangiitis obliterans, angina
pectoris and occlusion of the coronary, septicemia, bacterial
endocarditis, pyelitis, pyelonephritis, renal and ureteral
calculus — all of these have been the cause of many useless
abdominal operations.
Diseases of the central nervous system such as syphilk,
transverse myelitis, tumors of the spinal cord and its
coverings, infiltrating tumors, osteoarthritis or tubercu-
losis of the spine, scoliosis with arthritis — all frequently
cause pain referred to the abdomen. Thyrotoxicosis, pit-
uitary dysfunction, heart disease, particularly right-sided
failure ; renal infections and calculi, hydronephrosis, ure-
teritis, ureteral stricture and periarteritis nodosa.
Think of all the causes.
Be ever ready to swap off good diagnostic signs and
symptoms for better ones.
The Treatmen-t of Angina Pectoris
(N. C. Gilbert, Chicago, in Med. Clinics of N. A. for
Jan.)
Attacks may be brought on by exertion, indigestion and
emotional upsets, or may occur in pernicious anemia, from
insufficient oxygen for the heart muscle or in diabetes fol-
lowing temporary hypoglycemia after insulin; in some
patients the attacks can only be ascribed to an unstable
autonomic nervous system. A great deal of the patient's
future depends on what the physician says. The physician
should try to gain a common ground of understanding
with the patient, to encourage him and at the same time
evaluate the factors which predispose to the attack and
direct the patient as to how best to avoid the attacks.
The attacks are best relieved by amyl nitrite or nitro-
glycerine. Between attacks, most cases can be materially
helped by theobromine and theophylline salts. Treatment
is started with theobromine-calcium salicylate (Th:;ocalcin)
whkh only very rarely causes distress. Tolerance to its
puriness being acquired, Theocalcin medication is alternated
with theophylline ethylenediamine or theophylline-calcium
salicylate (Phyllicin), which is quite as effective clinically.
Theocalcin is given in 7^<-grain tablets, 1 or 2 at a time
and Phyllicin in 4-grain tablets. All the purine salts are
best taken during the meal. Rest from medication may
be allowed for a few days each week.
Some patients have received treatment with the purine
salts for as long as 11 years without having to discontinue
medication on account of intolerance. Phenobarbital, when
necessary, is used separately so that the dosage can be
properly varied; a sedative effect without drowsiness is
the aun. Digitalis is not used except where definitely indi-
cated, since it may precipitate an attack by reducing cor-
onary flow. Surgical methods for the prevention and treat-
ment of anginal pain should be used in cases chosen with
great care.
To BE a psychiatrist (Wm. H. Bramblett, Newbem,
Va., in Va. Med. Monthly, Jan., 1880), we must possess
a most intimate and thorough acquaintance with all the
diseases that flesh is heir to, together with a knowledge
of all their varied manifestations through the nervous sys-
tem.
Telepathy is too doubtful a medium to replace an un-
obtrusive and w'ell-timcd word of appreciation of a re-
ferred patient or other marks of favor. — Editorial Wis.
Med. JL, Jan.
SOUTHERN MEDICINE AND SURGERY
March, 1936
Chondrofibroma of the Trachea
Report of Case
E. Trible Gatewood, ALD., Richmond, Virginia
LIEUTARD recorded the first tracheal tumor
in 1767. Tuerck is said to have been the
first to observe such a tumor in the living.
Since these observations the literature has increas-
ingly recorded new growths of the trachea. This
has been particularly true since the advent of the
bronchoscope. However, chondrofibromas are in-
frequent enough to warrant reporting.
Semon stated the frequency relation of laryngeal
to tracheal tumors of all tj-pes as one hundred to
one. jMcKenzie is mentioned as having seen only
four tracheal tumors as compared to 800 new
growths of the larynx over a period of 23 years
(1906-1929). Schmidt studied 2088 new growths
of the upper air passages. Of these 748 were
laryngeal and three tracheal. These statements
tend to emphasize only a comparative infrequency.
The total frequency is best summarized by
D'Aunoy and Zoeller in their comprehensive paper
entitled "Primary Tumors of the Trachea." They
state, "V'on Bruns reviewed the literature in 1898
and collected only 141 cases. Krieg continued
this review in 1908 bringing the sum to 201 cases."
Their search of the literature extending through
1929 brought the total number of
all varieties of primary new growths
of the trachea to 351.
iNIany observers ascribe the infre-
quency of tracheal growths to the in-
activity and the simple structure of
the organ. The middle portion is
relatively immovable and protected
from various forms of trauma, hence
the predilection for the extremities.
The posterior wall is most frequently
elected. This is probably influenced
by the richer glandular structure and
a consideration of the tracheal lym-
phatic vessels.
The ratio of recorded tumors ac-
cording to sex is 2.3 males to one fe-
male. Notwithstanding the enormous
number of bronchoscopies that are
done, increasing each year, it can not
be denied that tumors of any variety
of the trachea are infrequently en-
countered. .According to a review of
the literature by several observers up
to 1930 there are only 65 cases of
tracheal chondromas, osteomas and
chondrofibromas, taken collectively, on record.
The case for report is that of a white athletic director,
aged 28, seen at the Johnston Willis Hospital at 7 o'clock
on the evening of August 18th, 1934, with his family phy-
sician.
The patient was in a semi-reclining position, semicon-
scious and cynosed, suffering with urgent dyspnea. His
physician stated that the patient had been under his ob-
servation for two or three days with mild dyspnea and
hoarseness which he regarded as asthmatic in nature. A
hypodermic injection of morphine was given at his ofiice
that morning and as there was no improvement the patient
was removed to the hospital the same day at 3 o'clock.
Morphine and adrenalin were repeated twice later in the
afternoon.
Examination at 7 o'clock showed a temperature of 97.6;
pulse, normal; respiration 12, with limited expansion and
diminished breath sounds over the entire chest. Laryngeal
examination with the patient in semi-recumbent position
was normal. In view of these findings an exploratory-
bronchoscopy was decided upon.
Passage of the bronchoscope was met immediately by
an obstruction which had a normal mucous membrane
appearance. Realizing that a high obstruction of an un-
known nature was present we resorted to a low tracheo-
tomy. This was accomplished without any form of anes-
thesia as the patient was then entirely insensible. Con-
sciousness was soon regained and respiration became nor-
mal.
Lateral View of Growth and Low Tracheotomy. Tube in situ
March, 1936
CHOXDROFIBROMA OF THE TRACHEA— Gatewood
137
Post-operative Lateral View
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'ji-f^^r
. -- • - ■ ■ *
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I'i /
-' •^
t.
~v V ».
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" ^pr-^.- ^^
Examination of the upper portion of
the trachea with a laryngeal mirror a
few days later, the patient in an up-
,,^^ right position, show'ed a questionable
• ^^ mass three-quarters of an inch below
the vocal chords. Roentgen films out-
lined a mass apparently attached to the
posterior wall of the first and second
rings of the trachea.
.An open operation was decided upon
with insufflation ether anesthesia. A
midline incision was made extending
from the upper border of the thyroid
cartilage to the fourth tracheal ring.
The thyroid gland isthmus was severed
and retracted. The thyroid cartilages
of the larynx and upper rings of the
trachea were opened. The vocal chords
were carefully separated at their imme-
diate anterior junction. The hard and
large cone-shaped mass was dissected
from the posterior tracheal wall which
appeared to invade the anterior esopha-
geal lumen and a portion of the pos-
terior surface of the cricoid cartilage.
After removing the mass completely a
nasal feeding-tube was fixed and the
esophageal defect sutured. The vocal
chords were approximated and the thy-
roid cartilages fi.xed by suturing the
overlapping ribbon muscles to insure
even cartilaginous union.
Nine days later the tracheotomy tube was removed and
the tracheotomy opening closed. Two days later the feed-
ing tube was withdrawn and the patient resumed the nor-
mal way of swallowing with no difficulty. The patient
was discharged 20 days after admission with a normal
voice.
Histologic study of the growth by Dr. W. A. Shepherd
showed dense fibrous tissue with small areas of cartilage
and calcification. The gross appearance at the operation
was mainly cartilage, covered and interspersed with dense
fibrous tissue, resembling a chondroiibroma.
Comment
1. Patients presenting symptoms of tracheal new
growths may, in certain instances, be confused
with cases of bronchial or pulmonary lesions.
2. New growths of cartilaginous origin are ex-
tremely rare.
This case emphasizes the serious mistake of
administering morphine to certain patients
with dyspneic tendencies.
Professional Building
3.
It is only in elementan,' education that we have made
good on the commitment of a hundred years ago. Twenty
years ago 1S% of the secondan.' population were enrolled
in school; now between 55 and 60% are enrolled. The
percentage of adult population going to school has been
increasing 1% a year for the last 15 years. — //. P. Rainey,
Prcs. of Bucknell, in Jl. Assn. Am. Med. Colleges, Sept.,
'.i5.
of Chondroflbroma
At least 200 doctors, it is said, will be needed for the
enlarged Public Health work contemplated by the Social
Security Act.
President's Page
Fellow Members of the Tri-Stale Medical Association:
My first act as president of this organization and
my first effort to fill the President's Page in its
Journal shall be to assure you of my appreciation
of the honor that you have conferred upon me and
to remind you that I am deeply conscious of my
responsibilities. It shall be my purpose to conduct
the affairs of the i^ssociation as you would have
them and to that end I will lean heavily upon our
capable and efficient Secretary and I beg you as
individual members to let me know your wishes and
to give me your counsel and advice.
Uppermost in my mind are ( 1 ) the desire to see
the medical profession of this section lead in scien-
tific research and the spread of medical informa-
tion, (2) the economic disturbances in the practice
of medicine, (3) the plight of several of our medical
schools, (4) the inauguration of group payment for
hospital care, and (5) the need for group payment
of medical care. However, I again assure you that
it is my desire to serve you and before outlining or
planning any particular project I shall expect and
await an expression of your wishes.
DOUGLAS JENNINGS.
March, 1936
SOUTHERN MEDICINE AND SURGERY
Surgical Observations
A Column Conducted by
The Staff of the Davis Hospital
Statesville, N. C.
Narcolepsy
Until recent years narcolepsy, or Gelineau's syn-
drome, has been regarded as a rare condition; dur-
ing the past decade more attention has been paid
to this subject, and it is either increasing rapidly
or is being diagnosed more accurately.
Many accidents of different kinds — such as auto-
mobile accidents and accidents to those who work
around machinery — with disastrous results to th§
individual and to others, may be due to attacks of
narcolepsy.
Approximately 80% of the cases are in men. It
occurs with greater frequency between the ages of
20 and 40, but may occur in one of 10 years or
after 40. The cause is unknown; there are many
conjectures but no one has ever demonstrated its
cause or a connection with any other disease.
Narcolepsy may be defined as an uncontrollable
desire for sleep. It must, of course, be differenti-
ated from natural sleepiness from fatigue or going
long without sleep.
True narcolepsy, with the sudden intense desire
for sleep occurring in an individual who ordinarily
sleeps a sufficient length of time each night is a
definite clinical entity, and as such has received
much attention and been carefully studied.
Pyknolepsy is a similar condition and is closely
associated with narcolepsy. In pyknolepsy the
patient has a sudden loss of muscular tone due to
excitement, pleasure or shock. In this case the
muscles of the body relax and the patient may fall
if standing — or if sitting may slump in the chair.
The group of symptoms now known as Gelineau's
syndrome were noted and published many years
ago by Fischer; Wcstphal, also, reported this
combination of symptoms before Gelineau.
Pathologic changes are indefinite. The attacks
of sleep have the characteristics of normal sleep,
and the fact that the patient does go to sleep sud-
denly, and may remain so for a second or two or
an hour or so, appears to be about all there is to the
condition.
The one symptom, usually is, an irresistible desire
for sleep which may occur at any time and any
place. Often the attacks are ushered in by yawn-
ing. Usually there are no premonitory signs.
Frequently patients fall asleep in company — es-
pecially when listening to speeches. This, how-
ever, may be merely the individual's method of
taking a rest when tired of listening to a tedious
harangue.
The patient is usually easily aroused from a nar-
coleptic sleep and becomes conscious immediately.
While at work he may stop for a moment and then
awake and resume his work as usual.
The attacks vary in frequency; five or six daily
are not uncommon. They are more frequent from
9:00 to 11:00 a. m., or after 5:00 p. m. Amuse-
ment, anger, fear or worry may bring on an attack.
For this reason many individuals who would laugh
and enjoy themselves do not do so far fear of
bringing on an attack.
Patients who are subject to attacks of this kind
frequently have disturbed nocturnal sleep. They
may have dreams in addition to the disturbance in
the sleep.
Many automobile accidents are doubtless trace-
able to this one cause. It is true that many pa-
tients become sleepy while riding along in a car,
due to loss of sleep and to over-exertion. In fact
many people who just need a rest may be driving
a car and become sleepy and drop off to sleep for
a sufficient length of time to cause an automobile
accident to occur. In true narcolepsy the patient,
even if he has had plenty of sleep, may lose con-
sciousness for a few moments and fail to make a
turn or run off the road, crash into a tree or tele-
phone pole or roll off down an embankment.
Almost everyone who drives a car a great deal,
especially on long night trips, will at times get
sleepy while driving. In a closed car with a steady
purring motor, one is more inclined to become
sleepy, especially if there has been insufficient sleep
for a night or two previously. Under such circum-
stances a driver may have great difficulty in keep-
ing awake. Those who have observed sleepy driv-
ers will notice that the car will wobble along and
sometimes run partly off the road, when the driver
suddenly becomes wide awake again and keeps
the car steady in the road until he again becomes
sleepy. In narcolepsy the driver of a car may have
had an excessive amount of sleep, but when driving
a car may suddenly drop off to sleep long enough
to cause a wreck. Narcolepsy may manifest itself
at any time and any place. A victim of this serious
disorder may even go to sleep while standing. A
careful study of any patient is necessary to differ-
entiate between narcolepsy and the natural ten-
dency to sleep — from loss of sleep, fatigue or ex-
haustion.
The treatment of narcolepsy is now on a sound
basis.
Years ago a large variety of drugs were used em-
pirically. In many cases ephedrine gave relief.
Ephedrine sulphate, grain one-half, given three
times daily at 8:00, 12:00 and 4:00 would aid
greatly in keeping off attacks and often prevent
140
SOUTHERN MEDICINE AND SURGERY
March, 1936
them entirely. Of course, a minimum dose is de-
sirable.
Ephedrine sometimes gave only temporary effects
due to various causes. One interesting thing that
was noted was the fact that two patients took
mineral oil and the attacks became more frequent
even in the face of the administration of the
ephedrine sulphate. By discontinuing the mineral
oil the attacks ceased. Evidently the mineral oil
prevented the absorption of the drug.
In recent years various observers have added
much to our knowledge of the treatment. Prinz-
metal and Bloomberg, among others, advocated the
use of benzedrine sulphate, which is almost a spe-
cific for the condition. The dose varies from 10 to
100 mgs. daily, divided into two or three doses.
Many cases, however, may be relieved by one or two
small doses in the morning.
Given after 4:00 p. m., it may interfere with
sleep that night.
A well person driving a car and getting sleepy
from natural causes, may find benzedrine sul-
phate useful.
This drug seems to be harmless and the only bad
effects, after taken over a period of time, may be
a slight nervousness or jumpiness, which effects
immediately disappear upon discontinuing the drug.
In the treatment of narcolepsy the minimum dose
should be established and the patient kept on this
indefinitely — especially when driving a car any
distance or working about machinery or where liable
to falls. It is extremely important that there be a
careful differential diagnosis between narcolepsy
and the tendency to sleep due to natural causes.
The same treatment, however, may apply to both.
The use of any drug over long periods of time
should be under the direction and control of a phy-
sician, so that optimum dosage may be given, any
untoward effects may be noted and the drug dis-
continued if necessary.
ILLUMINATING BITS FROM "THE STORY OF
MY LIFE," by J. Marion Sims, M.D.
His Observations on Trismus
In April, 1845, I was called to see a child in spasms for
2 days and nights. Touching it would throw it into con-
vulsions; laying it on its face would cause spasms; any
noise would produce them. It could not swallow, could not
take nourishment, and it was impossible for it to suck.
The legs and arras were as stiff as a poker. Its face was
drawn around so that it wore a sardonic grin. After ex-
amining the child for a while, I ran my hand under its
head to raise it up. While in the act of raising it, my
hand detected a remarkable irregularity in the relations
of the bones of the head. At the back of the head I
found that the occipital bone was pushed under deeply on
the brain, and the edges of it, along the lambdoidal suture,
were completely overlapped by the projecting edges of
the parietal bones. I immediately suspected that the spasms
were the result of mechanical pressure on the base of the
brain, effected by the dislocation of this bone by the child
lying on its back. I was surprised to find that by the
erect posture removing the pressure from the base of the
brain the pulse could be counted, and that the respiration
had fallen from 120 to 70.
The child died. The next day we held a post-mortem
e-xamination. I invited Drs. Ames, Baldwin, Bowling and
half a dozen other medical men to be present at the post-
mortem. We found that the spinal marrow was sur-
rounded by a coagulum of blood — extravasation of blood
between the spinal marrow and its membranes. I thought
that this was the cause of all the symptoms, and I published
an article on the subject, in which I elaborated a very in-
genious theory going to show that the compression at the
base of the brain had strangulated the spinal veins in
such a way that the blood could not be returned from the
spinal column, and had therefore burst through its thin
vessels. Subsequent experience, however, compelled m,'
to modify this view of the case, and I wrote a second
article on the subject, showing that this extravasation was
not the cause of the disease, but was the result.
Such cases should be placed first upon one side and
then upon the other, and should never be put in a cradle
or crib at all. A new-born child especially should be
placed upon a pillow, lengthwise of the pillow. If this
were done always, there would be no cases of trismus
nascentium. I have seen a great many desperate cases'
cured in a few minutes' time, simply by placing the pa-
tient on the side. My doctrines in respect to the path-
ology and treatment of trismus nascentium have not been
been adopted or accepted by the profession at large; but
I am satisfied they are true. Dr. , of Anderson, South
Carolina, reported in the American Journal of Medical
Science, for April, 1875, a dozen cases that he had cured;
whereas, before my discovery, medical literature had not
reported a single case of trismus nascentinum having
been cured on any recognized principle applicable to any
other case. Truth travels slowly, but I am sure that I am
right — as sure as I can be of anything. * This will yet be
fully understood and appreciated by the profession. I
consider this my first great discovery in medicine.
His III Health
I was very ill; the fever raged, and I didn't know how
fo arrest its progress by the treatment with quinine. This
was before the days of quininisra, (Sept. 18th, 1836) and
fevers were allowed to take their course. On the 14th day
of my illness a young Englishman, living in Montgomery,
a druggist, happened to arrive in Mount Meigs about ^
sundown. Last June I was in the Creek Nation with him.
He was told that I was going to die tonight. He came
up to see me and asked if I had been given any brandy?
any quinine? On my replying that I had not he sat up
all night giving me these remedies. That was the turning-
point in my disease.
It was not long before the practice of the country was
completely revolutionized. Until that day, the doctors
were in the habit of bleeding and physicking people until
their fever disappeared, and then giving them qumine, a
gr. or 2, 3 times a day. Fearne and Erskine and others
preached the doctrine of giving it always in the begin-
ning, if possible, and giving it in sufficient doses to
affect the system at once. It left me with an enlarged
spleen, and I had occasional attacks of intermitten fever.
I lost my hair but that soon grew out again.
Eariy in July, 1840, I felt a slight chill pass over me, and
the sensation ran down my spine. The next day I had
no paroxysm of fever. The next day, however, a little
•Dr. Sims %vrote this in 1SS3.
March, 1936
SOUTHERN MEDICINE AND SURGERY
141
shiver ran down my back, this chill increased in se-
verity ; 4 hours from the first sensations of chillness, I
was in complete collapse.
My first chill was a little trifling thing at eight o'clock
in the day; the second was an enormous congestive chill
at twelve o'clock in the morning; thus anticipating 4
hours I feared the next would come at four o'clock in
the morning, or 44 hours instead of 48 hours later. If it
came then 1 knew that I must die.
Dr. Holt, of Montgomery, came and told me: "Well
you must not have another chill at four o'clock tomorrow
morning. Thirty grs. of quinine, taken between now and
midnight, will save you. You must take it until you feel
a little ringing sensation in your ears; keep your bed, keep
warm, and keep up good courage." At four o'clock, pre-
cisely, my nose began bleeding, and that the ancients would
have termed a critical discharge. The chill did not come.
Six weeks after my successes with the silver suture, I
completely collapsed. I had contracted diarrhoea, and so I
took my family to Butler Springs. My disease could not
be controlled, and I saw that I was on the verge of
going into that chronic state in which, in that day, there
was such an attendant mortality. I concluded to go to
the North for a time. I was so weak I could hardly make
the journey to New York. I was there during July, Au-
gust and September (1S4Q). I returned to Montgomery in
October, not much better than when I left, if any. Soon
after my return I gradually grew worse. I was reduced
to eating milk and bread, and that ran away from me
almost like pouring water through a funnel.
My wife suggested that I should go to Columbus on a
visit to our relatives there. I walked around about 100
yards to the stage office.
Diarrhoea is a chronic disease of the climate. It is en-
demic all through the valley of the Mississippi. It is what
consumption is in New England. When you see in the
South a man in vigorous health and middle life grad-
ually wasting away, and at the end of IS months drop
to a skeleton into the grave, you may take it for a posi-
tive fact that he has died of chronic diarrhoea.
I did not stay long in Columbus, for I got no better
by the visit.
At last we arrived at Cooper's Well. Mr. Cooper, the
proprietor, was a Methodist Circuit Rider. He said that
a good many people were injured by the use of the water, as
they got impatient to get well, and consequently took too
much of it. But, with a prudent use of the water, he was
sure that I would reap a substantial benefit from it.
I ate, especially, fat meat, middle meat, and salt pork —
the latter had been salted perhaps a month before. The
diarrhoea was checked from the time I began to be a
partaker of the water; I had a ravenous appetite, and I
drank the water according to the express directions. I ate
as I had never been able to before. I remained there 27
days, and gained 27 pounds. I was impatient to get
away, and left too soon. The result of the sudden ar-
resting of the diarrhoea was to bring on a dropsical effect.
My ankles were swollen, my legs were swollen above the
knees, and my face and hands were very bloated. Still
I felt I was on the road to recovery, and, especially, be-
cause the wasting diarrhoea was controlled.
I left there on the 30th of January (1850) for New
Orleans, where I remained about a month. I carried with
me demijohns of the water from Cooper's Well and con-
tinued the use of it, and also continued to eat meat all
the time. About the first of March I returned home.
Everybody was amazed to see the wonderful change that
had been effected. In 2 months more I had a return of
the diarrhoea, a good deal worse than I had pver had it
before, and it grew worse day by day. In July I again
returned to Cooper's Well; but the water and the
treatment did not have the same beneficial effect that
it had upon me during my visit there before. I remained
there about 2 months, and then I concluded that it was
best for me to get into a colder clime. So I immediately
went to New York where I remained about 2 months. I
was always a little better in New York and Philadelphia
than in any other place. Whenever I left New York and
went to New England I was worse. If I went to Brooklyn
for any length of time I became worse, and always felt
better when I got back home again to New York.
I had supposed that in New York was better able lo
control my diet; but subsequent observation proved that
that was not the case. The cause of my being better in
New York and Philadelphia than elsewhere was the fact
of the purity of the water of those two cities. In all New
England, where I had been, the water was hard, and hard
water was and is very injurious to the irritated mucous
membrane of the gastro-intestinal canal.
At last I was compelled to go to bed. I thought that
I should die.
I had gone to New York during the summer of 1849,
1S50 and 1851, with the hope that the change of climate
would do something for me. In June, 1852, I fell down
with a sun-stroke, after a long walk, at the corner of
Fifth Avenue and 27th Street and was carried to my
boarding-house. This sun-stroke reproduced my disease
with the greatest violence, and nothing seemed to control it.
In a state of desperation, I went to Portland, Connecti-
cut, to visit a friend. I remained there a little while,
but got no better, so I returned to the city and went over
and engaged board in Brooklyn, which was the worst
thing that I could have done, on account of the water, and
I grew worse day by day. At last, thmking that I must
die, I concluded to go to Philadelphia. The day after
arriving in this city we got in a buggy and rode up through
the Spring Garden District, in various directions, in search
of a little house that I might rent.
I grew worse and worse daily. I sent for my friend,
Dr. Isaac Hays to come and see me. He said that he
thought I had better tak cod-liver oil. It was placed on
the mantel-shelf; I never took it. But this gave me an
idea. I said to my wife, "Cod-liver oil is a disagreeable
thing to take; pickled pork is a good deal more palatable.
Don't you remember with what benefit I used it the first
time I was at Cooper's Well, how I ate pickled pork, and
how I gained, and how I got well from that very mo-
ment?"
She said "Yes;" and immediately went out and bought
some. She boiled it, and then broiled or fried it, I do not
know which. I had always traveled, wherever I went, with
some of the water from Cooper's Well in jugs. So I said,
"We will inaugurate the same diet here that we did
at Cooper's Well, drink the water and eat salted pickled
pork." So we began it, and, to my great surprise, in 4
or 5 days the diarrhoea was under control. This was
inaugurated the last of August, and in a month I was
able to get up out of bed, and to walk about 200 yards,
with some little help.
In the month of October (1852) I was getting well. I
had always gone back to Alabama in October. We de-
cided this was too early, and so deferred return to the
19th of December (1852). I was feehng pretty well, had
no diarrhoea. Five days after my return I had a chill,
the diarrhoea returned, and could not be controlled by any
possible means. I grew worse and worse. By that time
my throat and tongue were so ulcerated that I could
hardly speak, and any nourishment that I took passed
(To p. 152)
SOUTHERN MEDICINE AND SURGERY
March, 1936
DEPARTMENTS
UROLOGY
For this issue, P. Emery Huth, M.D., Sumter, S. C.
Diverticulum of the Urinary Bladder
Report of a Case of Multiple Diverticulosis in a Woman
The urologist is called to treat patients who
complain of a symptom complex which causes him
to feel that the cystitis is not a simply inflammatory
matter. These patients will tell him that, aside
from the usual bladder symptoms, there are others.
Such a paitent will often make a determined effort
to direct the attention toward the unusually foul
odor which her urine has had over a period of time.
She will also direct attention to her inability to
completely empty the bladder except on straining,
and that this straining is unproductive.
Diverticula of the urinary bladder may be di-
vided into acquired and congenital. IMost research
workers feel that the majority of them are the
result of lower urinary-tract obstruction acting
upon a congenitally defective bladder muscula-
ture. This was made more likely by the finding
of 2% of bladders examined in autopsies of chil-
dren under ten years being the seat of bladder
diverticula. Young demonstrated that overdisten-
sion of the bladder would cause diverticula to form
and relief of the pressure permitted the bladder to
resume its normal shape.
Diverticula of the urinary bladder were once
thought to be found only in the male, but it is
r,cw found also, though less frequently in the fe-
male. The proportion of males to females is given
as ten to one. This has not been my experie.:ce
a^-r that of other urologists to whom I have ad-
dressed queries.
Some of these diverticula of the bladder are false
and some are true. The outpouchings vary in size
from a small hazelnut to a size equal to or larger
than the bladder itself. A diverticulum is rarely
palpable because the majority are in the base of
the bladder or in the bony pelvis out of reach of
the examining finger. Those of the vault are less
frequent but they are easily palpated when full.
The false diverticula or cellules empty easily and
have wide mouths, but the true diverticula are
often bottle-necked and empty with difficulty ii
at all. These latter often have a sphincteric action
of the muscles about their orifices. In one of this
type I noted a decided grab when I withdrew the
cystoscope from it.
The location of bladder diverticula may be
anywhere in the viscus. Most of them, how-
ever, are located in and about the base, even in
the trigone itself. Large ones are usually single
but the smaller ones are often multiple. These
smaller ones tend to arrange themselves in groups
and an attempt at symmetry is made. This is the
case in the report which follows.
Though there are a few symptoms which make
the urologist aware of some cause of cystitis other
than inflammation, there is nothing in them which
definitely singles out diverticulum as the cause in
a given case. It does however, make one more
apprehensive of its existence. The chief com-
plaints are always, when an infection exists with
the diverticulum, those of cystitis — urgency, fre-
quency, strangury and, at times, hematuria. When
no infection exists the only symptom may be that of
an obstructive uropathy or it may be found that a
diverticulum is the cause of upper urinary-tract
pathology. In this instance the symptoms of di-
verticulum are merely those of the existing path-
ological condition. There is, however, one symp-
tom which, though not pathognomonic of diverti-
culum, does put the urologist on guard. That symp-
tom is the unusually foul, musty odor, to the urine.
It is a characteristic odor which is not a usual at-
tendant to any other bladder dyscrasia. This i%
noted only in those diverticula which are infected.
In an uninfected case one finds that the patient
has periodic attacks of urinary frequency without
any known cause. In older patients, especially in
men, the symptoms of lower urinary-tract ob-
struction overshadow those of diverticulum. When
the symptoms of urgency, frequency, dysuria and
pyuria persist after removal of obstruction at the
bladder neck, then further examination should be
made with diverticulum in mind. In rare instances
hematuria may be the initial symptom of a bladder
diverticulum.
.As there is no pathognomonic symptom complex
which definitely will make a diagnosis of bladder
diverticulum, we must proceed with a complete
routine urological examination. Cystoscopy, cys-
tography, pyelography and mietoscopy all aid in
making this diagnosis. The greatest aid is cysto-
graphy. This demonstrates any and all irregulari-
ties in the bladder outline. It may be done either
by using an opaque medium of 5% sodium iodide
or by using air. These two methods may be used
either alone or combined. This latter method will
demonstrate any retention in the diverticulum, if
done after evacuating the bladder of the sodium
iodide. When making cystographic examinations
of the bladder one should make a plain film, one
from both right and left anterior oblique direc-
tions and another after evacuating the sodium
iodide. If surgery is decided upon the usual blood
chemistry and serological examinations are carried
out. It is also essential in this instance to examine
the upper urinary tract by pyelography to deter-
mine the extent it has been damaged, if at all.
March, 1936
SOUTHERN MEDICINE AND SURGERY
143
The treatment in each case of bladder diverti-
culum differs from that of every other case, but
certain essential principles are determined, accord-
ing to which further procedures are carried out. If
a diverticulum is not giving symptoms and is found
only on a complete examination, no treatment is
indicated. The cellules usually respond to con-
servative treatment. Infection in the bladder and
in the diverticulum must be controlled as far as
possible prior to active surgical intervention. If
this is not done a postoperative pericystitis will b?
the result. This makes the outcome very doubtful.
The lower urinary tract picture must be studied
and the exact nature of the cause determined and
removed before attacking the diverticulum. When
the diverticulectomy is done the surgeon will have
determined the exact relationship between the di-
verticulum and the surrounding structures so that
he will avoid them in his removal of the sac. The
plain x-ray film will have demonstrated the presence
or absence of a calculus and if one has been found
it must be removed to effect a recovery from di-
verticulectomy.
There are many methods of operating on these
sacs, but this paper is too brief to consider
techniques.
The following is a report of a case of multipl?
bladder diverticula in a female.
Case Report
The patient was a white woman, aged 51, married, septi-
para, with no history ol difficult labor and no lacer-tinns.
Past history- was irrelevant except for an attack of malaria
several years ago.
Seven and a half years ago she began having som; d ffi
culty in emptying her bladder. Soon she had to strain i;
she voided at all. This continued for three years when she
had a small growth removed from the urethra. The exict
nature and origin of this growth was not de'.ermincd. Thi?
was followed by marked improvement for four year=
Then the difficulty in voiding returned and became progres-
sively worse. .\s the difficulty in voiding increased it was
accompanied by marked pain on urination and frequency
and vesical tenesmus. At this time nocturia began, often
twenty to thirty times nightly. In July of 1935 she had
an attack of painless hematuria which stopped withju;
treatment or investigation. As the urgency, frequency and
dysuria became worse she noted an increasing difficulty in
voiding. She frequently had to strain very hard to ex:Jel
a few drops of urine. She states that her urine has had
a very foul odor for a long time. There is a slight back-
ache over the sacro-iliac joint.
The patient appeared about the age given, very nervous
and emaciated. There were no findings indicative of disease
except tenderness over the bladder area and and left tubo-
ovarian region.
The external genitalia were normal, the introitus that
of a multipara. On the floor of the vestibule of the vagina
was an inflamed edematous mass extending from the left
laljium minor to and across the external urinary meatus,
which was completely covered by the mass which was not
hard but extremely painful to palpation. The urinary
meatus resembled a slit parallel to the long axis of her
body. The lips of the meatus could easily be separated
but fell together at once on letting them free of the exam-
ining fingers. On vaginal examination the urethra felt
thickened and very tender. The base of the bladder was
indurated and gave the impression of a spongy mass above
it, this also very tender.
A 24-F. cystoscope was easily passed into the bladder
and met no obstruction. Ten ounces of foul-smelling
purulent urine was drawn from the bladder. The odor of
the urine was very foul and musty. Several washings
were necessary before the bladder could be cleansed suffi-
ciently for examination. The bladder capacity was about
300 c.c. On looking into the bladder a markedly trabecu-
lated area was seen posterior to the bas-jond and between
the muscle fasiculi many small cellules opened. There
was a severe generalized cystitis. The trigone was markedly
injected and the ureteric orifices were apparent. These
were located on small hillocks and were functioning nor-
mally. Just medial and superior to the left ureteric orifice
was a deep triangular recess and medial to this was a large
opening. The opening gave the impression that it led to
a large diverticulum. In the retrotrigonal area eleven
diverticula were found in one cystoscopic field. The right
end of the interureteric bar limited another group of diver-
ticula from the trigone. There were also many small
diverticula in the dome of the bladder.
At a later sitting a urethroscopic examination was made
with an endoscopic tube, having the patient in the knee-
chest position. Nothing indicative of obstructive lesions
was found, the only positive finding being a pale urethral
mucosa.
Five-per cent, sodium iodide was injected into the blad-
der until the patient complained of fullness and an x-ray
examination was made in the antero-posterior, right an-
terior oblique and left anterior oblique planes.
Figure No. 1 i.-. an antcro-postcrior cystogram.
This view shows that there are innumerable div'erticuia
all about the circumference of the bladder and that there
is one large diverticulum on the left side. Many of these
diverticula are the bottle-neck type and some are appar-
ently separated from the bladder. The majority of the
diverticula are on the right side in this view.
SOUTHERN MEDICINE AND SURGERY
HUMAN BEHAVIOR
James K. Hall, M.D., Editor, Richmond, Va.
Figure No. 2 shows a left anterior oblique cyslogram.
The largest diverticulum can be seen to be of the true
bottle-neck type. Those superior to it are plainly demon
strated to be of the bottle-neck type even though they are
small. There is no evidence of calculus.
Treatment: The urethra was dilated to No. 30 F. and
the bladder was irrigated with normal saline solution at
bi-weekly intervals. After the first few treatments either
acriflavine 1:1000 or 10-per cent, argyrol was instilled into
the bladder following each irrigation. Immediately after
these treatments were given the patient experienced great
relief of all her symptoms, especially from the nocturia.
Her urine became much clearer but retained the foul odor
even after several treatments. She has had two attacks
of severe cystitis which responded to the usual treatments
at daily intervals. I was unable to determine the exact
cause of these complications. At present the patient is
seeing us every three or four days and the above treatment
is being carried out. On this regimen she is improving in
general health and the bladder is no longer the source of
such great discomfort to her.
Surgery was considered and discarded because we could
not give her a favorable prognosis in the face of such
multiplicity of infected diverticula and her own unsatisfac-
tory condition.
Summary
1. A case of multiple bladder diverticula with
infection in a female patient with no discernible
infravesical obstruction is reported with a dis-
cussion of bladder diverticula.
2. Attention is directed to the exceedingly foul-
smelling urine as a possible indication of a diver-
ticulum.
3. An outline of conservative treatment in this
case is given.
Newspapers and lay magazines and the public rostrum
should be used freely for acquainting the public with facts
as to what Medicine can do for people; but the use of
either for touting any doctor or group of doctors should
be, as it is, sternly discouraged.
The Community's Responsibility for the
Mentally' Sick*
Socrates was highly intelligent, but he had no
interest in conformity, in mass thought, and in
mass conduct. The object of his concern was the
individual. He encouraged individual persons to
think: if jx>ssible, to know; and to have respect
for their own opinions. I can scarcely think of
Socrates as a member of any organization. Jesus
came four hundred years later. I know of no
reason for thinking that Jesus had the slightest
interest in organizing any sort of movement. He
was interested in individuals — all sorts of them —
and He insisted that His followers continue that
interest.
But — we are living in a highly organized society.
What are we going to do about it? We should try
to fit into it and try to make some contribution
to it without losing our identity or our self-respect.
Perhaps the loss of one would carry along the lo^s
also of the other. I hope I shall not be here when
human beings become mere socialized robots.
Not too much thought and attention is devoted
by the public to physical health. Although the
machine is making relatively useless the need of
human physical strength, a sound physical struc-
ture is still important. Emotional and mental
states make themselves manifest through physical
activity, and for that reason, as well as for many
other reasons, physical disease has its effect upon
mental health. We have discovered, of course,
that a human being is not an assortment of pigeon-
holes, but that physical and mental activity are
both manifestations of life, and that what affects
one part or attribute of an individual has its
influence throughout the totalized organism. And
that discovery, or confession, whichever it may
be, is significant. It means, of course, that there
cannot be one sort of physician who can limit his
concern to one small portion of the body, and an-
other sort of physician who can devote his thought
solely to another small portion of the body. The
body will not be treated in any such fashion —
specialists or no specialists. The human being
has found out that he is a unified organism; that
the related parts of him are each and all important
because their correlated activities give him life and
emotions and mentality and personality and char-
acter. And disease, whatever may be its cause
and its nature, is due to a disturbance of such
relationships.
•Presented by request to the Public Health Section
the Graduate Nurses" Association of the Fifth District
Virginia at Saint James Parish House, Richmond, \
ginia. February 21st, 1936.
March, 1936
SOUTHERN MEDICINE AND SURGERY
For centuries mankind remained in ignorance
of his physical body. Dissection, with its anatomi-
cal revelations, came only lately, and physiology
still later. For many centuries the treatment of
the diseased body was in the hands of the unin-
formed and the ignorant. ^len mutilated each
other in battle, but the human body was thought to
be too sacred for dissection and autopsy study.
Everything about the body was looked upon as a
mystery.
For purposes of emphasis I am going to ex-
aggerate by saying that our attitude towards mental
sickness is still mediaeval. That is true. We do
not quite think of mental sickness as belonging
within the domain of modern medicine and modern
nursing. Perhaps there may be something self-
defensive and self-protective in such an attitude
towards mental and emotional sickness. Are we
not inclined to protest that the things about which
we know nothing are of no importance? Occa-
sionally, but only occasionally, some doctor makes
inquiry of me about the nuts and the bugs and
the crack-pots. Of course, if he knew anything
about psychiatry he would not indulge in such
speech. He makes use of it to protect his ig-
norance. He cannot quite confess that he knows
nothing at all about any branch of medicine. He
has to keep psychiatry outside of his domain by
deriding its claims and keeping it in the realm
of demonism and mysticism.
Our first duty is to try to enable ourselves to
understand that the function we speak of as the
mind can become disordered, and that in such a
circumstance the individual is out of tune both
with self and with society. For, whatever mental
sickness may mean medically and legally, it means
practically maladjustment at the social level. And
because a human being constitutes a unit in the
social organization, it has become necessary for
society to deal with such disordered social units.
Such activity is neither wholly altruistic nor phil-
anthropic, for whatever is good for the unit is help-
ful to the whole.
Perhaps we have thought the mind too mys-
terious or too sacred to attempt to understand it.
Everything is a mystery in the sense that our
understanding of it is imp>erfect. There may be
nothing more incomprehensible about the operation
oi the psyche than about the function of the liver,
or of the spleen, or of a muscle.
But it is undeniably true that the mentally sick
person is less skillfully ministered to than the
physically sick person. That is true, but why is
it true? It is true largely because our thought about
mental sickness is still largely mediaeval, therefore
fatalistic, therefore hopeless. We do not cheerfully
and hopefully take charge of a mental patient be-
cause we feel that the outcome rests upxin the
knees of the gods and that nothing rational can
be done. Is it not true? I fear it is true, but if so,
it constitutes a dreadful reflection upon our intelli-
gence and our skill and our courage. Many men-
tally sick folks recover, and remain well.
But modern medical science has not yet been
brought to the bedside of the mental patient. That
statement is practically true. In the five state-
supported mental hospitals in Virginia there are
approximately ten thousand patients. On the
medical staffs of these five institutions there are
probably fewer than thirty physicians, including
five superintendents whose duties are administra-
tive. How much medical thought and investigation
can be given to ten thousand sick people by twenty-
five physicians? A solid weeks work can well be
devoted by one doctor to one mentally sick person.
And in those five institutions of ten thousand
patients there are probably thirty trained nurses.
And most of those have probably had little if any
psychiatric training. The patients, in other words,
are in charge of relatively ignorant and untrained
attendants. .Are such institutions, properly speak-
ing, hospitals, or merely places of care and deten-
tion? I am not criticizing any individual. I am
criticizing the attitude of society towards a branch
of the science of medicine. I am criticizing the
curricula in our medical schools and training
schools for nurses. What training of consequence,
with actual experience with psychiatric problems,
is given either to medical students or to nurses?
Practically none.
Xear Richmond are two large state hospitals
with an aggregate patient population of almost
four thousand. In these institutions clinics in all
the branches of medicine should be held for the
benefit of medical students, nurses, and patients.
Every young physician should be obliged to serve
as a part of his interneship, certainly two or three
months, in a psychiatric hospital. And every
nurse should, of course, spend a part of her student
days in a mental hospital. Such a rotating interne
and nursing service would bring new life into the
state hospital service, and keep the medical and
nursing staffs in constant touch with the latest pro-
gress in all the branches of medicine. Throughout
the period of the depression many excellent grad-
uate nurses have been unoccupied. Many of them
should have been engaged on the wards of the
state hospitals.
In no other form of sickness is diagnosis so diffi-
cult as in mental disease; in no other condition is
such a demand made upon skill and tact in minister-
ing to the sick; in no other condition is such pro-
ductive and social incapacity encountered as in
diseases of the mind. Mentally sick folks are gen-
SOUTHERN MEDICINE AND SURGERY
March, 1936
erally not only incapable of helpin.s; themselves;
they' often turn their energy destructively against
themselves. It is our duty, therefore, not only to
minister to the mentally disordered, but to deal with
mental sickness rationally, and to divest it of mysi-
cism and fatalism, and so invest it with intelligence
and skill and courage and dignity and hope.
Preventive work may be of even more importance
in the field of mental hygiene than in the domain
of public physical health. Yet I do not like at all
the tendency even to think of mental sickness and
physical sickness as if they are unrelated. It is gen-
erally impossible to be physically sick and to be
at the same time in wholesome and comfortable
emotional and mental condition. .\nd each of us
knows how susceptible the functions of the various
organs and the work of the body as a whole are to
emotional and mental perturbations. In man mind
and matter are so intimately related that what af-
fects one usually affects also the other. As a unit
of the structure that we speak of as society we
are concerned not primarily with the activity of
any individual organ or group of organs, but with
the manifestations of their correlated and har-
monious functioning. In other and better words,
we are interested in man the individual as a social
totality. Except for that interest in him we are
not concerned about his fractional functionings. We
should be as keenly interested in the morbid, emo-
tional condition of the patient — as exhibited by
fear, dread, anxiety, anger, suspicion, doubt, gloom,
despondency, or too much joy — as in the symp-
toms of any physical disease. And we should be
equaVly-as k«eBly--Gn the lookout for evidences of
mental abnormality in the higher intellectual levels.
.\11 of these things are not ony indicative of in-
stability, but they may manifest themselves in
physical behavior that may embarrass and stigma-
tize the individual, and do hurt also to society.
Preventive work is of the utmost importance in
mental hygiene. In the school, for example, it is
worse than futile, it is tragically wasteful and dis-
appointing, to attempt to educate by the use of
books the uneducable child. Efforts should be
made otherwise to lead such a child into self-devel-
opment — for that is what education should mean.
After all, the educator should not be expected to
do more than to discover the child's innate ca-
pacity, quantitative and qualitative, and to afford
the opportunities for the development of that ca-
pacity. I believe, for instance, that no educators
can accurately express by the use of any symbol
the knowledge and the intellectual capacity of
any student. And for that reason, marks should be
abolished. Those who receive high marks overesti-
mate their importance; those who do not get them
— yyell — even the fox turned up its nose and walked
away, remarking, as it did so, that the out-ofthe-
reach grapes were inedible, anyhow. .And I am per-
sonally unimpressed by the Phi Beta Kappa, the
Golden Fleece, and other symbolizations of acade-
mic omniscience. Let us patiently wait. Life will
eventually mark us all on the great blackboard
fairly accurately — at least inexorably.
I have no respect for the frequently repeated
statements that there are too many physicians and
too many trained nurses. There are not nearly
enough. The quacks and the charlatans and the
medical humbugs exist only because we doctors
and you nurses are not performing duties for those
who are in need of our training and our services.
The failure may be due to lack of opportunity; —
those in need of us may be unable for one of many
reasons to reach us. The failure may be due in
some measure to our own wTong attitude towards
our duty; our lack of skill. .And yet I read that a
medical senator in Virginia would by legislative en-
actment have your training made even poorer.
Many doctors, and many nurses, too, think of
themselves as ministers only to those who are ac-
tually sick in body or in mind. A duty equally as
important is to those about-to-be ill, either in body
or in the immaterial domain. For example, suicide
is theoretically, at least, preventable; and so also
are many homicides. Commercial prostitution must
be often an expression of economic inadequacy.
Drunkenness and drug addiction are manifestations
of maladjustment with an underlying cause that
may not be always beyond the reach of discovery.
The number of divorces would be infinitely reduced
if the dysharmonious pair could me medically
studied. A great many devotees to patent medi-
cines, many of them habit-forming and dangerous
to life, are really sick people — in mind, in body, or
in both structures — who are, in their fear and ig-
norance, making both patients and physicians of
themselves. .\nd that is something that no sensible
person, lay or medical, will ever do. And most
such drug-takers are propelled by fear. And there
should be accessible to every person who lives in
the grip of fear some understanding nurse or doctor
to whom that person could go for comfort and
relief. For I believe that long-continued repressed
fear causes more distress and suffering than phy-
sical disease.
Let me say finally, that in my opinion no people
are yet civilized to whom proper educational op>-
portunities are not available for all; to whom the
comforts of religion are inaccessible to any; and
to whom the science and the art of medicine,
through nurses, and doctors, laboratories and hos-
pitals, are not available for all, rich or poor, strong
or weak, black or white, believer or unbeliever. But
that domain in which understanding is most needed
SOUTHERN MEDICINE AND SURGERY
is the region of the immaterial — in the instincts, in
the emotions, and in the intellect itself. About that
aspect of man we know too little. But we should
take steps to equip ourselves to deal as hopefully
and as efficiently with mental sickness — pre-
ventively and therapeutically — as we now deal with
sickness of the body. I hope and I pray that all
nurses may become more and more insistent that
the mental hygiene aspects of their training be con-
stantly enlarged, and that they demand that the
ministrations to the mentally sick be made by
nurses trained also in mental hygiene and not by
untrained attendants. For, until that time comes,
those who are sick in mind and in spirit, will dwell
in the land of Gloom that lies in the Shadow of
Ignorance.
GENERAL PRACTICE
WiNGATX M. Johnson, M.D., Editor, Winston-Salem, N. C.
The Present Status of the Arthritis Problem
In the Annals of Internal Medicine for January
is a review of the American and English literature
on the subject of arthritis and rheumatism by a
subcommittee of the American Committee for the
Control of Rheumatism. North Carolina should
feel proud of the fact that Dr. T. Preston White,
of Charlotte, is one of the si.x members of this sub-
committee. The report covers one hundred pages,
including fifteen pages of bibliography. While
taking a holiday enforced by an attack of laryn-
gitis, I had time to read this review rather care-
fully: but must confess that "I came out by the
same door wherein I went," so far as real help in
understanding the problem of treating a victim of
arthritis is concerned. It is true that the rather
positive statement was made that gonorrheal arth-
ritis responded well to fever treatment, and that
few of the natives of Tucson, Arizona, suffered
from arthritis; but it has been many years since
I have had to treat a case of gonorrheal arthritis,
and very few of my patients have the financial
ability or the inclination to migrate to Tucson.
Indeed, a few to whom I broached the subject inti-
mated that they would rather live in North Caro-
lina with arthritis than in Arizona without it.
The review is of value in discouraging undue
enthusiasm about any method of treatment as
specific, and it frankly admits that the cause of
arthritis is still to be designated A',- and that, until
X is discovered, the problem is still unsolved.
The "authorities" on the subject are becoming less
authoritative in their opinions, as witness the
statements of one of them. "There is no one
cause for chronic non-specific arthritis of either
type. . . It is quite probably that a disturbed cir-
culation is often the primary disturbance." "In-
fection is the most important factor in the atrophic
typ>e." "Possibly the disease (atrophic arthritis)
cannot develop in the absence of bacteria but the
presence of bacteria alone is insufficient in most
cases to produce the disease, so other factors are
of equal importance." Evidently this man is pre-
paring to be able to say, I told you so; no matter
what A' finally proves to be.
Infection, "altered metabolism," diet, sulphur
deficiency, avitaminosis, endocrine disturbances and
neurogenic disturbances are all considered in de-
tail — and all dismissed as not having been proved
guilty. The now popular fetish of allergy is treated
with scant respect in an editorial comment which
quotes Freeman with approval: "We are work-
ing in a fog and have as yet no clear vision. The
word allergy is, to my mind, not a gleam of sun-
shine breaking through, but an extra wisp of fog."
The authors give their final conclusion, very
sensibly, in these words: "From this mass of con-
fusing, sometimes conflicting, data one cannot as
yet form any conclusive ideas on the etiology and
pathogenesis of the disease. It is obvious that . . .
to date no one etiologic factor . . . has been con-
clusively shown to be the prime cause of the
disease."
The discussion of treatment, likewise, is fairly
well summarized in the statement that "There
is no one specific, no one standard form of treat-
ment. Individualized, not routine, treatment of
each patient is required, and the patient, not just
the disease, must be vigorously studied and cared
for." And again, "A physician must not con-
centrate on only one form of treatment or he will
become a faddist. In selecting his physician a
patient probably will do best by choosing a well-
rounded internist." Which covers the ground as
well as anything yet said on the subject. The
authors are to be congratulated on the painstaking,
conscientious effort with which they have reviewed
the enormous mass of literature on arthritis pub-
lished last year; for the calm, unbiased way in
which they weighed the numerous claims and
theories advanced; and for the crisp, clearcut, con-
cise editorial comments which illuminated the
reader's pathway through the long and sometimes
dreary discussions set forth.
.\ Cocksure Opinion
Some time ago a wealthy lady, while taking a
holiday in a large city in a Northern state, be-
thought her to consult a dentist. He in turn sent
her to a nose-and-throat specialist, who had her
sinuses x-rayed and then insisted that an immediate
operation was necessary to her health and hap-
piness, if not, indeed, her very life; but she de-
cided to postpone it for awhile, and asked him
SOUTHERN MEDICINE AND SURGERY
March, 1936
to send the films and his findings in her case
to me.
In interpreting an x-ray film I am considerably
dependent upon the man who makes it to tell me
what to see; hence I do not doubt the findings,
since the roentgenologist is a national authority.
The right frontal, right maxillary and right anterior
ethmoid sinuses were cloudy. The right sphenoid
and all the left sinuses were clear. What amazed
me, however, was the absolute cocksureness of the
laryngologist : "Beyond peradventure of a doubt,
most if not all of Mrs. X's nervous and glandular
disturbances have been due to toxic absorption
from this closed right maxillary sinus. .\lso, the
mucous membrane changes in the right anterior
ethmoids and frontal sinuses will subside very
promptly after the cure of the right maxillary
which is diseased as the result of dental infection
some fifteen years ago. The time consumed and
the inconvenience of the patient are so slight in the
proposed operation that I was very much disap-
pointed when Mr. and Mrs. X decided to return
home as is" (sic).
Knowing the patient's "nervous and glandular
disturbances" somewhat better than the eminent
one — from a rather intimate acquaintance with
them for some years antedating the dental infection
supposed to have started all the trouble — I find
it difficult to subscribe to the opinion that the
"slight operation" spoken of will perform such a
miracle as making over the nervous system of this
patient. From the bottom of my heart, however,
I wish I could feel as certain of myself as this
specialist does. It must be a grand and glorious
feeling. If, however, he had to follow up a few
of his operative "cures" for years afterwards, he
would find that feeling of cocksureness gradually
oozing away.
The Country Doctor
The country doctor is disappearing, and a sad
day it will be for the country people when the last
one has gone.
We need country doctors on account of the doctor
himself, for several reasons:
1st. Because a country doctor may lead the
happiest life of anyone in aJl medical circles, for
he can be "a big dog in a small meat-house" and
this to my mind is better than to be "a little dog
in a big meat-house."
2nd. He has a great opportunity, — that of do-
ing his best, being his best, of doing many unusual
but needful things which he can do as well as any
specialist or would-be specialist. Recently I did
an unusual and much needed minor operation, —
one I had never done before, and will probably
never do again. A day later I did another, the
first of its kind I have ever done. It was to tie
and cut off a small polypoid tumor from the setter-
bone of a colored man. Had I been unable to do
this service it would have necessitated in each case
a very difficult trip to a hospital or surgeon.
3rd. A country doctor has more time to study
medicine in all its branches, as well as to do re-
search work along any line. He has more time
and opportunity to study his cases, to prepare the
treatment he thinks best suited to the patient, to
know what effect is desired and what effect is se-
cured, regardless of what the drug houses claim
for their preparations. He can study therapeutics,
and can find out by actual experience what drugs
will do and what they will not do. There is
enough in the pharmacopeia to meet the need of
any case without recourse to expensive proprietary
preparations — 60% of all prescriptions are for pro-
prietary preparations. In my 48 years of practice
I have found the country doctor better up on
diagnosis and therapeutics than his city brother,
whenever I have found it necessary to call a con-
sultant.
4th. The country doctor knows his folks. He
knows everybody in his territory, and everybody
knows him. He knows who requires kid-glove hand-
ling, and who the emery-wheel. He knows the
idiosyncracies, both medical and mental of his pa-
tients. He knows who will have nettle rash after
a dose of quinine, and who will not tolerate tur-
pentine. He knows where each family keeps its
skeleton in the closet, and how much that skeleton
affects the mental attitude of each member of the
family. He does not look on his patients as simply
cases, but as human beings with powers and frail-
ties like unto his own.
I have tried to show why the country is a good
place for a doctor to live, looking at it from his
own point of view, and now I will give some reasons
from the viewpoint of the country folks themselves
why they should have a doctor living among them.
1st. It is so much more convenient for them
to see him at his office or call him when a visit is
needed.
Knowing their doctor as they do they will meet
him when on a visit to a neighbor to consult him
about small ailments that do not seem of enough
importance to demand a trip to town, — to have
a child's tooth extracted, — to have him clip a baby's
tongue, — to get something for an annoying head-
ache, — to have him lance a felon.
2nd. It is less expensive, for the country doc-
tor, if he is wise, will dispense his own drugs, and ;,
if he has the welfare of his constituents at heart he
will study to provide drugs that are not ruinous
in price.
March, 1936
SOUTHERN MEDICINE AND SURGERY
When a city doctor is called he leaves one or
more prescriptions and this makes a trip to a
drugstore necessary. Country folks can pay a
country doctor on account many things that would
not be acceptable to one living in town. I have
taken on bills almost everything from a load of hay
to a basket of cucumbers. Recently I accepted, —
not at par however, — two Confederate bonds of
$100 each.
3rd. The last reason I would give for country
doctors is that the farmers who make up most of
the population in rural districts need a physician
who can see and appreciate their problems and diffi-
culties. As most country doctors are farmers them-
selves every problem that confronts the farming
class is their problem also. This being so, his
patrons can, in a sense, meet him on a common
level, and because of this he can be a leader in his
community, and a means of uplift in civic, social
and religious life. A country doctor has an un-
limited opportunity for service to others.
I quote from an article published a few years
ago in the Raleigh Times:
"The typical country doctor is one of the
world's choicest spirits. Usually little is said of
him. He is no famous specialist who operates and
charges thousands; he issues no bulletins about
his humble patients; he says little or nothing; but
he does a very real work in the world, becomes a
member of every family he visits, loves and is
loved as few men understand endearments, and
we can imagine no more hearty greeting than that
which he receives when he reaches the gates of
heaven and hears, 'Well dione thou good and
faithful servant; enter thou into the joy of thy
Lord.' "
C. C. HUBBARD, Farmer, N. C.
PEDIATRICS
G. W. KuTSCHER, M.D., F.A.A.P., Editor, Asheville, N. C.
Meeting of the Medical Society of the State
OF North Carolina
. The annual meeting of the North Carolina State
Medical Society will be held at Asheville, May 4th
to 6th. Here in the mountains it will be Spring!
Not so many flowers in bloom as in the Eastern
portion of our State perhaps, but we challenge the
rest of the State to supply as much invigoration
from the air and other surroundings. When we
meet at Pinehurst there is nothing to do but attend
the sessions and go to bed. In Asheville you will
be meeting in a resort city where entertainment will
make it hard for you to find time to go to bed.
Many physicians and their families will come to
Asheville at this time as part of their vacation.
Some will come early and we hope all who come
\vill stay late. In an effort to help you enjoy your
stay here with us the editor offers a few suggestions
as to places to go and things to do. Naturally we
hope to make the program sufficiently interesting
to give you your fill of the newest things in
medicine. In your spare time we offer:
The four general hospitals — Aston Park, Bilt-
more. Mission and Norburn — will be open for your
inspection as will all of the numerous sanatoria. We
are proud of our institutions for the care of the
ailing. Aston Park and Mission are in walking
distance from the headquarters hotel, the Battery
Park. Biltmore and Norburn are not far from the
hotel. An automobile will help greatly to enjoy
Asheville.
The doors of Grove Park Inn, known as the
finest resort hotel in the world, are always open
to visitors. You must include it in your tour of
the city. You may wish to visit the Biltmore
Homespun Industry on the grounds of the hotel.
The trip to the hotel and return will require about
an hour, and another hour may be spent profitably
taking in the views and seeing the industry. Just
beyond the hotel entrance is the auto toll road to
the top of Sunset Mountain. Pay a small fee and
drive to the top of the mountain over safe roads to
witness a Western N. C. sunset. One-and-a-half
hours is ample for this trip.
If you enjoy a 2-mile walk just before supper,
and incidentally to watch the sunset, try the paved
road to the top of Beaucatcher. In the morning the
sun will be to your back, and if you take along your
camera you can get a grand picture of the city.
A motor trip beyond description in this column,
taking a full afternoon, is over the Scenic Highway.
The road is good, but the driver had better not
be too interested in scenery unless he stops the
car to admire it. A camera on this trip is a neces-
sity. Take a lunch along and enjoy life once more.
More next month!
Measles Prophylaxis
If you are not already, you soon will be, in the
midst of a measles epidemic. This is not prophecy
for measles returns to us in epidemic form every
two years. It is a communicable disease that is
not controlled by quarantine. The reason for this
is the 4-day prodromal period, from the onset of
initial s}Tnptoms until the appearance of the rash.
Many children go about spreading the disease dur-
ing these four days. But measles can be con-
trolled!
In the large hospitals and childrens' homes it is
being controlled by the use of immune serum. To
prevent the disease requires larger doses of serum
and earlier administration than is necessary to
SOUTHERN MEDICINE AND SURGERY
March, 1936
modify the attack. The immunity derived from
a protective dose of serum lasts a few weeks only.
Poor health, acute illness at the time of exposure,
tuberculosis, and especially the presence of an acute
otitis media — each is an indication for complete
protection.
The immunity produced by an attack of measles
is generally lifelong. This immunity is not absolute!
Measles modified in severity by the use of immune
serum, likewise, generally produces lifelong im-
munity. Immune serum certainly modifies the
disease and reduces the complications to practically
nil. It was first used therapeutically, in the form
of convalescent serum, by Weisbecker of Germany
in 1896. In 1920 Degkwitz used it in a large
series to prevent the disease. When it failed to
protect, it was observed that the attack was greatly
lessened in duration and severity and complications
did not appear. From this observation has arisen
the modern method of giving a small dose of serum
to modify the disease.
Whole blood from a Wassermann-free and other-
wise healthy donor who has had measles can be
used, but it requires so much volume that serum
is to be preferred. One half as much of serum as
of whole blood is sufficient. Any physician can
prepare his own supply of serum. Allow the drawn
blood to stand, separate the serum from the clot,
add one drop of 5% phenol to every 40 c.c of
serum and keep on ice. The phenol is not a sub-
stitute for careless technique in the collection and
handling of the serum. Naturally the more recent
the attack of measles in the donor, the more potent
the serum. No absolute rule as to dosage can be
laid down, particularly if complete protection is
desired. From a donor who had measles 15 to 20
years ago, at least 30 c.c. serum for complete pro-
tection. In contrast, as little as 10 c.c. of serum
from a recent convalescent donor may be sufficient
to completely protect. It is better to give too much
serum rather than too little. Equally important is
early administration. It must be given not later
than the fourth day after exposure.
The more frequent need is for modification of an
attack of measles. In this instance it is best given
on the 4th, Sth, or 6th, (not later) day following
exposure. From 4 to 5 c.c. is an adequate dose.
All injections are made intramuscularly. Mild
local and systemic reactions occasionally occur,
but are gone the next day. Serum reactions do
not occur.
Immune Globulin (Squibb) (Lederle) is now on
the market in 2-c.c. and 10-c.c. packages at $2.50
and $10.00 respectively. It is a pseudoglobulin of
human placental extract. It is used in 2-c.c. doses
for modification, given not later than the fourth
day after exposure. For protection against the
disease 3 -c.c. is advised. It is also used curatively
in 2- to 5-c.c. doses. It seems to be more effica-
cious just after the appearance of the rash. The
principle behind the use of immune serum is sound,
but the exact dosage is still to be worked out.
SURGERY
For this issue, George McCutchen, M.D., Columbia, S. C.
Burns
Burns are usually considered as a minor surgi-
cal problem; but the fact that 25,000 persons die
from these accidents each year is sufficient reason
for giving them serious and critical consideration.
The widespread dissemination of knowledge of
Davidson's tannic-acid treatment has reduced the
mortality gratifyingly. It cannot be doubted, how-
ever, that Davidson failed to say the last word on
the treatment of burns. Reports of various meth-
ods have appeared since his publication. The gen-
tian-violet treatment of Aldrich and the hypertonic
saline treatment of Blair have probably received
more proponents than have other methods reported.
Since so many forms of treatment have been sug-
gested one is almost forced to the view that no one
form is applicable to all cases and that considerable
judgment is required in the selection of treatment
in each case.
The general measures to be employed in the early
burn cases are well recognized. First, relief of
pain which is accomplished by adequate doses of
morphine and, later, by the application of an
escar-forming solution which sometimes gives al-
most startling relief. Second, maintenance of body
heat is accomplished by a heat tent, hot-water bot-
tles, etc. The hypertonic saline bath serves this
purpose admirably for a short while and has the
additional advantage of aiding considerably in the
debridement, since the obviously dead skin will
tend to float and can be easily removed. Third,
restoration of fluids. Underbill has shown that
70 per cent, of the total blood volume of 5,000 c.c.
can be lost from a 20 per cent, burn in twenty-four
hours. This means that a person may lose 3^
quarts of fluid in 24 hours from a burn of one leg
or both arms. He maintains that the fluid lost has
the same composition as blood plasma. It has also
been shown that large amounts of chlorides and
alkaline elements of the blood are lost through the
kidneys. These facts serve as a rational basis for
giving fluids in abundance by transfusion, by in-
fusion of saline and glucose solutions, or by ad-
ministration of fluids by mouth. Fourth, debride-
ment. This should always be superficial, removing
only that tissue which is obviously dead and which
comes away easily. Extensive debridement may
destroy many valuable islands of epithelium and
SOUTHERN MEDICINE AND SURGERY
151
hair follicles on the burned area and always has a
tendency to augment the shock. Greases, oils, etc.,
should be removed gently but thoroughly with
ether or alcohol. Fifth, application of escar-form-
ing solutions. The reasons for the application of
such a solution are well known and will be men-
tioned in order of importance. It prevents fluid
loss. It prevents further bacterial contamination.
It gives relief from pain. It precipitates or fixes
the products of protein destruction in the burned
area. The importance of this factor has never been
satisfactorily determined since no one has been able
to definitely incriminate the elements of protein de-
generation in the causation of the toxic symptoms
in burns.
Gentian violet has all the advantages of tannic
acid with several virtues not possessed by the latter
agent, and these advantages prompt us to make a
plea for its use. First of all, gentian violet is much
more bactericidal than tannic acid, and since active
infection on a burned area is a devastating hin-
drance to good end results this factor gains prime
importance. Second, gentian violet promotes or
stimulates epitheliazation and thus lessens the like-
lihood of scar formation. And third, the escar
has a tendency to soften quickly if infection does
appear beneath it and thus serves for easier detec-
tion of this complication. In all of the cases which
we have observed there was a definite tendency to
diminution in scar formation and the development
of infection. The main argument raised against
the use of gentian violet is the fact that it stains
bed linen. This difficulty can usually be obviated
by the exercise of a little ingenuity. No attempt
should be made to treat old burns, that is, from
two to three days old or after active infection has
become apparent, with any escar-forming solution.
The hypertonic saline baths have been reserved
for those cases which are first seen after infection
has developed on the burned area or those which
have developed infection under an escar. It may
be well to insert at this point a warning about the
close observation which should be exercised in
watching for the appearance of infection under
any kind of escar. The crust should be sounded
daily and opiened at the first sign of fluc-
tuation. A rise in temperature should make one
suspect the presence of infection in a burn more
than 12 hours old, but the best index of beginning
infection is an increase in the sedimentation rate
of these patients. This test should be run at fre-
quent intervals after the first 72 hours and until
all danger of infection has passed. The fact that
infection is not recognized early and the proper
treatment for this complication instituted as soon
as it develops is responsible for a great many of
the complications which are generally attributed to
burns. If infection does appear, it is best to insti-
tute saline baths and to remove the escar gradually
and gently. It is impossible for islands of epithel-
ium to proliferate when they are bathed in pus held
on the granulating area by a thick escar. Saline
baths have advantages over wet dressings. They
do not traumatize the granulation tissue. The re-
moval of small islands of epithelium during the
process of dressing change is avoided. There is
also the great advantage, frequently overlooked,
of allowing active and passive motion to a degree
that would be impossible with any other method
of treating this granulating surface. This factor is
very important in the prevention of contractures
and subsequent disfigurement. They also serve as
an ideal mode of preparing the area for skin graft-
ing which should be done as soon as the granulat-
ing surface is ready and the progress of epitheliaza-
tion of the area has come to a definite standstill.
It is probable that the mortality and morbidity
of burns can be reduced still further by the use of
more judgment in the selection of methods in han-
dling each individual case and by the early recog-
nition and treatment of infection when it develops.
Some of the disfigurement which has always been
a sequel of burns can be prevented by the insti-
tution of active and passive motion early, and
grafting the area as soon as granulations are in
good condition and the process of epitheliazation
has ceased.
None of the ideas which we have set down are
essentially new or original. They represent only an
effort to apply basic, well recognized methods to
the cases which they reasonably seem to fit, and to
emphasize the fact that burns can be a real prob-
lem requiring painstaking care, tireless observation,
and discriminating judgment for their proper han-
dling.
GYNECOLOGY
Chas. R. Robins, M.D., Editor, Richmond, Va.
Relation of Chronic Cervicitis to Infection
OF the Urinary Tract
An extremely interesting paper* with this sub-
ject appears in the January number of Surgery,
Gynecology and Obstetrics. The authors base their
observations on a series of 400 cases of women pa-
tients suffering from urological conditions. The
frequency with which urinary symptoms are found
in women and the resistance of these symptoms to
treatment are matters of common observation. For
this reason this paper is particularly valuable, and
the following digest is offered as a summary of
the main points.
*By Herrold, Ewert and Morgan.
SOUTHERN MEDICINE AND SURGERY
March, 1936
The authors had found that the treatment of
granular urethritis and polypoid excrescences by
fulguration, dilation and the application of silver
natrate relieved many of these patients of their
symptoms, but with the lapse of time there was a
recurrence of symptoms in a certain percentage of
these cases. The report of Winsbury-White show-
ing a direct lymphatic connection from the cervix
to the urethra and the floor of bladder was ac-
cepted as establishing a route for extension of in-
fection from the cervix to the urinary tract. The
cervix had already been recognized as a chronic
focus of infection for systemic disease. Moench
found streptococci to be the most common bacteria
present in chronic cervicitis. Maryan likewise found
in a high percentage of infection, streptococci, of
the group enterococd, whose main characteristic is
their ability to resist heat of 60° C. for a longer
time than other streptococci.
Of the 400 patients studied, 32 had some or all
of these symptoms: frequent and burning urination,
intermittent deep pain at the neck of the bladder,
low back ache; and, less frequently, radiating pains
into the groin, the thigh and upward along the
course of the ureter. Many of these patients had
pronounced leucorrhea. This syndrome is fre-
quently described as irritable bladder.
It was their observation that bacteria may be
found in all urine passed by patients with irritable
bladder, by making careful smears and culture of
the urinary sediment, although in many instances
the smears do not reveal more than an occasional
pus cell.
Twenty-nine of this series of 32 patients were
followed long enough to permit of analysis. Coagu-
lation of the cervix was done in each instance. A
second or third coagulation was done on a few
of the patients. The results as measured by relief
of symptoms relative to the urinary tract are di-
vided into two qlasses. The first included those who
showed no improvement or but slight improvement.
There were five of each, ten in all. The second class
included those who reported marked improvement,
11 ; or complete relief, 8. Therefore, it may be noted
that 19 of 29 patients had a satisfactory clinical
response.
In the total series of 29, there were 12 patients
in whom the cultures revealed colon bacilli in the
urine, alone or associated with other organisms,
while 17 had predominant bacterial flora of mostly
cecal types, usually streptococci. Further analysis
indicated that 7 of the 10 non-responsive patients
were those with colon bacilluria, while 14 of 19 who
had satisfactory relief of symptoms were infected
with organisms other than the colon bacillus. This
would seem to lend support to the view that the
secondary focus in the urethra and bladder is the
result of continual inoculation by way of the lym-
phatics from the cervix.
Cultures made from the cervix and from urinary
sediment seemed to be identical.
An excellent description of chronic cervicitis and
of the technique of coagulation make the paper
quite complete. A definite method of dealing with
irritable bladder by removing the cause is advo-
cated and the treatment has been followed by a
convincing number of cures.
J. MARION SIMS
(Prom p. 141)
through me like water, and almost unchanged. Even
miUc was not digested.
Early in February (1853) I had given up all hope.
I left Montgomery for New York about the first of May
(1853), so near dead that no one thought that I would
ever get to New York. I had to lie down all the way on
the railway train. The diarrhoea was uncontrolled. We
went to Richmond, Virginia, without stopping, the journey
being a ver>' fatiguing one for me. I determined to go
from there to Rockford Island* Springs. I stopped at Lex-
ington, and sent to the springs for the water. I remained
there a week, but did not derive any great benefit from
it. I concluded it would be about as well for me to tak»
the water with me as to stay there, and so I left, and went
on to New York.
I spent the summer partly in New York and partly in
Middletown and Portland, Connecticut; and then, in Sep-
tember, we returned to New York to seek a home.
Some people have given me the credit of coming to New
York with the express purpose of establishing a great hos-
pital devoted to the diseases of women and their treat-
ment. When I left Alabama for New York I had no idea
of the sort in the world. I came simply for a purpose, the
most selfish in the world — that of prolonging my life. I
saw that I could not live in any other place than New
York, and for that reason, and no other, I came.
During the winter my health was tolerably good; but
I could eat no salt food, and even butter had to be de-
prived of its salt. I could eat no condiments, not a par-
ticle of pepper nor any vinegar; no fruits, and not a bit
of sweetmeats. The least variation from this rigid diet
would reproduce the diarrhoea. In walking on the street,
if I ever stumbled once, I would fall flat to the ground,
with no power to rise.
•Rockbridge Ahim. — Editor.
EDITOR'S NOTE.— From this time on to his death in
1883, Dr. Sims' health, while never robust, was equal to the
demands of a very active life. Some have thought that he
must have suffered from pellagra. Here are set down all
the statements in his autobiography which would seem to
bear on his symptoms and his own ideas as to their causa-
tion.
Think of the possibility of cancer of the larynx in every
case of husky voice, and look for it.
Everything that gUtters is not gold. Not every protru-
sion, from the anus is an internal hemorrhoid. — F. C. Smith,
Philadelphia, in Med. Rec, Dec. 8th.
If you have an ax'erage practice hardly a day goes by
that you do not let at least one patient go through your
hands with intestinal parasite infestation undiagnosed be-
cause unsuspected.
March, 1936
SOUTHERN MEDICINE AND SURGERY
1S3
THERAPEUTICS
Frederick R. Taveor, B.S., M.D., F.A.C.P., Editor
High Point, N. C.
The Christian Festschrift
A remarkable book has just appeared: Medical
Papers Dedicated to Henry Asbury Christian, Phy-
sician and Teacher, from his present and past asso-
ciates and house officers at the Peter Bent Brig-
ham Hospital, which was presented him on his
sixtieth birthday, February 17th. It might well
be called The Medicine of the Future. Probably
no man since Osier has trained so many able men
who are pushing back the boundaries of medical
knowledge. It is a volume of 1,000 pages with
an introduction in the form of a presentation
speech signed, "I. C. W.," presumably Dr. I.
Chandler Walker of Boston who was Dr. Christian's
original First Assistant Resident at the time the
Peter Bent Brigham Hospital was opened. The
last contribution is entitled "Henry Asbury Chris-
tian. An Appreciation." signed "W. T. V.," pre-
sumably Dr. Warren T. Vaughan of Richmond.
This last article gives a most interesting sketch of
Professor Christian's great life and work. Be-
tween the introduction and the final paper are
100 scientific papers, many of which record strik-
ing, even startling, advances in medical knowledge.
The contributors are from almost every State in
the Union, and practically every important medical
school is represented with a very few exceptions.
One of the remarkable things about the book is
the brevity of most of the contributions. 102 con-
tributions in 1,000 pages means an average of less
than 10 pages per contribution. This no doubt
deHghts Dr. Christian, who is a master at com-
priessing much into little space. The book is
edited by Dr. Robert T. Monroe, whose address
is Peter Bent Brigham Hospital, 721 Huntington
Ave., Boston; and its cost is ten dollars. The
writer ordered his copy from Dr. Monroe. He
does not know whether the work is generally on
sale to the public, or whether only copies ordered
in advance were printed. The book will doubtless
furnish many topics for discussion in this column,
for the papers teem with original ideas and sug-
gestions for further thought.
For the present, the writer is especially interested
in mentioning a few of the high spots in Dr. Chris-
tian's remarkable career.
Born in Lynchburg and graduated at Randolph-
Macon College, Dr. Christian was a young teacher
of Science when he decided to study medicine at
Johns Hopkins University. In his first year there
he wrote a paper on anomalous muscles in the
neck, and published it the following year.
Graduating at Hopkins, Dr. Christian entered
Dr. Frank B. Mallory's laboratory in Boston. He
worked with him for two years and with Dr.
Councilman three years. At the age of only 32,
he was made Hersey Professor of the Theory and
Practice of Physic, succeeding his chief. Dr. Reg-
inald Fitz, sr.; at the same time he was made Dean
of the Medical School. Then came the building
of the Peter Bent Brigham Hospital, one of the
greatest teaching hospitals in the whole world. Dr.
Christian had already studied at Greifswald, Ger-
many, but this was not enough. He, and every
one of his original officers at the Brigham, toured
Europe before the hospital was completed, getting
the latest information available. The party in-
cluded Dr. Christian, Physician-in-Chief to the
Brigham; Dr. Channing Frothingham, the first
Chief of Staff; Dr. Francis W. Peabody, Resident
Physician; Dr. I. Chandler Walker, First Assistant
Resident; and Dr. Reginald Fitz, jr.. House Officer.
Wherever something of special interest was found,
one of the party dropped off and learned what
there was to know about it so he could bring it
back to Boston. Dr. Christian brough back the
first electrocardiograph to be installed in a general
hospital in America. He thought he would find one
in the hospital in Leyden, but they referred him to
"a fellow named Einthoven who worked over in
the Department of Physiology, quite a distance
away!"
The author of the "Appreciation" lists nine
points of special excellence pertaining to the Peter
Bent Brigham Hospital, from its beginning. These
were: 1) A continuous service with the same phy-
sicians always in charge. 2) The Brigham was
the first hospital to have both a graded house of-
ficer system and a graded resident staff. 3) The
interne worked in the out-patient department only
after finishing in the wards, thus giving a transition
from hospital work to practice. 4) This was the
first hospital in which all records were dictated in
detail and the house officer was given a copy of
the record of every patient that had been under
his care when he left the service. 5) The system
of Physicians-in-Chief pro tempore was first inaug-
urated here. For one week in each year, some in-
ternationally famous man is invited to live in the
hospital and spend the week making rounds, lec-
turing, living with the staff, and throwing out ideas
and criticizing methods and diagnoses to broaden
their viewpoint. Our own Dr. Wm. deB. MacNider
has been honored with this position. 6) The
Brigham was the first hospital in Boston to use
the standard nomenclature of diagnosis, and it is
now using the new National Nomenclature. 7)
The medical service is freed from unnecessary in-
hibitions and prohibitions. It is assumed that
1S4
SOUTHERN MEDICINE AND SURGERY
March, 1936
those working in the hospital are doctors and
gentlemen. 8) The Staff Rounds became an in-
stitution widely copied by other hospitals. 9)
Last, but not least, was the great influence of "the
Professor" himself. He himself says that his great-
est contribution to medicine has been the training
of men. One has only to see him at work at the
Brigham to know that this is true. The list of
his old boys contains many of the most brilliant
investigators of the country, noted men in almost
every State as well as in Canada. Many honors
have been heaped on him, perhaps the greatest
being the Presidency of the Association of American
Physicians in 1934; though this book dedicated to
him must warm the cockles of his heart, great
teacher that he is, as almost nothing else that has
come into his life, for it exhibits not only the love
and loyalty of his past and present associates, but
a quality of work done by them that can make him
justly feel that they are carrying on the torch he
has given them to illumine the whole world.
ORTHOPEDIC SURGERY
John Stuart Gaul, M.D., Editor, Charlotte, N. C.
The a, B, C's in the Treatment of Fractures
OF THE Long Bones
A. Always reduce fractures of long bones by
use of traction and counter traction applied in
the direction of the long axis of the bone.
B. Break up the impaction in a Colles' frac-
ture and then reduce the fracture, making
certain the plane through the articular surface
of the lower end of the radius is at an angle
of 30 to 37° to the long axis of the radius.
C. Colles' fracture often has associated with it
a fracture of one of the carpal bones, or a frac-
ture of the head of the radius. Unrecognized
and untreated they give much trouble. Look
for them!
D. Delayed union occurs in from }4 to 4%
of fractures. There are general and local
causes for it. The general causes are tubercu-
losis, osteomalacia, rickets. Local causes are
gumma, carcinoma, sarcoma, osteomyelitis,
faulty position of fragments, interposition of
soft parts and too-strong traction applied.
E. Epiphyseal separation frequently occurs at
the lower end of humerus, in children who have
had injuries about the elbow joint. Fractures
of the condyles or epicondyles frequently are
associated with it, or occur alone. .Accurate
reduction of these injuries is essential. Make
certain the lower end of the humerus is carried
forward sufficiently far, or there will be bony
impingement, causing marked limitation of
motion in the elbow joint. Look for injuries
to other than bony structures. The median
nerve may have been injured, the brachial ar-
tery torn, the antecubital veins injured; or
there may be an accumulation of blood and
serum beneath the bicipital fascia. .All these
complications demand prompt treatment, or
disaster will result. These injuries should be
put up in the Jones position, with a strip of ad-
hesive plaster about the arm and forearm.
The radial pulse should be palpable at all
times.
F. Fracturedislocation commonly occurs in
Bennett's fracture — at the base of the thumb;
fractures about the elbow joint; fracture of
the upper third of the ulna, with dislocation of
the head of the radius; fractures of the lower
end of the radius; fractures about the shoul-
ders; fractures of the semilunar bone; and
fractures about the malleoli. It is good prac-
tice to reduce the dislocation first and then
align the fragments.
G. Gas gangrene is a complication of com-
pound fractures and particularly of gunshot
fractures, and more particularly of fractures
about the rectum. It should be looked for
and if the patient's economic status will not
permit him receiving the combined antitoxin
against gas gangrene and tetanus, he should
receive the tetanus antitoxin, and upon the
first appearance of air in the tissues he should
receive radical treatment.
H. Humerus shaft fractures are easily reduced
and handled in a Jones Humerus Traction
Splint.
/. Infection will surely take place in compound
fractures if the wound is left open. It is bet-
ter to remove the detritus consisting of dirt,
clothes and devitalized tissue under aseptic
precautions and then to suture the wound
tightly without drainage. You can always
open the wound later if necessary, but too
many times it is done unnecessarily!
J. Joints are meant to move. If a fracture ex-
tends into one, the joint surfaces should be
held apart with traction. Restoration of func-
tion should be attempted as early as the given
conditions warrant.
K. Knee-joint fractures give bad results because
a tibial condyle is crushed down and not ele-
vated, or a condyle of a femur is displaced
and not brought back to its normal position.
The result is poor weight-bearing function and
the setting up of an arthritis. Again a cru-
cial ligament may be torn, or a semilunar car-
tilage fractured, and both go unrecognized.
The result is an unstable weight-bearing joint.
L. Local anesthesia in the form of novocaine,
March, 1936
SOUTHERN MEDICINE AND SURGERY
injected into the fractured line, under sterile
precautions, will save the patient much pain,
and abolish much of the muscle spasm, making
reduction of the fracture easier.
M. Malignant edema is easier prevented than
treated. It means an anerobic infection, com-
plicating a compound fracture. Clean out the
wound by excising dead tissue. If it appears,
long radial incisions are necessary with re-
moval of whole muscles. Prevent it!
N. Neck-of-femur fractures do so well with
nailing of the fragments that we are not justi-
fied in the expensive methods we formerly used.
The nailing procedure produces no shock, the
patient can sit up in bed, and with crutches
can be put out of bed in a few days. Results
are as good if not better, the bugbear of hypo-
static pneumonia in the aged is largely elim-
inated, and the economic saving to the patient
is considerable.
0. Over treatment of fractures can and does
occur. It is better to have good function with-
out anatomical reduction, than to have anatom-
ical reduction without function, because of in-
jury to soft structures in the obtaining of the
perfect reduction.
P. Paralysis is associated with fractures and
may appear immediately because the trauma-
tizing force which produced the fracture has
injured a nerve trunk, or it may appear later
because the callus has caught the nerve trunk.
The common sites for this complication are
the shaft of the humerus with the musculo-
spiral nerve involved, the internal condyle of
the humerus with the ulnar nerve involved;
the lower end of the humerus with the median
nerve involved and fractures of the head of the
fibula with the p>eroneal nerve involved. Al-
ways look for these complications, note them
down and call them to the attention of the
patient's relatives. To do so will prevent mal-
practice suits.
Q. Queer ideas enter patients minds when
doctors talk too much about how some other
doctor has treated a fracture. A lawsuit
af^ainst a doctor usually follows.
R. Reduction of fractures is accomplished easier
before swelling and muscle spasm occur. Re-
duction and splinting eliminate the swelling
to a great extent. If swelling is marked fol-
lowing reduction and splinting be sure you
have a complicating factor. Look for it and
protect the circulation from the swelling and
pressure against the splinting device. If a cast
has been applied split the cast.
S. Sprain fractures — those occurring about the
ankle, elbow, wrist, knee and shoulder joints
will give more trouble than frank fractures. In
this type of injury a small portion of bone is
torn away by a ligament or tendon. Strap-
ping with adhesive is not sufficient. A plaster
cast will give greater comfort to the patient
and, usually, an excellent result.
T. Traction and counter traction can be ef-
fectively made by fastening the body to a
stationary object by means of a sheet. Using
your body as a powerful lever and tractor,
having someone hold the extremity flexed
against your body, your hands are free to
do any manipulating necessary.
U. Ulna fractures, particularly of the upper
third, require good reduction to avoid distress-
ing disability. A dislocation of the head of
the radius is frequently associated. Fractures
of the olecranon should be treated with the
forearm in extension.
V. Volkmann's ischemic contracture is a fairly
frequent complication of fractures about the
elbow. Abnormal swelling about the joint,
trauma to the median nerve, compression of
blood vessels and blood and serum collecting
beneath the bicipital fascia are the precipitat-
ing factors. Unusual pain or discoloration or
coldness of the hand requires immediate in-
vestigation.
W. Walking casts in case of fractures of bones
of the leg are appreciated by patients because
of the economic factor and for many other
reasons.
X. X-rays are looked upon by the courts as a
necessary part of the treatment of fractures.
Acquittal in a malpractice suit is hard to ob-
tain if x-ray examinations have not been
made.
Y. Youth is resilient; age fragile. Warn your
elderly patients to take precautions as to stairs,
bath tubs and in streets.
Z. Zeal in attention to what appear to be minor
details brings its own reward in the treatment
of fractures.
EYE, EAR, NOSE AND THROAT
Frank C. Smith, M.D., Editor, Charlotte, N. C.
Visual Requirements for Drivers of
Automobiles
With state licenses for automobile driving re-
quired in North Carolina and her sister states we
will soon have to consider the minimal visual re-
quirements for safe automobile driving.
While it is difficult to determine the percentage
of automobile accidents due to impairment of the
visual function, those of us doing an active ophthal-
mological practice have such cases brought to
SOUTHERN MEDICINE AND SURGERY
March, 1936
our attention not infrequently. In the past week
two cases came under observation which illustrate
the danger of impaired vision while driving. In
the first instance the driver of a truck recently
side-swiped several cars, three in one day. He was
brought in by an inspector for the company who,
while riding with him, had to grab the steering
wheel when he realized the car was about to collide
with another car. While the driver realized he had
hit several cars he had no idea why. He was
found to have lost the right half of each visual
field. The other case was sent in by a lawyer to
see if the patient had not damaged his sight in an
automobile accident. The boy had only 10/200
vision, right, and 20/148, left, due to near-sighted-
ness which had never been corrected. Immediately
the question arose as to whether the one suing
should not be the one sued because he certainly
does not have sufficient vision to drive safely.
It may be wise to inform ourselves as to how
other states are meeting this problem of minimal
requirements for safe automobile driving.
The law is most stringent in Delaware where
one must have 20/20 vision in one eye, or a 20/30
vision in the better eye and at least 20/40 vision
in the poorer eye, with or without correction.
Ohio and Minnesota issue no permits if there
is blindness in one eye, and these states require
at least 20/40 vision in each eye.
In California you must have at least 20/50 vision.
Connecticut requires 20/70 vision with both eyes,
or a 20/50 vision in one eye, the other eye being
blind.
The District of Columbia requires a minimum
of 20/40 vision with both eyes and a field of
vision of 140° or more.
For an unrestricted license in Maryland you must
have a minimum visual acuity of 20/70 in each
eye and a field of vision of 140°, together with
binocular vision. If the applicant has only 20/70
vision in one eye and not less than 20/140 vision
in the other eye, a license may be issued for day-
light driving only. The civil service, police and
fire departments require 20/20 vision in each eye
without glasses.
Visual acuity is the first consideration. R. E.
Mason whose eyes are normal fogged his vision
with plus lenses then on a bright day and at night
with legal headlights determined how far away he
could read the regulation stop sign with both
eyes open.
With the speed of the modern automobile we
realize how necessary it is to be able to distinguish
objects cltearly at some distance if we are to
avoid accidents. According to these tests a person
with normal vision can read a stop sign at 255 ft. on
a bright day, but no farther than 75 ft. at night
under normal conditions of driving. The minimum
vision permitted in states with regulations is 20/70,
which enables the sign to be read at 100 ft. in the
day time but no farther than 25 ft. at night. It
would seem unsafe for one to drive at night if he
cannot read a stop sign more than 25 ft. away.
To test the effect of narrowing his visual fields
Mason painted the periphery of the lenses he wore
and came to the conclusion that no one should
drive who has a field of vision less than 125° in the
horizontal arc with one or both eyes.
The importance of a visual field of reasonable
size is illustrated by a school teacher who had five
wrecks within eighteen months and felt the other
fellow was to blame each time until on examination
he saw that he could not see to the right out of
either eye due to a parietal lobe tumor which was
removed.
A chart giving the speed of the car, how many
feet the car travels per second at a given speed and
how many feet are required to stop at a given speed
with two wheel brakes and four wheel brakes is of
value when studied with the figures already given
showing how far a stop sign can be read day or
night, with a given visual acuity.
Speed
of car
Ft. traveled
per sec.
Ft. required
to stop at stated speed
Two-wheel Four-wheel
brakes brakes
10
14.67
9
5
20
29.34
39
21
30
44.00
87
47
40
58.70
155
82
45
66.00
196
104
SS
80.70
294
155
60
88.00
349
185
65
95.30
409
217
70
102.60
475
252
7S
109.90
544
289
80
117.20
619
328
100
146.60
968
514
Day
Night
20/20
2SS ft.
_ 75 ft.
20/30
200
20/70
100
25
20/100
74
20/200
50
From these figures we see that one with normal
vision (20/20) could travel at the rate of 70 miles
per hour with four-wheel brakes or 50 miles per
hour with two-wheel brakes and stop between the
time of reading a stop sign and reaching that sign
in the day time, but his speed would at night have
to be reduced respectively to less than 40 and 30
miles per hour. 20/70 is the minimum allowed in
any state requiring visual restrictions and this ap-
pears too low since such an individual would have
to drive at 45 miles per hour in the day time as
compared with 70 miles per hour for an individual
with normal vision, while at night his speed would
March, 1936
SOUTHERN MEDICINE AND SURGERY
1S7
have to be reduced to 2 5 miles per hour as compared
to 40 miles per hour. Such an individual should
probably receive a license limited to day driving.
A 26-to-l ratio of night driving over driving in
the day indicates clearly the increased hazard which
is largely one of seeing. The normal eye contracts
very rapidly in the glare of a headlight but dilates
very slowly in comparison. The period of two or
three seconds of indistinct vision after a glaring
light passes represents the time it takes the pupil
to dilate which is necessary to see at night. Eye
fatigue is much more pronounced at night than in
the day time, the constant straining in the effort to
see tires the whole nervous system with a tendency
toward drowsiness, then sleep if continued. We
have been speaking of normal eyes but we must re-
member that conditions which reduce vision in day-
light often reduced it far more in poor light. There
are persons with normal vision in good light who
have to be led about at dusk. Such conditions are
usually hereditary but many diseases produce lesser
degrees of night blindness.
As individuals each of us is sure that these figures
cannot apply to us yet 36,000 people were killed in
1934 by drivers who felt just as we do. Since
20,000 of these fatalities from automobile accidents
occurred at night when only 25% of automobiles
are in operation, night driving is an immediate
problem which will require the enforcement of
rigid restrictions if such mortality rates are to be
reduced within reasonable limits.
HOSPITALS
R. B. Davis, M.D., M.S., F..\.C.S., Editor, Greensboro,N. C.
The R. N. and Hospital Meetings
The author has visited hospital meetings of all
kinds and descriptions for a number of years. The
following is not a criticism but an observation.
The hospital associations were formed to bring
together hospital owners and administrators in-
terested in profiting by each other's experiences.
The majority of the membership of the association
have been doctors. As time went on these physi-
cians who felt that they were getting valuable
information would take along their superintendents
and supervisors. For a while all went well; then
the doctors would have real sick patients that they
would not want to leave, and so they sent their
superintendents and supervisors to the meetings,
more often than otherwise the hospital paying their
expenses and always continuing their salaries
straight through while they were gone.
There used to be discussed at the earlier meetings
the cost of food and how to preserve it, the cost
of materials and supplies, what make was the most
satisfactory, the names of the most reliable and
durable instruments, the composition of inside and
outside paint and which is most satisfactory, the
best method of collecting from poor patients, the
best psychology to use on the dead-beat and, last
but not least, how to render the best service to the
sick. Today at the meetings, which are predomi-
nantly attended by the nurse superintendents and
supervisors, you will hear discussed at length the
following subjects:
Salaries of the nurses. Which hospitals should
be allowed to run training schools for nurses. Nurse
maids. Hours on duty. Scrub maids. Graduate
dietitians.
Is it any wonder that economical hospital own-
ers and administrators are beginning to lose their
interest in the hospital meetings when those things
are discussed that tend to create friction at home
rather than harmony, and how to spend more
money than the hospitals collect. In short, without
realizing it the nurses are drifting into the customs,
opinions and ways of the labor unions.
At the hospital meetings there are representatives
from various types of hospitals operating in many
different localities, and under entirely different cir-
cumstances. It is absurd to try to standardize the
salary of the graduate nurses employed in the hos-
pitals. One nurse may be worth twice as much as
another in any given institution. For example, a
nurse who is willing to turn her hand to anything
that comes up, whether it be giving an anesthetic,
making a blood count or helping a patient into an
automobile when he or she is discharged from
the hospital, is the type of nurse who should draw
the biggest salary, and she usually does. Just as
is the case of the physician, income should be
based upon actual service and not upon a degree
such as M.D. or R.N.
The matter of nurse maids has grown up re-
cently to be a popular topic. Some graduate nurses
feel that they have reached the stage when it is
beneath their dignity to tidy up the dresser, dust a
chair or comb a patient's hair. They do not realize
that if such things are going to make the patient
feel better it never has been and never will be be-
neath the dignity of a true nurse. Nurse maids, if
they are intelligent, will gradually assume all of
the work of the graduate nurse except that of ac-
tually giving medicine and after a reasonable length
of time the graduate nurse is going to find her
services for that purpose less in demand.
Standardization of the nurse's training has
reached a stage that it is assumed that the pupil
nurse has no time to do any scrubbing and clean-
ing whatsoever. She must spend a good part of
her time learning the theory of nursing, the history
of the nursing profession, and other allied subjects.
What time is left out of the short number of hours
SOUTHERN MEDICINE AND SURGERY
March, 1936
that she is supposed to be on duty is set aside for
practical nursing. If a girl while in high sccool
can afford to go home and help her mother and
sisters wash dishes, polish furniture, prepare meals
and keep the house clean, why is it such a crime
for this same girl to help keep house for the sick
people in the hospital?
The writer is making an earnest plea that the
hospital meetings be well attended by operators and
owners who see all the subjects with unbiased eyes,
but who realize that the hospital is built and main-
tained in order that sick people might be well
treated, and that no hospital can possibly succeed
which spends more money than it is able to collect.
If such meetings were held with large attendance
of both nurses and doctors, and if both would call
a spade a spade when discussing these matters, the
meetings would be more profitable to all parties
concerned.
The hospital should be considered as a family
which must work in harmony and sympathy
throughout. Its part in the hospital association
may be likened to one merchant's part in a mer-
chants' association; that is a merchant must con-
duct his own affairs successfully before he is ex-
pected to give advice to other merchants.
RADIOLOGY
Wright Claskson, M.D., and .^llen Barker, M.D.,
Editors, Petersburg, Va.
Radio-curability of Tumors
The eradication of a neoplasm by means of irra-
diation is not entirely dependent upon the tumor's
sensitiveness to the ray. All tumors are sensitive
to sufficiently large quantities of roentgen or ra-
dium irradiation and they can be entirely destroyed
by this method of treatment. The question to be
answered in each individual case is, can all of the
tumor cells in the patient's body be destroyed with-
out causing permanent disability, or death of the
patient? Therefore, in order to decide intelligently
upon the advisability of attempting to cure a pa-
tient suffering with a neoplastic disease by the use
of irradiation, one must consider many factors in
addition to the probable radiosensitiveness of the
type of cells found in the growth.
The radio-curability of a tumor may be adverse-
ly influenced by large quantities of fat surrounding
the mass, by the presence of infection, by the in-
vasion of surrounding bone or cartilage, or by
metastases which are inaccessible or located in some
vital organ.
Lymphnodes are usually able to resist a malig-
nancy for a certain length of time and therefore
they often retard the spread of a cancer, but once
the malignant cells succeed in penetrating the gland
capsule they may rapidly become disseminated.
Likewise a surgical procedure, undertaken prior to
adequate preoperative irradiation, may by divid-
ing the IjTnph channels cause a widespread dissem-
ination of malignant cells.
As a general rule, young robest individuals suc-
cumb more rapidly to cancer than do old thin ones.
This is probably due to the endocrine activity in
the young. For the past si.x years, we have arri-
diated the gonads and the pituitary gland of prac-
tically all of our patients with generalized malig-
nancy'^ and with markedly beneficial results.
As a control, in April, 1933, we intentionally ir-
radiated only the breast and axilla of one patient,
aged 49, who had an advanced carcinoma of the
breast with pulmonary metastases. The local lesion
responded well, but the patient's general condition
continued to decline. When the treatment was be-
gun, the patient weighed 130 pounds. On April
23rd, 1935, she weighed only 117 pounds. She
was menstruating regularly. Her appearance was
cachectic. A roentgenogram of her chest showed
extensive metastases throughout both lungs, and
she was so dyspneic as to be totally disabled.
While she was in this state, 2200 r units of roent-
gen irradiation were directed to her ovaries and
2000 r units to her pituitary gland. Absolutely no
other treatment was given the patient.
The improvement was almost astounding. Today,
ten months later, she is apparently in good condi-
tion. Recent roentgenograms show a marked retro-
gression of the lung metastases. She has gained
13 pounds in weight, is able to do her housework
and she feels strong and well.
Many other factors influence the radio-curability
of tumors. For instance, long-continued low-in-
tensity irradiation is less harmful to skin cells but is
quite deadly to sensitive tumor cells.
Pedunculated tumors, and all very vascular tu-
mors, usually respond well to irradiation, while
those imbedded in scar tissue usually show consid-
erable immunity to the rays.
The size and the location of a growth are im-
portant. For example, a relatively radioresistant
tumor 3 cm. or less in diameter, located on the
skin, may safely be given sufficient irradiation to
completely destroy the neoplasm together with a
small border of the surrounding healthy tissue, but
the likelihood of trophic disturbances makes it un-
wise to administer this dose to a neoplasm involv-
ing a large skin area, particularly if the growth
happens to be overlying a bony prominence or some
sensitive vital organ.
Perhaps the most discouraging typ>e of growth
to treat is one that has previously been rendered
radio-incurable by the improper administration of
roentgen or radium rays by some one who prac-
March, 1936
SOUTHERN MEDICINE AND SURGERY
159
tices a little radiology along with a little of every-
thing else and who is consequently not capable of
properly irradiating neoplastic diseases. Tumors
thus treated may respond temporarily, but they
soon become radioresistant and begin to grow
again. Curable cancers are thus rendered abso-
lutely hopeless. Such cases are constantly being
referred to radiologists, who in these cases can give
the patient only temporary relief.
Bergonie and Tribondeau- in 1905 called atten-
tion to the radiosensitiveness of cells during mito-
sis. They believed that the sensitivity of the cell
varied directly with its reproductive capacity and
inversely with its degree of differentiation. Experi-
ence has proven, however, that there are many ex-
ceptions to this rule. In this connection, Packard^
calls attention to the fact that lymphocytes are
highly susceptible, although their power of repro-
duction is very limited, and that bacteria and yeast
cells are resistant, although they are comparatively
undifferentiated, and are capable of long-continued
cell division.
Ewing^ has classified tumors in decreasing order
of radiosensitivity as follows: "(1) lymphoma,
(2) embryonal tumors, (3) cellular anaplastic tu-
mors, (4) basal cell carcinoma, (5) adenoma and
adenocarcinoma, (6) desmoplastic tumors, such as
squamous carcinomas and fibrocarcinoma, and (7)
fibroblastic sarcoma, osteosarcoma, and neurosar-
coma."
DesjardinsS divides neoplasms into three main
groups: "(1) radiosensitive tumors, growths the
radiosensitiveness of which is greater than that of
the skin; (2) moderately radiosensitive tumors,
growths the radiosensitiveness of which approxi-
mates that of the skin; and (3) radioresistant tu-
mors, growths the sensitiveness of which is less than
that of the skin." He states, as a fundamental law,
that each variety of cell in the body has a specific
range of sensitiveness to roentgen rays or radium.
He also says, ''The sensitiveness peculiar to each
kind of cell appears to be related chiefly to the
natural life cycle. Thus the lymphocytes, the meta-
bolic cycle of which among human cells is the
shortest, are also the most radiosensitive, and the
nerve cells, the life cycle of which is the longest,
are also the most resistant to irradiation." He
classifies cells according to their radiosensitiveness
in the following order, from the most sensitive to
the least sensitive: lymphoid cells; polymorphonu-
clear and eosinophilic leucocytes; epithelial cells;
endothelial cells; connective tissue cells; muscle
cells; bone cells; fat cells; nerve cells.
Geschickter", speaking before the Eastern Con-
ference of Radiologists meeting in Baltimore re-
cently, gave a new classification of the radiosensi-
tiveness of tumors, based on the tissue of origin.
He states that while the radiosensitiveness of tissues
does not always vary directly with the amount of
anaplasia, this rule does hold true when com-
paring tumors derived from the same type of tissue.
Therefore the radiosensitiveness varies directly with
the amount of undifferentiation, when comparing
tumors belonging to any one of the major subdivi-
sions shown in his classification.
Geschiokter's Classification of Tumors
1, TUMORS OF ECTODERM
la. Ectodermal derivatives
(RS*) Tegmental tumors (Epidermoid)
Appendal tumors (Basal)
Breast — anterior pituitary
2. TUMORS OF NEURECTODERM
(RR)
Neuroblastic
Glial
Sheath tumors
(Sympathetic)
(Melanomas)
(Neurofibromas)
3. TUMORS OF ENTODERM
(RR)
Digestive tube
Biliary
Pancreatic
4. TUMORS OF BRANCfflAL ENTODERM
(RR) Branchial
Bronchiogenic
Thyroid and Parathyroid
5. TUMORS OF SOMATIC MESODERM
(RR)
Voluntary muscle
Connective tissue (bone, cartilage, etc.)
6. TUMORS OF CELOMIC MESODERM
(RS) Mesothelium
Genito-urinary (gonads, kidney, uterus, prostate)
Celomic mesenchyma (angioblastic) (smooth muscle)
7. BLASTODERMAL TUMORS
(RS)
Choriomas
Teratomas
Sex cell?
•RS=Radiosen8ltlve ; RR=:Radloreslstant
SOUTHERN MEDICINE AND SURGERY
March, 1936
Geschickter expressed a dislike for the term "tu-
mor bed," and he stressed the fact that the rate of
spread of a tumor determines its operability. He
explained why cancer cells in muscle tissue seem
so much more radioresistant than those in lymph-
nodes by stating that cancer cells in muscle tissue
follow the intramuscular septa and through muscu-
lar action are rapidly carried away from the sur-
face and thus becoming more inaccessible to irra-
diation they appear to be more radioresistant.
We believe that Geschickter's conclusions are
correct and that his new classification of tumors,
whereby he determines their radiosensitiveness by
their cell of origin, will prove extremely valuable to
all who are interested in this subject.
In conclusion, we wish to emphasize the fact that
the radio-curability of tumors is dependent upon
many interrelated factors and therefore in order to
treat neoplastic diseases successfully, one must be
well trained in the entire science of radiology and
likewise possess a broad knowledge of tumor path-
ology.
References
1. Cl-^rkson, Wright and Barker, Allen: Five- Year
Cure of Mammarj' Carcinoma with Multiple Metasta-
ses to Bone, to be published in Am. Jl. Roentgenol,
and Rad. Tlierapy.
2. Bergonie, J., and Tribondeau, L.: The Science of Ra-
diology.
3. Packard, C: Biologic effects of Roentgen Rays and
Radium. The Science of Radiology.
4. E-iviNG, J.: Editorial, J. A. M. A., Feb. 24th, 1934.
5. Desjardins, a. a.: A Classification of Tumors from
the Standpoint of Radiosensitiveness. Am. Jl. Roent-
genol, and Rad. Therapy, Oct., 1934.
6. Geschickter, C: Address before Eastern Conference
- of Radiologists, Jan. 31st, 1936.
PRACTICAL PRACTICE NOTES
From C. C. Hubbard, M.D., Farmer, N. C.
A thing which might be helpful to other doctors— Dr.
Jeff D. BuUa, Trinity, N. C, R. F. D. 1, told me to use
saturated solution salicylic acid in alcohol twice a day in
cases of athlete's foot. I never saw it fail. In bad cases
use it freely at night when the shoes will be off, and use
boric acid solution in the morning— using soap and water
both at night before using the salicylic mbrture. I use it
in skin diseases of the fungus type. I find it good in dan-
druff.
S. T. 37, 1 part to 3 parts of water, is an excellent thing
for nasal catarrh sprayed in nose twice a day. Also with
1 Rhinitis (full strength Rhinitis) spray every 2 hours till
a Uttle dryness of mouth, then every 4 to 6 hours. Have
seen it abort many colds.
I often think we do big harm by using new drugs in
place 'of the old. When I used ammonium chloride in big
doses every 4 hours in pneumonia, as much as the stomach
would bear, I had a much smaller death rate. Now we
seldom hear of muriate of ammonium or the carbonate in
lung troubles. When I really want a man to get well I put
him on muriate of ammonia and potassium bromide every
4 hours day and night to point of nausea.
I have not used tincture digitalis in 2 years or more. I
give the fresh leaves in capsules (3 gr.)
INTERNAL MEDICINE
W. Bern-.\rd Kinlaw, M.D., F.A.C.P., Editor Pro Tern,
Rocky Mount, N. C.
Some Early Medical PosT-OpER.ATrvE
Complications
During the early hours following a major opera-
tion in which one of the general anesthetics, aver-
tin, or spinal anesthesia has been used, there may
be a complication of a medical nature, which, if
discovered early, will change the prognosis and
lessen the number of post-operative days in the
hospital, ilost of these are respiratory or cardio-
vascular in nature, or due to shock. Post-opera-
tive shock is usually a part of the surgical proce-
dure and is treated as such, but these cases fre-
quently will cause considerable worry as to wheth-
er the heart is not going bad, or whether a lot of
stimulation including digitalis is indicated. Pro-
vided the cardiovascular system was all right prior
to operation, this type of case will usually respond
to glucose (10%) in the vein, with adrenalin or
pituitary extract. The foot of the bed is elevated
and other general measures for shock carried out
until the low pressure has been brought back near-
er a normal figure. There is usually no dyspnea;
no rales are heard at the bases of the lungs, and
the neck veins are not distended; so digitalis is
not indicated.
When the temperature jumps to 102 to 105,
twelve to twenty-four hours after some abdominal
operation, naturally the surgeon does not think
anything (in the average clean case) can be in
the abdomen to account for it. The chest is where
most of the explanation is usually found, and if
carefully examined will reveal atelectasis — from a
small area to a whole lung. We discontinued the
use of carbon dioxide after operation the first of
the year, on the theory that the increased inspira-
tion produced might suck mucus, etc., deeper into
the smaller bronchi, but we cannot see any differ-
ence unless we are seeing more of this complica-
tion without its routine use than with it. One
cannot expect the classical signs such as displaced
heart (to the affected side), decreased expansion
on one side, etc., to find the cause of fever. There
is frequently a small area in the back or axilla
which reveals practically no breath sounds and
when turned on the opposite side and given carbon
dioxide there usually comes forth the tjqjical grey-
green thick sputum that forms so quickly in these
cases. Due to the thickness of the sputum, a re-
turn of the condition is not unlikely and it^niust
be watched and treatment continued for several
days. Nitrous oxide and spinal anesthesia seem
to be associated with a larger percentage of these
complications; however, we have not analyzed a
March, 1936
SOUTHERN MEDICINE AND SURGERY
161
large series of cases yet. A recent visitor to one
of our hospital staff meetings reported three cases
of death within twelve hours after operation, all
in operations on the tongue. Avertin was used in
all three cases. The use of avertin in selected cases,
supplemented with ether, has given us very few
complications to worry about. Post-operative lobar
pneumonia is very, very seldom seen if the atelec-
tasis is recognized and treated.
There is a condition frequently seen by the medi-
cal man after some major operation when the sur-
geon wants to push "all the hypoclysis the patient
can take." That would be all right, but when the
internist sees them there are numerous fine bub-
bling rales throughout the chest and there is still
saline in puddles under the skin of the upper chest
and axilla. The nurse has given more than they
can take. Taking out the needles and giving con-
centrated glucose (20-30 per cent.) in the vein
will usually clear up the chest condition.
It is (or probably it is not, when given serious
thought) remarkable how few real cardiac compli-
cations occur following even long, serious opera-
tions. Careful heart study and a history of what
it could stand before operation is a great help in
telling what it is doing after operation. Our elderly
men with angina are having their thyroids removed
with good results. Our toxic-thyroid cases with
fibrillation are greatly benefited by thyroidectomy
with seldom a circulatory mishap, and our hyper-
tensive cardiovascular cases can have gallbladders
or large renal calculi removed with very little car-
diac embarrassment.
An occasional case of auricular fibrillation is
seen after some major operation in a patient who
was perfectly well, apparently, prior to onset of
recent acute condition and was doing his work
without cardiac symptoms. These cases in persons
under forty are usually cleared by the time they
have had three doses of quinidine, but they should
have a longer convalescence and be observed for a
longer period of time because of the fact that there
is usually some organic heart change even in pa-
roxysmal fibrillation. In pelvic operations, even
more in those on the extremities, an uncommon
complication is a pulmonary embolism, and a sud-
den attack of dyspnea may be the only symptom.
The prognosis depends on the size; oxygen therapy
and sedatives are indicated.
In all chest complications a nasal tube to the
stomach, to keep gas at its minimum and prevent
toxic dilatation by hot water injections to it sud-
denly, even if removed quickly, is certainly very
helpful in treatment.
MANACE3krENT OF AnAL FlSSURE
(C. E. Hall, Atlanta. In Jl. Med. Asso. of Ga., Feb.)
Anal fissure is of common occurrence, and causes pain
and disability.
Non-traumatic fissures or ulcers result from some in-
fection: epidermophytosis, chancroid, chancre, secondary
syphilis, gonorrhea, tuberculosis and granuloma. Diagnosis
depends upon the historss the clinical manifestations; and
smears, cultures and blood tests. Treatment includes the
proper therapy for the underlying causative disease.
The great majority are from constipation, straining at
stool, passing of foreign bodies in the stools, or rough
instrumentation.
With antiseptic precautions 2 or 3 c.c. of 1% novocain
is injected beneath the fissure. For prolonged anesthesia
the tissues beneath and surrounding the lesion are then
infiltrated with 1% diothane. When the anesthesia is
complete the fissue is cauterized with 10 to 20% silver
nitrate.
The after treatment consists of ample mineral oil to insure
easy bowel actions, hot sitz baths 2 or 3 times daUy, and
daily applications of mild antiseptics. Heahng will take
place in the majority of cases in 10 days to 2 weeks by
these simple measures. If not, the fissure must be treated
as a chronic lesion.
A traumatic fissure is chronic if it is of more than a
few days duration and presents a sentinel pile or skin
tab, purulent infection, connecting sinuses, infected anal
crypts with hypertrophied papillae or induration of the
surrounding tissues.
Treatment must relieve pain and spasm, also establish
adequate drainage. The involved area is infiltrated, a small
quantity of 1% novocain is injected for immediate effect
plus a sufficient quantity of 1:1000 nupercain solution for
prolonged effect— usually 10 to IS c.c. is sufficient.
It is sufficient to anesthetize merely the involved area of
tissue. When the anesthesia is complete a bi-valve and
retractor is inserted and adjusted to give clear view A
careful search is made with a hook-shaped probe for sinuses
or involved anal crypts, and any that are found are excised
with scissors. More often than not an infected anal crypt
will be located beneath a chronic anal fissure, and adequate
dramage will not be obtained unless this crypt be excised
Next, an incision is made with a sharp scalpel, beginning
above the fissure at the ano-rectal or papillary line, and
extending longitudinally downward to the anus, and thence
externally for a dktance of V/. to 2 inches on the perianal
skm. The depth of the incision is J^ inch and is sufficient
to sever those fibers of the sphincter which decussate pos-
teriorly. These fibers constitute a tendinous band— the
Pecten band. Sufficient relaxation is obtained without
dividing the entire sphincter.
AU overhanging edges of skin and mucous membrane
with the sentmel skin tab, are freely ablated with scissors.
The retractor is now wtihdrawn and the wound packed
with a small piece of vaseline gauze in order to keep the
edges of the incision separated and to control the slight
hemorrhage. A firm cotton pad is applied to the anus
and the patient confined to bed 12 to 24 hours. A move-
ment is allowed after 24 hours.
Dress the incision daily, being sure it heals from bottom.
Mild antiseptics are applied locally and any excessive
granulations kept down with silver nitrate. The skin por-
tion of the incision is kept open until the mucous mem-
brane of the anal portion is entirely healed. Ample mineral
oil renders the stools soft, and frequent hot sitz baths ari
valuable aids in promoting healing. Generally, the patient
is able to return to his usual occupation after 2 or 3 days
and healing is complete in 2 weeks.
SOUTHERN MEDICINE AND SURGERY
March, 1936
!••^•5••5•^•♦♦•■^•^•M~^•^•^~^*
President's Page |
Medical Society of the State of North Carolina %
For many years members of our profession inter-
ested in legislative matters touching the physicians
of North Carolina, have urged the necessity of hav-
ing more doctors in both the Senate and the House.
This, of course, is a difficult objective to obtain
because the physician's life being such an individ-
ualistic one, he cannot, in the vast majority of
cases, drop his practice for the indefinite period
during which the General Assembly is in session.
As a result, we have always been tremendously
nnder=represented in the legislative bodies of our
State.
If it is impossible to have a considerable number
of physicians (it is estimated that a total of about
twenty in both houses would satisfy our needs),
there is another avenue open to us; namely, to
select as our representatives in the General Assem-
bly individuals who will be favorably disposed to
the desires and objectives of the medical profes-
sion. Physicians as a class occupy a particularly
respected position in their several communities and
if, individually and collectively, they exercise their
influence in the selection of candidates for the legis-
lature, there is little doubt that the right sort of
men will be chosen.
The demand of the medical profession of North
Carolina upon the legislative powers of the Gen-
eral Assembly have never been excessive. These
demands have been of two kinds: the furtherance
of legislation that is favorable to the medical pro-
fession and the blocking of legislation prejudicial
to it. Space does not permit comment upon the
excellent work done by the Legislative Committee
of the Medical Society of the State of North Cato-
lina, but this work could be extended and immeas-
urably facilitated if care were taken that the in-
coming legislators be chosen with an eye to their
attitude toward the profession of medicine. I urge
each and every physician throughout the State to-
bear this in mind when candidates announce them-
selves, and I urge the organized units of the State
:Medical Society to operate collectively in order to_
further a condition more advantageous to our per-*
sonnel throughout this commonwealth.
—PAUL H. RINGER.
VV^'^t^i-^
*' uo
March, 1936
SOUTHERN MEDICINE AND SURGERY
163
Southern Medicine and Surgery
Official Organ of
Tri-State Medical Association of the
Carolinas and Virginia
Medical Society of the State of
North Carolina
James M. Northincton, M.D., Editor
':")--
-Charlotte, N. C.
-Charlotte, N. C.
Department Editors
Human Behavior
James K. Hall, M.D ,^ _ ^..._ -Richmond, Va.
Dentistry
W. M. Robev, D.D.S - -Charlotte, N.C.
Eye, Ear, Nose and Throat
Eye. Ear and Throat Hospital Group - Charlotte, N. C.
Orthopedic Surgery
0. L. Miller, M.D )
John Stuart Gaul, M.D.)
Urology
Hamilton W. McKay, M.
Robert W. McKay, M.D.
Internal Medicine
W. Bernard Klnlaw, M.D Rocky Mount, N. C.
Surgery
Geo. H. Bunch, M.D Columbia, S. C.
Therapeutics
Fbederick R. Taylor, M.D
Obstetrics
Henry J. Langston, M.D
Gynecology
Chas. R. Robins, M.D. .^ -Richmond, Va.
Pediatrics
G. W. KuTSCHER, JR., M.D. - Asheville, N. C.
General Practice
WiNCATE M. Johnson, M.D Winston-Salem, N. C.
Clinical Chemistry and Microscopy
C. C. Carpenter, M.D. „ Wake Forest, N. C.
.High Point, N.C.
— -- Danville, Va.
R. B. Davis, M.D.
Hospitals
Greensboro, N. C.
...Albemarle, N. C.
Pharmacy
W. L. Moose, Ph. G...- _
Cardiology
Clyde M. Gil,more, A.B., M.D. - - -Greensboro, N. C
Public Health
N. Tnos. Ennett, M.D
Allen Barker, M
Wrichi Clarkson
I.D. 1
<:. M.D./
Radiology
-Greenville, N. C.
— Petersburg, Va.
an^^gVven' careful' r^o^n^.'S °^.*^'i» . Jo"'-nal are requested
The Columbia Tri-State Meeting
Despite interference by influenza among our
members and their patients and the terrible state
of many of our roads, the recent meeting in South
Carolina was one of the most enthusiastic and suc-
cessful in Tri-State history.
Looking back over a meeting we like to be able
to discern distinquishing features. The feature
which most emphatically distinguished this get-to-
gether of doctors for the general good was a spirit
to encourage family doctors to do things for their
patients, and to give out helpful information as to
how to do certain of these things.
This spirit characterized the offerings of our
guest speakers and of our own members, affording
a happy illustration of the pronounced reaction
from the over-emphasis of specialism of a few years
back, of general recognition in this Association that
the function of specialists is to advise in or manage
cases of unusual difficulty.
Our scientific sessions were instructive and en-
joyable and, outside the classroom, our resourceful
and energetic Committee on Arrangements provided
handsomely.
A thought comes up that it may be well to hold
our annual meetings ten days or so later, as our
present meeting-time conflicts with a meeting of
medical educators and, so, nearly every year, we
are deprived of the participation of Dr. Robert
Wilson, Dr. W. C. Davison and many others.
The number of new members and reinstatements
IS gratifying and Dr. C. H. May, of Bennettsville,
S. C, and Dr. J. E. Smithwick, of Jamesville, N. C.
are entitled to special thanks for their zeal 'in this
cause. The Tri-State Medical Association is not
recruited automatically through additions to the
various County medical societies, as is the case
with the State societies. On one occasion we in-
duced a good doctor to join his State society as a
preliminary to getting him into the Tri-State. This
does not work in reverse. So there's a special obli-
gation on every Tri-State member to bear his As-
sociation in mind along through the year and tell
those doctors with whom he comes into intimate
contact that he would be glad to have them in
with us, that they will find welcome and that we
all can help each other. So, do not depend on the
Membership Committee; everybody lend a hand.
Finally, payment of annual dues is now in order
and every member who sends in his dues without
waiting for a statement saves the treasury just that
much and puts himself to no inconvenience. Along
with your dues, send your ideas of how the Associa-
tion can add to its usefulness in promoting the best
in medical practice and in goodfellowship among
practitioners.
SOUTHERN MEDICINE .\ND SURGERY
March, 1936
President Jennings
The Tri-State Medical Association has chosen
for its highest office a doctor who is known in his
good home town as physician and surgeon, and he
wears both titles worthily.
Douglas Jennings was born in Bennettsville,
graduated in Charleston, served his internship at
Roper, practiced three years of general medicine at
McColl and ten years of it in Bennettsville; then,
after special work in surgery, he was placed in
charge of the Marlboro County General Hospital,
and under his management and leadership this in-
stitution has been developed into a heaUh center
worthy of the excellent Marlboro County Medical
Society.
Perhaps ahead of either physician or surgeon
would come the word, student, as an apt descrip-
tive term; for Dr. Jennings is tireless in keeping
in the van of medical progress, and he exercises a
discriminating judgment in holding fast to what is
good until something of proved superiority is of-
fered in its stead.
The Marlboro General Hospital with Dr. Jen-
nings at its head affords an inspiring lesson in the
soundness of the concept of the county hospital as
the center of, and the means of improving, medical
service throughout the county; for he is not one
of those extremists who hold that every sick person
should be in a hospital.
Dr. Jennings knows at first hand the problems of
the doctors of this Section; he has demonstrated
that he knows how to solve them satisfactorily in
his own practice. He believes in medical organiza-
tion and that the main purpose of such organization
is better health care. His service in this office will
be good for the Association and good for the pa-
tients of the Association's members.
Dr. Hubbard as a Representative Faaiily
Doctor
In this issue those interested in genuine medicine
will find a piece by a genuine medicine man — a
good doctor, a good man to have about when there's
something wrong with you. Peculiarly apt it is
that the place of habitat of this good doctor is call-
ed Farmer.
This Country has gone a long way— many of us
think on the wrong road— since Thomas Jefferson
spent his life in unselfish planning for the greatest
happiness of a nation of Farmers. It seems that
everybody is in favor of farmers getting more for
their produce, provided nobody has to pay more
for cotton, tobacco, flour, meal, meat, eggs, poultry,
fruits or vegetables; just as indulgent mothers al-
low their children to go in swimming provided they
don't get wet in so doing.
Once in a while an individual comes out under a
headline 'Tf I were God." Here there is no in-
clination to indulge in such a phantasy; but I
have a very definite idea of what I would do, if I
were a farmer. If there were no local organization
of the Grange I would organize one. Then the
ideas would be put forward, vigorously supported,
and widely dessiminated, that every farmer and his
family agree to: (1) buy nothing that he can do
without: a) call it frequently to attention that
patched clothes are just as warm as unpatched,
and offer prizes (homegrown) — at meetings of the
Grange to the farmer or farmer's wife, at school
or Sunday school to the farmer's child — who has
the most-patched garments; b) under no circum-
stances buy a vehicle that does not derive its power
from horse, mule, ox or man; c) arrange that far-
mers who have skill as mechanics, carpenters,
plumbers, tinners, masons, painters and so on swap
labor so as to keep the price of such services in
the hands of farmers; (2) set about bringing pres-
sure to bear on well-to-do farmers — ^who, custom-
arily, immediately they become well-to-do, identify
themselves with bankers and merchants — to re-
member that they, themselves, are farmers, and
that it is incumbent on them to provide money for
financing purchases of necessary fertilizers and
other farm supplies in wholesale quantities and at
wholesale prices, and for marketing whenever the
farmers choose rather than when the time-mer-
chants choose.
If the farmers of this State and Section would
resolutely determine not to buy a thing beyond
what they and their families are bound to have,
and stick to it for a year, they would find the high-
and-mighty city merchants and bankers well dis-
posed to show the farmers a lot more consideration,
and the newspapers would pipe low on what is
"being handed the farmers," and how wrong it is
for city workers to have to pay as much for a
farm product as it costs to produce it.
Salute patches as badges of merit — whether on
men, women or children — and the reaction that
will grow out of this vdW get the foot of the banker
and the merchant off the neck of the farmer and
his family, and give them an independence they
have not enjoyed for a century.
Although you may not perceive it at first, this
fits in with what Dr. Hubbard has to say in this
issue.
This journal believes in farmers and the doctors
of farmers, and it hopes to see the time that these
doctors, and all other family doctors, will require
that all the strings of the health skein of every in-
dividual patient be put into the hands of his family
doctor — that preventive medicine and surgery, gen-
eral medicine and surgery, and special medicine
SOUTHERN MEDICINE AND SURGERY
16S
and surgery, be all done by the family doctor or
at his direction and by consultants of his choosing.
Which We All Appreclite, and From Which We
Take Heart
Dr. J. M. Northington,
Charlotte, N. C.
Dear Dr. Northington:
I am enclosing you check for Medical Journal, and
want to tell you that I take five journals, including A. M.
A., Southern Medical and Virginia Monthly, but like
Southern Medicine and Surgery better than any and get
more out of it. Something interesting in every number of
your journal and the thing that I like most is the good
common sense and practical information it contains for
the general practitioner.
The Original Articles are of a high order, and surely
must be well selected; so much better than the average
journal. I always find something interesting, too, among
the .■\bstract5 News Items and Surgical Observations are
worth their space in the journal. I wonder why so many
journals are lacking in Department Editors, such as write
condensed, easily and quickly read and understandable
editorials in Soiithern Medicine and Surgery. It would be
a stupid mind indeed that wouldn't be interested in the
editorials of James K. Hall and Wingate Johnson. Some
other good writers are Frederick Taylor, Tucker, Langston,
W. L. Moose, Ennett, Kutscher, the Davise? — in fact all.
And now for the last, and certainly not the least, why
I like the journal is the breezy editorials, by the Editor,
and of course I accuse you of being solely responsible
for them. I certainly admire the stand you take for the
medical profession. We are certainly in need of more
out-spoken, hard-hitting defenders of our profession who
will carry our cause (fight) to the enemy, the politicians
who want to get control of our noble profession. I admire
just 100% the position you take with regard to State
Medicine and Sickness Insurance, the latter the first step
to State Medicine. I certainly hope you'll continue as
Editor of the journal. I fear, yea — almost know — another
could not be found to take your place.
I wish the Tri-State held their meetings in the Spring
instead of Winter. .'\s it is I rarely ever can get off to
attend their meetings.
In conclusion I wish for the Editor, the Tri-State Asso-
ciation and Southern Medicine & Surgery, that the best
of all things may be theirs throughout the coming year.
Most sincerely,
Floyd, Va. C. W. THOMAS. M.D.
Feb. nth, 1936.
The .\merican Assocmtiox of the History of Medicine
Note. — Through the courtesy of it.s Secretary a cordial
invitation is extended each reader of this journal to come
into the membership of the American Association of the
History of Medicine. — J. M. N.
You are cordially invited to active membership in this
Association which recently completed its eleventh successful
year of affiliation with the International Association of the
History of Medicine.
The .American Association holds an annual meeting with
afternoon and evening (dinner) sessions and its officers
anticipate a future of regional meetings of interested groups
in various cities of North America.
Membership, .'51.50 annually.
— with subscription to Medical Life, ,$2.50.
— with subscription to either Janus (German) or
Aesculape (French), $4.50.
— with subscription to both foreign journals, $7.50: to
all three, $S.0.
The Membership Committee is made up of Drs. Walte r
C. Alvarez, Rochester; Charies S. Butler, Brooklyn; C. N.
B. Camac, New York City; Felix Cunha, San Francisco;
Harvey Gushing, New Haven; Edward H. Gushing, Cleve-
land; Elliott G. Cutler, Boston; Howard Dittrick, Cleve-
land; Jabez H. Elliott, Toronto; John F. Fulton, New
Haven; Roland Hammond, Providence; James D. Heard,
Pittsburgh; James B. Herrick, Chicago; Edgard F. Kiser,
Indianapolis; Charles F. Martm, Montreal; W. S. Middle-
ton, Madison; Hilton S. Read, .Atlantic City; David Ries-
man, Philadelphia; Walter R. Steiner, Hartford; Henry R.
\'iets, Boston; Gerald Webb, Colorado Springs; Carl V.
Wcller, .Ann .Arbor; Bernard Wolf Weinberger, New York
City.
Dr. William S. Middleton, president the University of
Wisconsin, Madison; Dr. J. G. Beardsley, secretary, 1919
Spruce St., Philadelphia.
Next meeting May 4th, 1936, at Haddon Hall Hotel. At-
lantic City.
.After Cholecystectomy
(T. F. Hahn, DeLand. in Jl. Fla. Med, Assn., Feb.)
Not all cases of chronic cholecystitis, with or without
stone, are cured by cholecystectomy, and some are not
helped at all.
-After cholecystectomy a compensatory dilatation of the
common duct takes place within a few months and takes
care of the balancing of bile pressure formerly regulated by
the gallbladder. Some have pain with this readjustment,
usually attributed to spasm of the sphincter.
Stones in the hepatic or biliary ducts may have escaped
observation at operation.
Graham found only 60% well after gallbladder operations
in which no stones were found. Many patients never need
any medical treatment after cholecystectomy, but few have
persistent and intractable symptoms.
-After cholecystectomy symptoms are more likely to be
due to infection than to stone.
We must decide if the symptoms are due to disturbed
biliary function, incomplete surgery, recurring infection,
stricture of the common duct, adhesions or spasm of the
sphincter of Oddi.
Attention to oral and intestinal hygiene, regular habits,
moderate e.xercise, deep breathing, avoidance of constipa-
tion, freedom from mental strain are all details which the
physician must supervise. Removal of foci of infection
is as important as it was before cholecystectomy. The
prevention of biliary stasis is very important; it can be
accomplished by stimulating bile flow by means of bile
salts and duodenal tube drainage. The value of methena-
mine and other so-called bile antiseptics is questionable.
The treatment of reflex gastric disturbances is medical;
alkalis, antispasmodics or dilute hydrochloric acid is indi-
cated. Sedatives are valuable in the nervous and irritable
patient. Careful adjustment of the activities and energy
of the nervous patient is required. In no case is there any
short road to relief.
Diets should be low protein and high carbohydrate; fats
are to be avoided. Frequent feedings and prevention of
rigid dieting arid food fads are to be insisted upon.
In the early ye,vrs of the 19th century the Medical
School of the University of Pennsylvania was occupying a
building which had been erected in 1792 by the State of
Pennsylvania, as a home for the President of the United
States when Philadelphia was the capital of the nation. —
JL Ind. Slate Med. Assn., Mch.
SOUTHERN MEDICINE AND SURGERY
March, 1936
NEWS ITEMS
Spring Postgraduate Cunics Medical College of
Virginia, Richmond
Monday, April 6th, 1936
S:30 p. m.— Focal Infection and Elective Localization,
Dr. Edward C. Rosenow, University of Minnesota, Roch-
ester, Minnesota.
Tuesday, April 7th, 1936
10-10:30 a. m. — The Importance of Alveolar Infection in
Focal Infections, Dr. Harry Bear, Dean, School of Dentis-
try.
10:30-11 a. m.— The Importance of Tonsils and Nasal
Accessory Sinuses in Focal Infection, Dr. Karl S. Blackwell,
Professor of Otolar>'ngology.
11-11:30 a. m. — Focal Infection and Eye Disease, Dr.
Emory Hill, Professor of Ophthalmology.
11:30-12 m.— Focal Infection and Chronic Arthritis, Dr.
Donald M. Faulkner, Associate in Orthopedic Surgery.
12-12:30 p. m.— Focal Infection and Infections of the
Genito-Urinary Tract, Dr. A. I. Dodson, Professor of
Genito-Urinary Surgery.
12:30-2 p. m. — Luncheon, Cabaniss Hall, as guests of
the college.
2-2:30 p. m.— Focal Infection and Diseases of the Nerv-
ous System, Dr. L. S. Meriwether, Neuro-Pathologist.
2:30-3 p. m. — Focal Infection and Cardio-Vascular Dis-
ease, Dr. William B. Porter, Professor of Medicine.
3-3:30 p. m.— Round Table Discussion of Symposium.
Discussion led by Dr. William B. Porter, Professor of Med-
icine.
8:30 p. m. — Streptococci in Relation to Diseases of the
Nervous System, Dr. Edward C. Rosenow, University of
Minnesota, Rochester, Minnesota.
Members of the profession are cordially invited. There
is no registration fee.
Dr. L. R. Broster, surgeon to Charing Cross Hospital,
London, addressed the Richmond Academy of Medicine
February 10th. The subject was Eight Years' Experience in
Surgery of the Adrenal Glands.
While in Richmond, Dr. Broster was the guest of Dr.
Frank L. Apperly, pathologist of the Medical College.
Dr. Broster, who is a native of South Africa, holds both
academic and professional degrees from Oxford University
and is a former Rhodes scholar.
Richmond Academy of Medicine, regular meeting held
on February 2Sth, at 8:30 p. m. Scientific Program: Re-
port of Proceedings of International Society of Surgery at
Cairo, Egypt, with Travel Notes, Dr. J. SheUon Horsley;
The Neurological Aspects of Pellagra, Dr. Beverley R.
Tucker.
The Staff of The M.^ry Eliz.weth Hospital, Raleigh,
N. C, announces the association of Kenneth Dickinson,
M.D., General Medicine and Surgery; R. H. H.^ckler,
M.D., Diagnostic and Therapeutic Roentgenology; and
Harold Glascock, jr., M.D., General Medicine and Sur-
gery.
Meeting of the staff of the McGuire Clinic on Feb.
18th, at 8:30 p. m., in the Library of the Clinic Building.
Program: Is Chronic Appendicitis a CUnical Entity?, Dr.
W. P. Barnes; Report of Verj- Unusual Gallbladder, Dr.
W. Lowndes Peple; Full Term Extrauterine Pregnancy
with report of seven cases. Dr. H. H. Ware.
Gill Memorial Eye, Ear and Throat Hospital, Roa-
noke, Virginia, will give its Tenth Annual Spring Graduate
Course in Ophthalmology, Otology, Rhinology, Laryngol-
ogy, Facio-Maxillary Surgery, Bronchoscopy and Esopha-
goscopy, April 6th-llth.
Dr. Roger G. Doughty, Columbia, Dr. J. W. Tankers-
ley, Greensboro, and Dr. Julian A. Moore, Asheville,
addressed the Southeastern Surgical Congress at New Or-
leans last week.
Buncombe County Medical Society, Asheville, Feb.
17th, City Hall Bldg., Pres. Parker in chair, 41 members
present, visitor Dr. Mellencroft of Black Mountain.
Address by Dr. Walter R. Johnson on Painless Jaundice,
discussion by Drs. Crow, Schoenheit, Moore, Cocke and
Parker, closed by the essayist.
Dr. Huffines of the Committee on .\wards for the be-t
paper of the year recommended that the president appoint
two additional members for this committee to review the
papers written by our members during the year and award
the prize. Dr. Moore moved the society establish an
award for the best paper written by a member during the
year and a committee of five members be appointed by
the chair to review the papers and make the award, sec-
onded by Grantham, carried.
Dr. Swann moved the society have one of its regular
meetings soon at the society librarj' room in the Arcade
Building, carried.
The society take notice of the fact that tonight one of
our members is being honored as President of the Tri-
State Med. Soc. meeting at Columbia, S. C, and authorized
the secretary to send a telegram to Dr. C. C. Orr.
Buncombe County Medical SociETy, Asheville, regular
meeting the evening of March 2nd at the City Hall Bldg.,
Pres. Parker in the chair, 40 members present, visitor Dr.
Carey Harrington, of the Oteen Med. Staff.
Paper by Dr. Karl Schaffle on Nervous Disorders Asso-
ciated with Pulmonary Tuberculosis. Discussion by Drs.
Mark A. Griffin, L. G. Beall, Herbert, Ringer, Huston and
White.
The secretary presented the application for membership
in the society of Dr. Carey L. Harrington, referred to
Board of Censors.
The president announced the personnel of the Commit-
tee on Awards as Drs. Carr, C. H. Cocke, Huffines, Schoen-
heit and Hollyday.
(Signed) M. S. Broun, M.D., Sec.
Mecklenburg County (N. C.) Medical Society (1),
special meeting, evening of March 2nd. Report was heard
from the Committee on Hospital Savings .Association Plan,
Dr. Andrew Blair, chairman. The plan as modified was
voted as acceptable to the membership of the Society. It
was also voted that plans of the Hospital Care Association
and any other such association having essentially the same
features has the endorsement of this Society.
Dr. Wm. .Allan, chairman of a Committee on Additional
Hospital Facilities in Charlotte, reported for the committee
a recommendation that the Society resolve that there is a
pressing need for a 300-bed endowed hospital. After lib-
eral discussion such a resolution was passed by unanimous
vote.
(2) The evening of March 3rd, regular meeting. The
Society was addressed by Dr. Geo. Wilkinson of Greenville,
S. C, on Conditions of Hypoinsulism; by Dr. R. S. Cath-
cart, of Charleston, on Historical Surgery. A large turnout
to hear these distinguished guest-speakers.
March, 1936
SOUTHERN MEDICINE AND SURGERY
Eli Lilly and Company
FOUNDED i 8 76
IMakers of ^Medicinal Products
Clinical results obtained with Undenatured
Bacterial Antigens, Lilly (U B A), indicate
that they are more specific than ordinary
vaccines, that they produce a prompter
therapeutic response.
Undenatured Bacterial Antigens, Lilly
(UBA), contain in unaltered form the native
antigenic substances of the bacterial cell.
The method used in their preparation was
developed by Dr. A. P. Krueger, of the
University of California.
Particularly timely: Respiratory UBA in
5-cc. and 20-cc. vials for subcutaneous and
intracutaneous use, and Respiratory UBA,
Topical, in 20-cc. vials.
Prompt Attention Qiven to Projessional Jncjuiries
PRINCIPAL OFFICES AND LABORATORIES, INDIANAPOLIS, INDIANA, U.S.A.
Please Mention THIS JOURNAL When Writing to Advertisers
168
SOUTHERN MEDICINE AND SURGERY
March, 1936
The Robeson Cotjnty Medical Society, meeting Feb-
ruary 7th, heard Dr. R. D. McMiUan, Red Springs, on
Public Indifference to Physical Welfare, and Dr. J. E.
Boone of the South Carolina State Hospital, Columbia, on
Malaria for Syphilis Therapy.
Dr. C. T. Johnson, Red Springs, president of the society,
presided. Dr. H. M. Baker, Lumberton, was host. Dr.
N. 0. Benson, secretary, in reading the minutes, called
attention to action taken by some other county societies
on hospital insurance, and President Johnson appointed
Drs. R. D. McMillan, J. A. Martin and S. Mclntyre, the
two last-named of Lumberton, a committee to report at
the next meeting.
From Dr. A. E. Baker, jr., Charleston
With the recently elected president, Dr. L. P. Thackston,
presiding, the regular monthly meeting of the Edisto Med-
ical Society was held February 27th at the Hotel Eutaw,
Orangeburg, S. C. The society is composed of physicians
from Orangeburg, Calhoun and Bamberg Counties and
each of these counties was well represented at the meeting.
Dr. L. C. Shecut, of Orangeburg, read a paper on typhus
fever, tracing the history, symptoms and the treatment of
the disease. The society regretted the absence of Dr. A. W.
Browning of Elloree, who is at present at the Tri-County
Hospital in Orangeburg, where he underwent an operation
several weeks ago.
Work of the Crippled Children's Society of South
Carolina was discussed February 28th before members of
the Charleston Rotar>- Club by Dr. Frank A. Hoshall,
Chairman of the Mayor's Committee on work for crippled
children and Assistant Professor of Orthopedics in the
Medical College of the State of South Carolina.
Of widespread interest is the approaching wedding of
Miss Betty Barnwell of Charleston to Dr. Samuel Eugene
Miller which will take place March 10th. Dr. Miller is a
graduate of the Medical College of South CaroHna and
interned at Roper Hospital last year.
Miss Dessie Strawborn of Donald became the bride of
Dr. S. R. Hickson of Fairfax in a simple ceremony at
Beldoc February 14th.
Dr. and Mrs. William Evans, jr., of Bennettsville have
returned home after spending a week in Florida.
Dr. and Mrs. E. F. Mikell announce the birth of a
daughter. Hazel Anne, Tuesday, February 11th, at the Bap-
tist Hospital. Mrs. Mikell and baby have returned to their
home in Oak Court, Columbia.
Dr. S. B. McPheeters has been elected Health Officer
of Wayne County to succeed Dr. C. Fletcher Reeves, re-
signed. Dr. McPheeters is a native of Rockbridge County,
Virginia. He is taking a special course in pubhc health
work at the University of North Carolina, and will assume
his new duties April 15th.
Dr. Milton J. Roslnau, director of the Division of
Public Health of the University of North Carolina, ad-
dressed the Greensboro Nursing Council on February 11th.
Dr. W. Ambrose McGee announces his return to Rich-
mond, 616 West Grace street, prepared to study and treat
Allergic Diseases of children and adults in addition to
continuing his practice of Pediatrics.
Dr. Soitthgate Leigh, prominent Norfolk surgeon, was
stricken with apople-xy March 5th, while attending a Civic
meeting and died shortly afterward. A more extended
notice will follow.
Deaths
Dr. C. H. C. Mills, well beloved Charlotte obstetrician,
died suddenly at his home the morning of March 5 th. A
more extended notice will follow.
Dr. H. C. Grubb, jr., of Churchland, near Lexington,
North Carolina, died of a pistol wound at his home, Feb-
ruary 10th. He was twenty-nine years of age, a graduate
of Wake Forest College, and in medicine of Temple Uni-
versity.
Dr. Samuel L. Perkins died February 27th at his home
at Wilkesboro, N. C, following a serious illness of several
days.
He was 76 years of age, a son of the late Dr. David
Perkins, of Ashe County. He was graduated in ISOl from
Baltimore Medical School and practiced in Baltimore, later
moving to east Tennessee, the State of Oregon and back to
Jefferson, in Ashe County.
Dr. L. V. Grady, of Wilson, died of pneumonia Febru-
ary 21st at the home of a relative in Bladenboro. He
was stricken Feb. 15th while en route to Florida with
Mrs. Grady. A native of Seven Springs, in Wayne County,
Dr. Grady was 47 years of age. He was one of the foun-
ders of the Carolina General Hospital in Wilson and was
prominent in his profession. Dr. E. C. Grady, Elm City,
is a brother.
Dr. Willcox Ruffin, 33, Norfolk, died February 28th of
complications following injuries sustained February 19th.
He had just returned from a hunting trip. In some man-
ner, his shotgun fell as he opened a closet in his home,
inflicting the injuries. One foot was later amputated and
he was given several blood transfusions. His condition was
considered favorable until the night before his death.
Dr. Ruffin was a son of the late Dr. Kirkland Ruffin.
He was educated at the Virginia Episcopal High School
and the University of Virginia and later received the Uni-
versity of ■ Minnesota fellowship at the Mayo Clinic at
Rochester, Minn. He returned to Norfolk three years ago
and had since been specializing in surgery.
Dr. H. T. Pope, dean of the medical profession in
Lumberton, died unexpectedly at his home February 12th.
He had been indisposed for a few days, but he prescribed
for patients who came to see him on the 11th and was not
considered seriously ill until a short while before he died.
Receiving his medical training at the North Carolina
Medical College at Davidson, Dr. Pope entered the prac-
tice of medicine when 25 years old and enjoyed a large
practice for 39 years. No person was ever denied medical
attention by Dr. Pope.
Dr. Pope was largely instrumental in organizing the
Robeson Medical Society. He was chief of the obstetrical
department of Baker Sanatorium and taught obstetrics for
15 years, endearing himself to the young women with whom
he came in contact there. He was also a member of the
medical staff of Thompson Memorial Hospital.
The stores were closed and all business suspended in
Lumberton during the funeral services.
Our Medical Schools
University or Vircinia
At the meeting of the University of Virginia Medical
Society on January 13th, Dr. W. C. Spain, of New York
City, spoke on the subject of Hypersensitiveness to Com-
mon Foods. On January 20th, Dr. Tracy J. Putnam, of
March, 1936
SOUTHERN MEDICINE AND SURGERY
yo(\v^sj^AWl
M E L L I E
2112 LOCUST
in Rheumatoid Arthritis
is ANALGESIC, ELIMINATIVE
and RESTORATIVE
Arthritis is recognized as being merely a local reflec-
tion of systemic disease variously manifested in the
form of myositis, neuralgia, iridocyclitis, headache,
neurasthenia, etc.
Improved peripheral circulation, effective diuresis,
sedation and analgesia fortify and intensify the tonic
and anti-rheumatic action of Tongaline.
Through systemic approach with salicylate action
in synergistic combination, Tongaline overcomes the
symptoms of influenza and arthritis.
An interesting digest of the literature entitled
"Relation of Metabolism to Rheumatism and Rheu-
matoid Arthritis" will be mailed free upon request.
R DRUG
STREET, ST.
COMPANY
LOUIS, MISSOURI
Boston, spoke on Hydrocephalus.
On February 1st, Dr. Lawrence T. Royster spoke before
the Raleigh .\cademy of Medicine on the subject of Acute
Nephritis in Childhood.
DurE
On January 23rd, Dr. C. F. Strosnider, President-elect
of the North Carolina Medical Society, talked to the fac-
ulty and students on Organized Medicine and Medical Eth-
ice.
On January 30th and 31st, Dr. Alfred Blalock, Associate
Professor of Surgery, Vanderbilt University School of
Medicine, lectured on Shock and Lymphatic Obstruction,
respectively.
Medical College of Vircinia
Dr. W. T. Sanger, president, and Dr. Lewis E. Jarrett,
superintendent of the hospital division, attended the annual
congress on Medical Education and Hospitals in Chicago
February 17th and 18th.
Dr. M. B. Jarman of Hot Springs was a recent college
visitor.
Dr. L. R. Broster, chief surgeon of the Charing Cross
Hospital of London, and prominent endocrinologist, re-
cently lectured to the students here.
There were 4,844 patient visits to the outpatient de-
partment during the month of January, these visits being
made by 2,210 individual patients.
Dr. Grant Van Huysen has recently joined the staff of
the college in the capacity of associate in anatomy.
Dr. Fred J. Wampler has been appointed medical ad-
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visor for the Works Progress Administration of Virginia.
The annual Stuart McGuire Lectures and the spring
postgraduate clinics will be held April 6th and 7th. Dr.
E. C. Rosenow, Director of Experimental Bacteriology,
Mayo Foundation, Rochester, Minnesota, will lecture the
night of April 6th on Focal Infection and Elective Locali-
zation. During the day of April 7th the clinics will h-^
held by members of the college faculty and at night Doctor
Rosenow will lecture on Streptococci in Relation to Dis-
eases of the Nervous System.
Meeting in annual session in Raleigh, February 22nd,
the University Medical Alumni of the Oi.d University
Unit of Raleigh elected Dr. J. R. Hester, Wendell, as
their president for the coming year. The group holds its
meeting on Washington's birthday each year.
170
SOUTHERN MEDICINE AND SURGERY
March, 1936
Dr. Hubert A. Royster, dean of the old school, was host
to the alumni gathering, attended by 15 of the 81 alumni
of the Raleigh medical unit, discontinued some years ago.
Other officers named were Dr. W. W. Green of Tarboro,
vice president, and Dr. Robert P. Noble of Raleigh, re-
elected secretary-treasurer.
New officers of the association are to select the place for
next year's meeting at a later date.
Those attending the alumni meeting included: Dr. Roys-
ter, Dr. Hester, Dr. Green, Dr. Noble, Dr. J. M. Buckner
of Swannanoa, Dr. M. L. Matthews of Sanford, Dr. L. V.
Dunlap of Albemarle, Dr. J .8. Talley of Troutraan, Dr.
A. G. Woodard of Goldsboro, Dr. Battle A. Hocutt of
Clayton, Dr. C. A. McLemore of Smithfield, Dr. A. C.
Campbell of Raleigh, Dr. Z. M. Caviness of Raleigh, Dr.
C. B. Wilkerson of Raleigh and Dr. A. E. Riggsbee of
Durham.
BOOK REVIEWS
THE 193S YEAR BOOK OF PEDIATRICS, edited by
Isaac A. Abt D.Sc., M.D., Professor of Pediatrics, North-
western University Medical School; .\ttending Physician,
Passavant Hospital; Consulting Physician, St. Luke's Hos-
pital, Chicago; with the collaboration of Arthur F. Abt,
B.S., M.D., Associate in Pediatrics, Northwestern Univer-
sity Medical School; Associate Attending Pediatrician,
Michael Reese Hospital; Attending Pediatrician, Chicago
Maternity Center; Attending Physician, Spauding School
for Crippled Children, Chicago. The Year Book Publishers,
Inc., Chicago . $2.25.
The editor opens with an elaborate article on
Progress in Infant Feeding. Breast Feeding is con-
sidered best by Grulee, of Chicago; Davison, of
Duke, advocates whole lactic acid evaporated milk.
It is conceded that there are plenty of vitamins in
a normal diet. A new diagnostic sign of scarlet
fever is described: on the outer edge of the auricle,
on the helix, and on the nail wall of the fingers
and toes there are tiny vesicles with a water-clear
content as early as the 2nd day. Infants should be
vaccinated against smallpox between the 3rd &
6th mo. Glucose seems to be the only remedy in
diphtheritic myocarditis. Present studies have
failed to disclose any relationship between a num-
ber of dietary factors, including vitamins, and the
incidence or severity of colds. Hyper- as well as
hypothyroidism must be looked for in children,
even small children and infants. The gravity of
appendicitis in infancy is emphasized.
Wise selection has been made of the articles to
be abstracted, and the editorial comment is dis-
criminating.
RADIUM TREATMENT of Skin Diseases, New
Growths, Diseases of the Eyes and Tonsib, by Francis H.
Williams, M.D. (Harv.), S.B. Massachusetts Institute of
Technology; Senior Physician Boston City Hospital; Fel-
low American Academy of Arts and Sciences; Emeritus
Member Association .'\merican Physicians; Member Societe
de Radiologic Medicale de France; Corresponding Member
K. K. Besellschaft der Aerzte in Wien; Honorary Member
.American Society of North America, etc. Author "The
Roentgen Rays in Medicine and Surgery" (3 editions).
1901-1903. With 12 illustrations. The Stratford Co., Bos-
ton, 1935. $2.00.
The result of a 30-year experience in the use of
this still wonderful agent, this book commmands
attention as the work of a master.
Part I treats of the nature and properties of
radium, of measurements and of the use the ele-
ment in superficial conditions; Part II with diseases
of the eyes and eyelids; and Part III with throat
conditions.
The author's elaborate training in physical
science fitted him unusually for work with this ele-
ment, with which he has been on terms of the great-
est intimacy through its developmental period and
on to its great triumphs.
A MANUAL OF THE COMMON CONTAGIOUS DIS-
EASES, by Phtlip Moen Sttmson, A.B., M.D., Assistant
Professor of Clinical Pediatrics, Cornell University Medical
College; Visiting Physician, Willard Parker Hospital; Chief-
of-Staff, The Floating Hospital of St. John's Guild; Asso-
ciate Attending Pediatrician, The New York Hospital;
School Physician, The Horace Mann Schools, 1919-1923;
President the School Physicians Association, 1928-1930.
Second edition, thoroughly revised; S3 engravings and 3
plates. Lea and Febiger, Philadelphia. 1936.
It is commonly said that it is not necessary to
carry medical facts in your mind, that it is neces-
sary only to know where to find them in your li-
brary. To a great extent this is true; but it does
not apply everywhere. In cases of common con-
tagious diseases it is esssential that doctors know,
and, at the first examination, be able to give proper
directions.
The author has given us such a book and has
revised it to date. The chapters are headed Princi-
ples of Contagion, Serum Reactions, Diphtheria,
Vincent's Angina, Scarlet Fever, Measles, Rubella,
Whooping cough, Mumps, Chickenpox, Smallpox,
Vaccination against Smallpox, Meningococcus Men-
ingitis, Poliomyelitis and (especially valuable)
General Management of Contagious Diseases.
The author says he includes Vincent's Angina
in the book because of its resemblance to diphthe-
ria, and that the two diseases not infrequently co-
exist. His attitude toward preventive injections in
poliomyelitis is one of conservatism.
The book is built on wide observation and sound
reasoning.
Homatropine not Satisfactory for Children
(M. S. Harding, Indianapolis, in Jl. Ind. State Med. Assn.,
Mar.)
I wish to register my objection to the practice of depend-
ing upon hematropine in the refractions of children. It
seems that some oculists very frequently use this drug as a
mydriatic in these cases, I have had occasion to recheck
many of these cases and have long since come to the con-
clusion that we cannot use homatropine, in children, with
any success.
March, 1936
SOUTHERN MEDICINE AND SURGERY
171
INHALANT
No. 77
An Ephedrine Compound used as an inhalant and
spray, in infections, congested and irritated condi-
tions of the nose and throat. Relieves pain and con-
gestion, preventing infection, and promotes sinus
ventilation and drainage without irritation.
Description
Inhalant No. 77 contains Ephedrine, Menthol, and
essential oils in a Paraffin oil.
Application
Can be sprayed or dropped into the nose as directed
by the Physician.
Supplied
In 1 ounce, 4 ounce and 16 ounce bottles.
Burwell & Dunn Company
Manufacturing Pharmacists
CHARLOTTE, N. C.
Sample sent to any physician in the U.S. on request
The Treatment or Pneumonia est Early Childhood
The problem is a challenge to our ingenuity and re-
sourcefulness.
I consider it of utmost importance though difficult to
put children to bed when they have fever until entirely
well; an afebrile period of 48 hours after a respiratory
infection before a child is allowed out of bed — then 1 or 2
hours the first day, with a convalescent period of 3 days
before he is allowed to go to school.
The air should be between 65 and 68° by thermometer
placed near the child. Permit light clothing: it is exhaust-
ing to struggle under many layers of clothing and bed
covers. Moistened, plain steam inhalations are useful, or
volatile oils may be added to the water. Inhalations
should be continued as long as there is distressing cough
or scanty secretions. In the milder cases sufficient relief
may be obtained by allowing a kettle to boil constantly
in the sick room.
As much nourishment as the digestive apparatus can
tolerate, milk, broths, soft eggs, purees, creamed vegetable
soups, scraped beef, jeUy, junket, custard, and fruit juices.
If milk is vomited, boil, or give smaller amounts of food
at 4-hour intervals.
Counter-irritation when pleural pain and cough are
prominent. Mustard plasters are most effective, varying
strength with age.
A child will rarely voluntarily take sufficient water;
offer orangeade, lemonade, canned fruit juices or bottled
soda water, given as such or diluted with water.
A sponge bath at 90° given under the covers often gives
refreshing sleep of several hours. An ice bag to the head
and a tepid sponge bath can transform a delirious patient
into one enjoying a quiet sleep. The bath begun at 95°
FOR
A I N
The majority of the phy-
sicians in the Carolina^
are prescribing our new
tablets
^AMOg
751
AnalgtsU and Sedative ' P^'ts S parts I part
Aspirin Phenacetin Caffein
JFe will mail professional samples regularly
with our compliments if you desire them..
Carolina Pharmaceutical Co., Clinton, S. C.
gradually being reduced to 90° and even 84° according
to the degree of fever. The cloth should be wrung fairly
dry, the bath continued for 10 to 15 minutes, and the
moisture allowed to evaporate on the skin.
Abdominal distention: All food should be withheld for
12 hours and a cathartic given. Turpentine stupes and
enemas, if these are ineffective, O.S c.c. of obstetrical pit-
uitrin every 3 hours, or as needed. These will fail some-
times — usually means peritonitis or circulatory failure.
Useless medication may irritate and exhaust the child in
172
SOUTHERN MEDICINE AND SURGERY
March, 1935
the effort to administer it. It is apt to turn him against
taking nourishment. Parental demands may be met by
emphasizing the importance of rest, less disturbance, and
the hour by hour nursing care. We are well repaid for
time spent in education of parents.
Ccnigh: warmed fresh air, inhalations, and counter-
irritation are the first things. Hot drinks are soothing.
One oz. of hot milk with a little bicarbonate of soda, given
frequently, will often allay coughing. In the early stage,
when secretions are scanty, syrup of hydriodic acid is
effective.
Rest and sleep: barbital and chloral hydrate serve if no
pain. If there is pain, codeine is by all odds the drug of
choice, by mouth or hypodermically. For too rapid and
irregular pulse, caffem and digitaUs are the stimulants of
choice. Reserve for the time when, and if, indicated.
Digitalis if auricular fibrillation occurs. Camphor in oil
is a drug deserving of the high regard in which it is held,
both as a stimulant and because of its bacteriostatic effect
upon the pneumococcus. Alcohol is good in the grave
pre-critical period — brandy, or whiskey, in doses of 20 to
30 drops in sweetened water to a young child every 3
hours.
Atropine, as a respiratorv' stimulant and at those times
when profuse bronchial secretions sfljriously embarrass
respiration, may be almost lifesaving. A single dose of
1/400 grain to a child of 4 years may dry secretions and
overcome the dyspnea and restlessness.
While it is not advisable to increase the blood volume
by any large amount when pulmonary congestion exists,
small transfusiom, perhaps repeated, are not subject to
this objection. Four infants under 16 months, sick from 4
to 8 days with profound toxemia and prostration of severe
bronchopneumonia were given 85 to 125 c.c, and each
showed a prompt decline of temperature with convalescence
within a week.
Serum therapy : the rapid typing as proposed by Sabin is
simple and well within the powers of the small hospital
or the clinician himself.
Commercial antipneumococcus serum is readily available
for types I and II and there seems to be little doubt as to
its efficacy in type I.
Before administering serum it is of the utmost im-
portance to determine whether or not the patient is sensi-
tive to horse serum. In addition test with the serum
to be used: intradermal injection of 0.02 c.c. of serum
diluted 1 to 10 with normal saline; or one to 2 drops of
undiluted serum directly into the conjunctival sac, which
shows sensitiveness, by reddened and injected conjunctivae
within IS minutes.
If the tests reveal only slight sensitiveness, serum may
be given in graduated doses at ^-hour intervals, beginning
with a very small amount. A syringe loaded with adrenalin
shold always be at hand in case of a reaction. (It is also
wise to have a tourniquet. — Ed.) If both the intradermal
and conjunctival test;, are positive, the patient is so highly
sensitive as to render inadvisable the administration of
serum.
The natural low mortality of lobar pneumonia in chil-
dren, and the relative infrequency of type I infections
make serum therapy rarely indicated.
Oxygen therapy: I always regard as the ace-in-the-hole,
because it affords such rapid relief from the exhausting
dyspnea and restlessness. Cyanosis is the indication for
oxygen therapy. Detectable cyanosis of the finger nails
and lips represents approximately 10% unsaturation. A
concentration below 30% is rarely of value; the optimum
is between 40 and 60%. To administer the optimum con-
centration it is necessary to use an oxygen tent. This
equipment is well within the means of a private practi-
tioner. The body stores no oxygen ; so if oxygen is needed,
the need is constant. The beneficial effect is prompt and
sometimes spectacular. The p. and r. become slower, the t.
often drops 2 degrees or more, breathing becomes easier,
and increased comfort is followed by much needed rest.
Cyanosis is relieved as the arterial oxygen saturation in-
creases, and it will frequently prolong a life until such
times as the child can build up his immunity.
Fluids by mouth, if a satisfactory amount — from 1 to 2
quarts a day — cannot be given in this manner, we resort
to infusion. For this purpose we prefer Ringer's or Hart-
mann's solution, 20O to 500 c.c. every 8, 12, or 24 hours
with complete absorption and without irritation. The
giving of fluids by rectum is unsatisfactory with children.
Otitis media may and frequently does occur without
pain ; the ears are objects of suspicion when there is a
sudden rise in t., increasing restlessness, rolling of the head
from side to side, or the definite complaint of earache.
Irrigate if this can be done without too much antagonism
from the child. An ear drum which shows increasing red-
ness and swelling, and is painful, should be incised early.
If drainage of pus, douching should be carried out care-
fully, and the external ear kept scrupulously clean to avoid
furunculosis.
A moderate albuminuria is to be expected bu tpersisting
pyuria demands the treatment of pyelitis.
Empyema: effusion, frank pus, as determined by re-
peated aspirations, demand open drainage by rib resection.
This has been followed by the lowest mortality and most
rapid obliteration of the abscess cavity.
Repeated spinal drainage offers the best hope of relief in
meningitis, and will alleviate the nervous symptoms of
meningismus.
Children with pneumonia should be kept in bed at least
a week with a normal t. In any case the child should feel
perfectly well before he is allowed to get up. Out-of-doors
periods must be carefully guarded and of short duration.
The diet need not be limited and the appetite is usually
such that it is not necessary to force food.
Cod liver oil is one of the best reconstructive tonics;
syrup of ferrous iodide, or iron and ammonium citrate
should be added if anemic.
It shall be health to thy navel and marrow to thy bones.
-Proberbs 3:8.
From REPORT OF THE SECRETARY TO THE TRI-
STATE MEETING IN 1903
DR. ROLFE E. HUGHES (Sec.-Treas.) :
Every effort has been made to curtail expenses and col-
lect dues. In the first case fair success has been made, but
in the latter I confess failure.
For instance (and upon this the society should act), I
find 24 members who have never paid initiation fees or
dues since the organization of the Tri-State in 1899 (ad-
mitting some to become members in 19J30 and 1901), makes
an approximate average of $15 for each one, or .'?366 due
the .'\ssociation. For five years they have enjoyed the
privileges at a cost to the Society, with transactions, sta-
tionery and postage, of about $7 per capita, or §168 for
the number of delinquents. This, it will be observed, will
soon deplete our treasur>', and some action is earnestly
recommended.
PROFESSIONAL CARDS
GENERAL
Nails Clinic Building
THE NALLE
Telephone— 3-2141 (If no
General Surgery
BRODIE C. NALLE, M.D.
Gynecology & Obstetrics
EDWARD R. HIPP, M.D.
Traitmatic Surgery
PRESTON NOWLIN, M.D.
Proctology & Urology
Consulting Staff
DOCTORS LAFFERTY & PHILLIPS
Radiology
HARVEY P. BARRET, M.D.
Pathology
CLINIC
answer, call 3-2621)
General Medicine
412 North Church Straet
LUCIUS G. GAGE, M.D.
Diagnosis
G. D. McGregor, m.d.
Neurology
LUTHER W. KELLY, M.D.
Cardio-Respiratory Diseases
J. R. ADAMS, M.D.
Diseases op Intants & Children
W. B. MAYER, M.D.
Dermatology & Syphilology
BURRUS MEMORIAL HOSPITAL, INC. High Point, N. C.
(Miss Gilbert Muse, R.N., Supt.)
General Surgery, Internal Medicine, Proctology, Ophthalmology, etc.. Diagnosis, Urology,
Pediatrics, X-Ray and Radium, Physiotherapy, Clinical Laboratories
STAFF
John T. Burrus, M.D., F.A.C.S., Chief E\'erett F. Long, M.D.
Harry L. Brockmann, M.D., F.A.C.S. ^- ^ Bonner, M.D., F.A.C.S.
Phillip W. Flacge, M.D., F.A.C.P.
S. S. Saunders, B.S., M.D.
E. A. Sumner, B.S., M.D.
L. C. TODD, M.D.
Clinical Pathology and Allergy
Office Hours:
9:00 A. M. to 1:00 P. M.
2:00 P. M. to 5:00 P. M.
and
by appointments, except Tliursday afternoon
724 to 729 Seventh Floor Professional Bldg.
Charlotte, N. C.
Phone 4392
WADE CLINIC
Wade Building
Hot Springs National Park, Arkansas
H. King Wade, M.D. Urologist
Charles S. Moss, M.D. Surgeon
J. O. Boydstone, M.D. Internal Medicine
Jack Ellis, M.D. Internal Medicine
N. B. BuRCH, M.D.
Eye, Ear, Nose & Throat
Raymond C. Turk, D.D.S. Detitist
A. W. ScHEER X-ray Technician
Miss Etta Wade Clinical Pathologist
Please Mention THI$ JOURNAL When Writing to Advertisers
PROFESSIONAL CARDS
March, 1936
INTERNAL MEDICINE
JAMIE W. DICKIE, B.S., M.D.
INTERNAL MEDICINE
DISEASES OF THE CHEST
Pine Crest Manor, Southern Pines, N. C.
STEPHEN W. DAVIS, M.D.
Diagnosis
Internal Medicine
Passive Vascular Exercises
Oxygen Therapy Service
Medical Arts Bldg. Charlotte, N. C.
JAMES M. NORTHINGTON, M.D.
Diagnosis and Treatment
in
INTERNAL MEDICINE
Professional Building Charlotte
ORTHOPEDICS
J. S. GAUL, M.D.
ALONZO MYERS, M.D.
ORTHOPEDIC SURGERY and
ORTHOPEDIC SURGERY and
FRACTURES
FRACTURES
Professional Building Charlotte
Professional Building Charlotte
HERBERT F. MUNT, M.D.
FRACTURES
ACCIDENT SURGERY and ORTHOPEDICS
Nissen Building
Winston-Salem, N. C.
EYE, EAR, NOSE AND THROAT
AMZI J. ELLINGTON, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
PHONES:
Burlington
Office 992— Residence 761
North Carolina
H. C. NEBLETT, M.D.
OCULIST
Phone 3-5852
Professional Building Charlotte
J. SIDNEY HOOD, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
PHONES; Office 1060— Residence 1230-J
3rd National Bank Bldg., Gastonia, N. C.
Please Mention THIS JOURNAL When Writing to Advertisers
March, 1936
PROFESSIONAL CARDS
NEUROLOGY and PSYCHIATRY
W. C. ASHWORTH, M.D.
W. CARDWELL, M.D.
NERVOUS AND MILD MENTAL
DISEASES
ALCOHOL AND DRUG ADDICTIONS
Glenwood Park Sanitarium, Greensboro
Urn. Ray Griffin, M.D.
Appalacliian Hall
DOCTORS GRIFFIN and GRIFFIN
NERVOUS and MENTAL DISEASES,
and ADDICTIONS
M. A. Griffin, M.D.
Asheville
UROLOGY, DERMATOLOGY and PROCTOLOGY
THE CROWELL CLINIC OF UROLOGY, DERMATOLOGY AND PROCTOLOGY
Suite 700-717 Professional Building Charlotte, N. C.
Hours— Nine to Five Telephones— 3-1Wl—i-1l02
STAFF
Andrew J. Crowell, M.D. Claude B. Squires, M.D.
Raymond Thompson, M.D. Theodore M. Davis, M.D.
Dr. Hamilton McKay Dr. Robert McKay
DOCTORS McKAY and McKAY
Practice Limited to UROLOGY and GENITO-URINARY SURGERY
Hours by Appointment
Occupying 2nd Floor Medical Arts Bldg. Charlotte
WYETT F. SIMPSON, M.D.
GENITO-URINARY DISEASES
Phone 1234
Hot Springs National Park Arkansas
C. C. MASSEY, M.D.
Diseases of the Rectum & Coloh
Professional Bldg. Charlotte
Please Mention THIS JOURNAL When Writino to Advertisers
PROFESSIONAL CARDS
March, 1936
SURGERY
G. CARLYLE COOKE, M.D.
GEO. W. HOLMES, M.D.
R. B. Mcknight, m.d.
Diagnosis, General Surgery and X-Ray
General Surgery
Nissen Bldg. Winston-Salem, N. C.
Professional Bldg. Charlotte
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 will be rendered on terms comparing favorably with those
charged generally in other Sections of the Country — taking into consideration the
prices paid for cotton and tobacco.
SOUTHERN MEDICINE & SURGERY.
Please Mention THIS JOURNAL When Writing to Advertisers
Journal
of
SOUTHERN MEDICINE ^ SURGERY
Vol. XCVIII
Charlotte, N. C, April, 1936
No. 4
Kh^y^Xts^
What Life Teaches the Doctor
E. J. G. Beardsley, M.D., Philadelphia
Clinical Professor of Medicine, the Jefferson Medical College
MR. PRESIDENT and Members of the
Tri-State Medical Association: In a brief
but happy acquaintance with members of
this association, life has taught one doctor that he
could have been happy and content had kind fate
and fortune established his professional life in this
delightful section. The term, Southern hospitality,
is so familiar and expressive that it is traditional
that visitors to this friendly region, forever after,
insist upon hyphenating those two memory-evok-
ing words. It has been an unalloyed pleasure to
be your guest, to enjoy the privilege of the contacts
with your members and to witness your association
at work.
Had I known, Mr. President, the members of
your association at the time I selected the title of
my proposed presentation, as I feel I know them
now, the subject chosen would have been a very
different and a much more appropriate one for your
fortunate group. One learns in conversing with
your members that they possess an attitude of
mind regarding their profession that is both re-
freshing and truly inspiring. The patient, in this
friendly land, is considered to be more important
and more interesting than is the disease process
and he or she is given an amount of consideration
and attention, as an individual, that is, all too fre-
quen ly, thought unnecessary in circles designated,
ultra-scientific. It would be strange indeed if pro-
fessional men from Virginia and the Carolinas did
not believe in heredity but it is most gratifying to
note that familial tendencies and traits are looked
upon, as they should be, as a most important fac-
tor in determining matters of health and, all too
frequently, of bringing about certain types of de-
generative diseases. To visit a community in which
the physician takes time to get acquainted with the
patient and does not attempt to convince himself
that laboratory studies, important as such studies
•Presented liv Invitation to t
South Caiolina, February 17th
frequently are, can replace an intimate study of
the patient's personality is a unique experience in
one teacher's life. If one may judge from the
human and humane approach that your members
adopt in their scientific papers and, similarly, by
the broad-gauge philosophy expressed or suggested
by the character of the friendly but critical dis-
cussions of the subject-matter presented, one can
not fail to be impressed with the realization that
the members of this fortunate association practice
the type of helpful and practical medicine that it
was in my heart to preach.
It is to be remembered, unfortunately, that all
sections of our country are not so fortunate. There
are areas where there has been and continues to
be over-emphasis on the Science of medicine, and,
if I am correct in my estimate concerning relative
values, a lamentable underestimation of the poten-
tial and actual value to the patient of the Art of
medicine in everyday practice. We are all proud
of the scientific advances that are so wonderfully
helpful in modern medicine but it will prove useful
if we stop to question whether all changes are, in
reality, in the best interest of the patient and the
patient's family.
It is to be remembered that the art was under-
stood, appreciated and helpfully used for centuries
before the beginnings of the science and it is, in my
opinion, even more important at the present time
that we be not deluded into a belief that science
can replace the value of sound common sense in
everyday medical problems. It is obvious that the
art of medicine must, of necessity, be based upon
a thorough knowledge of the infinite varieties of
individuals illustrating what we term human nature.
Those who would attempt to mechanize the prac-
tice of medicine, to standardize patients and phy-
sicians alike, fail to take into consideration the
fact that nature never produces two individuals in
WHAT LIFE TEACHES THE DOCTOR— Beardsley
April 1936
all respects similar; nor do two patients react to
life, to stress, or to disease in exactly the same
manner.
It is an interesting and somewhat astonishing
fact that the most important single factor influenc-
ing a physician's success and usefulness, namely,
his understanding of human nature, finds little em-
phasis or practical support in the curricula of med-
ical schools.
The faculties of extremely few medical colleges
include a psychologist, and students of the healing
art discover little official encouragement for a
serious and intimate study of a patient's personal-
ity.
Sound reason indicates that the best and most
efficient method of studying human nature is for
the student, undergraduate or graduate, to bagin a
serious investigation and study of the unit that
one is, of necessity, most familiar with, namely,
him- or herself.
To attempt to understand the nature or to cor-
rectly interpret the characteristics of patients, con-
cerning whom we know relatively little, when we
have not an intimate and correct understanding of
our own natures, traits and tendencies, is evidence
of an unsound philosophy of life. Nearly two
hundred years ago the great French philosopher
Rousseau expressed his conviction that "the most
useful and least advanced of human knowledge
seems to be that of man himself." Can we say
with truth that we physicians have advanced in
understanding of human nature to the extent that
our almost unlimited opportunities have made pos-
sible in the period that has elapsed since Rousseau's
writings were published?
We have, I fear, been content to learn more and
more about disease and, becoming so engrossed in
this phase or accident of human life, we have, per-
haps, neglected that which is frequently much more
important and fundamental, namely, a sympathetic
and thorough understanding of the human being
whose disease causes him to seek our aid.
To understand a doctor's view of life one must,
of necessity, know something of the doctor as an
individual; and to understand any patient — man,
woman or child — one must know, or at least be
able to surmise, much concerning the patient's per-
sonality in health.
That hereditary influence is, in both physician
and patient, the most important single influence
in an individual life is undoubted: but environ-
mental conditions exert a great, though less vital,
influence. The physician is influenced, consciously
and subconsciously, by the history and ideals of
the medical profession. Medicine is fortunate in
possessing a background of sixty centuries of writ-
ten history. Each year's research by archeologists.
paleontologists, biologists and historians increases
and clarifies the understanding of man's past and
illuminates his relationship to his physician.
A survey of the medical-literary riches now
available serves to emphasize anew the statement
made in 1927 by George Sarton, the eminent his-
torian of science at Harvard, that "the acquisi-
tion and systematization of positive knowledge is
the only human activity which is truly cumulative
and progressive."
We physicians cannot, with justice, assume that
we are more intelligent than were our medical an-
cestors. Authorities who are in a position to know
the unbiased and unflattering truth assure us that
although we may seem more intelligent to ourselves
this is simply because we, as Claude Bernard so
wisely pointed out, "are standing upon the intel-
lectual shoulders of those progressive medical giants
of bygone days and, because of the help they give
us we can see a little clearer than they were able
to do."
The physician who possesses wisdom, and the
physician who wishes to acquire it, studies life in
all its manifestations; and, if he is not medically
myopic, he studies the evidences and minor varia-
tions of health with as great interest as he does the
signs and symptoms of disease.
What individual, other than the physician, is in
a position to make an understanding and intimate
study of human beings in health and in sickness?
Does not the doctor hear the first wailing, protest-
ing cry of the babe in its new and strange environ-
ment? Does he not study, with unbiased interest,
the characteristics of infants, children, adolescents,
adults, senescents and the senile, sick and well?;
and, at last, does he not stoop to hear the last
sighing respiration of the world-weary patient
whose race is finished?
Our beloved Osier describe well the ideals of
the medical profession when he stated, "The prac-
tice of medicine is an art, not a trade, a calling,
not a business: a calling in which your heart will
be exercised equally with your head. Often the
best part of your work will have nothing to do with
potions and powders, but with the exercise of an
influence of the strong upon the weak, of the right-
eous upon the wicked, of the wise upon the foolish.
To you, as the trusted family counsellor, the father
will come with his anxieties, the mother with her
hidden griefs, the daughter with her trials and the
son with his follies.''
It is not strange that the medical profession,
each member of which has in his heart Osier's
ideal, even if he, at times, fall far short of this
high standard, should be entrusted with the world's
greatest treasure — the health and -life and, common-
ly, the earthly happiness of individuals. Doctors
April, 1036
fVHAT LIFE TEACHES THE DOCTOR— Beardslcy
have their share of human faults. They always
will until they are fathered and mothered and an-
cestored all the way back by beings free from
human weaknesses; but even with his faults a phy-
sician with a helpful imagination and a sound
philosophy leads a life full of interest to himself
and helpfulness to others.
A true physician tries to place himself, mentally,
in the position of the patient. He has learned,
through the experience of generations of sons of
Aesculapius that the Golden Rule has never been
e.xcelled as a guide for physician and patient alike.
The physician knows, too, that character in a
member of the medical profession is much more
'mpcrtant that is brilliance of intellect without it.
It is wise for each of us to pause daily to con-
template why we are what we are and not some-
thing less worthy, and the realization that for what-
ever of merit we have we can claim little credit
is spiritually helpful. We are what our heredity
made us. If we inherited a favorable constitution
and temperament we d!d nothing to deserve it and
when we see a loafer, a drunkard, a human para-
site, a criminal we may well say, with John Bun-
van, "But for the Grace of God (and the benefit of
a good inheritance) there goes John Bunyan."
That truly great physician, Oliver Wendell
Holmes, stated with revealing truth that "Man is
an omnibus in which all his ancestors ride,'' and
it is particularly necessary that physicians remem-
ber that it is in a narrow sense only that men are
created free and equal.
If we, or our patients, have inherited poor con-
stitutions or unfortunate traits we may feel that
if we have the ability to recognize such potential
weaknesses we, also, can acquire the wisdom and
determination to conquer them and much will be
accomplished for this and future generations. It
is too often forgotten that we not only have ances-
tors but we become ancestors and, therefore, have
obligations toward the unborn generations.
Before a physician expresses great dissatisfac-
tion with the traits encountered in his patients, it
is a salutary experience to endure a dispassionate,
and unbiased self scrutiny of one's own life be-
havior.
Such an experience should not be indulged in if
one lacks a sense of humor, for the results are fre-
quently disastrous to one's self-respect. When we
encounter troublesome patients who possess obvious
faults that may be quite different than our own
particular weaknesses we must attempt to under-
stand him or her and to excuse such faults if they
are, as is usual, due to hereditary traits or to lack
of proper discipline in the patient's infancy, child-
hood and youth.
Life teaches the doctor that next in importance
to the gracious boon of fortunate heredity comes
the powerful and life-long helpful influence of an
understanding, sympathetic but firm discipline in
early life. Lack of discipline is said by authorita-
tive observers to be the most marked characteristic
of American childhood.
Can any experienced physician deny that lack
of proper discipline and its cause, selfishness, are
among the greatest of evils? For the boy or girl
not to be disciplined in youth almost surely
means that he or she will arrive at unhappiness
in later life and, worse still, cause unhappiness
to others. Selfishness is at the bottom of the love
of money and power, which is said with truth to
be the root of all evil. The divorce courts, the
criminal courts and even the International Courts
seem to exist largely because of the selfishness of
individuals. We doctors, better than any other
public servants, have the opportunities for observ-
ing selfishness and unselfishness every day of our
professional lives. We see the evils of selfishness
and what it leads to and where it is not we see
Heaven on earth.
A physician's opportunities for observing and
weighing the relative values of life are unequalled.
He encounters the nobility of natures worthy of
the highest traditions of the race, and he meets them
as frequently among the poor and unlearned as
among the cultured, the educated and those for-
tunate in this world's goods. Is it not one of life's
ironies that physicians who occupy positions to
accurately estimate the ultimate values of life and
of living all too frequently ignore the verities in
their own method of existence?
A physician must be a teacher and an exemplar
of what is best if he is to exert the greatest influ-
ence for good.
A doctor's ideals, like those of his patients, are
derived as a rule from his mother. If all the wo-
men of our land appreciated to the full the extent
of the influence that they consciously and uncon-
sciously exert they would keep their standards of
thinking and living on a high plane. . Can it be
said that our American women are happier than
they were a generation or two ago? Is it not pos-
sible that work is, for the woman as well as for
the man, a solution for most emotional and tem-
peramental difficulties? If an individual is in
health has any physician ever noted an instance
in which physical work did harm to man, woman
or child? There is much modern agitation over
what we should do with our leisure: it would be
far better to concern ourselves first that we earn
our leisure.
Does this great country of ours possess an ideal
educational system? We physicians are not trained
educators but much that we observe of schools,
WHAT LIFE TEACHES THE DOCTOR— Beardsley
April, 1936
colleges and universities causes us pause. Are the
finished products of these educational institutions
soundly educated? Are -they happier, healthier and
more useful citizens because of the higher educa-
tion that they have received? Do the teachers
whom we meet impress us as being ideal instructors
for the most precious possessions of our citizens,
namely, the next generation? One frequently meets
the noblest men and women in the teaching pro-
fession; but, unfortunately, among them one also
meets, as in other walks of life, time-servers and
indifferent characters who are a menace to the fu-
ture of their students.
What is success from a doctor's viewpoint? It is
easy to state. A man or a woman is a success if
the members of his or her family, if his or her col-
leagues and friends are happier because of his or
her presence. Life teaches the doctor that success
that is purchased by the sacrifice of one's ideals can
never be true success. The medical profession was
never intended to be a money-making profession.
We physicians are licensed by the State to preserve
the lives and health of its citizens in every way.
Properly, we are allowed to be recompensed by
the citizens for our services. It is, somehow, dis-
quieting to derive one's income from the misfor-
tunes of others: certainly it imposes a heavy obli-
gation on physicians to render honest and conscien-
tious services for the fees received.
In these troubled times, the majority of our citi-
zens find economic security difficult to obtain. All
citizens desire and even demand luxuries, while
many postpone the obtaining of the necessities of
life. No man is in as favorable a position to under-
stand the truth concerning life's problems as is the
true physician. There was, probably, never a time
when it was so essential that patients discover in
their physician a true and understanding friend.
The practice of the Golden Rule by both physician
and patient would eliminate many of the economic
difficulties of each. The physician is in a position
to teach the world the supreme values that life
holds and how they are to be obtained.
The physician's life should exemplify the ideals
that he so well understands and appreciates.
Teaching the Tuberculosis Patient
(H. E. Kleinschmidt, in Tuberculosis Abstracts, llarcli)
What the tuberculous patient should be taught: (1) a
way of life, (2) an understanding of tuberculosis, partic-
ularly his tuberculosis, and, (3) knowledge of how to pro-
tect others.
The essence of the cure (for most cases at least) consists
in learning a new way of life. While the tubercle bacillus
is the sole, direct cause of the disease, environment (in its
broad sense) tips the scale in favor of, or against, the
infected person. Of the many people who are invaded by
bacillus tuberculosis, only those few whose mode of life or
environment or attitudes (again in a broad sense) violate
nature's demands, are most likely to develop the disease.
.And if, after arrest of the disease has been achieved, the
patient returns to his old ways and attitudes, he is, almost
surely doomed to relapse. It is essential, therefore, to
make a diagnosis of the patient's habits of living and
thinking. Mental attitude perhaps comes first, for hope,
cheerfulness and confidence are the patient's staunchest
allies, and depression of spirits his cruelest enemy. How-
ever, cheerfulness that is put on like a top coat or like a
cosmetic will not outlast the grueling experience of the
cure with its many ups and downs. Unless well grounded
in a sound philosophy of life, hope is likely to give way
to deeper despair. Self-deception is not called for. Indeed
for most patients the only tenable policy is to face frankly
the fact that an unwelcome guest has established headquar-
ters in his lungs and that for the rest of his life he must
effect a truce with th^ invader, the terms of which call
upon the patient to surrender cherished desires for guar-
antee of bacterial peace.
Long ago Dr. LawTason Brown instituted his famous
Question Box for patients at Trudeau Sanatorium. This
was acknowledgement that patients have a right to know
the answers to their personal questions. By skillful guid-
ance and deft answers he managed in these group meetings
to teach his patients what he believed they should know,
in well-rounded form. Today every sanatorium follows
that precedent in principle at least. Our job as teachers
and trainers is to interpret the highly technical knowledge
that we have in easily understood terms. The basic facts
of tuberculosis are simple and a child can understand them,
if the teacher is competent. Carefully explain the nature
of a fresh tubercle and show how exertion may undo its
protective tendencies. Then the patient is persuaded to
elect bed rest. Since his choice is of his own volition based
on intelligence the act becomes his own and he may be
depended upon not to break training. Do not discuss the
patient's physical findings nor his complications with him,
for that leads to introspection, but encourage objective
study. Let it be with the understanding that symptoms
:ire to be regarded as red and green signal lights and not
something to worry about. The educational vehicles at
the disposal of the sanatorium are abundant: the printed
vvord, spoken word, the library, motion pictures and stere-
opticon slides. Surpassing all these methods is the personal
contact of the doctor w'ith the patient. He best knows
the time and place for imparting this or that particular bit
of information.
Furnishing a patient with a sputum cup and installing
cm incinerator may be the alpha of prophylaxis but it is
not the omega. He should learn why such scrupulous
attention is paid to sputum disposal ; also the numerous
ways in which tubercle bacilli migrate from one person to
another. He should develop automatic habits of safety.
To learn by rote that kissing, spitting, the use of common
eating utensils, etc., are forbidden is well but not enough.
Teach simply and clearly the manner in which the germ
gels from one person to another, and how it does its
dcjidly work. Give the average person an understanding
background and a few specific examples, and he will reg-
ulate his conduct to the best interests of other; and his
own good.
Every patient who leaves the sanatorium should have a
good grasp of the broad epidemiologic picture of tuber-
culosis. The graduate of a sanatorium should be a cru-
sader striking his blows in season and out of season. In
him burns an everlasting fire. There are thousands like
him. Against the cumulative effect of such force the old,
old enemy is bound sooner or later to crumble.
April, 1936
SOUTHERN MEDICINE AND SURGERY
Bacterial Vaccine Therapy*
J. T. Wolfe, M.D., Washington, District of Columbia
MEDICAL science having failed to deter-
mine the cause of the so-called common
colds and to decide upon satisfactory
treatment, it is my purpose to report results of the
use of bacterial vaccines upon thousands of cases
in treatment of colds and other infections over a
period of more than twenty years.
It is also my desire more to emphasize the com-
plications and sequelae that do not occur in respir-
atory infections where bacterial vaccines are em-
ployed than to emphasize the immediate beneficial
effects from the treatment.
Earnest students of common colds have made
exhaustive studies of the nose, throat, mouth and
bronchial secretions of patients suffering with colds
in clim.es all the way from the Arctic to the
Equator, and they claim that the secretions taken
from victims in no way differ in bacterial flora
from the secretions of healthy individuals. They
have also made e.xtensive studies to determine
whether colds are caused by bacteria or by a filter-
able virus and have not been able to arrive at any
positive conclusion.
It is well to recognize the fact that no matter
how extensively laboratory experiments may be
conducted, unless they can be reduced to clinical
benefit in treatment of humans, they are of little
value.
In the meantime, innumerable victims still con-
tinue to have recurring colds, a large majority of
whom use various nostrums because the medical
profession does not offer them anything better. This
statement I make justifiably because recently an
investigator from one of our largest medical centers
concluded his talk on the common cold by the
statement that the profession does not know what
causes the cold, nor what to do for it, and that one
treatment is as good as another. It is in view
of these facts that I venture to present my findings
based upon my clinical experience in the employ-
ment of bacterial vaccines on literally thousands
of colds treated, and I might say that the conten-
tion of observers that there is no increase in the
bacterial flora in the secretions obtained from the
area of the cold does not disprove the fact that
colds may be due to invading bacteria; because
if they are so due, the causative bacteria are
buried in the tissues of the nose, throat and
bronchial tubes and therefore are not available for
counting or study. It can readily be understood
that bacteria floating on the surface of the mucous
membrane are harmless to the patient as long as
they remain floating in the secretions and that they
cannot produce the inflammation and increased se-
cretions accompanying the cold till they actually
invade the tissues. It has been my observation
that exhaustion and fatigue are the greatest pre-
disposing factors in the production of colds. Ex-
haustion may be built up over a long period of
years; fatigue by prolonged hours of duty, work or
exposure. In both there occurs a lowering of body
resistance, with resulting greater susceptibility to
an invading infection. In this sense the cold may
be considered a fatigue reaction. Shock, either
mental or physical, may predispose to a cold. After
all, it is immaterial whether the cold is caused by
bacteria or by a filterable virus, if we find that it
is responsive to treatment by bacterial vaccines,
for what the patient wants is relief from his dis-
ease. The use of bacterial vaccines does not pre-
clude the employment of other valuable aids to
recovery, such as rest, gargles, nasal and throat
applications, etc.
It has been my observation that the ordinary
head or bronchial cold does not cause a fever, and
that, when there is a rise of temperature and pulse
rate, it can be presumed that influenza is com-
plicating the cold and rest in bed is indicated as
well as treatment and medication.
The cure of the immediate cold is not so import-
ant as the prevention of complications and sequelae
of the cold, for never to my knowledge has a cold
that was treated by bacterial vaccines been followed
by any involvement of the accessory nasal sinuses
requiring opening or drainage, and never was one
followed by otitis media or mastoiditis; though I
have seen numerous cases with redness of the ear
drum accompanied by pain in the ear rapidly sub-
side following the use of vaccine. Also secondary
pleurisy, empyema, and pneumonia have not devel-
oped as sequelae.
Upper respiratory symptoms and bronchitis ac-
companying measles are greatly ameliorated by
vaccines as described, and no complications have
ever developed or sequelae followed a case of
measles that I have so treated. Likewise, no pneu-
monia has developed in influenza where the vaccine
was used promptly at the onset of bronchitis. And
here I wish to give my impression that influenza
is a systemic disease, not necessarily accompanied
•Presented to the Tri-State Medical Association of the CTiroIinas and Virginia, meeting: at Columbia, South Caro-
lina, February 17th and 18th.
BACTERIAL VACCINE THERAPY— Wolfe
April, 1936
by any respiratory symptoms, as I have seen cases
with flushing of the face, purplish-pink injection of
the eyes resembling iritis, generalized pains, fever
usually 102, with pulse about 120 with no signs
of cold whatever. Of course, in this type of in-
fluenza no vaccine is indicated for it is best em-
ployed when respiratory symptoms are present.
After influenza pneumonia has developed,
pneumococcus and streptococcus vaccine have a
remarkably beneficial effect and may be given ac-
cording to the need of the patient, who, if possessing
a high reaction, will show a brilliant red, sharply
circumscribed zone following inoculation that will
peel after several days. On the other hand, if the
patient has a low reaction with a sluggish pale
pink zone, inoculations may be given as frequently
as twice daily. If this treatment is enforced
promptly after the onset of pneumonia, it has been
my experience that, under anything like normal
conditions of care of a patient so ill, prompt im-
provement will occur. Of course, it must be under-
stood that vaccine therapy does not supplant the
practice of medicine upon these cases and that any
treatment beneficial to the patient without vaccine
must still be used.
An interesting observation has been that a
patient who showed such a sharply defined, brilliant
red reaction when suffering with influenza pneu-
monia would later, when treated for a bronchial
cold with the same vaccine, show a pale red zone
fading out into the adjacent skin.
By pneumonia I mean that the symptoms must
be radically changed from those of the ordinary
influenza with bronchitis and must show rapid res-
piration — from 26 to 60; rapid pulse — around 140;
temperature usually 103^ to^ 105 and with definite
sharp respiratory note usually at the lower angle
of the left scapula.
Many cases of rapid rise of temperature and
pulse rate with developing respiratory symptoms
following a serious trauma have been checked by
the prompt administration of streptococcus and
pneumococcus vaccine, and prevented from pro-
gressing into traumatic pneumonia.
Many cases with acute tonsillitis, running fever
up to lOZyi, with a pulse of 120 to 130, have walk-
ed into my office and been given an inoculation of
the bacterial vaccine and sent home to bed; and
upon my visiting them the next day would be
found normal or nearly so and ready to return to
work on the third or fourth day. On the other hand,
if tonsillitis is allowed to run for several days it
cannot be broken up so promptly, though in no
case of longer duration have I ever had an extension
to the middle ear or mastoid after the patient was
placed on the bacterial vaccine treatment, provid-
ing the extension had not already occurred.
Chronic bronchitis of as long as 52 years dura-
tion has responded to persistent treatment, which
may be required three times weekly for nine months
to a year.
Bronchial asthma caused by acute or chronic
respiratory infections, which irritate any of the
portals to the vagus nervous system is likewise re-
sponsive to bacterial vaccine treatment, and the
asthmatic seizures discontinue after the successful
removal of the infection which has caused the in-
flammation that acted as an irritating stimulation
to the vagus sensory end fibres to bring about
bronchospasm, as described in my paper of 1934. ^
We have long recognized the value of bacterial
vaccines in certain fields for both prophylactic and
curative purposes for it has been an established
therapeutic measure for years to use smallpox vac-
cines, typhoid vaccines, furunculosis vaccines and
gonorrheal vaccines: smallpox and typhoid for im-
munization; furunculosis for treatment of boils;
and gonorrheal vaccines for specific treatment of
gonorrheal arthritis, but it still remains for the
profession to recognize the invaluable further uses
to which they can be put.
Regarding prophylaxis, it is well to state that
no bacterial vaccine can produce immunity to a
dissease, unless an attack of the disease caused by
the type of bacteria from which the vaccine is
made leaves antibodies in the patient to resist a
later invasion by the same microorganism: these
are few — smallpox, typhoid, anthrax, etc.; while,
on the other hand, one cold predisposes to more
cold, so it cannot be expected that any bacterial
vaccine will immunize against colds, as a patient
can catch repeated fresh colds while under bacte-
rial vaccine treatment for a tenacious cold. Like-
wise pneumonia vaccines do not immunize serologi-
cally.
It is the belief of the writer that serological im-
munity plays only a small part in the increased
resistance developed by patients under bacterial
vaccine treatment for colds, and that the greatest
benefit comes from the actual stimulation of the
phagocytes and the tissue cells. We must certainly
accept the fact that there is interchange of the fluid
contents of the invading bacterium and of the hu-
man host because of the difference in the chemical
nature of the fluid in the bacterium and in the fluid
of the normal host. Osmosis alone could accom-
plish this interchange and, because of this fact,
there is probably a serological change on the part
of the host, at least for the time of the invasion,
which may in a small degree assist toward recovery.
Patients with recurring tonsillitis, subject to attacks
every winter, seem to generate more immunity from
this treatment than patients with other throat in-
fections, for I have a number of patients who have
April, 1936
BACTERIAL VACCINE THERAPY— Wolfe
gone ten years or longer without attacks of ton-
sillitis after treatment.
Some patients have exceedingly low resistance
to cold and so have some families, and while treat-
ing a patient in such a family he will light up a
fresh cold even while under treatment, and it may
take a year or two to get this particular case in
the condition where he will catch only one mild cold
eac:h winter.
My purpose is not to discuss the physiologic
reactions to bacterial vaccine treatment but to give
the results of clinical experience; and there is need
for more clinical study and observation and for less
attention to the extensive laboratory research on
so many of our patients. Our position might be
likened to that of an engineer, who in his studies
has worked out vast calculations to arrive at math-
ematical formulae which he accepts and applies to
the solution of problems as they present them-
selves : but our practice is rather to evolve anew the
formula to apply on each patient. Our clinical
knowledge and experience should be so broad that
we can proceed with treatment of the patient with-
out subjecting him to all the laboratory tests that
can be performed upon him, and thus in probably
90% of our work get quick results to benefit
him and prevent further advancement of his
disease while waiting for the technician's report.
This latter group is exemplified by our practice of
administering diphtheria antitoxin in suspected
cases before getting a report on the throat culture.
It will be only on a small percentage of patients
that treatment based on good clinical judgment will
fail; and on whom laboratory work will be re-
quired during treatment for a more accurate diag-
nosis than is possible by clinical study.
Reason for employing bacterial vaccines can
best be given as expressed in my paper entitled
"Etiology, Mechanism, and Treatment of Asthma"^
published in American Medicine, October 1934, a
sentence of which reads as follows: "This was done
because I had heard Dr. Wright of England, pioneer
in vaccine therapy, deliver a lecture at the old
George Washington University Administration
Building while I was a medical student and because
of the fact I had absorbed the fundamental idea of
increasing resistance by the injection of killed
bacteria." This increased resistance may be frac-
tionally serological, but it is my belief that the
sudden injection of a suspension of killed bacteria
. causes a stimulation of the phagocytic leucocytes
with resulting increased activity, thereby develop-
ing a better defence army against infection. For
this purpose naturally I selected organisms against
which the normal human body produces the highest
leucocytic reaction when it becomes invaded by
them, namely, streptococcus and pneumococcus.
Here it is well to state that a person with very low
resistance is unable to react against any invading
bacterium, and therefore the use of bacterial vac-
cine is less effective. From these statements it can
be seen that I rejected all specificity except where
the bacterium has the power of provoking the pro-
duction of immune bodies by the invaded host.
We are confronted with an organism that
must play a dual role, for it has the faculty
of causing inflammations in the throat, tonsils etc.,
which are not followed by serological immunity. On
the other hand, it can produce manifestations which
are followed by serological immunity. I refer to
the streptococcus, which, among its various affini-
ties and manifestations, can produce such a specific
disease as scarlet fever which causes to be left in
its wake immune bodies to prevent further attacks
of this disease.
It was my observation over a period of years
that no child developed scarlet fever whom I had
treated for colds with streptococcus and pneumo-
coccus vaccines, and as far back as 1920 I injected
for prophylactic purpose children who had been ex-
posed to scarlet fever and none of them developed
the disease. About 1923 I was called to see a child
eight years old, ill with scarlet fever, and who,
after running a temperature from 104 to lOS for
a week with extensively coated tongue and mouth
was in a state of stupor verging on coma. Real-
izing the desperate illness of the patient, I suggest-
ed to the father that bacterial vaccine might help.
He told me to do anything to save her. She was
given one dose of the combined streptococcus and
pneumococcus vaccine and in 24 hours her tem-
perature was normal, she was awake taking nour-
ishment and the coating disappearing from her
tongue. This fact so impressed me that I looked
through the literature and found reference in
Sajous' Analytic Cyclopedia of Practical Medicine,
published in 1919, to the work of Russian phy-
sicians as early as 1907 in the use of strepto-
coccus vaccine with beneficial effect against scarlet
fever, and also the statement by Smith- that
American physicians should follow up this work
to prove or disprove the truth of their claims. Wat-
ters^ was also quoted in the same work from an
article in 1912, that in 700 cases he concluded that
the vaccine had decided prophylactic effect against
scarlet fever. These references confirmed my own
observations in a very limited field.
In 1934 I was called to see a child 6 years old,
with a typical strawberry tongue, acute sore throat,
beginning otitis media, fever and vomiting. These
constituted typical symptoms of onset of scarlet
fever. I told the parents my former experience and
they readily consented to the injection of strepto-
coccus vaccine, which was given, with a result just
BACTERIAL VACCINE THERAPY— Wolfe
April, 1936
as spectacular as in the former case, though for
several weeks traces could be seen of the fading
strawberry marliing on her tongue.
A remarlcable case was that of a young man
in 1922, who, while feeding a squirrel in a public
park was bitten on his finger by the squirrel. When
he came to my office about three hours after the
accident he had an erysipelas-like rash covering
his entire hand end e.xtending up his wrist, termi-
nating with a definite, abrupt line of demarcation.
This was one of the fastest spreading infections I
have ever witnessed. He was given streptococcus
vaccine with the sudden and complete cessation of
advance of the inflammation. The next morning he
was given a second injection as the hand was still
very red, but no farther advance of inflammation
was in evidence. The evening of the second day the
third inoculation was given, after which the red-
ness began to fade and by the following day was
rapidly disappearing. This case was spectacular in
that the control effect of the vaccine could be
watched. Patient made rapid recovery.
Furunculosis has responded very satisfactorily to
staphylococcus vaccine. One interesting case was
that of a graduate nurse who had crops of boils in
both axillae. She brought me a vial of bacterial
vaccine made from the discharge of her own boils
and she responded promptly and satisfactorily to
treatment with the vaccine and only one third of
the vial was consumed. In a few days a man came
in with boils in both axillae. He just as promptly
and satisfactorily responded to treatment with the
nurse's autogenous vaccine. Scarcely had I com-
pleted this case when a second man came in making
the third patient within a few weeks, and he also
responded equally well to the nurse's vaccine. This
group of cases shows that results in vaccine therapy
do not depend on autogenicity of vaccines. In
many instances the use of the patient's autogenous
vaccine has been discontinued and the patient put
on a stock vaccine with better results than with his
autogenous. This change was made with the idea
of injecting a foreign bacterium with which the
patient was not on such friendly terms as with his
own flora.
I have never obtained beneficial results in acne
vulgaris from the use of bacterial vaccines.
Infections of traumatic and gunshot wounds have
been prevented from farther progress, giving an
opportunity for healing. One case of gunshot
wound in the forearm, with shattered bones and
generalized suppuration of the arm, in a patient
who showed 4-plus Wassermann was benefited by
streptococcus and staphylococcus vaccine and his
arm saved, though several surgeons had advised
amputation.
Arterial hj^ertension has responded to colon
bacillus vaccines satisfactorily in a high percentage
of cases and they were given because of the belief
that intestinal or colon toxemia is a large factor
in stimulating the vascular system to bring about
constriction of the arteriole muscles to produce in-
creased tension. In some of these cases very sat-
isfactory reduction of pressure has been obtained,
even in the presence of 4-plus Wassermann. In
this therapeutic application I admit specificity.
General improvement in health occurs, following
colon vaccine therapy.
All vaccines are preserved in tricresol solution
and dosage and administration are to be determined
for each individual, and any contention that the
bacteriologists have made that the reaction has been
due to the tricresol is not well founded because of
the varying intensity of reactions in different pa-
tients. In fact a month-old baby can take, in
many instances, a larger dose than some adults who
react vigorously. The number of killed organisms
for individual dosage varies from one fourth of a
billion to three or four billion. Both hemolytic
and non-hemolytic streptococci and four types of
pneumococci are used. Only gold needles of 23
or 24 gauge are used because tricresol corrodes
steel or rustless steel and these needles and syringes
are kept sterile in the Sherman type container
equipped with lamb's wool saturated with weak
solution of phenol in alcohol. Injections are given
subcutaneously in arm.
Dosage ranges from twice daily to intervals of
three days, depending upon the reaction and need
of the patient; and the local reaction should be at
least 2 to 3 inches in diameter. The patient with
an active red reaction at the site of inoculation
usually shows a more prompt recovery than the pa-
tient with the sluggish reaction. In advanced
tuberculosis no reaction appears at the site of in-
oculation, which fact I feel is due to the extremely
low vital force of the patient and to his inability to
react against any bacterial invasion.
In a paper of this length, it is impossible to dis-
cuss all the phases of bacterial vaccine treatment,
but the following list of diseases may be treated
with benefit: Head colds: acute and chronic
pharyngitis; follicular tonsillitis; acute otitis
media without suppuration; acute laryngitis;
tracheitis; acute and chronic bronchitis; influenza
pneumonia, and lobar pneumonia during first 24
to 36 hours after onset: infections following bites
by animals, etc.; chronic discharging ears; acute
and catarrhal inflammation of eustachian tubes
with resulting deafness; acute and chronic eczema;
gonorrheal arthritis: infected nasal accessory sinu-
ses without suppuration; bronchitis in measles;
scarlet fever; pleurisy without empyema; whoop-
ing cough; hayfever; bronchial asthma caused by
April, 1936
BACTERIAL VACCINE THERAPY— Wolfe
18S
respiratory infections: and pneumonia following
trauma.
A very large percentage of cases that come in
for bacterial vaccine treatment are those suffering
from fresh colds, and one thing can be counted
upon, and that is after a victim of recurring colds
has once obtained relief and is able to withstand
greater stress and exposure without bringing on a
cold, at the first indication of one, he will come
back for what he terms his "shot."
References
1. Wolfe, J. T.: Etiology, Mechanism and Treatment of
Asthma. Ant. Med., Oct., 1934.
2. Sjiuth: Bostoti Med. & Surg. JL, Feb. 24th, 1910.
3. Waiters: //. Am. M. A., Lvm, 546, 1912.
Discussion
Dr. M. R. Gibson, Raleigh:
Dr. Wolfe has given us a well prepared, thorough paper
on vaccine therapy, and I am glad to open the discussion.
Being especially interested in the treatment of asthma,
and having found vaccines beneficial in treatment of in-
fections found in asthma, I will confine my discussion to
this phase of his paper. He mentioned that bronchial
asthma which is caused by respiratory infections is re-
sponsive to vaccine therapy.
The treatment of bronchial asthma is difficult because
of its complex and varied causation. The fundamental
condition seems to be an unduly sensitive bronchomotor
mechanism, and spasmodic conditions of the bronchioles
can be induced by a large number of exciting agents.
The July, 1929, issue of The Practitioner was a special
asthma number. It dealt with the psychological and reflex
aspects, with nasal abnormalities; with climatic factors,
with tissue damage, with toxins and with asthma as a
vasomotor neurosis. Each contributor recommended his
own methods of treatment, based on his beUef as to eti-
ology, and all claimed good results.
One must keep in mind, therefore, in his consideration
of bronchial asthma the effects which psychic, endocrine,
nasal, toxic, dietary and environmental factors may have
on the production of an attack. A person may become
asthmatic when he has a cold because of his general low-
ered resistance and the lowered resistance of the mucous
membranes of the respiratory tract. Or, if there have
been repeated respiratory infections with resulting path-
ology, a sensitive area is produced, which will react to
the specific agent producing the asthma ; or engorged tissues
may press on a certain area of the nose and produce reflex
bronchospasm, which may then initiate an attack.
Part of the treatment of such cases, certainly, would be
to remove the cause of infection or to lessen its recurrence
as well as to insure proper drainage and free ventilation.
Again, certain of the gram-negative bacilli (among them
B. Friedkmder, Hemophilus injhienzae, and B. proteus),
during growth, produce histamine-lLke substances and in
asthmatics they represent a secondary infection capable
of increasing bronchiolar constriction in subjects whose
bronchi are already in a state in which further stimulation
will produce bronchospasm.
It would appear, then, that a bronchitis, caused partly
or wholly by these gram-negative bacilli, would be partic-
ularly troublesome to asthmatics.
Walker (Arch. Int. Med., 43:429, 1929) found that fol-
lowing the administration of a vaccine consisting of the
more prevalent streptococci, 59% of those patients who
were very susceptible to colds and to asthma associated
with colds obtained freedom or comparative freedom from
colds and asthma. In another 39%, the frequency of
colds and asthmatic colds was reduced SO or 75%. In the
remaining 5% there was no benefit.
Benson (Ann. Int. Med., 6:1136, 1932), culturing spu-
tum from asthmatic cases and in particular Curschmann
spirals, found in the order of frequency Streptococcus
viridans, hemolytic streptococcus, nonhemolytic strepto-
coccus, Staphylococcus aureus, pneumococcus, and others of
less importance. He also considers that the intestinal
flora is of significance in these cases.
Wilmer and Cobe (//. Allergy, 4:414, 1932-1933) cul-
tured the sputa of 500 asthmatic patients and found bac-
teria in the following predominance: streptococci. Micro-
coccus catarrlialis, pneumococci, and staphylococci. Nasal
smears of 222 asthmatic patients with nasal or sinus infec-
tions showed the incidence of bacteria in the following
order: staphylococci, streptococci, diphtheroids, and pneu-
mococci.
Bacteria, it must be conceded, are direct and primary
etiologic components in man's environment that precipitate
an asthmatic reaction in a sensitive person.
"There can be no reasonable doubt," says Benson, "that
bacterial infection may, by its mere presence in the bron-
chial tree, cause irritation of the vagus nerve endings or
bronchial musculature directly and thus furnish the modus
operandi of the bronchospasm and attendant exudation and
asthma."
Bacterial vaccines or antigens have been used in the
treatment of bronchial asthma for many years. There i;
a considerable difference of opinion regarding their efficacy,
as would be expected in a condition in which the primary
agents are so varied and the contributory elements of
such tremendous importance. It is claimed by some that
vaccine treatment in asthma is nothing more than foreign
protein shock therapy, while others claim a definite specific
action.
Voorsanger and Firestone (California & West. Med., 31:
336, 1929) treated 66 cases of asthma with vaccines. They
classified 63.6% as well and improved, and 36.4% as un-
improved. Failure of treatment was the result of struc-
tural changes in the lung parenchyma or an associated
myocardial lesion.
George Piness, discussing this paper, says that since the
influenza epidemic of 1918 he has seen a great many cases
of asthma. It is apparently a very common sequela to
influenza and other acute infectious respiratory diseases.
He did not get such a high percentage of good results.
Wilmer and Miller (M. Clin. North America, July, 1934,
p. 133).
The treatment of bronchial asthma is individual in every
case. There is no routine method of therapy.
The patient often furnishes a story of an attack of severe
coryza, influenza, bronchitis, pneumonia, or other acute
infectious disease preceding the first attack of asthma. The
practitioner is called upon to treat the bacterial asthmatic
more often than any other type of case, because it is so
often a secondary factor in patients with a hypersensitive-
ness to other substances.
Stock and autogenous vaccines both have more to rec-
ommend them from the nonspecific protein standpoint than
for any other reason ; but if a true specificity is encoun-
tered, as it is in certain cases, the results are remarkable.
Wilmer and Cobe (Jl. Allergy, 4:414, 1932-1933) say
that the question of the value of vaccine therapy in the
treatment of bronchial asthma has been the subject of
much controversy. The actual status of vaccine therapy,
in general, ranges today from utter condemnation by one
186
BACTERIAL VACCINE THERAPY— Wolfe
April, 1Q36
group of internists to complete dependence by another
class.
They say that the use of stock vaccines has often given
very satisfactory results.
Beaver (Southwestern Med., April, 1935) gave whooping
cough vaccine as a prophylactic measure to a number of
children. Among the children thus treated was a boy,
eight years of age, who suffered frequent attacks of bron-
chial asthma since he was about a year of age. The
mother noticed that this boy did not have any trouble
throughout the six weeks he took the vaccine. Four other
patients were treated in the same way, with the same re-
sults; namely, a total absence of asthmatic attacks as long
as the vaccine was administered (0.2S c.c. gradually in-
creased to 1 c.c.) After withdrawal of the vaccine the
attacks recurred (permanent pathology?)
I. Chandler Walker (//. Lab. & Clin. Med., March,
1931, 16:539, 1931) refers to his other numerous pubhca-
tions and says that a mixed vaccine, comprising the more
prevalent varieties of streptococci, for a given period has
considerable value as a curative and still more value as a
preventive in chest colds and asthma.
The results of treatment in all of the 89 patients pre-
sented in the present paper are against any nonspecific
effect of vaccines and, to the contrary, support specificity.
In many instances, vaccine treatment was undoubtedly
specific.
Banks and Beasley (//. Indiana M. A., 27:151, 1934),
writing on the use of autogenous vaccines in the treatment
of bronchial asthma, had good results in 80% of cases.
Havaky (M. Clin. North America, July, 1933) studied
409 cases of bronchial asthma. In 19%, there was infec-
tion of the sinuses and lungs following winter colds; in
28%, infection of the respiratory tract.
Given a chronic focus of infection, the subsequent clini-
cal phenomena will evolve in accordance with the clinical
make-up of the patient and the nature of the shock tissues
affected, whether confined to special cellular, humoral, or
vegetative nervous system. Thus, when the shock tissue
is in the lung, the effect of bacterial hypersensitiveness
may take the form of a characteristic asthmatic attack.
If it is in the skin, it may appear as urticaria, eczema, or
angioneurotic edema; in the joints, as arthritis.
Mitchell and Cooper (Arch. Pediat., Dec, 1931, 48:751).
Their own results and a review of the literature make
it appear that a certain number of children, whose asth-
matic attacks are associated with upper respiratory tract
infections, are decidedly benefited by vaccines; and in
some instances, attacks, which have been previously fre-
quent and severe, cease for months and years after treat-
ment. Vaccines may be helpful when other methods have
failed.
Rackemann and Scully (New England Jl. Med., Aug.
16th, 1928) used vaccines in the treatment of 346 cases
with asthma. Of the 307 adults, the results were good in
74% and poor in 26%. In the 39 children, the results were
good in all the cases.
In the prevention of colds, vaccines gave good results
in 68% of 101 cases. Both in asthma and colds, the results
were only temporary, but they could be reproduced by
repetition of treatment.
Stock vaccines were just as effective as autogenous vac-
cines.
Unger (South M. J., Jan., 1935).
Next to specific treatment, he values the use of a good
respiratory vaccine — stock or autogenous. He does not
believe in large doses.
Dr. Wolfe, closing:
This subject is so broad and of such universal interest
(though we would not judge so today), because there arc
so many respiratory infections, but the phase of asthma is
a tremendous study in itself. My paper in October, 1934,
published in American Medicine, New York, attempted to
delineate the portals of pick-up stimulation of the vagus
nervous system. No matter what the cause of the asthma,
we shall have a secondary bronchitis if the asthma persists
for any length of time. Then, by irritation of the mucosa,
it brings about bronchospasm.
The argument about bacteria as foreign protein might
be true; but, if so, there is a tremendous variability in
the protein substances of different bacteria, because, for
instance, the colon bacillus produces a tremendous reaction.
It brings about chills after very small doses and brings
about a tremendous area of redness on the skin, in com-
parison to other bacteria. So, if the reaction is only from
the foreign protein, there is a big difference in the activity
of the different proteins. I feel, however, it is the toxin
inclosed within the capsule of the bacterium itself that is
very active.
It is not so important to cure a cold. We all have
colds, and we get rid of them ; but I do think that such a
record, covering thousands of cases over a period of 20
years, does mean something in preventing these distressing
complications and sequelae. Years ago a leading internist
of Washington told me that I would be getting these pneu-
monias complicating influenza; that I had been lucky.
Well, I continue to remain lucky ; that is all I can say.
It is perfectly true that there is no routine treatment
for asthma, because there are at least six or seven major
portals of vagus stimulation that can bring about asthma.
The good result obtained, I think, in 76% and poor result
in 24% of adults with respiratory infections is very easily
accounted for. The inability of the patient to react, as I
brought out in my paper, is low resistance. Many, many
times I have to resort to the trick of combining colon
bacillus vaccine with the streptococcus vaccine, because a
patient gets no reaction from the latter alone. But when
I combine them I get a marked reaction. I think it is
the reaction and the stimulation from the colon bacillus
vaccine that brings about the improvement in the patient's
general condition.
Alopecia Traltmatica
(B. L. Dorsey, Los Angeles, in R. I. Med. Jl., March)
The hair is lost only on that part of the scalp supplied
with blood from the Temporal .irteries and no other part
of the body. Why the partiaUty?
Alopecia Traumatica is found in men whose skull is
broadest over the temporal bones. Here the temporal
arteries pass over the bulging bones in such a course that
a hat cannot help compressing them to a dangerous de-
gree.
Dissection of the temporal veins and arteries in a bald
head will reveal that the veins and arteries have been
injured by the hatband pressure and the lumen diminish-
ed, distorted and the walls contracted. Veins above this
point are fouttd enlarged and arteries diminished in size.
It is not possible to restore the hair of which the roots
are destroyed. To protect the hair still remaining, remove
the cause of the baldness by preventing the slightest pres-
sure over the temporal region. Stretching the hat is not
sufficient as the hat will resume its former shape when
placed on the head. Medicine, internally or externally, is
useless.
There is a fortune awaiting the hat manufacturer who
may devise a type of hat slightly more convex at this
point bridging over the temporal arteries and veins to per-
mit normal circulation without perceptibly distortmg the
hat.
April, 1936
SOUTHERN MEDICINE AND SURGERY
Physiology of the Colon: Practical Considerations*
A. Stephens Graham, M.D., Richmond, Virginia
Stuart Circle Hospital
NATURE, it has been asserted, is interested
in function rather than appearance, in
physiology rather than anatomy. The
value and effectiveness of surgical measures depend
very largely upon the functional end-results ob-
tained. It is insufficient, therefore, that the sur-
geon think in terms of anatomy alone, and partic-
ularly is this true in regard to surgery of the colon.
In man the most important function of the colon
probably is that of a storehouse to accommodate
feces until it can be conveniently eliminated. The
next most important function appears to be that
of returning to the blood the water which has been
poured into the small intestine during the progress
of digestion. Impairment of this function, as in
the presence of diarrhea, leads to dehydration and
the inability of the colon to serve as a storehouse
for fecal residue. That the colon is not an indis-
pensable organ has been shown many times by
surgeons who have removed it in its entirety.
Usually after a short interval the terminal portion
of the ileum becomes adapted to the retention of
fecal matter; in fact, one of my patients even be-
came constipated and required an occasional laxa-
tive in less than three months following the estab-
lishment of an ileostomy preliminary to resection
of the colon.
A study of the physiology of the large intestine
leads one to conclude that it is a bifunctional organ
and, indeed, when one considers its embryologic
development such a conclusion is obvious. The
right half of the colon is the absorbing half, and
is comparable in function to the small bowel with
which it has a common embryologic beginning.
From the papilla of Vater approximately to the
middle of the transverse colon the large intestine
develops with the small intestine from the midgut,
and the function of this whole division is digestion
and absorption. Beyond the middle of the trans-
verse colon the large bowel is developed from the
hindgut, and its duty is one of storage. The two
halves not only differ structurally, they derive their
blood supply from different sources, the superior
mesenteric artery supplying the digestive or ab-
sorptive part of the gastrointestinal tract, the in-
ferior mesenteric the distal half. These differences
are significant in that they decidedly influence the
types of nonmalignant and malignant neoplasms of
the large bowel, the choice of operative procedure,
the prognosis and the end-results. Notwithstand-
ing the tendency to become large fungating growths,
the liquid nature of the fecal current and the great-
er diameter of the lumen in this segment prevents
obstruction by carcinomas in the right half of the
large bowel. The symptoms are chiefly due to
some perverted or inhibited physiologic function
of the mucous membrane which permits the ab-
sorption of toxins from the extensive infected sur-
face of the growth and neighboring segment of
bowel, giving rise to a characteristic profound sec-
ondary anemia. On the other hand, in the distal
segment of the large bowel carcinoma usually is
scirrhous and annular and the fecal matter of a
solid nature; and there, obstruction — chronic, sub-
acute or acute — almost invariably develops.
It is well known that the feces in the cecum and
ascending colon are liquid, in the transverse and
descending portions, more solid, and by the time it
reaches the rectum it is often in the form of in-
spissated balls. The feces of constipated persons
float, whereas if the stools are loose much of the
matter settles to the bottom of the toilet bowl.
In other words, the specific gravity of the feces is
so near that of water that the colon can be said
to float in the abdomen, and the mesentery serves
more as a guy-rope than a support. It is a njis-
take, therefore, to speak of the colon as being
weighted down with feces.
It is highly probable that some mild, long-con-
tinued and unexplained diarrheas are due to failure
of the mechanism which normally removes water
from the feces; conversely one may explain some
cases of constipation on the basis of a too efficient
such mechanism. Many experiments and consider-
able experience have shown that, besides water,
only dextrose and salt can be absorbed in appre-
ciable quantities from the greater part of the co-
lonic mucosa. For this reason the so-called
nutrient enema of eggs, beef-juice, cream, etc., has
fallen into disrepute. As is well known, when drugs
are given by rectum the amounts are generally
twice those that are effective by mouth. The fate
of glucose solution, even, administered by rectum,
is quite problematic. McNealy and Willems list
these possibilities: It may stay in situ indefinite-
ly; it may be expelled; its character may be chang-
ed by bacterial or other action; absorption in the
colon may take place; or it may pass into the small
bowel. The later is generally conceded to be the
•Presented to the Tri-State Medical Association or the
hna, February 17th and 18th.
Carolina-s and Virginia, meeting- at Columbia, South Caro-
PHYSIOLOGY OF THE COLON— Graham
April, 1936
most likely alternative if the glucose is utilized,
absorption occurring in the lower ileum.
The ease and rapidity with which solutions plac-
ed in the rectum reach the cecum and even the
ileum, as can readily be demonstrated in instances
of cecostomy, would appear to contraindicate such
a practice following operations on the colon or
ileum. There is an abundance of experimental and
clinical data (Drummond, Friedenwald and Feld-
man, Alvarez, Rolleston and Je.x-Blake, Bine and
Schmoll, and others), which clearly demonstrates
that nutrient enemas, and even simple glucose so-
lution, frequently hinder emptying of the stomach,
inhibit normal peristalsis, or, occasionally, initiate
reverse peristalsis and, eventually, vomiting of a
fecal nature. Such data, and my own observations,
have thoroughly convinced me that the rectal in-
stillation of fluids following operations on the in-
testine is unphysiologic, even dangerous. It is rare
indeed that an adequate fluid intake cannot be
maintained orally, subcutaneously, or by the intra-
venous route.
The mucous membrane of the colon appears to
be very efficient in preventing the passage of toxins
back into the circulation. One of the features that
protects the body from intestinal auto-intoxication
is the dryness of the feces in the left half of the
colon. Most of the toxic end-products of protein
digestion which have been suspected of causing
symptoms are either blocked by the mucosa of
the colon, or split up and changed during the prog-
ress through it. Some of them that do get through
are changed in the liver or during their passage
through the capillaries of the lung. It is obvious
that any material that succeeds in running the
gauntlet must trickle into the general circulation in
quantities too minute to have an effect. In many
sensitive persons the distention of the rectum with
cotton or a balloon gives rise at times to nausea,
sleepiness, mental haziness and depression. When
the distending body is fecal material the impression
of the patient is that he is being poisoned: but it
would seem obvious that the symptoms cannot be
due to absorption of toxins as they disappear almost
immediately on removal of the distending body,
Vv'hereas relief from circulating toxins would not
come until enough excretion had taken place to
lower the concentration of the poison in the blood.
No doubt intestinal auto-intoxication does occasion-
ally occur, but most students of the subject agree
that it is far more likely to be present with diarrhea
than with constipation. Indeed, it has been the
exception, in my experience, to observe symptoms
of toxic absorption in cases of chronic obstruction
produced by carcinoma of the colon, even when
obstruction had reached the stage in which flatus
alone was expelled. In these cases it has been al-
most the rule to find the blood chemistry normal.
A function of the colon about which little is
known is the excretion of heavy metals and other
substances which have been absorbed higher in the
bowel. Quite possibly some of the hypersensitive-
ness of the colon which so often occurs is due to
irritation caused by the excretion of a toxic sub-
stance, the nature of which is not yet known. Many
investigators have found various products of excre-
tion in the intestinal secretions, such as aluminum,
iron, magnesium, bismuth, calcium and phosphates.
Ulceration of the large bowel so commonly associ-
ated with mercury poisoning has led to the belief
that the metal is excreted by this route. Peola's
studies have led him to believe that sugar might
be eliminated by the colon in cases of diabetes,
thus giving rise to the diarrhea occasionally seen
in these cases.
The chief colon secretion is mucus, and it serves
as a lubricant to the feces and a protective agent
to the lining of the colon. Although it possesses
no anti-bactericidal power it probably acts as a
mechanical barrier to infection. It is noteworthy
that of the salivary glands the parotid is the only
one frequently subject to inflammation and few
mucus-producing cells are found in this structure.
In the submaxillary and sublingual glands mucus is
abundant.
The term mucous colitis has originated because
of the presence of an excess of mucus in or about
the stools. No one has ever demonstrated path-
ologic data sufficient to allow this condition prop-
erly to be called colitis. The literature on this
subject is vast and there is much difference of
opinion as to its character and etiology. The pre-
ponderance of evidence favors the view that the
condition is purely neurogenic and the mucus pro-
duced is a hypersecretion. The idea prevails —
especially among laymen, but also among some
physicians — that the colon is a constant source of
danger because of the presence of bacteria or of
toxins produced by decomposition of foods, and
that these must be responsible for many ills of
man; and it is often difficult to convince a patient
that certain intestinal disturbances could be the
result of a disordered nervous state. All of the
200 consecutive cases studied by Bargen had defi-
nite symptoms of neurosis. Often there was a his-
tory of much nervous strain, anxiety, worry, intol-
erance of the presence of crowds, excessive physical
or mental effort, introspection, insomnia, unhappi-
ness with their lot, family difficulties, excessive use
of tobacco or liquor, and dissipation in one form
or another. Nervous phenomena tended to precipi-
tate attacks of the abdominal symptoms. My ob-
servations are in full accord with those of Hurst
who has pointed out "not the slightest sign of in-
April, 1936
PHYSIOLOGY OF THE COLON— Graham
flammation is observed in the mucous membrane
of patients with so-called mucous colitis unless they
have been treated with irritating enemas."
The various types of peristaltic movement in the
colon are of considerable interest to the gastro-
enterological investigator, but the scope of this
paper will not permit their consideration in detail.
Of more practical consequence is the reflex mech-
anism generally termed appetite reflex or gastro-
colic reflex, in which the placing of food into the
empty stomach is followed by activity in the colon.
The so-called mass movements which ordinarily
precede defecation are most likely to take place
immediately after breakfast when the bowel is
most sensitive after the night's rest. As is well
known, one of the causes of constipation is the
tendency of many persons to disregard this call.
After weeks and months of such neglect the lower
colon and rectum become more than usually toler-
ant of the presence of feces, and less able to re-
spond with a defecatory reflex.
^Manj' investigators have shown that distention
of the colon delays emptying of the stomach and
gives rise to loss of appetite, nausea and even vom-
iting. Inflammatory lesions in the ileocecal region,
appendicitis for example, may produce all grades
of back pressure up to vomiting large amounts of
fluids; likewise intestinal injury such as cutting
or handling the bowel will delay the emptying time
of the stomach. It is conceivable that a protective
mechanism is present for the purpose of holding
back food until the bowel becomes healed. The
presence of formed fecal material in the rectum
will, after abdominal incision, often inhibit peris-
talsis until evacuated. This was strikingly revealed
to me several years ago at a consultation for a
patient on whom a left inguinal colostomy had
been established for a rectovesical fistula seven days
previously. A marked ileus, not associated with
symptoms of peritonitis, had existed for four days,
in spite of an opened colostomy through which a
large tube for irrigation purposes could be readily
passed. Since rectal examination was the only pro-
cedure not already carried out this was done and
the rectum found to be filled with solid residue.
In less than half an hour after its removal, and
the irrigation of the rectum with warm saline solu-
tion, there was a copious discharge of intestinal
contents through the colostomy which was followed
by an uneventful recovery.
Xo attempt has been made in this brief consid-
eration of the subject to discuss all the facts per-
taining to physiology of the colon and rectum.
There are many problems yet unsolved. A contin-
uation, however, of such investigations as have
been recently reported on by Larson and others
should soon remove from the subject the mantle of
prejudice, ignorance, and mysticism with which it
has been clothed for so long a time and which has
made possible the wholesale exploitation of a gulli-
ble public by a host of unscrupulous manufacturers
and merchants through the mediums of radio, press
and periodical.
SUMM.AKY
( 1 ) The bif unctional nature of the colon, due
to the independent embryologic development of its
proximal and distal halves, is of practical signifi-
cance in that it decidedly influences the type of
non-malignant and malignant neoplasms of the
large bowel and alters materially the type of oper-
ative procedure indicated, the prognosis and the
end-results.
(2) In constipation the specific gravity of the
feces is so near that of water that one cannot right-
ly speak, as many do, of the colon as being weight-
ed down with excrement.
(3) The administration of the so-called nutrient
enemas is shown to be irrational, and the rectal
instillation of fluids, following operations on the
intestines, to be often dangerous.
(4) Although intestinal auto-intoxication may
well exist at times, it is believed to be of rare oc-
currence and, contrary to popular conception, far
more likely to be present in cases of diarrhea than
in cases of constipation.
(5) The excretion of heavy metals and other
substances by the colon, about which little is
known, may be responsible for instances of hyper-
sensitiveness of this organ.
(6) The term mucous colitis is thought to be
incorrect since it would appear that the condition
is purely neurogenic and the mucus produced a
hypersecretion.
(7) The gastrocolic reflex initiates a wave of
peristalsis which usually results in a call for defeca-
tion, and if habitually disregarded leads to consti-
pation.
Discussion
Dr. T. Neill Barnett, Richmond:
The paper just presented by Dr. Graham is most timely.
All too often we become preoccupied with the pathological
and overlook the physiological.
To discuss the physiology of the colon aside from the
remainder of the gastrointestinal tract is somewhat an-
alogous to discussing one chamber of the heart without
considering the whole. The rhythm of both is somewhat
analogous and there is a similar nerve supply controlling
the orderly movements of both these hollow, involuntary
muscular organs in the form of the vagus and sympathetic
systems. The whole gastrointestinal tract works on a
definite time table, with the colon working on a much
.slower schedule although it is geared to the same definite,
regular rhythm unle.^s disturbed by disease or meddlesome
interference. As indicated by the barium meal and various
dyes, the normal one-way trip of food through the alimen-
tary canal requires 48 hours — one-sixth of this time in the
190
PHYSIOLOGY OF THE COLON— Graham
AprU, 1936
stomach and small intestine, five-sixths in the colon.
It is significant that the alimentary canal is so designed
that the esophagus at the beginning and the rectum at the
end, serve as an entrance or exit respectfully. No alimen-
tary contents should remain in either for any length of
time. The sigmoid is the normal receptacle for the fecal
contents and when its contents are emptied into the rectum
immediate defecation should take place. When the act
of defecation is delayed repeatedly there is an obtunding
of these specialized nerves and relaxation of the muscula-
ture and the fecal mass becomes dry and hard, resulting
in the rectal type of constipation. When the rectum is
found to be overloaded with fecal contents a difficult
condition confronts us. Laxatives are contraindicated. The
rectum should be evacuated at a definite time each day;
if necessary, by means of a small lukewarm saline enema
until such time as the nerve endings regain sensation and
the muscular tone is restored; provided, of course, there
is no general contributing etiology, such as involvement of
the central nervous system et cetera.
Since the advent of intravenous therapy it is seldom
necessary to resort to proctoclysis; nevertheless, I can re-
member many lives that it has saved and am still old-
fashioned enough to beUeve that it has a definite value at
times when it is impossible or impracticable to use the
intravenous or the subcutaneous route for the adminis-
tration of sedative drugs, saline or nutritives. To my
mind, the Murphy drip is the most irritating and least
useful method. Comparatively small injections instilled
at regular intervals cause less discomfort, and far more
is accomplished.
The secretory function of the colon probably plays a
more important part in metabolism than we realize, as is
evidenced by the improvement noted on the administra-
tion of thyroid extract in cases of mucous colitis and
spastic colitis in which basal metabolic readings are low.
It is a travesty that so often unexplained conditions of
the alimentary tract are labeled gastrointestinal neurosis;
so long as we are content with such a meaningless con-
clusion no real progress can be made as to the underlying
etiological agent.
Dr. Stephen W. Davis, Charlotte:
The essayist has brought forth considerations which to
my mind are analogous to those in hypertension. A fault
has developed in our profession that I think could be
safely charged without creatmg an introspective view in
patients suffering with gastrointestinal discomfort and
which the patient himself terms coUtis since an excess of
mucus in the feces was found and he was informed of this
fact. The theory that the over-secretion of mucus b
purely a reflex mechanism is primarily true, and, in my
opinion, it has no pathological significance. I have a
patient in mind who was told several years ago that she
had mucous colitis, and at present she will test the patience
of her physician. The individual is a high-strung, emo-
tional woman who, for the most part, carries along quite
well, but when her husband or some other member of the
family is ill and her attention is centered upon sickness,
she immediately flares up with a colitis.
I am very happy that Dr. Graham spoke of the soap-
suds enema. The ill use of soap in the enema solution is
one of our secretary's pet hobbies, which I think has been
covered quite well. During my period of internship on
the service of Dr. O. H. Perry Pepper in Philadelphia,
there was a standing order that no soapsuds enemas should
ever be given a patient on his service; his preference being
the normal saline solution. I am using only saline enemas
in my practice where ordinarily the soapsuds enema is
prescribed. Among the many fads and fancies in the prac-
tice of medicine is that of diet. Many mothers are informed
that spinach is good for little Willie which he dislikes, but
he is stuffed with this food, which results in an emotional
disturbance precipitating a gastrointestinal upset. It would
have been far better for the spinach to have been given
to the cow and little Willie be given the milk.
Another point I wish to stress is the indiscriminate use
and the poor judgment with which purgatives are employ-
ed. The hydrocarbon oils have been abused to a certain
extent. It is known that certain vitamins are dissolved
in the oils and are excreted unassimilated. It might be
well to regulate the patient to a common-sense diet, since,
for the most part, no harm comes to the average patient
from meat in sufficient quantity to maintain the protein
requirements, but to overload a patient with roughages,
particularly those vegetables which they do not tolerate, is
poor judgment. In order to lessen the absorption of the
vitamins in the hydrocarbon oils, it is probably better
that they be given on retiring when food is not being
taken. The indiscriminate use of phenolphthalein in va-
rious propriety preparations and alone is mentioned only
to be condemned because of its residual harmful effects.
Dr. R. B. Davis, Greensboro:
The gentlemen who have been speaking certainly know
what they have been speaking about. They have, for the
most part, been representing the specialty of internal med-
icine. We surgeons probably do not study physiology as
do the internists. What is a purgative or a laxative?"
If it is not an irritant, what is it? And if an irritant is a
bad thing for the patient's intestinal canal, why give a
laxative? Practically all of the patent medicines on the
market today, with the exception of analgesics or seda-
tives, contain some form of laxative. It is not fair to say
that patients do not get some good from the highly adver-
tised and much used patent medicines. If the patients
did not get some good they would not buy them, and if
the firms that make them did not make money on them
they would not make them. So they do good — some good;
how and where it is for us to find out.
In regard to water in the colon, all the speakers have
said enemas are harmful in most of the cases. I dare say
there is not a surgeon in this audience today who would
attempt to practice medicine 30 days without enemas. We
may be wrong, but if we are wrong I hope somebody will
show us. Gentlemen, we can't practice surgery- without
enemas, unless we are content to have our patients suffer
intolerable gas pains. I have seen, and so have you, cases
of epilepsy cured by resection of the colon. I have seen
cases of epilepsy relieved by appendicostomy, with daily
ilrrigation of normal saline. I have seen, as one doctor
suggested here he had seen, patients with high fever and
rapid pulse and distention — ill patients — who had a cecos-
tomy done at the ileocecal region, and that an enema that
cleaned out the rectum relieved the patient of symptoms
and he recovered. If Dr. Graham's assumption that ab-
sorption takes place only in the ascending colon be true,
how can we explain this? That was in a patient with an
impaction in the descending colon — certainly not in the
ascending colon, because it was following a cecostomy.
So the final question that remains with me is, how can we
get elimination from the ill patient without purgatives,
laxatives, or enemas?
Dr. David C. Wilson, University, Va.:
I think it is about time that the psychiatric standpoint
should receive a little attention. The thing that I want to
say, or emphasize, especially is the force of an idea. Just
the other day I saw a man who 25 years ago had lost his
job and at that time had eight children. He did what a
good many other people do; he said: "I have the weight
April, 1936
PHYSIOLOGY OF THE COLON— Graham
191
of the world on my shoulders." He continued with that
idea and went into an institution 20 years ago; and at
present he is still holding his head in both his hands, he
is bent over, and he still has the weight of the world on
his shoulders. His hands have pushed into his skull. Other-
wise he is in splendid condition, but he is held by that
idea. A discusser said a few minutes ago that as long as
we call the^e diseases of the colon neuroses we shall not
get anywhere. I thmk until we recognize that a great
many of them are neuroses, and treat them as such, we
shall not be getting anywhere. The colitis idea and the
hypertension idea have tremendous power, and they must
be treated as ideas. Undoubtedly we have neuroses from
a great many different causes. You can operate on them,
can give them enemas, can do this and that, but you still
have your spastic colon and your disturbed patient until
someone goes down and finds out what is the idea, what
is the fundamental trouble that causes the gastric neurosis.
Dr. W. C. Ashworth, Greensboro;
Sir Arbuthnot Lane said that the colon is only a cess-
pool of the human body. He also said that God Almighty
made a mistake when he gave human beings colons. Prac-
tically even,- disease except tuberculosis and carcinoma is
greatly improved by colostomy. Dr. Lane had a very
strong supporter in New York, Dr. Bainbridge, who like-
wise believes, that colostomy will cure a large part of the
ailments from which we suffer.
Dr. Jas. M. Northington, Charlotte:
Dr. Davis referred to one of my pet aversions. That
is the soapsuds enema. As I understand the speakers in
general, there was no adverse criticism of enemas as such
but only of irritatinu' enemas, .\bout a dozen years ago
an eminent proctologist told me he was confideiit that at
least half his practice was due to the use of soapsuds ene-
mas. That was the first intimation I had that the soap-
suds enemas were harmful. I had used them as an intern
and in my own practice. But as soon as he mentioned it
to me, it seemed evident that an engorged condition of
the lower bowel would result. I was reminded of what
Bill MacNider said in his investigations of the effect of
alcohol on dogs. The dogs took the alcohol with avidity,
and he said he was astonished that the dogs had so much
sense. I was astonished that I had had so little sense.
As to the curing of epileptic convulsions by resection
of the colon ; you can cure them for a while by any oper-
ation, even by the amputation of a finger.
Dr. Graham, closing:
I am very glad to hear so much discussion about enemas
and laxatives. I wanted to say more about them ; but I
thought I was going pretty far, for a man who does noth-
ing but surgery, in discussing physiology of the colon. I
am known somewhat as a crank among the nurses and
interns in the various hospitals where I do my surgery,
and even among the doctors. But I was raised among
men who hated enemas as if they were poison, and after
years of such contact I just got into that frame of mind.
I feel that by doing away with the enemas, by not using
them in large quantities and large numbers of them, I have
not go so much distension and trouble afterwards; but,
since most of my work is in the gastrointestinal 
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